all the preventive safeguards, which most of our population takes for granted, is a complex and expensive undertaking. The constant advent of new, sometimes subtle health challenges resulting from our increasingly sophisticated society also requires ever greater emphasis on training health personnel. We have, and we continue to be ready, to accept these challenges but we must have help. This concept of a Federal support grant for basic health services and staffing is of paramount importance in the opinion of the ASTHO. We question the advisability of the unlimited availability of public funds for nonprofit private agencies. This appears to us to be contributing to fragmentation.

We are in complete agreement with the proposed 15 percent of each State's grant being devoted to activities under the mental health authority, and we agree, too, to the requirement that 70 percent of the amounts received be earmarked for health services in communities. We are persuaded of the necessity of a variable in grant allotment which would provide additional funds to low economic areas. But we would impress upon the committee the fact that, irrespective of the affluence of any particular area, an irreducible expenditure is required to provide needed basic health services. And since disease, especially communicable disease, is no respecter of political boundaries, minimum basic public services are needed throughout our Nation.

We respectfully caution the committee, however, on one point, illustrated by the absence of inclusion of a specific amount to be appropriated for this support grant. Rearrangement of mechanisms for granting funds or for their administration can result in limited improvement in the quality of health service programs. Essential, however, to the principal objective is a considerable increase in the level of Federal financial participation. Until the Federal Government bears its legitimate share of these basic programs, we in the States will not be able to realize our long-held aspirations. Until State and local health programs have strong foundations, specific disease and disability problems such as mental health, mental retardation, vaccination assistance, migrant health, tuberculosis, venereal disease, chronic disease, alcoholism, nutrition, family planning, heart disease, cancer, and water and air pollution control programsthese and other programs will not be adequate to the needs of our people.

We wish also to support the provisions for the interchange of trained personnel between the Federal Public Health Service and State and local health agencies. This cross-fertilization would, in our view, be a most beneficial educational experience both to the individual and to the respective organizations. Essential to any true partnership arrangement is a mutual understanding of problems, potentials, and capabilities. As of now, the loan of Federal personnel is possible, an exchange is not. We believe this feature of the bill to be most desirable.

In summary, the ASTHO believes this legislative proposal to be a much needed authority whereby the Federal, State, and local health service agencies can provide to the American people a markedly improved quantity and quality of the health care needed and desired. We urge your favorable consideration.

The CHAIRMAN. Now, Mrs. Fitzhugh W. Boggs, chairman of the Committee on Governmental Affairs, National Association for Retarded Children, Inc.

We are always glad to have you with us.

You may proceed.

STATEMENT OF MRS. FITZHUGH W. BOGGS, CHAIRMAN, COMMITTEE ON GOVERNMENTAL AFFAIRS, NATIONAL ASSOCIATION FOR RETARDED CHILDREN, INC.

Mrs. BOGGS. Thank you very much, Senator.

We appreciate very much indeed your recognition of the impact which this legislation will have on the field of mental retardation.* It is a pleasure to appear here once again.

As you know, we turn up fairly frequently when health or education or mental health or rehabilitation or employment subjects come up, and this means frequently, before your subcommittee.

The reason for this, of course, is that mentally retarded people are affected by each of these kinds of programs, and we have a stake in each of them.

From the point of view of the mentally retarded person, this means that services are and will continue to be somewhat fragmented, because I anticipate that in spite of what is said about being comprehensive, we are only comprehensive in health or comprehensive in education or comprehensive in mental health or rehabilitation, or whatever it is.

So, we, in the field of mental retardation, have had a rather full course in the need for coordination and planning and all this sort of thing.

As a matter of fact, I was glad to hear Under Secretary Cohen refer to the effectiveness of the State planning operations vis-a-vis mental retardation, because this has demonstrated not only the breadth of needs in the area of service to the mentally retarded, but it has also been a good demonstration of the interesting variations among the States in the way they can tackle problems of this kind.

In respect to mental retardation planning, no preconceived notions were established by the Federal Government as to how these plans. ought eventually to turn out to be. The main basic requirement was that all the major agencies that had a stake in this should be involved and included in the process of planning.

Now, as a result of all of this, the States have come forward and are coming forward with a number of plans, each of them with a comprehensive mental retardation plan. Some of these have already been published and are in hand; others will be forthcoming in the next few weeks.

It has become quite apparent to us, as a result of this planning, that there are needs that are urgent in the States and the communities and that the States and communities need encouragement, and they need it now, in terms of what kind of assistance they might reasonably expect, what kind of partnership with the Federal Government they might expect.

They need to begin to know now what this might consist of, so that they can capitalize on the impetus and enthusiasm that has been created by this planning process.

In my opinion, for some of these purposes, next year will be too late. The CHAIRMAN. We ought to start now.

Mrs. BOGGS. I think there are some things that should be done now, and these are logical in the overall development of the Federal program in mental retardation.

Now, you may have thought, and I am sure there are other Members of Congress who may have thought, that the Federal program is very generous in the area of mental retardation. But I think it should be emphasized that something less than 15 percent of what the Federal Government is now putting up in the area of mental retardation does filter down into support and encouragement and assistance for direct services to the retarded, and most of this money that is channeled is channeled through just two agencies.

Now, we did have, as Senator Javits has mentioned, in 1962 a President's Panel on Mental Retardation, and there are a number of recommendations of that Panel which are still unfilled, and they are coming due.

One of the recommendations that was made was that an evaluation should be made by HEW of the gaps in its own authority to carry

forward and implement and assist in the implementation at the State and local level of the spectrum of services that the retarded need. And I have to say that we asked for that evaluation for a couple of years, and when it was not forthcoming, we did it ourselves.

The Secretary's Committee on Mental Retardation does an excellent job in telling you what the Federal Government does do, what the Deaprtment does do, but they are very careful not to mention anything that it does not do or is not able to do.

This analysis on our part led to the conclusion that there are gaps in relation to the promotion of health and health-related services to the retarded.

Now, some of the gaps are related to the construction area, and we believe it would be proper this year to extend and amend Public Law 88-164, and I hope we may have the privilege of presenting our thoughts on this subject to you.

Right now I want to direct attention more particularly to the area of services and the questions raised by S. 3008, which is the subject of this hearing.

Now, I was reminded when I was contemplating this bill, and the processes by which it had been derived, of a wise, little book published in 1908 in England, a guide for the young academic politician, written by a renowned British classical scholar, Prof. F. M. Cornford. With your permission, I would just like to quote a couple of excerpts here.

He defines the parties in academic politics and he says:

A Conservative Liberal is a broadminded man who thinks that something ought to be done, but something which was not done in 1881 to 1882. A Liberal Conservative is a broadminded man who thinks that something ought to be done, and that most things done in 1881 and 1882 ought to be undone. The NonPlackets are people who think that nothing should be done. The Adullamites are dangerous because they know what they want, and that is all the money there is going. They are not refined like classical men, and that is why they succeed in getting all the money there is going. Finally, there are the young men in a hurry. The young man in a hurry is a narrowminded and ridiculously youthful prig who is inexperienced enough to imagine that something might be done before very long, and even to suggest definite things.

We, in NARC, are the young men in a hurry, and we think definite things can and should be done now, and we are prepared to suggest some of them.

I would carry this analogy further by saying it seems to us that the Conservative Liberals and the Liberal Conservatives and the Adullamites have been caucusing, and they have come up with what Cornferd would call a wildcat idea.

Now, "wildcat" is an epithet applicable to persons who bring forward a scheme unanimously agreed upon by experts after 2 years of exhaustive consideration of 35 or more alternative proposals. And we have before us, I think, a "wildcat" proposition in that

sense.

Now the only reason we are raising any questions about this fine bill is that we are not experts, we are merely representatives of what is called in the language of your legislation, "the consumers of services," the people whom all this is supposed to benefit.

From our outside position, not having been in the caucus of the parties concerned with the drafting of this legislation we would respectfully like to make some comments on how we think it might perhaps be still further improved.

Before I do this, I want to make clear that where the mentally retarded are concerned, we have a great variety of services, even within a field such as health.

We have services that can be performed within a generic setting. We have services to individuals. We have services to be performed where groups of individuals are brought together. We have services that are special but are purveyed in a general setting, for example, a special clinic in a hospital. And we have services which may be purveyed within facilities that are called in the language of our present legislation "facilities for the mentally retarded," which means they are constructed primarily for this purpose.

So, we consider that S. 3008, to the extent it may benefit the retarded, would make it possible to contribute to the cost of services in all these categories would make it possible. But in particular, we think that it would be, could be, used to strengthen services which are interwoven with other more general services.

Now you have, I think, received a copy of our formal prepared statement. I would be grateful if we might have this inserted in the record, and then I would just touch on one or two points.

The CHAIRMAN. We will have that appear in full in the record. (The prepared statement of Mrs. Boggs follows:)

PREPARED STATEMENT OF MRS. FITZHUGH W. BOGGS, CHAIRMAN, COMMITTEE ON GOVERNMENTAL AFFAIRS, NATIONAL ASSOCIATION FOR RETARDED CHILDREN, INC.

STATUS OF HEALTH SERVICES FOR THE RETARDED IN THE FRAMEWORK OF COMPREHENSIVE PUBLIC HEALTH SERVICES

Mr. Chairman, the National Association for Retarded Children, which I have the honor to represent here today, is grateful for your invitation to be heard on the proposed Comprehensive Health Planning and Public Health Services Amendments of 1966"-embodied in S. 3008. We appreciate your recognition that the country's mentally retarded children and adults, for whom we speak, have important health needs and hence an important stake in this major revision of the Public Health Service Act. We heartily support the general objectives of S. 3008: "strengthening the leadership and capacities of State health agencies," and broadening and making more flexibile the "support of health services provided people in their communities."

Among these people are the mentally retarded, many of whom have some rather special health needs. We are concerned that in the global approach proposed under this act these mentally retarded people will not receive their fair share of the attention of the health agencies to be aided.

To be specific, the current Federal budget is supposed to obligate close to $8 million for mental retardation activities under section 314 and section 316 of the

present act. This is in addition to $8.5 million annually which the Children's Bureau has been making available to the States for special projects for retarded children under their maternal and child health and crippled children's programs. Both of these amounts are included in a total of slightly more than $300 million which the Department of Health, Education, and Welfare identifies with mental retardation when all agency activity in research, training, construction, income maintenance, prevention, and planning are pulled together. It is significant that, of all funds identified, less than 15 percent is being invested in any kind of direct service to the retarded.

The $8 million first mentioned will, of course, be directly affected by the repeal of the present section 314(c). The maternal and child health and crippled children's programs will certainly be indirectly affected by the proposed "comprehensive" health planning within the States.

As the members of this committee well know the mentally retarded are people, who have needs which in some respects resemble and in other respects differ from those of other people; these needs are apparent in almost every aspect of their lives, affecting their health, their education, their employment opportunities, their

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living arrangements, their leisuretime activities, and their ability to look after themselves and their own interests. Therefore mentally retarded are and must be a special concern of all agencies-Federal, State, and local-with responsibility in health, education, and welfare broadly defined.

We have some specific recommendations, for amendments to S. 3008 which reflect our ideas on how concern for the retarded can be given appropriate emphasis within the field of health. What follows is by way of background for these recommendations.

RESULTS OF STATE COMPREHENSIVE PLANNING IN MENTAL RETARDATION

Responsibility in the field of public health is twofold-to prevent where possible and to identify, treat, and alleviate when prevention has not been effective. Most State departments of health are increasingly contributing significantly to the prevention of mental retardation through a great variety of activities, from emphasis on prenatal care to immunization for measles and control of syphilis and lead poisoning. None of these activities are targeted narrowly on mental retardation. Indeed, they are good examples of public health measures which cannot be "categorized."

A heightened awareness of the implications of mental retardation for health agencies and of the need for intensified effort in prevention has come about in some States as a result of the last 2 years of federally aided comprehensive planning in mental retardation.

With respect to alleviation through available forms of treatment the impact of planning has been less clear. The comprehensive mental retardation planning reports are now being published. The first dozen or so to come in show great variability in recognition of the health and health-related needs of the retarded themselves and the role that health agencies can play in meeting them. Generally speaking, where there was already some interest-some commitment within State government-the recommendations indicate how much more can be done. Where health department efforts have been weak, the voice of need is more often heard but weakly; for, make no mistake, despite what may be said about including "consumers of services" and "nongovernmental organizations" as "advisers" in planning, when a State agency receives a Federal grant for planning, its views (and those of its sister agencies, if represented) are the ones most likely to come through clearly.

By Federal regulation, State health authorities were represented and involved in this planning. To the extent that their involvement may be reflected in continuing interest and thus in incorporation of new emphasis on mental retardation within the comprehensive public health planning, the new legislation may advance the cause of prevention and amelioration of mental retardation and associated chronic disability originating in childhood. To the extent that such prior commitment does not now exist, S. 3008 in its present form would, we feel, tend to perpetuate this neglect.

Most State mental retardation plans, for example, stress the need for early case finding, diagnosis, and evaluation of the young retardate. The recognition of this real need is in no small measure the result of 10 years of consistent effort and support by the Children's Bureau for services of this type. This is why the most significant advance for the retarded which President Johnson could find to pinpoint in his recent health and education message was the establishment of 32 new clinics in the last 3 years. Emphasis in the State mental retardation plans on adapting health services whose values have been demonstrated, such as visiting nurse and homemaker services, speech and hearing therapies, physical therapy, information and referral services, and specialized dental care is erratic, for all age groups. Very little attention indeed is given to the retarded adult, although the larger numbers of mentally retarded who were born in the postwar years are about to pass beyond the legal purview of the Children's Bureau and the State programs it supports. There are two broad modes of service to the retarded the need for which should be recognized here, individual case management, care, and treatment and group care and treatment. It is quite apparent that support and encouragement are needed for both types. Programs of group care on a daily basis (whether day or residential) for children or adults with multiple handicaps so severe as to preclude participation in programs likely to receive support by way of the Elementary and Secondary Education or Vocational Rehabilitation Acts have been initiated in a few States and are being advocated in the State plans of additional States. These retardates have complex physical and sensory as well as emotional disabilities requiring prolonged multidisciplinary care and treatment. Although the numbers of persons requir