mental health centers. The authorization of appropriation for the 5 years of the bill's duration is not specified. This matter is left to the good judgment of Congress in hopes that with a need so unmet they will be as liberal as possible.

The innovation and radical departure contained in the bill, of course, is not solely the fact of construction, but also the fact of construction at the community level. The near barbarian practice of exorcising the mentally sick person to a State institution, miles from home and usually even farther from recovery, would be abandoned. And, in case if any advocates did remain for this form of public institution and treatment up until 1962, certainly the report of the Joint Commission on Mental Illness and Health filed with Congress in that year must have proved to them that here was an unmodified black mark on our national conscience. As I recall some of the counts of indictment were these: more than one-half of mentally ill patients in public hospitals receive no active treatment of any kind to improve their condition: only 20 percent of these hospitals have instituted therapeutic reforms in line with modern trends; in contrast to a general hospital where $31.16 is spent on a patient, $4.44 is spent in a mental hospital per day: little, and usually no, research is done in these hospitals; and, finally, only 29 percent of the Nation's 277 such institutions have ever received approval from the Joint Commission on Accreditation of Hospitals.

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Maybe to further bolster my case, I should use the experience of my home State of New York as an example of how quickly progress be effected with funds and interest. New York was the first State to pass a Community Mental Health Act in 1954. Although I do not have the figures to describe the initial situation when the act was instituted, I do have some figures for the 1959-62 years to show the momentum the program is gaining. The following are from the Interstate Clearinghouse on Mental Health of the Council of State Governments.

The number of clinics rose from 142 in 1959 to an estimated 167 in 1962 * * * The first emergency clinic opened in 1959-60; there were three in 1960-61, and establishment of another two was anticipated for 1961-62. Inpatient units of general hospitals during the same period grew from 16 to an estimated 25 (from 1,992 to 2,300 beds).

Now, this growth is just a beginning: many are still not being reached by present facilities, personnel shortages still exist, and chiefly the New York act does not provide for construction. The best it has been able to do is to create small units for mental health purposes in general hospitals or existing institutions.

Needless to say, New York is in the vanguard with her mental health and community activities. Yet, if she ever is to achieve a program of the desired preventive, diagnostic and rehabilitative scope she must have the spur of Federal money in expanding facilities and staffing them. Moreover, her need with all she has done is ample evidence of the need that must exist in some areas of the country where States simply could not budget such a program.

My own bill, H.R. 3940, is identical to H.R. 3689. I especially urge the passage of this separate bill for mental retardation because a separate bill for research and facilities for this 3 percent of our population is by now imperative.

Always before, this group has received from the Federal Government only a small share of someone else's allotment-either earmarked or channeled through the allocation of research grants. The only exception to this is the public law of the 87th Congress financing scholarships for leadership personnel in this area.

As in H.R. 3688, and my bill H.R. 3939, the authorization in title II for the construction of treatment facilities is not specific, although $5 million in fiscal year 1965 and $10 million in the following years must go to facilities associated with colleges or universities or their hospitals.

The authorization for the construction of research centers is specific, $6 million for 1964, $8 million for 1965, $6 million for 1966 and 1967, and $4 million for 1968.

Under these two titles the ultimate goal of prevention and the immediate goal of maximum care and training would be furthered simultaneously.

I guess there are many, although it is hard for me to believe, who still do not see the justification for spending so much on a small segment of the population like the mentally retarded. It seems to me there are two urgent reasons and it is faulty or incomplete logic that prevents people from recognizing them. One is purely mathematical: mental retardation disables 10 times as many people as diabetes; 25 times as many as muscular dystrophy, 20 times as many as tuberculosis; and 600 times as many as infantile paralysis. Yet, these programs receive many times the attention and money directed toward the mentally retarded. People have permitted themselves until now to be lulled into a false sense of hopelessness. Or, maybe the absence of either the prospect of actual death (in contrast to a living vegetablelike death) or the prospect of recovery to a somewhat normal life befuddled thinking so that no one for a long time could see his way clear from complete neglect to the intermediate solution of demanding maximum performance from a very real but limited capacity for living.

My second broad reason is (Mr. Kennedy has emphasized this) the possibilities for discovery about the entire learning process in examining the particular malfunctionings of the mental processes that lead to retardation.

As to the actual construction of research and treatment facilities authorized by the bill, I can see no difficulties arising from the two titles. Under title I, the Surgeon General would oversee that the research facility grants go to public or nonprofit institutions who will have proven fiscally sound and could be responsible for keeping the facility dedicated to mental retardation research for at least 10 years. The chief criterion for approval will be the potential of the planned research for "advancing scientific knowledge pertaining to mental retardation and related aspects of human development."

As for title II, construction estimates at the Public Health Service project that my home State of New York could receive anywhere from $648,143 to $2,930,244 (the first figure being computed on a possible $10 million appropriation and the second on a possible $40 million). As I mentioned before a piece of legislation devoted exclusively to the mentally retarded could accelerate considerably the present development which is now only one small facet of the Mental Health Act of

1954 in New York State. At present, there are estimated to be only 10 public clinics in the State, which clinics are probably far less ambitious ventures that the more comprehensive facilities anticipated by this act.

H.R. 3688 and H.R. 3689 deserve and demand passage this year. The need is too acute for further delay to be tolerated. Through the standard grants-in-aid formula every State in the Nation, and, thus, the Nation stand to profit by their enactment. I urge the passage of both.

Mr. ROBERTS. Thank you for a very fine statement, Mr. Farbstein, we hope you will come back soon.

Our next witness will be Dr. Robert E. Cooke, professor of pediatrics, the Johns Hopkins University School of Medicine, Baltimore, Md.

STATEMENT OF DR. ROBERT E. COOKE, PROFESSOR OF PEDIATRICS, THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE, BALTIMORE, MD.

Dr. COOKE. Thank you, sir, very much.

Chairman Roberts, it is a great pleasure and privilege to testify again before your committee. The technical as well as legislative knowledge demonstrated by the previous committee was most impressive. I appear today in support of H.R. 3689-the Mental Retardation Facilities Construction Act-as chairman of the Joint Committee on Pediatric Research, Education, and Practice, whose constituents are the American Academy of Pediatrics, the American Pediatric Society, the Society for Pediatric Research, the American Board of Pediatrics, and the Pediatric Section of the American Medical Association.

This legislation is the result of the deliberations of the outstanding people in the United States-scientists, educators, lawyers, businessmen, clergymen who have pooled their best thoughts on how to meet the increasing problem of mental retardation. I have had the privilege of serving on the President's Panel on Mental Retardation, as well as on various National Institutes of Health special committees and study sections. As chairman of the medical advisory board of the Joseph P. Kennedy, Jr., Foundation, which is concerned with the support of research, service, and training in mental retardation, I have been concerned with the development of research, service, and training programs to meet the major handicapping condition of our children mental retardation.

As a physician, research worker, and educator in a great medical institution, I see daily the hardships and heartaches which families endure without complaint that result from this most disabling symptom of all handicapping conditions. Although progress is being made and the efforts of the National Institutes of Health have been rewarding, there are now perhaps a dozen treatable cases of mental retardation such as phenylketonuria, galactosemia, maple sirup urine disease, tyrosine disease, fructose intolerance, leucine intolerance, hyperglycinemia, cretinism, and hydrocephalus which account for less than 1 percent of the retarded. Even though we have at least 70 labels to put on causes of mental retardation, the term "idiopathic" or unknown cause applies to the majority.

Why, then, are there so many causes?

If one visualizes the development of the nervous system as a gigantic wiring operation, far more complex than any computer that will ever be built, which begins as a single unit that reproduces itself repeatedly, specializes and differentiates, it is little wonder that there may be missing or abnormal circuits. Thus, slight deviations in this developmental process may produce a myriad of disturbances, all with the major symptom-mental retardation.

Although we know almost nothing of the detailed reasons for mental retardation, cases can be put into one or another pigeon holes. Some are the result of genetic abnormalities caused by mutant genes transmitted by normal-appearing, intelligent parents. Others are the result of environmental influences, some operating shortly after conception, others during pregnancy or during the birth process. Many factors operating in the newborn period, particularly in the premature infant, arrest or slow development of the brain. Environmental influences such as intellectual stimulation, experience, maternal contact, emotional stress, play a major role in intellectual development in the early years of life.

If we consider some of these areas in detail, for example, the genetic causes which have been studied more intensively in the last few years with modern basic science techniques than any other field in mental retardation, we see widespread application in one condition-phenylketonuria (PKU). Knox has reviewed all cases of phenylketonuria treated with diets low in phenylalanine up to 2 years ago. Of 466 untreated cases, only 21/2 percent had intelligence quotients over 60. The use of a low phenylalanine diet in the treatment of 44 patients over the age of 3 did not produce any improvement in mental ability, although seizures at times may have been lessened. A low phenylalanine diet was used in the treatment of 43 patients under the age of 3. The mean age at the start of treatment was 16.2 months, the mean duration of treatment of 16.8 months. This group had 18 times as many children with IQ's over 60, and twice as many children with normal EEG as the untreated group. Of the whole treated group, the final IQ was inversely correlated with age at the start of treatment in a highly significant manner. In fact, a minimal loss of nearly five points in the IQ occurred each 10 weeks that treatment was delayed. These results indicate how important full understanding of cause is. But it is worth remembering that this condition, PKU, accounts for less than 0.1 percent of all the mentally retarded.

What about mongolism.

This disorder occurs as the largest single entity causing severe retardation which requires-at least in some people's minds-institutionalization. Here a major breakthrough has occurred. A duplication of a chromosome was found-either trisomy 21 or translocation of a segment of 21-which results from a disturbance in the separation of chromatin material in the formation of egg or sperm. Such advances represent enormous progress. Yet what do we really know of mongolism? How does this extra chromosome bring about the physical and mental stigmata of mongolism? At the moment, trisomy 21 represents little more in our understanding of the problem than the curved little finger which is so characteristic of these children.

These are not idle academic questions. Unless detailed understanding of each of these conditions is known, specific treatment is impossible. Infection during pregnancy is known to produce mental retardation. The German measles virus accounts for only a small number of the babies damaged by viruses during pregnancy. How do these viruses get into the fetus? What alters the placenta-the guardian of the fetus so that these can pass? How can the infant be protected against such infection? These are unknown quantities at the present time.

Likewise, totally unknown are the factors which interfere with the nutrition of the fetus by the placenta. What are the factors that bring on prematurity which so frequently leads to mental retardation? Such factors as virus infection, ionizing radiation, mutant genes, maternal medication, dietary deficiency, require far more investigation during fetal life than through other periods since minor events in the mother at these times may produce catastrophic defects in the fetus crippling him for his lifetime. Nevertheless only a handful of investigators is presently exploring exclusively some of these avenues largely because no focus of interest and concern in fetal and neonatal development exists within the present structures of medical schools.

Cultural retardation is thought to be a major cause of mental retardation. Literally millions of children in the low socioeconomic groups do not rise above the intelligence of a normal 12-year-old child. What impairs their development? Factors during pregnancy? Nutritional disturbances? Inadequate stimulation? Emotional disruption? These questions remain unanswered despite the obvious therapeutic implications. At Johns Hopkins over half of the children born on the ward service seem severely deficient in language ability by 36 months of age, yet ability to communicate is the most important skill in our society. Do these children suffer from early brain damage during pregnancy or during delivery? We have little evidence for this. Could this be genetic? Or is their environment in some way stifling their development?

Why is there so much scientific ignorance of this problem? All these processes are the result of arrest or slowing of development. Human development has received less attention in many respects than the growth of cattle. Medical schools have had neither physical facilities, funds, nor personnel to carry out research in these areas or to conduct even elementary teaching programs.

Traditionally, medical research and education have been concerned with the death-dealing disorders. It is only within the last few years that even meager attention has been given to problems of early life which lead to handicapping, lifelong disabling defects.

Because of the broad spectrum of causation of mental retardation, research in the development of the nervous system and its functions ranges through most of the existing departments of medical schools. and universities. At the present time, these interests are diffuse and scattered, bearing little relationship to each other, and there is little likelihood that numbers of investigators will emerge in this generation with our present system of medical education which concentrates interest on the later stages of life. The creation of the centers for research on mental retardation and related aspects of human development through title I of the Mental Retardation Facilities Construc