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Our reasons for requesting this lie partly in our experience and partly in our recognition of the research, training, and demonstration potential offered by Federal hospitals.
Since the original"point of order” authority in 1960, a wide range of projects has been carried on in Federal hospitals, from studies of specific behavioral problems to experiments in new treatment methods and drugs. The diversity of patient population and treatment conditions make Federal hospitals no less valuable than non-Federal institutions for such study and research purposes.
In addition, the Federal hospitals have attracted physicians and scientists with valuable research, training, or demonstration ideas. They should be given the same opportunity to apply for grants that a physician or scientist in non-Federal institutions now has.
To put it another way, this section of the bill is an invitation to the physicians and scientists in our Federal hospitals to compete on the same terms with their counterparts in non-Federal institutions for Public Health Service research, training, and demonstration grants.
I would now like to turn to section 6 of H.R. 6431, which would authorize the establishment of a contingency account in the Treasury, giving the Secretary of Health, Education, and Welfare what we believe is needed flexibility to act promptly in extraordinary situations.
In an enterprise of such scope and complexity as the Department of Health, Education, and Welfare, it is inevitable that opportunities to accelerate the achievement of program objectives in these three areas, as well as new problem areas will arise during the course of a fiscal year. As much as we try, these breakthroughs and emerging problems cannot always be anticipated during the preparation of the President's annual budgetary plan. In certain instances, the need is met through requesting congressional enactment of a supplemental appropriation. On other occasions, the critical nature of the situation demands immediate action through a realinement of already available resources.
Let me give you some illustrations:
An emergency situation occurred in fiscal year 1964, when outbreaks of botulism poisoning from fishery products focused public attention on this longstanding public health problem. This incident was the first time a significant outbreak involving commercially processed foods had occurred. Investigations disclosed a new type of botulism of alarming severity (22 cases, 9 deaths). At the same time, prevention of the so-called type E botulism from smoked fish and other nationally distributed products was hampered by inadequate information concerning such matters as sources of the organism in food products.
You can well imagine that the Congressmen and Senators from those districts that were affected, as well as the businessmen, were really quite concerned about this situation, and asked us for immediate action. Because of the urgency of the problem, adjustments had to be made to provide funding for emergency research and training activities. A total of $315,000 was allocated within existing appropriations for the award of research contracts and purchase of necessary research equipment to develop necessary control measures. The availability, however, of a contingency fund would have made it unnecessary to reduce or discontinue other necessary health activities in order to carry out the emergency activity.
Another illustration: In March 1961, a chlorine-laden barge sank in the Mississippi River seven and a half miles below Natchez, Miss. To avert any possibility of endangering the public health, the President directed the Office of Emergency Planning to initiate and coordinate a broad-scale plan to insure safe removal of the barge and its cargo. Public Health Service was asked to assume responsibility for the public health and public information aspects of the project.
As part of this effort, the Division of Air Pollution rendered technical assistance by sending meteorological observers and chemists to the scene. Since no funds were available from the Office of Emergency Planning, $45,000 had to be diverted from other air pollution activities to support this emergency effort.
At any time there may be a breakthrough in any one of a number of targeted research and development programs in the whole field of health, education, and welfare. This could require the immediate availability of additional funds during the course of the fiscal year. If an effective German measles vaccine should be at the threshold, of development, we would certainly want to move as quickly as possible to move into the stage where there could be wide public use.
In the past, as in 1957, when there was a serious Asian flu epidemic in this country, the Division of Biologics Standards, National Institute of Health, worked for about 6 months assisting in the effort to get an effective vaccine on the market. This work, costing some $50,000, was done at the expense of the Division's regular activities related to the quality and safety of biological products coming within the jurisdiction of the Public Service.
In 1961, because of frequent polio outbreaks in local areas, large numbers of previously unvaccinated individuals were seeking polio vaccination. In such cases, however, it was usually too late for the Salk vaccine to be effective in combatting the epidemic. Accordingly, the Surgeon General's Advisory Committee on Poliomyelitis Control recommended that the Public Health Service maintain reserve stocks of oral poliomyelitis vaccine for use during epidemics. A supplemental appropriation of $1 million was required for the establishment of such an epidemic reserve.
We believe, particularly with the many new breakthroughs coming to our attention, that a new approach is required to cope with situations of this kind-an approach which affords the Secretary of Health, Education, and Welfare greater flexibility in the administration of a myriad of programs without at the same time infringing on the constitutional responsibilities of the Congress. The mechanics of our proposal, Mr. Chairman, are relatively simple.
A contingency account of indefinite duration would be created on the books of the Treasury with a monetary ceiling of not to exceed $50 million. Into this account would be deposited those amounts provided in any general fund appropriation of the Department which remain unused at the end of their period of availability. Prior to withdrawing money from this contingency account to supplement appropriated funds, the Secretary would be required to make a determination that
Such action was necessary to fulfill his responsibilities;
Delay pending further appropriations by the Congress would be contrary to the public interest;
The withdrawal was required to carry out a significant purpose; and
The need for additional funds to purchase supplies or equipment, negotiate contracts or perform similar functions could not reasonably have been anticipated in the most recent President's
Budget. Numerous procedural safeguards have been incorporated to meet the needs and the opinions of the Congress. In addition to the provisions just mentioned, these include:
Congressional authorization of both the amount of deposits into and withdrawals permitted from the contingency account as part of the Department's annual appropriation act;
À prohibition against using funds from this account to conduct an activity for which funds were denied by the Congress in considering the appropriation bill for that year;
A requirement that the program to be financed must be otherwise authorized by law;
At least 10 days' prior notification to the Committees on Appropriations of any intended use of the contingency account; and
Submission of an annual report to the Congress on the operations of the account. Thus within carefully prescribed limits, the Secretary of Health, Education, and Welfare would be able to react swiftly to important new findings gained from the Department's programs to extend the frontiers of man's knowledge. Support for large-scale clinical trials of a vaccine to protect pregnant women and their offspring from the ravages of German measles, and exploration of promising new leads in the quest for a fully implanted artificial heart are but two illustrations of how funds from the contingency account might conceivably be used.
Research does not represent the only area which may benefit from this proposal, however. Of equal importance is the opportunity to move quickly to cope with threats to the Nation's health or safety, broaden the dissemination of newly acquired knowledge, or deal with the impact of natural disasters.
This, then, Mr. Chairman, is the administration flexibility and operational efficiency which we seek to achieve through the establishment of a contingency account under the direction of the Secretary of Health, Education, and Welfare.
Thank you very much for giving me the opportunity to come before you to testify on these provisions of H.R. 6431. I know of your deep interest in mental health, and I urge that you report this bill favorably. If you have any questions, Dr. Stewart, Dr. Yolles, Mr. Kelly, and I will be happy to answer them.
(The report referred to by Mr. Cohen follows:)
COMMUNITY MENTAL HEALTH CENTERS PROGRAM STATUS REPORT
(By Director, National Institute of Mental Health, March 31, 1967)
PART 1-GENERAL OVERVIEW Twenty-one years ago, when the National Mental Health Act was passed, only very few workers in the field were concerned with the development of community mntal health services. Even to them, the goal of effective services near home seemed distant and remote, barely visible on the horizon. The limited community
mental health facilities of the day served primarily as transfer agents-between the shattered lives and homes of citizens and the back wards of custodial institutions. Across the country, the American's attitude toward mental illness was still heavy with centuries-old traditions of shame and fear.
The challenge was great and it could not be denied -a challenge embodied in those hundreds of thousands of mentally ill Americans, whose doom was being inexorably sealed in isolated hospitals across the country. Today, only three years after the passage of the historic Community Mental Health Centers Act, we can gauge the degree of our progress: Our Government has now supported the development of 173 community mental health centers, with funds totaling 73 million dollars to be devoted to the dual tasks of construction and staffing, By the end of Fiscal Year 1967 we will have supported 286 centers serving 47.2 million persons.
As of March 27, 1967 : Grants made: Construction only
100 Staffing only-
47 Construction and staffing
Total number of centers funded.
173 Funds Obligated : Construction :
FY 1965 : 33.6 million or 94% of 35 million.
FY 1966: 21 million or 42% of 50 million. Applications pending : approximately 28 million or 56% of 50 million.
FY 1967: 300,000 obligated or 0.6% of 50 million,
FÝ 1966: 15.2 million or 80% of 19 million (new grants) (4 month availability).
FY 1967: 2.6 million or 14% of 19 million (new grants). Applica
tions pending: 19.5 million or 102.6% of 19 million. Funds obligated at all levels (Federal, State, Local) $209 million. Averaging as follows: Construction cost per center 1.2 million ; 1st year operating cost $776 thousand ; Rate of Federal participation 50%.
Currently, 28 million persons have community mental health centers available to them, or have centers slated for construction and/or staffing in their communities. Each center serves an average population group of 165,000.
These centers—the symbols of a new era in mental health care-serve 45 States and Territories. They have sprung from the creative collaboration of mental health professionals, and political and civic leaders at the Federal, State and local level. And, they have evolved from a solid base: a broad range of public and private agencies—hospitals, clinics, medical schools—many of them combining their efforts to develop a single comprehensive center.
Procedures for implementation are functioning well-as NIMH staff members join with professionals and volunteers in States and communities across the Nation, taking those necessary technical steps that lead, ultimately, to the construction of individual centers. State plans are being reviewed as they are developed and submitted--a prerequisite for the formal submission of proposals for specific centers within the State. In this way, inventories of existing community resources and surveys of current needs are made to mesh with projected goals.
There are those who, sharing our own zeal, would have wanted us to speed ahead at a faster pace-who would like to see new community mental health centers offering services in every American community now. Today. In the face of our country's need, they share our own impatience.
This ideal cannot be faulted, and we will not be satisfied until the entire American community is served. But our enthusiasm must be tempered with realism. Attempts at speed without the careful development and utilization of sound professional and administrative procedures are unrealistic; and, quantity without quality is self-defeating.
Ours is an innovative program—involving new concepts in architecture, in manpower, in services and such programs require time to build : time between the appropriation of funds and the psychological readiness of communities and States to act; between the readiness to act and the development and submission of tangible plans and proposals; and between the approval of a program and
its actual operation. History teaches us that all new programs—if they are to be successful-must follow a similar course of careful planning and development.
Even more important is our insistence on quality-our conviction that there is no substitute for excellence where the health and welfare of our citizens are concerned. Implied here is no lack of concern for human needs, but rather the sure knowledge that we serve these needs best if, as scientists, we adhere to high standards. We mean to build a program in which numbers and novelty will not replace soundness of purpose and design. A community mental health center can only rise from firm foundations : from systematic priorities in the allocation of resources; from convincing evidence that services will in fact reach the people for whom they are intended; from a certainty that care will be comprehensive that the continuum of human needs will be met by a continuum of responsive services.
I want to share with you our conviction that our progress cannot be gauged solely by bricks and mortar. Those of us close to the centers construction task are aware that this new program is far more than one of construction alone that its impact cannot be measured solely in physical terms. The fact is that we have inspired here a revolution in mental health activities across the country.
Old and unrewarding attitudes toward mental health needs are changing, and they are being restructured in communities and States across the Nation. No longer is mental health seen as the privilege of the few who can afford private care with the sickest and neediest of our fellow men shunted away in distant hospitals, removed from the conscience and concern of the community. All Americans—the indigent along with the wealthy, the laborer and blue collar worker along with the professionals—are beginning to be seen as the community of effort that forms the centers program. A community mental health center can succeed only if it is accepted by the citizens of the community in which it is located.
Long entrenched patterns of passivity are changing. Communities have be. come involved in planning for the mental health of their own residents—with new services appearing at the local level; and, the States-29 of which have now passed Community Mental Health Services Acts—have begun to advance the organization and distribution of their own mental health resources.
Patterns in the financing of mental health services have been revolutionized. In some States Federal money is being matched with State money exclusively; in others with State and local money ; in still others with private funds. As recommended by the National Governors' Conference, the NIMH-working with the Council of State Governments—is encouraging the development of the broadest possible base for the financing of community mental health programs.
MEASURES OF PROGRESS
It is important at this point to assess the shape as well as the degree of our efforts. We must evaluate the extent to which we are meeting the criteria of quality we set for ourselves and for the millions of citizens who are the potential beneficiaries of this contemparary approach.
The program requires, for example, that each community mental health center make its services not only available, but readily accessible to all. How have the results of our efforts matched this objective?
It was clear from the outset that communities seeking support for mental health programs would ultimately represent a sweeping cross section of the total American community. Initiative has come from depressed areas and from regions of great wealth; from one-industry towns to cities built on a broad industrial base; from areas containing some of the strongest medical centers in the country to those which have until now attracted few or no professionals in the mental health field.
The image of the mental health center as serving populations concentrated only in the metropolis is hardly valid. The developing centers are marked by a broad regional diversity: a third are in cities of a half-million persons or more; another third in cities of fifty to five hundred thousand : and a final third in communities of fifty thousand residents or fewer. Mental health services will thus reach big city dwellers, suburbanities, and rural residents alike. In fact. nearly 150 predominantly rural counties are included in the population areas served by centers now being formed; residents of many areas will now have mental health professionals in their midst for the first time.