§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Thomas Cox.]
§ 9.18 p.m.
§ Mr. John Ovenden (Gravesend)I am very grateful for the opportunity to raise an issue that I believe should be of serious concern to all hon. Members and to the country as a whole. I can assure my hon. Friend the Under-Secretary of State for Health and Social Security that it causes great concern in my constituency. I refer to the changes in the port health regulations in April this year, which many of us believe have undermined effective public health controls and proper controls over infectious diseases.
Events since April have proved that the decision to remove the obligation on ships' masters to complete a maritime declaration of health in all circumstances was ill advised, and that the assurances given to the House by my right hon. Friend the Minister of State on 3rd April were over-optimistic and perhaps complacent.
I wrote to my hon. Friend the Under-Secretary making representations about the changes. In his response on 23rd May, he told me that almost everyone welcomed the changes. I find the word "almost" significant. Perhaps my hon. Friend can tell us tonight who did not welcome them. It is little use to those who know nothing about the subject welcoming them if all those who are involved in the issue and concerned with the health regulations take the opposite view. Perhaps my hon. Friend can tell us in particular what views were expressed to him by the health authority of the port of London and by other port health authorities.
What consultations took place with area health authorities in the port areas and with community health councils, which also have a role to play in representing the views of local people on issues of this kind? Were they even consulted? I doubt it very much. I am almost certain that community health councils in my own area were never consulted. In fact, they have made representations to me about the order since it came into force. They were even unaware that the Government intended to make such changes. I think that that requires some explanation.
1606 Since April, it has been necessary only for masters to report if they believe that they have infectious diseases on board their ships. This runs the risk of missing cases of infectious disease by oversight on the part of the master, by laziness, by incompetence or simply by the mistake or misjudgment of the master. After all, masters are not trained in medical techniques. They are not trained to recognise infectious diseases and to know the difference between a serious disease and a case of the sniffles. Those are matters for the medical authorities
In present circumstances, it is impossible to know whether the absence of a maritime declaration means that a ship is disease-free or whether it is simply a case of neglect by the master. It is impossible for the port health authority to follow up suspicious cases as it could have done in the past. In the past, had no certificate been received, investigations would have been made. Now, one has to assume that the master has acted responsibly and has assured himself that there are no diseases on board.
In the port of London, which is the area to which I want to refer specifically. the deterioration in port health standards has perhaps been even more dramatic than in other areas. I say that because the standards which existed in the port of London prior to these changes were higher than those in the rest of the country and, therefore, the reduction has been that much greater. Boarding by medical officers was common practice in the port of London area. The port health authority there assured me that it was trying to continue the old practices and to maintain a medical presence on the river, but its efforts and effectiveness are surely undermined by the attitude of the DHSS and by the introduction of these new port health regulations.
Ships' masters are now under no obligation to co-operate with the port health authorities or to provide the information which is needed to police the river and the port of London effectively in health terms. Under the previous regulations, it was necessary before berthing for the ship's master to inform the authorities. As I understand it, there is no power in the new regulations to make the master do so.
1607 On 3rd April of this year, the Minister of State told the House that there were options open to the port of London health authority which would overcome the difficulties which had been raised in the debate. It is quite clear from the statements of the medical officer for the port of London that he, for one, does not accept that view. Perhaps my hon. Friend the Under-Secretary will say what discussions have taken place since April with the port of London health authority, what proposals have been made by him and what discussion there has been about the options referred to by the Secretary of State. If there has not been any action so far, perhaps my hon. Friend will also say when he intends to convene a meeting with the health authority there and whether he will regard that as a matter of urgency.
My concern arises out of two incidents, both of which have occurred since April. one in my constituency at the Isle of Grain and the other at Tilbury, which is a few hundred yards across the river from my constituency.
The incident at Grain in August concerned the tanker "British Holly". A seaman employed on that ship left the ship and travelled by taxi to a general practitioner's surgery, thereby exposing people in the area to the risk of infection if he had an infectious disease. He was then taken by ambulance to Joyce Green hospital, Dartford, where it was found that he was suffering from typhoid.
The second incident concerned the better known case of the Russian cruise liner "Litva]" which was moored at Tilbury, where passengers were found in September to be suffering from typhoid. That case came before the courts recently. The master was fined £100 in Gravesend magistrates' court a few weeks ago.
I wrote to the Minister of State about both incidents. I wrote about the "British Holly" on 18th August and about the "Litva" on 18th September. I finally received a reply on 30th September in respect of both cases. I tried to raise with my right hon. Friend how the new regulations affected those incidents, and the ability of the authorities to deal with those cases. In the Isle of Grain incident involving the "British Holly", the Under-Secretary told me in his letter of 30th September that as the ship was operating to excepted ports it 1608 was not subject, even under the old regulations, to the full controls. In a further letter, of 1st November, he went even further and said that in the particular circumstances of this ship there had been no change in the health regulations which had in any way affected what controls were exercised over it.
Since that letter I have made further inquiries. I am reliably informed that the procedure since 1st April in respect of that ship is somewhat different from that which would previously have been adopted. I understand that the "British Holly" would probably have been contacted by radio, by the port health authority and perhaps not boarded. Had that happened, the master would have been asked specifically to state whether he had illness on board. It would have been possible from such a conversation—from specific questions asked of the ship's master and a description of the state of health of members of the crew—to identify that case of typhoid a little earlier, certainly before the man suffering from it left the ship, got into a taxi and travelled to a doctor's surgery. Under the old regulations the masters knew that they had to report illness on board, either by radio or when they were boarded by medical officers. The new regulations remove such clarity and make it possible to evade proper reporting. This has been shown to be evident in the instance of the British Holly".
The instance of the "Litva" was perhaps even more serious. The Russian cruise liner was docked off Tilbury and typhoid was detected there in September. That caused great concern to my constituents because, although the ship was moored at Tilbury, when cruise liners use the dock the passengers often visit Gravesend to do their shopping because the shops in Gravesend are a bit better than the shops in Grays. They use the British Rail ferry across to Gravesend. Consequently, any typhoid outbreak on the ships using Tilbury exposes the people of Gravesend to possibly a greater risk than it does the people of Essex.
The port medical officer for the port of London is on record as saying that the outbreak could have been detected earlier, and appropriate action taken earlier, if the old regulations had been in force. Again, as in the case of the "British Holly", the master would have been 1609 questioned and cases would have come to light. The master of the ship has been prosecuted for failure to contorm with the new regulations. That does not alter by one iota the fact that under the old regulatons this evasion could probably have been prevented.
In his letter to me of 30th September, the Minister told me that
the only difference between the old and the new regulations was in the filling in of maritime health declarations.From correspondence which I have had with the port of London health authority since then I have reached the conclusion that that is not a fair analysis of the position. It is an oversimplified version of the story. Under the old system, masters were required to report for questioning by medical officers. The regulations were strong enough to enforce that. Now, the master does not even have to make his ship's presence known unless he suspects that there are infectious diseases on board.How can a master tell such a thing? How can a non-medical man appreciate symptoms or, indeed, the seriousness of any symptoms? How can he decide whether the symptoms are sufficiently serious to justify being reported? One may well ask: why should he? It is not his job, as a ship's master, to be an expen on infectious diseases. Further, the temptation is always to underplay the incident and not to report anything if it is on the borderline. In the past, things were reported and could be properly investigated.
I have two further general points to make about the enforceability of the new regulations, and I wish to ask two specific questions. If ships are not boarded under the new regulations, and if no report is submitted by the master, how can the health authority effectively prove that someone was ill on board at that time, should the case come to court later? How can it be proved that someone has been ill on the boat and has recovered later or been removed from the ship en route to the port? These changes in the regulations undermine our ability successfully to conduct prosecutions in such matters.
I turn to the fines issue. The master of the "Litva" was detected and prosecuted. I suspect that under these weak regulations he would be one of the excep- 1610 tions. Few people will be detected under the regulations. That master was convicted for breaking the port health regulations, but he was fined only £100 by the Gravesend magistrates' court. That is a ludicrously small amount. I do not criticise the magistrates, because they used their full powers. The maximum fine for such an offence is £100. I hope that the Minister will assure us that he intends to do something about that. It is ludicrous that people can openly defy health regulations and expose the population around the port area to infectious diseases and be fined only £100. That situation makes the law a laughing stock.
The two incidents which have occurred since April prove that even after a few months there is enough evidence to reexamine the changes. There is strong evidence that the changes were misguided and dangerous. The arguments made in the House in April now appear to be complacent. They imply an abdication of responsibility by the Department.
During the 3rd April debate, the Minister argued that the major dangers of infectious diseases arose from air travellers. He said that we could not impose effective controls in that sector and that, therefore, there was no point in doing much about the dangers imposed by sea travellers. That is an abdication of responsibility. The Minister said that because we could not be certain about the control of infectious diseases, we should not go as far as we could. Since we cannot be effective for air traffic, we should perhaps concentrate more on those areas where it is possible to have some effect.
In his letter to me, the Minister said that there had been few serious infectious diseases detected in the port of London in 1977, despite the stringency of the old health regulations. He told me that there had been only four cases of serious disease—hepatitis, malaria, pyrexia and tuberculosis. No mention is made of typhoid. Am I right to assume that there were no cases of typhoid? Alternatively, does the Minister regard typhoid as a disease which is not of a serious nature? He has said that typhoid is neither a disease for which quarantine is necessary nor one that is imported. How many cases of typhoid occurred in 1977? How many cases have been detected so far this year?
1611 We should have a full inquiry into the new regulations. There should be a full and detailed discussion between the London port health authority and the Department about such problems. There should be effective action to ensure that ships are obliged to report their presence whether or not passengers or crew suffer from infectious diseases.
We must give back to medical officers adequate power to question masters about the health of crew and passengers. I hope that the Minister will introduce a realistic level of fines for those who break the regulations and so undermine the control of infectious diseases.
§ 9.35 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)I am grateful to my hon. Friend the Member for Gravesend (Mr. Ovenden) for raising the subject of these regulations this evening. It will enable me, I hope, to dispel some of the incorrect information about them which has been given publicity following an outbreak of typhoid amongst passengers of the cruise liner "Litva" in August and September this year. These are the regulations to which my hon. Friend has alluded in not very glowing terms.
The Public Health (Ships) and the Public Health (Aircraft) Regulations 1970 as amended provide for the public health control of ships and aircraft arriving at or leaving sea and airports in England and Wales. But it would be misleading in this day and age to exaggerate their importance in the protection of this country against the spread of infectious disease from abroad. They were very important in the nineteenth century when infectious disease was more prevalent in the world, when such people as arrived here came by ship, sanitary conditions and habits here and abroad were not so good and medical science less advanced. Nowadays, as my hon. Friend has acknowledged, the vast majority of people arriving in this country come by air—about 30,000 a day at Heathrow airport alone. They arrive within 24 hours of leaving and diseases have incubation periods of days, weeks and sometimes even months.
Of the few who have contracted infectious diseases abroad, the majority will be unaware of it themselves and it will not 1612 be detectable by medical inspection at the point of entry. Where it is apparent, we must of course have the machinery to take necessary precautions, but the main defence must rest within the country on a high level of sanitary conditions and habits and a rapid reaction by medical practitioners when a case arises.
Our regulations comply fully with the international health regulations. The World Health Organisation, in the light of the experience of the USA and Canada, which were before us in streamlining, and ourselves are likely, in proposing amended international health regulations, to recommend procedures very similar to those we have produced. It is likely to drop the international maritime certificate of health.
Having made that important point, that we are not concerned in this criticism of the regulations with any major leak in our defences against infectious disease imported from abroad and that there is no sanitary iron curtain possible, I shall turn to what happened when revised regulations were introduced in April this year after over two years of testing and with the agreement of all those organisations consulted.
The City of London, as my hon. Friend has fairly said, as port health authority for the Thames estuary was virtually alone—I believe that Newhaven was the other exception—in its opposition to the changes. It did not have the support of the Association of Sea and Airport Health Authorities.
Up to April of this year, the master of a ship arriving from a port outside the excepted area of Europe had to produce an international maritime declaration of health giving various details, whether the ship was "healthy" or not. The excepted area of Europe consists of Belgium, France, Italy, Luxembourg, the Netherlands, Ireland, Greece and Spain. If there had been an occurrence on board which might indicate infectious disease the master had to radio in ahead of arrival. On arrival he could not allow embarkation or disembarkation or working of the ship until that certificate had been cleared. This was normally done by the customs and excise staff who were boarding the ship, but, if there was any problem, port health authority staff gave clearance.
1613 From April the requirement for a maritime declaration of health and restrictions on boarding were dropped in relation to healthy ships and these procedures were retained only for those ships where the master had circumstances indicating the possibility of infectious disease. This was in line with what had been the practice for many years, without difficulty, at airports, where no action is taken unless there is a report by the commander of the aircraft, or, of course, if customs or immigration staff notice anything untoward. It also follows the line taken for procedures in the United States since 1973 and in Canada. It was done only after lengthy and satisfactory pilot studies over two years at Southampton, Immingham and Milford Haven.
My hon. Friend asked me about consultation. On matters of general public health at ports, my Department consults the appropriate bodies. In the light of the experience that I have mentioned in the trial runs, proposals were put to the Association of Sea and Airport Health Authorities, the Environmental Health Officers Association, the General Council of British Shipping and interested Government Departments in December 1976. Draft regulations were circulated on the same basis in August 1977, and a final revision was circulated in January 1978. The principle of the amendment regulations has been generally welcomed, although I understand that objections were received from the City of London and Newhaven at a late stage.
At the same time as the unnecessary form filling and restrictions were dropped in April, the amending regulations and related procedures tightened up certain actual controls. It is impossible and unnecessary to inspect medically all passengers and crew and consequently it has always rested with the master to report indicative circumstances.
From April, the master was given much more precise guidance as to the signs that should lead him to make a report. For the first time, a leaflet setting out the rules was distributed on a national basis, via customs and excise officers, port health authorities and shipping organisations. Masters were required to report the presence of animals on board and powers to 1614 sample food and water were included in the regulations. Certain new diseases—viral haemorrhagic fevers—were brought into the ambit of the regulations.
The regulations have been in force for more than six months and no one outside the London port health authority has found any difficulty. On the contrary, the changes have been welcomed not only to shipping interests, because they enable a quicker turn-round, but to port health authorities which have been enabled to divert staff to preventive work—to investigating thoroughly situations where they feel that there may be a health danger.
I turn to the situation in London. As I explained, until April this year, customs and excise officers were usually involved in giving health clearance to ships unless there was a problem requiring the attention of the port health authority, or port health authority staff were in attendance on arrival. This involvement of the customs and excise is historic—it antedates the establishment of port health authorities, or port sanitary authorities as they were at first named. In recent years, however, with staffing difficulties, customs and excise had been seeking to be relieved of this work. In London, the port health authority took over the work four or five years ago and set up a system, based on Gravesend, with launches and full-time medical officers attending to give 24-hour cover. All ships reported by radio and were either given clearance by radio or boarded by a medical officer in the Thames. That is a more elaborate and expensive system than any that I am aware of elsewhere.
Let us look at what happened under that system. In 1977, about 6,000 ships arrived in the port of London. A proportion of those would, of course, come from the expected area of Europe, and, under international agreement, no maritime declaration of health can be required from these ships. In 1977, a total of 4,680 ships were cleared by radio and 878 were boarded. Despite falling traffic, the numbers boarded had risen to that figure from 541 in 1975. What did this system of inspection with medical officers on watch for 24 hours achieve? In 1977, a total of 13 cases of notifiable and other infectious diseases are listed; in 1976 there were 16. But these figures include many minor matters—"bronchitis", 1615 "chicken pox", "coryza and pharyngolaryngitis". This has been the pattern for a number of years, there is no evidence of, or even room for, much failure to report under the old or new systems and I think it highly unlikely that, by dispensing with hundreds of radio messages and forms with "nil" returns, anything much is going to be missed. I must emphasise that no procedure can cope with a wilful and flagrant breach by the master of a ship of the requirement to notify.
The centre at Gravesend, which is of great concern to my hon. Friend, is aware of ships' arrivals and, indeed, can see them. The port medical officer and his staff can still board a ship if so desired at any time. There is provision that the port medical officer can require a maritime declaration of health if, in particular circumstances, he wishes. The City of London, although well aware in advance of the changes to be made in the regulations, made no preparations. The medical officers at Gravesend are still in post but are, I understand, likely to be replaced at the end of January by doctors on call.
Certain cases of typhoid related to ships arriving in the Thames have been quoted as showing the inadequacy of the regulations in relation to London but this is not so. My hon. Friend mentioned the instance of the MV "British Holly". Four members of the crew of this ship were sent on 2nd August, on arrival at the Isle of Grain, with apparently minor medical problems to see a local doctor. The Isle of Grain does not come within the main London port health system. There are local arrangements, and the dotor was in fact deputising for the port medical officer responsible for ships arriving at the Isle of Grain while that officer was on leave. On examination of one crew member, the doctor arranged for the individual to be taken to the appropriate hospital, where he was found to be suffering from typhoid.
As my hon. Friend acknowledged, this is not a disease giving rise to quarantine. It is not in the same category of highly infectious diseases such as, for instance, smallpox, because transmission is normally by food or water contaminated by faeces or urine by a patient or carrier. This fever occurs world-wide, and there were 228 cases notified in England and Wales in 1977 with three deaths. These 1616 are all provisional figures. The ship and crew were checked at subsequent ports of call and further tests were made.
The changes in the Public Health (Ships) Regulations which relate only to ships arriving from foreign ports are not relevant in this case. This is, first, because the ship was operating coastwise and, in the main, to excepted ports in Europe and was, therefore, either not subject to control or subject to very limited control. The crew of the "British Holly" had recently been brought in by air, and, if anything, the case supports the view I expressed—that the danger to public health from infectious disease lies in latent cases arriving by air rather than by sea. This case could equally well have occurred anywhere else in the community in the United Kingdom and, as I have said, protection rests with good sanitation, clean habits and—as was indeed the case here—rapid reaction by medical practitioners.
The second case mentioned—here there was rather more publicity—was the my "Litva", a Russian vessel under contract to a British cruise operator which gave rise to five typhoid cases and some dysentery cases—not all of the same type—following cruises to Portugal and North Africa ending at Tilbury on 19th August, 2nd September and 16th September. This came to light following diagnosis in a cruise passenger who had returned to Jersey. The situation was notified to the London port health authority on 30th August. This illustrates the difficulty of these cases, since although the individual had been ill on board there had been recovery and illness again after return home.
The London port health authority boarded the ship on both 2nd and 16th September when the master was still proceeding as if he had nothting to report. On 26th October the master of the ship was fined £300 and ordered to pay £415 costs for failing to report illness on board. There had been a large number of cases of diarrhoea during the cruise ending on 19th August and during the cruise ending on 2nd September, yet when a port health inspector boarded on the 19th he was told there was nothing to report.
In what way were the regulations ineffective? It is alleged that had the old regulations been in force the problem would have been discovered earlier. This seems unlikely, since the ship was boarded 1617 on all three occasions. It is possible that the circumstances would have been reported on the written certificate of health, but the similar case of the cruise ship "Ellinis", at Southampton in 1976 can be quoted, where the certificate made no difference. Sample checks are provided for in the revised regulations, and the new powers to sample food and water were put in the revised regulations precisely to meet problems arising from cruise ships such as this. No contamination on the "Litva" was in fact found by the inspections of 2nd and 16th September and the source of infection has not been traced.
It seems to be the impression that health officials have no automatic right to board a ship coming from a port where it is known that there were, or had been, infectious disease. This is not so. Regulation 7(1), in conjunction with regulations 11 and 36 of the Public Health (Ships) Regulations 1970, as amended, enables an authorised officer to inspect any ship on arrival or already in his port health district, and changes in the definitions have in fact widened this power. The provision in paragraph 4 of circular LAC(78)5 that a percentage check of ships not reporting illness should be made was not intended to inhibit the port medical officer from directing his inspections to particular ships calling for greater attention or coming from areas which give rise to concern, or his power to increase the numbers of inspections if circumstances so warranted. At the request of my Department, the General Council of British Shipping is drawing the attention of its members to this possible misinterpretation.
It has been said that there would be difficulty in prosecuting under the new 1618 regulations and I am glad to see that the case of the "Litva" has shown that this is not so. It has also been said—and my hon. Friend echoed this phrase tonight—that the maximum fine is "ludicrously inadequate". I am inclined to think, and would agree with my hon. Friend, that revision may be needed, but this would have been so before the new regulations came in and there were no representations until then about the level of fines. My Department is raising the matter with the Home Office, but, as hon. Members will be aware from some recent court cases, the formal penalty is not necessarily the prime deterrent. In the case of the "Litva" there would be defence costs in addition to the fine and costs I have mentioned, there would be the cost of flying 38 passengers home, the cancellation of a final cruise and losses due to adverse publicity. The attention of the Russian health authorities has been drawn to the matter, and I understand from ports that their ships are being especially careful regarding notifications.
I am satisfied that this case provided sufficient deterrent effect in relation to the failure to report to the health authorities and that it provides no evidence of the regulations being ineffective.
In conclusion, I emphasise that the effective working of port health controls rests with port health authorities and local authorities and with medical staff provided to them for this purpose. There is ample discretion in the regulations and under the operative circular for the controls to be exercised and applied effectively.
§ Question put and agreed to.
§ Adjourned accordingly at nine minutes to Ten o'clock.