Also if we merely continue to build more institutions to care for those people, even though they are better fed, this will not solve the problem that we face.

I think another point I would like to emphasize is that there is a great need for more professional manpower, psychiatrists, psychologists, social workers, and nurses, as well as trained research personnel.

Next, we have concerned ourselves with the problem of psychiatric services in State hospitals which badly need improvement. Those services would save a great deal of money to people if the patients were given intensive and early treatment.

Also we need some help for institutions where the mentally subnormal are cared for.

There is also a need for more concentrated use of the newer therapeutic tools than are available.

We need more scientific advances, we need more incentive to get the mentally ill person back to a useful life and become self-supporting. Moreover, we need more concentrated attention directed toward this field of prevention, control, and public education.

I think I speak for all the members of this panel of experts when I say we thank your committee for this kind opportunity to come before

you.

We could go on for days, we realize, but we are mindful of your time and have tried to boil this material down to the smallest common denominator of fact and prospect.

Also to some of you, and I am sure to many of us in this room we may have, perhaps, in some places, oversimplified some of these problems. We did so in the service of clarity lest we get into professional jargon.

The problems we discussed are a little more difficult than some of us have intimated in our short statements today.

I thought I would like to make this short statement in the interest of briefing the hearing this morning.

Dr. STEVENSON. I would like, on behalf of the whole committee to express our appreciation to all of the members of the committee for the interest taken in this matter by the members of the committee on Interstate and Foreign Commerce of the House of Representatives. The CHAIRMAN. Thank you.

Mr. HESELTON. Mr. Chairman.

The CHAIRMAN. Mr. Heselton.

Mr. HESELTON. There is one point that has been in my mind in these hearings as we have gone along, and I think every panel of expert witnesses has stressed this. We see the need of more adequate appropriations. That is one matter. The other is the need of more trained personnel. I do not know what the total figures are today, but I imagine they would run into the thousands and thousands. That raises the question in my mind about what can this committee do in that field, and what can Congress do in that field.

Are there enough young people who want to be trained, but who cannot be trained, or is it a matter of stimulating interest among young people who can do it.

Dr. WORTIS. I think Dr. Felix has a statement on that.

Dr. FELIX. As regards the manpower situation there are people who want to be trained, but who cannot be because the training facilities

are overloaded. You will find some training facilities where they may be able to accommodate 1 or 2 more students.

On this point of overloading, 1 instance comes to my mind of 1 institution that has facilities for training 15 people at a time, but had applications from 200, and they were faced with the job of selecting out of that number 15 whom they felt to be the most apt.

So, there are people who can be trained if the facilities permit it, but a professor or a teacher can only effectively teach a certain number of students, because we who sit here, and our colleagues over the country represent not a production line kind of manufacturing, but a hand job, a Swiss watch kind of a job, if you will. We cannot do it en masse. We have to do it, to a great extent, by the preceptor system, where we have constant access to our students and where they can ask many, many questions.

This is the reason that we find more people, I believe, who want to go into this work than there are facilities with which to do the job.

Mr. SCHLAIFER. I think in addition to that, I am of the opinion that if anything is going to really happen in this field, and if we are going to do something about the problem, that it will not be done until there is interest on the part of lay people, professional people, and the interest of Federal and State Governments and the general public, and I hope that you gentlemen in your wisdom, or judgment, after these hearings will be able to come out with some results that will be sort of a clarion call to the entire public and all of the groups to bring it all together in this field.

Mr. HESELTON. I have in front of me one of the volumes of the Report of the President's Commission on Health Needs of the United States in 1951, and I would like to read a couple of sentences with reference to personnel which is required, the first one of which is: Medical schools have between 200 and 500 unfilled faculty positions, mostly physicians.

Also:

To bring these figures up to standard for clinical departments alone would require the equivalent of 600 full-time physicians.

So there will be a shortage at least for the immediate future, as you do not educate physicians overnight.

The CHAIRMAN. Does that report set forth whether the deficiency is due to a lack of interest upon the part of those who could or should become teachers?

Mr. HESELTON. I have not found that, Mr. Chairman.

The CHAIRMAN. Or is it due to insufficient funds?

Mr. HESELTON. I do not happen to have an answer to either one of those questions.

Dr. WORTIS. May some of us comment about this point which has been made by Mr. Heselton.

I am a teacher in a medical school in the department of psychiatry at New York University and my colleague to the left, Dr. Braceland, has been dean of a medical school.

The medical schools of the country today need money.

It costs a good deal to educate a physician. It is different compared to a medical education in other parts of the world.

I have been over on teaching missions to Austria, Hungary, Finland, and Poland while we were still allowed to go in there. I have been very much impressed by the fact that the American student or the American citizen trained in American medicine is trained in a remarkable type of education.

We do not take those people into the first year class and let them go whether they sink or float because we are not interested in them very much.

We are very much interested in training people and giving them the best possible training, and this is extremely expensive.

The medical schools have the same economic problems that industry has. The funds that they have available for teaching do not pay for the medical education which is given to the students. It costs approximately $2,800 a year to educate a doctor throughout each year of his medical training, and the tuition he pays to the school, whether it is $300 or $500, in some States supported by State funds, or in some private institution, the kind of which I belong to, where they pay $800 a year tuition nowhere nearly pays for the training they get.

This field has been helped first because of Federal funds being made available for the training of physicians which will reflect itself in better care of the citizens of the United States.

Dr. SANFORD. On the question of manpower shortage there is one important factor that I should like to mention, and that is this recent change in selective service procedures whereby postponements from induction into the service are no longer given to any students in scientific fields. It is a matter of great concern that the Government should spend money through the Public Health Service and other sources for the support of scientific and technical educational and then have another branch of the Government come along and cut it off before that education is completed rather than having a postponement of that student's induction.

The CHAIRMAN. That point is very well made.

Dr. BRACELAND. The Federal money which has been coming to medical schools has come to them with no strings attached to it, and it has been accepted very gladly by the deans and has been utilized to the very best of their ability.

I might say we are particularly fortunate in psychiatry that we can talk freely, without the question of cost of mental diseases in it because in 1773 nobody wanted patients with mental disease. Nobody else was interested in them, and they all wanted the States and the Federal Government to take care of them. So we have been able to talk rather freely because we are outside of the pale. If this were not done by the States and the Federal Government it would not be done. Now, without confusing the other groups who have helped with research, I am talking simply about the care of the mentally sick. The CHAIRMAN. Are there any further comments?

Dr. BLAIN. I would like to say that there is one method by which we can pull ourselves up by our boot straps, which is still important in the personnel situation that has to do with further investigation and administrative practices all down the line. What I am thinking is possibly our national authorities, and particularly the National Institute of Mental Health be encouraged one way or the other to have more money available to make such studies.

In one State in which I personally made a survey about the utilization of manpower it was generally agreed that they were not making the best use of the people that we did have.

We could improve our service I believe 10, 15, or 20 percent by better administrative practices.

There are some researches going on as to the actual time being spent by people working in certain wards.

Informally in mental research we need to see whether all those people are using their valuable time properly.

One major factor in this whole personnel matter throughout the country lies, I believe, in the general principle of the pyramid with the most highly trained people being at the top or the apex of the pyramid, that they can be taught to delegate a certain amount of their wisdom and authority to people who are slightly less trained, who will, in turn, delegate it to those slightly less trained below them, and then you get on down to the vast reserve of those available citizens in the communities and others who can be used.

I would suggest that a lot of effort should be made into looking into that field.

1

The CHAIRMAN. We feel greatly indebted to you gentlemen for your appearance here today. You have made a very real contribution to the work of this committee.

Last night, in speaking of the work of this committee, I stated that I wished people generally could appreciate the extent to which research is being carried on by distinguished doctors and laymen who are interested in promoting public health, who are not doing it because of any financial return that will come to them which would adequately compensate for the time and effort that is put forth, but who are doing it solely and entirely because of their very great desire to be of help to their fellow men.

That has been one of the most encouraging elements of these hearings that we have held, to see the vast number of individuals who are distinguished in their particular activity who are working in behalf of their fellow men.

We feel greatly indebted that so many of these people, including yourselves today, have come before this committee and given of your knowledge and of your experience to this committee, and it is my hope that the committee will be able to do something that is commensurate with the fine effort that has been put forth by those who have appeared before us as witnesses.

This summary and recommendations on training and research in State mental-health programs will be included in the record at this point.

(The matter referred to is as follows:)

TRAINING AND RESEARCH IN STATE MENTAL HEALTH PROGRAMS-SUMMARY AND RECOMMENDATIONS

By the Council of State Governments, Chicago, Ill.

THE RESPONSIBILITY OF THE STATES IN THE FIELD OF MENTAL HEALTH

1. The field of mental health has broadened rapidly in recent years. Care and treatment of the severely psychotic and the mentally deficient in State institutions remain as important as they ever were, but action for mental health no longer is confined to the hospitals. Concern is growing for the mentally ill

who do not require hospitalization. Important efforts are being made toward early recognition and treatment of all mental illnesses-in mental health clinics, child guidance centers, schools, welfare agencies and other community institutions. New emphasis is being placed on development of measures aimed at prevention of mental illness, through biological, psychological and social research and through public education.

In view of those facts, the States have a widening responsibility for the promotion of mental health both inside and beyond the State hospitals.

Each State, therefore, should appraise the breadth and adequacy of its entire present mental health program in the light of future needs and, within the limits of its resources, assume necessary additional responsibilities for the early recognition, treatment, and prevention of mental illness.

2. Care and treatment by existing methods alone, however, are not sufficient to cope with mental illness. Better treatments and more positive means of prevention are needed, and also a larger number of persons competently trained to put them into effect. Training and research are primary hopes for eventual reduction of admissions to mental hospitals. In addition, immediate benefits accrue to institutions engaged in training and research activities because competent staff can more readily be obtained and retained under these conditions. Mental health training and research programs, accordingly, should be encouraged and supported by the States, and specific appropriations should be made for them.

ORGANIZATION AND ADMINISTRATION

3. The administration of training and research programs in most States is unsystematic and uncoordinated. Although it is impractical to unify the administration of all State agencies concerned with mental health (hospitals, correctional institutions, public schools, university laboratories, public and mental health authorities, etc.) under one department of State government, increased integration and coordination of their programs is feasible and desirable.

It is recommended that a position of director of training and research be established within the mental health agency in each State to assume responsibility for the coordination of mental health training and research within the State's jurisdiction. It is recommended further that, where possible, regular meetings of the heads of all State agencies concerned with mental health be held for the purpose of integrating their efforts. A technical advisory committee, composed of scientists and educators in the field of mental health, should be established in each State to advise and assist the mental health agency and other State departments concerned in the coordination of training and research activities.

The advisory committee should include qualified representatives of the State hospital system, institutions of higher education in the State and such other private and public agencies as are involved in training and research efforts. The committee should be of the highest technical competence, and thus command the respect of scientists and the public generally. To insure continuity its members should be appointed for specific terms on a staggered basis.

In regular consultation with the advisory committee, the director of mental health training and research should recommend the allocation of appropriate funds for training and research, facilitate arrangements between State hospitals and teaching institutions for internship and affiliate training, cooperate in interstate agreements for professional training, assist individual hospitals and other institutions in establishing training and research activities, secure information on research projects in his own and other States, and participate in an interstate clearinghouse for mental health training and research.

4. Present lack of communication and coordination among State hospitals, universities, professional schools and community agencies makes procurement of staff for hospitals more difficult than it need be, isolates hospitals from the main streams of research activity, prevents maximum improvement in the quality of training and results in duplication of effort and equipment.

The States should encourage their mental hospitals and clinics to affiliate with teaching centers in order to encourage greater participation of State hospitals in field training and internship in the biological and social sciences. Through joint university-hospital staff appointments and other means members of university faculties should be encouraged to originate and participate in research in State mental hospitals. The State mental health advisory committee can be active in promoting close communication between hospitals and teaching centers. 5. One of the important obstacles to adequate evaluation of procedures and therapies is the lack of uniformity in statistical methods in mental hospitals