At this point, I have a wire from H. A. Carlson, who is scientific director of the Research Council on Problem of Alcohol, of which the executive committee endorses the principles of this bill. Dr. Carlson had hoped he might be here as a witness, and since he is not here today, I would like to insert this telegram at this point in the record. (The telegram is as follows:)

[Telegram]

CHICAGO, ILL., September 17, 1945.

CHAIRMAN, PUBLIC HEALTH SUBCOMMITTEE,
Interstate and Foreign Commerce, House of Representatives,

Washington, D. C.:

The executive committee of the Research Council on the Problem of Alcohol approves the principles and urges the passage of H. R. 2550, as this act will provide some funds for fundamental research, by competent public and private institutions, leading to better understanding of the complex causes of mental ill health, thus rendering the prevention of at least some forms of mental ill health more probable.

Dr. A. J. CARLSON,

Scientific Director, Research Council of the Problem of Alcohol. Mr. PRIEST. Dr. Felix, will you give your full name and your title?

STATEMENT OF DR. ROBERT H. FELIX, CHIEF, DIVISION OF MENTAL HYGIENE, UNITED STATES PUBLIC HEALTH SERVICE

Dr. FELIX. Mr. Chairman, I have a prepared statement which I would like to read, but I would crave the indulgence of the committee to allow me to depart from it at certain points to amplify my statement, particularly in view of some of the questions the gentleman from Ohio has asked this morning, which I will try to answer.

Mr. PRIEST. Very well, Doctor, and we may crave the indulgence of the witness, also, when questions occur to us.

Dr. FELIX. I will be happy to have you do that.

At the beginning of these hearings Dr. Parran analyzed the various provisions of this bill; subsequent witnesses have stressed the need for various phases of this legislation. I propose, therefore, to discuss some of the means which would be used by the Public Health Service to implement the provisions of the bill in the event it becomes law. The responsibilities and functions to be conveyed to the Service under the authority of this bill will follow the familiar pattern established under the National Cancer Institute Act, the Venereal Disease Control Act, and the tuberculosis control legislation. That is, while the primary responsibility for operating and financing services of the public health belongs to the State and local communities to the limit. of their resources, it is the responsibility of the Public Health Service, for the benefit of the whole Nation, to mobilize the collective knowledge of the Nation in matters pertaining to the prevention, diagnosis, and treatment of illness; to make such knowledge available to public health authorities and practitioners of medicine throughout the land, and, as provided by law, to equalize the opportunities of the several States to provide comparable service to their citizens by technical aid and grants.

Mr. BROWN. Just what do you mean by that? That is the thing I have had my eye on all the time.

Dr. FELIX. Mr. Brown, by that I conceive the intent of Congress, in the legislation that has been passed, to be that the several States. should be assisted to meet their immediate needs, or stimulated to develop facilities over and above what they themselves are able to provide.

Mr. BROWN. Will you clarify that a little further? Who is going to define what the immediate needs are?

Dr. FELIX. You are speaking in general terms?

Mr. BROWN. Yes. Who is going to decide what the immediate needs of my county or my State may be?

Dr. FELIX. I think that would depend on finding out what the extent of the problem under consideration would be in your State or county or city, and determining what facilities are now in existence, what it costs to maintain those facilities, what it would cost to maintain minimum facilities above that now in existence, and, estimating: from such standards as per capita income, what could be expected of the community; and, subtracting that from the total, to determine the financial need.

Mr. BROWN. But you are still not answering my question; who is going to make the decision?

Dr. FELIX. I would assume, under the legislation, that decision would be made by the agency authorized by Congress to provide. this aid.

Mr. BROWN. It is your idea the Public Health Service would. decide, under this law, whether or not the State of Ohio has sufficient facilities to care for mental cases, or whether any community of the State may have sufficient facilities to care for such mental cases; and if, in your wisdom, you decide that the State or community does not have the facilities you think it should have, then if you. can't through persuasion get the State or local community to spend. the money to build and operate those facilities, the Public Health Service of the United States should?

Dr. FELIX. I don't believe I would go as far as you have stated it, Mr. Brown. I am speaking for myself now. I don't believe that it is the responsibility of the Federal Government to subsidize those facilities in a State which it is the responsibility of the State itself to maintain. I am thinking, when I speak of that, of mental hospitals.. As I shall indicate later on in my testimony, there is a need for outpatient clinics in order to treat individuals before they reach the point where they must avail themselves of such asylum as is provided. If it would assist to stimulate the States to provide those out-patient facilities, I think it is proper for the Federal Government to contribute a certain amount of money. I do not think the Federal Government should subsidize beds in mental hospitals, Mr. Brown.

Mr. PRIEST. Will the gentleman yield for one further question at that point? Referring to the original question asked by Mr. Brown, that if the facilities in the State of Ohio were deemed inadequate and a grant-in-aid, either for the city of Cleveland or some hospital or institution in the State, if it is requested, the initiation of such request and the determination of whether the facilities were adequate would come largely from the local authorities in the Public Health. Service?

Dr. FELIX. Yes, sir.

Dr. THOMPSON. I think we would depend largely on the local authorities. We are not going to determine all these problems ourselves.

Mr. PRIEST. Thank you, Dr. Thompson.

Mr. BROWN. There are many local communities, perhaps even some in my State, that would very quickly and very readily ask for aid if they thought they could get it from the Federal Government and wouldn't have to pay for it out of their own pocket. That is, for a hospital or anything else they might want, because a lot of our citizens are very short-sighted and don't seem to realize that when the Federal Government spends the money it costs them just as much, if not a little more, as when the local government spends the money, and that they have to pay for it in the end, anyhow. That is the point I raise on this bill, as to how far we are going. We have got to have a dividing line somewhere. I don't want to get another agency of the Government established to go in and take over and assume the responsibilities of the State and local communities. I think the Federal Government does have certain definite responsibilities in connection with this problem. We have a responsibility in research; we have responsibility in giving expert advice and aid and assistance, and perhaps furnishing facilities for the education of postgraduate students; but I want to get away from the idea and I don't want to endorse a bill that provides-that the Federal Government shall go in and run the hospitals of Ohio, Tennessee, or any other State. As I said earlier, I am not fearful of what this present administration of the Public Health Service might do, but I have seen a lot of things happen in 30 years of public service. Men get strange ideas; they get hobbies, and they decide the only way in the world they are going to solve all the problems of mankind is to do a certain thing, and that their field is the most important. And the man in this field or any other field of endeavor that doesn't think his field is as important, if not more so, than any other endeavor, is not worth much. I realize that, and appreciate it, and yet, here we are sitting, as Members of Congress, trying to decide between the wishes and endeavors of many different people.

Dr. THOMPSON. Mr. Chairman, I think if Dr. Parran were here he would tell you he would welcome the advice of your committee in putting into the bill language that would accomplish what Mr. Brown is thinking about. That is our purpose, no question about it.

Mr. BROWN. There is no difference of opinion between Dr. Parran and myself, so far as I can ascertain from conversations we have had, but I still want to write safeguards into the law. I don't want somebody else to decide, later on, what they can do under this act.

Dr. FELIX. I am sure, Mr. Brown, as an individual who would bear some of the responsibility of administering this act, I would welcome having it sufficiently clarified.

Mr. PRIEST. All right, Dr. Felix; go ahead with your statement. Dr. FELIX. To implement this responsibility, with regard to research in the field of mental health, this bill wisely provides for the creation of a national institute dedicated to this problem. It will be one of the first obligations of the Service, if this legislation is passed, to organize this research institute. It would seem essential, even before the cornerstone of the physical property were laid, that key personnel, including the research director and principal members of

the staff, be employed in order to aid and assist in the planning of the facilities and the subsequent operation of the institute.

Physically, the institute must consist of clinical facilities adequate to accommodate patients needed for clinical research and special laboratories for all disciplines bearing upon the problem.

Another responsibility is to aid the States, upon request, in the planning and organization of mental-health services. In so doing, the methods which have been found successful in various communities can be quickly and efficiently applied to any community within the Nation, thereby making it possible for even the smallest community to profit by the experience of others. The Service would employ a staff of skilled personnel which would be available to States and local communities for consultation and advice in organizing and improving services for the prevention, diagnoses, and treatment of mental illnesses.

The Public Health Service would foster standardization and simplification of clinical and research information, in order that valuable statistical analyses might be made defining problems and indicating trends in all sections of the country.

The selection of individuals to be trained for employment in State or local jurisdiction facilities would be the responsibility of the various States. The Public Health Service, however, with the advice of the National Advisory Mental Health Council, would award Federal fellowships for research at the institute or elsewhere. In this manner

the most outstanding men in the various fields would become available for appointment to the institute and for loan to or employment by medical schools, universities, and other institutions for teaching and research.

It was not until the words "syphilis" and "gonorrhea" became printable and acceptable as part of a radio script that any significant advances could be made in the control of the venereal diseases. A situation which serves as a comparable obstacle to the advancement of the early diagnosis and treatment of the mentally ill exists today because of the stigma associated with mental illness in the minds of the laity and, unfortunately, in the minds of many physicians as well. Only when the public has a better understanding of the nature of mental and nervous disorders will service be made of the psychiatric services to be provided by means of this legislation. It would be one of the responsibilities of the Service, therefore, to foster the spread of authentic information pertaining to mental illness for the use of the press, schools, civic organizations, and the like.

Professional education can likewise be stimulated through the media of training courses, publications, training aids, and library services. Since the establishment of the Mental Hygiene Division of the United States Public Health Service in 1930, the Service has received requests for consultation services, loan of personnel and some funds to assist various States, counties, and local organizations in establishing better mental health practices in their localities. The war has focused the attention of the public and responsible organizations on the great need for more and better health-treatment facilities. As a result, the number of requests received by the Service for assistance has materially increased during the past 2 years. The Public Health Service has on file requests seeking assistance for out-patient clinical facilities. Universities have asked for help in training and research programs. So far we have been unable to render these services

because of limitation in authority and appropriation. If this legislation is enacted the Service can take constructive action on such projects, provided they are found to have merit and appropriations are available.

This legislation contemplates the extension of as nearly uniform mental health services throughout the Nation as it may be possible to achieve. This implies an obligation on the Public Health Service to fully inform itself of the existing needs and resources. Although some very excellent surveys of certain aspects of the problem have been made, there has been no single over-all evaluation of the Nation's needs. Furthermore, due to the war, surveys of the type presently needed to implement a program were discontinued. The most recent data available which might be applicable to peacetime conditions was obtained in 1940. The Nation is now in a state of flux. Significant shifts in the population are under way. Medical facilities, both clinical and teaching, are undergoing readjustment, so that the material gathered 5 years ago is not completely pertinent to the problem at hand.

Surveys of the States, counties, district, and other political subdivisions and nonprofit agencies in the States are necessary to determine the adequacy of the facilities, including personnel for the prevention, diagnosis, and treatment of mental illness. There must be in addition a survey of the existing and potential facilities for training all categories of personnel needed in the mental health field. The latter survey can be done in a relatively short period of time and should be given priority, since it is essential to accurate initial planning of the early phases of the total program. For example, it must be determined how many additional residents in psychiatry can be trained in the existing facilities. It must be determined which facilities not now training psychiatric residents can be utilized for this purpose. The same procedure applies to the allied fields which are concerned in the over-all program, such as, for instance, clinical psychology, psychiatric nursing, the therapeutic aids, psychiatric social services and the vast army of attendants working in mental institutions.

In order that the research to be undertaken at the Institute may be coordinated with existing or contemplated projects elsewhere, a survey of research facilities must be made to determine the nature of the problems now being investigated. Furthermore, there are a large number of institutions where vast amounts of clinical material are available which could well be utilized in additional research. The survey would attempt to discover which of these institutions desire to undertake research through Federal aid.

According to the latest available information there is provided in the entire United States only approximately one-fifth of the minimum of clinic hours estimated by the National Committee for Mental Hygiene as essential to meet the needs of the country. As Dr. Stevenson stated in his testimony, these are contemplated in cities having a population of 150,000 or more in 35 States One of the first objectives would be to assist, through grants, the organization and operation of treatment facilities of this nature in communities not already served by such a center.

At this point, Mr. Chairman, I would like to submit for the record two tables which will illustrate what I have said.

Mr. PRIEST. They may be made a part of the record.

(The tables referred to are as follows:)