themselves with the needs of the surrounding community, providing services to individuals after they leave the hospital as well as providing services for the purpose of preventing hospitalization. Let there be professional consultation to the schools and other public and private agencies that deal with individuals who may have emotional difficulties of one kind or another. Who finances and administers this unit is of secondary importance. That it exists where needed is of primary importance. No one governmental source can bear the sole responsibility. Federal-State-local partnership, with formulas based upon revenue resources, is a must for the future.

THE ROLE OF PRIVATE ENTERPRISE

These bills being considered by the committee are the only health bills, to the knowledge of the witness, which have the full and complete endorsement of the American Medical Association. The medical association recognizes what we have demonstrated in California and other States; namely, that with the development of Government sponsored and financed programs for the mentally ill and mentally retarded the feasibility of treatment and rehabilitation can be demonstrated, and this encourages the private sector of medicine to increase its activities in this field. This is one Government expenditure which we recognize as being an investment to help get the Government out of the health service business and to encourage organized medicine to accept greater and greater responsibility. Even now, health insurance companies are considering the inclusion of mental disorders in their health coverage plans, and already millions of people are covered by health insurance which includes assistance for mental disorders.

In California, we are proceeding as rapidly as possible to develop broad spectrum services of the nature described. Without the stimulus of Federal assistance at this time, progress will be tortuously and agonizingly slow. We have a long-range plan which establishes a medically and fiscally sound mental health program to meet the requirements of a State growing at the rate of almost a million new people a year. The plan adheres to the widely accepted psychiatric concept that adequate "treatment should be available as early as possible, as continuously as possible, with as little dislocation as possible, and with as much social restoration as posible." We anticipate that the reponsibility for the treatment of mental illness and retardation will be the same as in other diseases, resting first with the patient, his family, and his local doctor. Government mental health services will backstop private mental health resources, taking care of individuals who cannot be assisted privately.

CONCLUSION

Gentlemen, concern for the mentally ill and mentally retarded is now deeply rooted in the public conscience. This concern has resulted in steadily increasing expenditures for mental health programs, both State and local. The private sector of medicine is beginning to accept greater responsibility for providing psychiatric services. State and local governments, for the most part, have extended themselves as far as they dare and still remain solvent. Their willingness to do

this is based upon recognition that the restoration of health to thousands of our citizens is a sound investment. We now call upon you as we reach the threshold of success to give us the assistance to keep going at the accelerated rate necessary to overcome the long years of inertia. The fate of thousands lies in your hands. Please don't let them down.

Thank you very much.

Mr. ROBERTS. Thank you, Dr. Lieberman, for a very fine statement. I have some questions I would like to ask, but the hour is getting late, and I have other very important witnesses that I want to hear from. So I am not going to say anything except to commend you on a job well done. We appreciate your coming this long distance to give us the benefit of your fine experience, and I appreciate the help that you have given our committee on these important matters. The gentleman from New York.

Mr. O'BRIEN. I would like to say that I compliment the doctor and the State of California.

Mr. ROBERTS. The gentleman from Minnesota.

Mr. NELSEN. Just to thank the gentleman for the statement.

I am sure that you can go back in good conscience and tell the folks back home that your Congressman is a good salesman for his State. You have made a very fine statement.

Thank you.

Dr. LIEBERMAN. Thank you.

Mr. ROBERTS. Our next witness is Jack R. Ewalt, Director, Joint Commission on Mental Illness and Health.

Dr. Ewalt, I know you have done great work in this field. You have been associated with it for a long time. I am sorry to be so long getting to you as a witness, but I hope you will understand that we have a very crowded schedule.

STATEMENT OF JACK R. EWALT, M.D., DIRECTOR, JOINT COMMISSION ON MENTAL ILLNESS AND HEALTH; BULLARD PROFESSOR OF PSYCHIATRY, HARVARD UNIVERSITY; SUPERINTENDENT, MASSACHUSETTS MENTAL HEALTH CENTER

Dr. EWALT. I am pleased to be here and have this opportunity. I feel that everybody who has spoken today has been espousing my cause. In 1955 this very committee, I believe, first heard Congressman Priest on the Mental Health Act of 1955 (H.J. Res. 256) which started the study on which these proposed acts are based. Congress authorized a committee made up of national organizations to conduct a study and to make recommendations. There were 36 such associations with such diverse representation as the American Medical Association, the American Legion, the American Educational Association, and the American Hospital Association; quite a mixed group. But they all worked amiably on this study. They each sent representatives to form the Commission, and I was privileged to be the Director. We published the results of our study in eight books, plus the final volume, "Action for Mental Health," on which this legislation is based.

I won't repeat the recommendations here, because I want to be very brief. The theme that ran through the testimony you heard today

was that if one of our citizens becomes ill or retarded or finds himself becoming so, if he is to get adequate care under today's practices, he must know the facilities in his State and what the laws and regulations are, and then regulate his illness precisely to those needs, otherwise he receives inadequate care. If he gets a little bit sick his family doctor can treat him, or his clergyman can give him counsel. If he is a little bit sicker and needs part-time hospital care he is just out of luck, he must get sick enough so that he can qualify as a bona fide mental patient or mentally retarded person. But then his troubles aren't over, he needs to go to court, in some cases waiting in jail for his turn. He is then taken by a court officer into a hospital with expenses for his relatives to meet, or to an institution which has too much business.

In many cases he will be placed in an institution in which one bed may be so close to the next that you can ride a bicycle across them and never hit the floor. These places are staffed by employees who are heroes in a quite desperate sort of way. You really wouldn't care to visit in some of these places because of the conditions. We find the superintendents of these hospitals being called inefficient anad ineffective, often by other hospital administrators who run hospitals which are spending $30 a day or more to care for a patient, without providing the cost of the physicians fee, and our poor inefficient administrator is supposed to provide all care plus medical care and food for somewhere between $3 and $5 a day. We need to go to a new system. The old one is not getting the job done. These bills, House 3688 and 3689 will provide care for patients when they need it without a long wait-where they need it; that is, near their home, and of the amount needed.

They can be outpatients, part-time patients, full-time patients, according to their needs. This bill furthermore provides that the initiative for planning and saying they want such a unit comes from the local community. For the most part, these will be in regular medical facilities, but you can use facilities as the bill is now written. I don't care much for some of the amendments offered today, I like the bill as it stands as being most likely to get the job done.

The bills also provide that the Federal Government will aid in planning if the community asks for it. They will aid in stimulating the start of these community centers, but the final decision for running them and paying for them remains in the local community.

Now, we know that Federal stimulation in these programs originally came from this committee in the Mental Health Act, establishing the Institutes of Health. A bit later you provided a program for the National Institute of Mental Health to give some aid to States. At the time you appropriated the first $3 million, the States were spending less than a million dollars a year in total on their community mental health programs. This current year the States are spending more than $100 million of their own State and local money, principally stimulated by your action.

We will make a tremendous step forward in the mental health of our Nation and in improved care for the citizens of our Nation if this bill is enacted. I speak on behalf of my colleagues on the Commission, all of whom now have gone back to their own jobs. We represented organizations with many millions of members. We beseech you to pass this bill.

Thank you.

(The statement of Dr. Ewalt is as follows:)

STATEMENT OF JACK R. EWALT, M.D., DIRECTOR, JOINT COMMISSION ON MENTAL ILLNESS AND HEALTH; BULLARD PROFESSOR OF PSYCHIATRY, HARVARD UNIVERSITY; SUPERINTENDENT, MASSACHUSETTS MENTAL HEALTH CENTER

The implementation of the program authorized by H.R. 3688 would be another major advance toward solving one of our major health problems. The groundwork was laid for this act when the Congress enacted (and by unanimous vote) the mental health act of 19551 which authorized a study of the services for the mentally ill of the Nation, and directed that a report and recommendation for action be made to the Congress, the Governors of the States, and certain agencies of the executive branch of the Government at National, State, and local levels.

Thirty-six professional and citizens' groups joined forces to establish the Joint Commission on Mental Illness and Health, and each organization selected one or more representatives to be members of the Commission. To the Commission was assigned the task of conducting the survey and making recommendations for action. The details of the report are in eight books. A summary of the studies plus the recommendations for services to our citizens suffering from mental illness were published in 1961 in a book titled "Action for Mental Health." The Council of State Governments, the American Psychiatric Association, the American Medical Association, the American Orthopsychiatric Association, the National Association for Mental Health plus many others devoted special meetings to studying the report.

The studies revealed a variety of services to our mentally ill persons, but services shamefully inadequate in kind and distribution. As one example of the irrational organization of services in some places I will present the plight of a hypothetical patient. A citizen becoming tense and upset over some personal problem or because of some disease must have his illness in exactly correct amounts and severity if he is to be adequately served, and these amounts must be corrected for the resources available in his town. If he can confine his symptoms to mild discontent and anxiety, his family physician may prescribe a sedative or tranquilizer, and his physician or minister give counsel. If a psychiatrist is available in his town, and has time to see him, our hypothetical patient can allow himself a few more serious symptoms, but he must not show behavior that will irritate or frighten his fellow citizens. If our patient is too ill or too troubled to confine his symptoms to either of these categories, but in fact needs hospital care for a few hours daily on some days he is out of luck. He must be sick enough to require hospital based treatment 24 hours per day every day. Why? Because the laws and regulations and policies of most hospitals, and especially mental hospitals, require that the patient adapt his symptoms to the hospital policies and rules (i.e., that he be sick enough to be confined all the time or be well enough to stay out). Our patient cannot regulate the nature and severity of his illness nor can be know the policies of his local hospital. But if his symptoms and his need for care do not conform to hospital policy and rules he will need to become more seriously ill or socially disruptive so he may qualify as a mental patient. Further, in many areas of the country, having allowed his illness to progress so he can qualify as a bona fide mental patient, he must now travel some distance from home to a large, overcrowded, understaffed institution called a mental hospital. He will find in most instances too many patients and too few employees, all trying to do the best they can with what they have. He may live in surrroundings more terrible than you can imagine. Beds may be so close together that you can ride a bicyclefrom one bed to another, beds entered by patients by climbing over the foot (and this, gentlemen, has none of the desirable features of "togetherness" espoused by some of our sociologist colleagues).

He will find the hospital employees for the most part devoted people, heroes in a quiet, desperate sort of way in my opinion. He will find a superintendent who is accused of being inefficient and ineffective for giving such poor care. Some superintendents are ineffective, but many do wonders with the money and resources they do have. And some of the persons who call the superintendent inefficient and lacking in business methods are those who operate hospitals in which the cost of caring for a patient is $30 or more per day, plus the phy1 Public Law 182, 84th Cong., ch. 417, 1st sess., H.J. Res. 256.

sicians' fees, and the mental hospital superintendent, poor, unbusinesslike person he is reputed to be, spends from $2.50 to $5 per day caring for his patients and this sum must include the physicians' pay, not only for ordinary medical and surgical treatment of our patient, but also for treatment of the mental illness. Our hypothetical patient is fortunate indeed if he avoids any substantial part of this story.

The care of the mentally ill is a disgrace. To allow such conditions to exist challenges the very concept of democracy. Plans must be made to rectify this situation.

The President read "Action for Mental Health," the report of the Joint Commission on Mental Illness and Health, as did many Members of Congress and many Governors (about 24,000 copies were purchased by citizens). The 87th Congress made money available to plan services needed in communities. Several States have started plans, and some States have initiated portions of a new program like that envisioned in "Action for Mental Health." All States need assistance in planning and initiating the new services.

The President appointed a Cabinet level committee to study the report and to recommend what further roles should be taken by the Federal Government in coping with the mental health of our citizens. The President's message of February 7 recommends plans formulated by the President's study group on mental health, and plans prepared by a special committee on mental retardation. These actions by Congress, a citizens' study group, and the President provide the background for H.R. 3688 which has important features that deserve emphasis, features with origins in the joint commission report and in the President's message.

The basic theme in H.R. 3688 is that services for all types of mental illness will be available when needed and in the patient's home community. The service will be as much needed but no more. For example, a patient needing 3 to 6 hours of daily treatment available in a hospital will not be required to spend 24 hours per day in the hospital to obtain these treatments as is now the case, except in a few places.

Preventive programs will be directed to the medical and social causes of mental illness and retardation. These programs of prevention, treatment and rehabilitation will be planned by each community to make maximum use of existing facilities, and to expedite the creation of additional ones needed within the health and medical facilities and resources of each community.

The Federal program is to be confined to the stimulation and facilitation of adequate plans by the communities, aid in financing construction of mental health centers, and assistance in initial staffing of the mental health centers. H.R. 3688 recommends a large amount of assistance at the beginning of the program, with a formula for decreasing the Federal share of support, and with local and State support assuming the total burden within 5-years of the opening of each mental health center.

Thus we have the desirable features of planning and operation at the local and State levels, with the Federal Government offering assistance in financing the planning and services needed in each community, and assistance in starting the program.

The Congress should be proud of its role in initiating this survey of our citizens' needs; and being informed of the shameful neglect and economic waste caused by inadequate plans and services. Congress now contemplates enactment of H.R. 3688 which if placed in full operation would represent a major step toward correcting this inequity suffered by our citizens who are, or who may become, the victims of mental illness.

6

On behalf of the staff and members of the Joint Commission on Mental Illness and Health—a study group formed by organizations with a membership totaling several million- I respectfully recommend and request enactment of H.R. 3688. Mr. ROBERTS. Thank you, Doctor.

I appreciate your reference to Mr. Priest, late chairman of this committee. I had the privilege of serving with him at the time that he was the chairman of the Subcommittee on Health and Science, which later became the Subcommittee on Health and Safety, and now is known as the Subcommittee on Public Health and Safety. It was my privilege to support him in his efforts to set up the study you referred to. And I congratulate you on the fine job that you have done. I