CO129-559-17 Dysentry Epidemic- report- etc. 11-11-1936 - 26-11-1936 — Page 8

Enclosure No.1.

I have caused to be laid on this table (a copy will

be found in the portfolio of each Honourable Member and there are a number of copies on the Press Table) a Report by the Director of Medical Services on an Epidemic of Dysentery caused by the Shiga Bacillus.

That epidemic has resulted, as we all know to our sorrow and consternation, in the deaths of eight little children; and our sympathy with the parents who have suffered this inconsolable loss is deeper than any words of mine can express.

A number of the bereaved have sent me a request, which has been published in the Press, for the appointment of a Commission of Inquiry with the object of ascertaining the answer to four questions. It is because I feel myself in a position to answer those four questions as well as could any Commission of Inquiry, and without

the inherent delay, that I have decided to make a statement

supplementary to the Report of the Director of Medical Services.

The first of the questions is "What was the source of the

infection?" Inasmuch as the food and drink consumed by the

patients prior to their illness was not analysed, and was not

subsequently available for analysis, the source can never be proved.

Those who are conversant with the limitations of inductive logic and

with scientific method will recognize that from obtainable data

there can emerge nothing more than reasonable inference. From the

data on which the Director of Medical Services has based paragraph

14 of his Report I have inferred, exercising my reason to the best

of my care and conscience, that the main immediate source of

infection lay in milk (probably in a single batch of milk) supplied

from the Farm Depot of the Dairy Farm, Ice and Cold Storage Co.,

What may have infected the milk seems to me a problem

incapable of solution by a Commission of Inquiry; it requires

rather active professional and technical investigation; and this is

already being prosecuted along three main lines, (a) search for a

human carrier of the disease among those who manipulate the milk,

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(b) search for possible contamination by water, and (c)

search for possible opportunities for contamination by flies.

The second question is "whether the Dairy Farm Company's 'Nursery Milk' was pasteurised prior to the epidemic".

The answer is in the negative. Since the 15th November,

however, the Company has pasteurised all its deliveries.

third question is "whether any or all of the deaths could have been prevented had the authorities taken immediate precautions

when the epidemic was first notified on or about the 7th

November, 1936" The answer is again in the negative. The epidemic was not in fact notified, because dysentery is not a

notifiable disease; but, even if it had been, such notification

could not have prevented fatalities which have been confined to

children who were taken ill on the 8th November and to one

connected case.

The fourth and last question is as to "whether any

action is contemplated by Government to prevent a recurrence of

this or any other type of epidemic". I am not prepared at

this juncture to state that any particular measure is

contemplated, for that would imply that a decision has already

been taken. I do state however that certain measures are under

consideration and will form the subject of early reference to

my Executive Council. One is the compulsory pasteurisation of

milk. I am aware that there is some medical opinion against

it, and the pros and cons will need to be carefully weighed;

and they will be carefully weighed. In the meantime the only

pasteurisation plant known to me in this Colony, that of the

Dairy Farm Company is, as I have already stated, being applied

to all their deliveries. Another measure under my considerat-

ion is for the statutory notifiability of dysentery.

Arguments against it emerge from the Report now on the table;

nevertheless the question must be thrashed out before a

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definite conclusion is reached. Thirdly I am determined to

prosecute any line of precaution, compatible with common sense

and with our financial resources, which may be indicated by the

results of the threefold investigation which I have already

adumbrated, and which may be summed up in the three words

carriers, water and flies. In conclusion I feel it my duty

to utter a few words of caution. Public analysis of all

food and drink is impossible; it can only be an analysis of

samples and, whatever the method and frequency of selection employed, the samples can never be representative of the whole

supply. Secondly the results of analysis, and still more of

bacteriological examination, do not come to hand until after

the substances, of which samples are analysed and examined,

have been consumed. Thirdly however comprehensive and drastic sanitary regulations may be, and however great the vigilance of the Sanitary Authority, there will always be those who

break the regulations and go undiscovered. When there is discovery it may often be after harm has been done. Local methods of agriculture are known; the conditions obtaining in our, now happily doomed, Central Market are known. From personal inspection and collaboration I am satisfied that our Medical and Sanitary Service is an efficient machine manned by

an able and untiring crew. But however great their efficiency and perseverance, and however many statutory or other implements and equipment we may add to their armoury, honesty compels me to confess that I cannot foresee the day when the principle of "caveat emptor" can be safely abrogated in its application to the purchaser of comestibles in this Colony.

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