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e never know where an idea is going to be stimulated. I know I never do. I go to a meeting of some kind and something comes up that causes me to think of something I would not have thought of at all. It may not be directly related to what is going on. It seems to me this might result from a central filing by agencies of this year's needs in a way in which they could be indexed and retrieved by people who are interested.
Dr. SHANNON. Well, sir, to do it in precisely that way—to be so meaningful that it can be demonstrated by a specific example, quite frankly, sir, is going to be rough. But I think an effort to satisfy a large part of that need is in progress.
Decisions in the executive branch have been made that under the auspices of the Office of Science and Techonolgy, agencies will indeed develop information systems that, while they may address themselves to their individual problems, would be compatible one with the other. In other words, this is a past decision. Now comes the problem of implementing it.
The President directed the Secretary of HEW, to take a broad look at the area of toxicological information as was defined by the Panel on the Handling of Toxicological Information of the President's Science Advisory Committee. This panel defined toxicological information as information which related to the understanding of an interaction of chemicals and biological systems. Thus it is substantially wider than toxicology in the conventional sense. In discussions we felt this assignment would be a normal extension of the computerized operations of information storage and retrieval within a library system to satisfy modern needs, going beyond the simple filing of books. The National Library of Medicine has been assigned this responsibility. But the systems that they come up with will relate to the filing and retrieval of information across the whole range of scientific interests. One of the factors in this information system would be a citation index of those things that relate to the compatibility of chemical substitutes and living systems, mechanisms of clot formation and the like. But this will have to be done in such a way as will be compatible with other material and research, whether done in NASA, in Defense, in the Atomic Energy Commission, in the Department of Commerce.
I would say, Senator Harris, one is going to have to be patient. This is a rough thing to do. But I think the proper decisions to bring this information system into being have been made, and I think we need both to support the people asked to do it and to exercise some restraint in getting results.
Senator HARRIS. We have to break off now because of a vote in the Senate.
Thank you very much, Dr. Shannon. You have ben very helpful.
Mike, I apologize to you. There were three roll calls in rapid succession rather than just one, so it took a little longer than I anticipated.
Mike Gorman of Washington is the Executive Director of the National Committee against Mental Illness.
Without objection we shall place in the record a biographical sketch-rather an impressive one to me—at this point.
Biographical Sketch: Mike Gorman Director, National Committee Against Mental Illness, Washington, D.C.
Member: National Advisory Mental Health Council, appointed to a four-year term in 1961 by President Kennedy.
Helped draft Community Mental Health Centers Act of 1963. Instrumental in the Congressional action which led to the formation of the Joint Commission on Mental Illness and Health and served as a member from 1955 to 1961.
Appointed by President Truman as director and chief writer of the President's Commission on the Health Needs of the Nation.
Author: “The Doctors' Dilemmas”, “Oklahoma Attacks Its Snake Pits", “Every Other Bed.”
Awards: Edward A. Strecker Memorial Medal, U.S. Junior Chamber of Commerce outstanding young men award along with 9 others.
TESTIMONY OF MIKE GORMAN, EXECUTIVE DIRECTOR, NATIONAL
COMMITTEE AGAINST MENTAL ILLNESS, WASHINGTON, D.C. Senator HARRIS. You may proceed as you wish.
Mr. GORMAN. Mr. Chairman and members of the committee, in the previous hearings and seminars of this committee, I have noted a deep concern with the necessity for long-range planning efforts and mechanisms in the field of medicine, as well as in all other scientific areas. I should like to address myself to this problem because, in the 22 years I have been active in the mental health field, I have discovered that the resistances to long-term planning have been a major obstacleif not the major obstacle—to progress against mental illness, whose victims still fill more than 50 percent of our hospital beds.
Starting with my first tour of State mental hospitals in Oklahoma in 1945, I soon learned that any attempts to discuss a 5- or 10-year blueprint for planned mental health efforts invited the accusation that the proponent was either naive or unrealistic, or both. Since the establishment of the first public mental hospital in Williamsburg, Va. in 1773, State mental health commissioners and State hospital superintendents have ben engaged until quite recently in a frenetic race to build additional beds to accommodate the ever-increasing floodtide of mental patients.
For example, in the immediate period after World War II, many of us in the journalistic field pointed out the gross deficiencies of a mental hospital system which provided only the most limited form of custodial care for those afflicted with mental illness. When we suggested that there were alternatives to this traditional, massive warehousing of the mentally ill, we were answered in scornful terms. As a result, in the period from 1945 through 1955, 130,000 additional beds were added by the States to the existing custodial real estate. This was a costly endeavor—the States poured $100 million a year into this building program—but it is their time-honored reflex response to public concern and public indignation.
I became convinced that we were merely doing some patching and filling on a tattered, old custodial garment. I was impressed with the observation of the anthropologist, Margaret Mead, that significant revolutionary change comes about only through a dramatic, incisive break with the past. In other words, we had to create a climate in which Government officials and the public generally would view the glaring shortcomings of the existing system in the perspective of the goal we all sought—the return to the community of thousands upon thousands of patients needlessly hospitalized.
I had some illusions at that time that the National Institute of Mental Health, created by the Congress in 1946 to pull together our national resources against mental illness, might be the catalytic agent. However, its view of its mission was a most circumscribed one. Under restricted annual budgets, it concentrated upon project grants to individual research investigators along with a quite modest training program for psychiatric personnel. It venerated basic research, and it was convinced that it would eventually come up with the answer to schizophrenia.
We therefore turned to the Congress. We asked it to appropriate moneys for the support of a nongovernmental joint commission on mental illness and health which would take a hard, sociological look at why we were failing to make any progress against mental illness and what measures should be instituted to reverse the trend. We requested and received authorization over a 5-year period for this most difficult task, and we were asked to make our findings available to the Members of the Congress and to the Governors of the several States.
The joint commission report was completed in 1961. It called for an unprecedented break with past patterns of confining the mentally ill, characterizing the then custodial State mental hospital system as therapeutically bankrupt. It recommended a network of community mental health centers which would involve all levels of government and many voluntary agencies in an intensive attack upon the early and treatable manifestations of mental illness.
The impact of that report was tremendous. President Kennedy incorporated its major recommendations in his historic 1963 mental health and mental retardation message to the Congress; the Congress followed through by passing enabling legislation providing Federal matching moneys to States and localities for the construction of mental health centers.
As a consequence of this report, long-range planning suddenly became fashionable. Even before the 1963 Kennedy mental health message, the Congress had authorized Federal matching moneys to enable the States and localities to draw up detailed plans for the advent of community psychiatry. Citizen participation in these planning efforts exceeded all predictions; by the time the last plan had been filed in 1965, 30,000 people in all walks of life had taken an active part in charting a new day for the mentally ill.
It is difficult to summarize in a few sentences the totality of the revolution which has taken place. In addition to the commission report and the broad-scale planning efforts, the introduction of new drugs brought about a tremendous change in the locus of treatment of most mental patients. For example, over the past decade there has been an historic, unprecedented drop of more than 100,000 patients resident in State facilities. In 1965, just over 4 million Americans were treated for mental illness; of this number, only one in five was treated in a State institution. Compare this with the situation just two decades ago, when these same institutions handled three out of every four mental patients.
The general hospitals of this Nation, once almost totally off limits to the mentally afllicted, treated and discharged almost 600,000 psychiatric patients in 1965—far more than the number handled by State hospitals.
Barriers to health insurance coverage of mental illness, once fierce and formidable, came tumbling down. Commercial and nonprofit health insurance companies gradually drew the mentally ill within the spectrum of their coverage, and important sections of the 1965 medicare legislation extended psychiatric coverage to the elderly mentally ill.
Local government, which for almost 200 years dumped its unwanted mentally ill upon the doorsteps of State institutions, is now assuming a growing proportion of the burden of their care. Twenty-eight States have now formalized this shared responsibility in community mental health laws which provide State and local matching moneys in support of augmented hometown psychiatric services.
I have included the aforementioned data because I believe that a discussion of the Federal role in long-range planning would be meaningless without a thorough understanding of the broad-gaged effort to make planning “respectable.” I submit that abstract, germ-free planning at the Federal level is doomed to ineffectuality unless it seeks nourishment and ideas from the professional and lay community. National planning is not only more effective, but more acceptable, when it draws upon the hard-earned experiences and insights of people at the local level.
When I was appointed in 1961 to a 4-year term on the National Mental Health Advisory Council—which passes upon all applications to the National Institute of Mental Health and then transmits these recommendations to the Surgeon General of the U.S. Public Health Service I was shocked at the absence of a mechanism through which the Council could assess the existing state of the psychiatric art and then formulate plans to rectify any deficiencies which were uncovered. We were snowed under with bales
of individual research and training pro;ect applications; our 3-day deliberations" were in actuality a frenetic race against the clock to finish the last lingering application by 6 p.m.
6 of the last day.
After several meetings of this kind, a number of us revolted. We voted for a planning subcommittee which was instructed to analyze existing procedures and devise some way in which a considerable portion of each meeting could be devoted to the broad issues in the mental health field. Early in 1962, the subcommittee transmitted a report which recommended spending less time on routine project applications and devoting at least a day of each Council meeting to uninhibited discussion of any one of a number of major problems which had been singled out either by Council members or NIMH staff for exploration in depth.
I want to emphasize that this approach did not relieve us of the necessity of reviewing those applications which were either large enough, or controversial enough, to merit careful debate. However, we leaned more heavily—and properly so—upon the recommendations of the various study sections of the NIMH which had done the first de
tailed examinations of the projects including, in a number of cases, a site visit to the individual investigator. Several congressional committees over the past few years have suggested that this nurtures a rubberstamp procedure in which we unthinkingly follow practically all of the recommendations of the study sections.
I vehemently disagree. An outside observer attending a meeting of the Council might get the impression that the 10 minutes or so devoted to consideration of an individual application is somewhat perfunctory. However, what is overlooked is the many days and nights of study which the Council members devote to the applications prior to each meeting. On the basis of this advance work, we are able to single out those projects which we want discussed; I have never felt the slightest degree of restraint in moving to reverse a study section recommendation.
I submit that this double review of applications is absolutely essential to a detailed understanding of the obstacles and bottlenecks holding up progress against mental illness. In other words, planning in the abstract—while dear to the hearts of some academicians is an exercise in futility unless it is solidly based upon an almost microscopic knowledge of current practices and procedures, both successful and otherwise.
Let me cite just one example. Within the past year, the National Institute of Mental Health has launched a long-range attack upon alcoholism, which affects some 5 to 6 million Americans. I would have grave doubts about the advisability of this enterprise were it not for the fact that, over the years, we in the Council have reviewed scores of applications in the field of alcoholism. In this highly disputatious field, we have been exposed to the leading investigators; we have reviewed countless projects running the gamut from basic physiological studies in alcoholism to sociological attempts to buttress and restore the alcoholic to productive living.
However, I do not want to delude this committee with too rosy a picture of the planning process. In the first place, the basic laws creating the various Institutes made no provision for long-term planning and the setting of national goals. In the early years of all of the Institutes, when the budgets were quite small, the almost mechanistic project review procedure entrenched itself because the level of financial support practically precluded any large-scale research endeavors. As this committee knows, this situation has changed somewhat dramatically in the past decade, but the old procedures seem to have a conditioned reflex life of their own.
In recent years, there has been a growing realization that successful attacks upon disease in the present climate of multiple investigative teams and costly equipment mandate a careful selection of priorities and national goals.
For example, there is no question that we must mount a much larger clinical training program if we are to improve our State mental hospitals, care for the psychiatric needs of the elderly, develop programs for emotionally disturbed children, build a network of community mental health centers, and so on. However, for many years our training programs were hampered by annual administration budget recommendations which added just a little more each year over the previous year. We broke out of this budgetary squeeze only when the House