There is enclosed for your information in this connection a copy of my letter of this date to Senator Murray, regarding an identical proposal contained in S. 1160. Very truly yours, PAUL H. APPLEBY, Acting Director. SEPTEMBER 21, 1945. Hon. JAMES E. MURRAY, Chairman, Committee on Education and Labor, United States Senate, Washington 25, D. C. MY DEAR SENATOR MURRAY: The bill, S. 1160, the National Neuropsychiatric Institute Act, to which reference is made in your letter of August 2, 1945, has been carefully considered. The bill would provide for an extensive mental hygiene program in the Public Health Service. There is no doubt that more intensive efforts should be directed toward the developing and applying methods of treatment for mental and nervous illnesses, which have become one of the great problems in public health. However, the bill, S. 1160, is open to several objections. (1) It considerably overlaps authorization already existing in the Public Health Service Act (Public Law 410, 78th Cong.), especially with reference to research and grants-in-aid. (2) Section 314 (c) of the Public Health Service Act authorizes grants and other assistance to States for general public health services. If instead of an over-all grant, separate grants are established for a variety of special needs, coordination of programs is difficult, and a distorted emphasis on some programs at the expense of others is likely to develop. Also the existence of a number of separate Federal grants-in-aid programs is already throwing a heavy burden of paper work on the States. In view of existing authorization in section 314 (c) for grants for public health services of all types, the establishment of additional separate grant programs for specific diseases is regarded as undesirable. If Congress desires that special attention be given to a particular disease, e. g., neuropsychiatric disorders, by the Public Health Service in administering the general grant program, it would seem desirable that section 314 (c) be amended to provide that special consideration be given to such disease in determining the allocation of the general grant funds among the several States. (3) Under existing legislation, the National Institute of Health has been established as the research branch of the Public Health Service, with responsibility for research into health problems generally. It does not seem desirable or necessary to establish, in addition, separate institutes for research in particular diseases. The proposal which has been suggested of having a relatively large number of research institutes loosely correlated under the National Institute of Health is not regarded as a sound or acceptable administrative arrangement. (4) The provisions of S. 1160 relating to training are not desirable. Section 314 (c) of the Public Health Service Act above referred to authorizes the appropriation of $2,000,000 per year for training and demonstrations by the Public Health Service. Training in the neuropsychiatric field would be included under this head, as the law now stands. If necessary, this over-all limitation could be raised in lieu of separate legislative provision relating to neuropsychiatric training. Further, the provisions of S. 1160 relating to grants-in-aid for training are not considered an effective way of meeting such needs as may exist for training of personnel in the general field of mental hygiene. For these reasons the bill to establish a neuropsychiatric institute should not be considered as in accord with the program of the President. Sincerely yours, PAUL H. APPLEBY, Acting Director. Mr. PRIEST. This bill was introduced in March, and subsequently there has been rather widespread approval of the bill in many of the medical journals and in editorials in the daily press, and at some point later in the record I will ask permission to include three or four of the most representative of these editorials. We are pleased to have the Surgeon General, Dr. Parran, here as our opening witness this morning. Dr. Parran, if it is agreeable, we will proceed to hear you at this point. STATEMENT OF DR. THOMAS PARRAN, SURGEON GENERAL OF THE UNITED STATES PUBLIC HEALTH SERVICE Dr. PARRAN. Mr. Chairman and members of the committee, I am glad to appear here in response to your request. I am not advised of the relation of H. R. 2550 to the program of the President. Therefore, I shall confine my testimony to an analysis of the bill and discuss the nature and extent of the huge problem of mental ill health, the amount of sickness, disability, and economic loss caused by it, and some of the methods which, from the professional point of view, may be effective in improving this area of the national health. Mr. Chairman, as I have read the comprehensive provisions of H. R. 2550, I can only say that you have made a profound study of this complicated problem and have been very well advised in regard to the practicable steps which the Federal Government may take to aid in its solution. The new authority which this bill gives to the Public Health Service merely projects into the field of mental disorders the existing authority which this subcommittee ratified last year in the Public Health Service Act of 1944, as regards research, grants-in-aid and fellowships, aid to the States, and cooperation with the States in the solution of their public-health problems. The Public Health Service Act, however, did not single out the problem of mental ill health as a subject for special action. This bill does just that. It also follows the traditional pattern of Federal research-including grants-in-aid and fellowships-as developed in the National Institute of Health and in the National Cancer Institute. This bill would apply to the mental health problem the same grant-inaid pattern that was started by the Social Security Act in 1935 for general health service, and that was extended for venereal-disease control in 1938, and for tuberculosis control last year. Your bill, Mr. Chairman, also recognizes the need for Federal aid to medical schools in the training of doctors in the elements of psychiatry, the training of other professional personnel, such as nurses, psychologists, psychiatric social workers, and research personnel, all of whom are necessary if this Nation is to find the causes of and control the mental diseases. The war has brought into sharp focus the full importance of this problem. Late last December, Mr. Justice Byrnes, then Director of War Mobilization and Reconversion, at the depth of the manpower shortage, at the time of the Battle of the Bulge asked me to study and report upon the possibility of salvaging some of the lost manpower that was among the 41⁄2 million rejectees. With the advice of very competent students of the problem we reviewed the Selective Service figures and in that manpower pool, that lost manpower pool of 4%1⁄2 million, we found that 1,600,000 of them had been rejected on account of various types of mental disorders and mental inadequacies. The most frequent cause of rejection have been mental diseases. In fact, mental diseases equal all physical diseases in subtracting from the total vigor, the total fitness of our population. As one example, I want to point out that of all the hospital beds in the United States, more than one-half are occupied by patients with mental diseases, and mental diseases in a stage so severe as to require their legal commitment as insane. The Army and Navy, in spite of the large number of rejections on account of mental conditions, still found it necessary to return to civil life many men disabled, many men who broke down in service because of one or another type of mental disorder. Over and above the measurable results of mental illness as seen among the patients in mental hospitals, there is a much larger number of people who escape the stigma of being mentally sick, but who nevertheless are less healthful, less useful citizens because of what their minds and emotions subtract from their otherwise normal performance: H. R. 2550, is designed to deal with this whole area of mental abnormality. Their causes are probably as diverse as are the causes of physical ailments and disabilities. They are in some cases the direct result of physical conditions. Some types of mental disorder, I repeat, result directly from physical difficulties. One example is the. insanity which accompanies many cases of pellagra, and can be cured promptly by curing that disease. I want to point out also the disease of general paresis, or general paralysis of the insane, which is caused by the inroads of the spirochete of syphilis in the brain and nervous system; also senile dementia results from physical changes, especially in the blood supply to the brain. In other cases mental and physical disease are interrelated. The term "psychosomatic" has been applied to this interrelation of mind and body in causing ill health. It is thought that such a condition, for example, as gastric ulcer is related to the emotional state and is a psychosomatic disorder. In other cases, the mental illness or mental maladjustment seems to be purely psychic. This term, however, may mask our ignorance of the basic biochemistry of the human organism. Other witnesses with much more expertness than I, who claim no competence in this field, will discuss these specific professional problems. I wish to say only that in proportion to the importance of the mental diseases, importance as measured by any yardstock, very little research is being done, very few brilliant minds are at work on this huge problem, almost none of the basic and related fundamental sciences are being brought to bear upon this problem with a view to its solution. Moreover, even the few elementary facts that we have learned about psychiatry, and I use "few" and "elementary" in no disparagement of my psychiatric colleagues, but they are few and elementary in proportion to the total size and total of the unknown in reference to the mental diseases, but even these facts which we now possess are not being well applied, they are not being well taught to most of the current medical graduates. In fact, I would estimate that not more than one-quarter, of our seventy-odd medical schools give their students proper instruction with reference to mental diseases or mental health. It is in this over-all situation, Mr. Chairman, of the lack of research, shortage of trained personnel, of adequate instruction and teaching, of poor care of patients, of public ignorance, that you have proposed this bill. With your permission I should like to attempt to analyze its major provisions, and after doing so, to suggest some minor technical amendments which may clarify further its purpose and authorize more specifically certain administrative actions now implied but not clearly stated. This bill would serve three general purposes: It would foster and aid research relating to the cause, diagnosis, and treatment of neuropsychiatric disorders. It would provide for the training of personnel in various phases of neuropsychiatry, both at the central Federal institute, and elsewhere in the scientific institutions of the country through grants-in-aid. It would assist through grants in the formation and establishment of clinics and treatment centers, for the prevention, diagnosis, and treatment of neuropsychiatric disorders, and would provide for demonstrations, pilot-plant studies, in this field to adduce new knowledge. Referring more specifically to the bill, Mr. Chairman, the title expresses very completely its general purposes. Section 2 Mr. PRIEST. Dr. Parran, would you prefer to finish, or if a question occurs to us during your statement, is it permissible to ask questions at that point? Dr. PARRAN. I shall be glad to be interrupted. Mr. PRIEST. On the question of the title, I have a number of letters. Three or four of them have suggested that in the title the word "neuro" be removed from the title, and it be called "National Psychiatric Institute." I wonder if that suggestion has any merit. Dr. PARRAN. Mr. Chairman, the term "neuropsychiatric" came into use in the last war as a diagnostic title in the medical service. I find great disagreement among the experts as to this term, or the alternative term "psychiatric." In that circumstance I hesitate to express my own lay opinion. From some points of view neuropsychiatric may be considered more limiting than psychiatric, because, as I have indicated, the imbalance in the endocrine system of the body may cause a psychiatric condition, also the defects of the cario vascular system may do the same thing. I have two alternate suggestions for the title of the institute, without expressing an opinion. One would be to call it National Psychiatric Institute. The other would be to call it the National Institute for Mental Health. We, at the Public Health Service, deal primarily with the prevention of disease. I should like to emphasize the preventive aspect of this problem ard hope the committee may consider such a positive approach in deciding upon the title. Mr. PRIEST. Thanks. Dr. PARRAN. Shall I proceed? Mr. PRIEST. Yes; you may proceed. Dr. PARRAN. Section 2 of the act establishes the institute, and sets forth its broad purposes. Mr. BROWN. May I interrupt to ask a question? Dr. PARRAN. Yes. Mr. BROWN. Do you understand that it is the broad purpose to include the establishment of various clinics throughout the country in cities and States? Dr. PARRAN. The purposes include Mr. BROWN. Are you going to authorize research and study in a central place, or is it your idea to establish Federal clinics throughout the Nation for this purpose? Dr. PARRAN. No, Mr. Brown; the bill does not contemplate the establishment of Federal clinics throughout the Nation. I am sure you and other members of the committee are familiar with the National Cancer Institute, in the inception of which you had such a determining part. This bill would do with the field of mental ill health what the Cancer Institute has been attempting to do and has been doing successfully in connection with that great problem. In addition, two other general provisions are contained in this bill, one of which is also authorized in the National Cancer Institute Act, namely, the training of personnel and, second, aid to the States in developing mental health service. I had expected to come to this analysis later, but now is a good time to take it up. Mr. BROWN. Is it your thought the new institute created by this bill would follow very closely the pattern set in the development and administration of the Cancer Institute? Dr. PARRAN. It would, and do other things in addition. Dr. PARRAN. If you will refer to section 7 of the bill, on page 8, you will probably recognize the language contained in that section as being similar to the language which this committee put into the Public Health Service Act of 1944, section 314, and this language, in turn, was taken from the provisions of the Social Security Act and of the National Venereal Disease Control Act. In other words, the type of cooperation and of aid to the States envisioned with reference to the problems of mental disease parallels and is almost identical with the grants-in-aid provisions under which we now aid the States in developing their public health service, and the specific programs like tuberculosis. Mr. BROWN. Section 7 is the implementing power to section 5, is it not? Dr. PARRAN. It is the implementing power of section 2 (j), Mr. Brown. Section 5 deals with the review and approval of research applications, particularly from universities, hospitals, and other institutions, public and private, and with grants-in-aid for training. Section 7 Mr. BROWN. Just a minute, please. Section 5 goes just a little bit further than just providing for a review of research projects and programs. It also deals with the collection of information as to studies Dr. PARRAN. That is correct. Mr. BROWN. And goes on to deal with applications from universities and so forth, and finally with the review of applications from any public or nonprofit institution for grants-in-aid. Dr. PARRAN. I would underscore the words "training and instruction," in that section. Mr. BROWN. Is it your thought that out of this fund will be contributed money by the Federal Government to State and local educational institutions, that is, medical schools, for training? Dr. PARRAN. That is a part of the concept of this bill as I read it. Mr. BROWN. Do we do that now with the Cancer Institute program? Dr. PARRAN. We do, as follows: We give stipends and travel expenses to trainees, for postgraduate training of persons who wish to acquire expertness in the diagnosis and treatment of cancer, and who take such training in one or another university. Mr. BROWN. But the Cancer Institute Act doesn't go as far as this does. Dr. PARRAN. No, that doesn't go as far as this bill does, and I want to emphasize the importance of going further in reference to this problem in aiding the medical institutions, the teaching institutions of the country, both in their undergraduate and postgraduate instruction in matters of mental health. |