All Pung v 1G0 ), Uo 1Y PROCEEDINGS OF THE NATIONAL CONFERENCE ON MENTAL HEALTH IN PUBLIC HEALTH TRAINING bic f pub # 1899, lS l ¢ ~ MAY 27-30, 1968 U.S &.D. PROCEEDINGS OF THE NATIONAL CONFERENCE ON MENTAL HEALTH IN PUBLIC HEALTH TRAINING MAY 27-30, 1968 SPONSORED BY THE NATIONAL INSTITUTE OF MENTAL HEALTH IN COOPERATION WITH THE ASSOCIATION OF SCHOOLS OF PUBLIC HEALTH Compiled and Edited by Stephen E. Goldston, Ed.D., M.S.P.H. Special Assistant to the Director, NIMH Public Health Service Publication No. 1899 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 - Price 60 cents (paper cover) PUBLIC HEALTHY LIBRARY Table of Contents Page PREFACE, Stephen E. Goldston, Ed. D., M.SP.H_________ v ACKNOWLEDGMENTS _______ viii INTRODUCTION TO THE CONFERENCE, Raymond J. Balester, Ph. D_______________________________________ 1 KEYNOTE ADDRESS, Stanley F. Yolles, M.D___________ 5 GROUP REPORTS. ____ 12 SECTION REPORTS... com inn mm mo si sm i ssn 36 INVITED ADDRESS, René J. Dubos, Ph. D______________ 59 APPENDIXES: A. Conference Planning Group_______________________ 77 B. Section Reporters and Group Chairmen_____________ 78 C. Work Groups... ___ 79 D. Conference Sehedulh. . ... vm womens mmm someon sms sos = 79 E. List of Participants_______________________________ 81 Preface The National Conference on Mental Health in Public Health Train- ing was held at Airlie House in Warrenton, Va., on May 27-30, 1968. The idea to convene such a conference emerged out of the mutual con- victions, expressed by representatives of the Division of Training and Manpower Programs, NIMH, and the deans and mental health train- ing program directors in the various schools of public health, that it would be timely to take a fresh look at the relationship between train- ing in public health and mental health, and how these two areas might more effectively be integrated and articulated. From an historical per- spective, there appeared to be a real need to follow up the Arden House Conference of December 1959 on Mental Health Training in Schools of Public Health. In addition, the new emphasis on medical care as a part of public health responsibility, and the increasing accent on community mental health and comprehensive health planning, served as further imperatives for holding a conference. Planning the conference structure and subsequently implementing these plans was the responsibility of NIMH staff in cooperation with an Advisory Committee composed of the following persons: Viola W. Bernard, M.D., Clinical Professor of Psychiatry, Columbia University School of Public Health and Administrative Medicine; Edward M. Cohart, M.D., Chairman, Yale University Department of Epidemi- ology and Public Health; Paul V. Lemkau, Professor of Mental Hygiene, Johns Hopkins University School of Hygiene and Public Health ; Philip Margolis, M.D., Professor of Psychiatry, University of Michigan; James L. Troupin, M.D., Director of Professional Educa- tion, American Public Health Association; and Myron E. Wegman, M.D., Dean, University of Michigan School of Public Health. The stated purpose of the conference was to bring together faculty members from the schools of public health to explore and identify op- portunities within the public health curriculum for the inclusion of relevant mental health content which would be professionally mean- ingful to the general student body enrolled in the schools of public health. From the outset, it was agreed that this conference should be task oriented primarily structured around small work-group sessions concentrating on the mental health aspects of the various public health subspecialty areas. The following 12 public health subspecialty areas were selected as being most representative of community health con- cerns in which public health and mental health considerations come to- gether: Public Health Administration, Medical Care and Hospital Administration, Public Health Education, Epidemiology, Biostatis- tics, Chronic Diseases, Maternal and Child Health, Public Health Nursing, Family Planning and Population, Environmental Health, Vv Occupational Health, and Nutrition. Each subspecialty was a separate work group at the conference. The conference plan called for staffing each group with faculty and deans from the schools of public health. Seven persons were to com- prise each group, five of whom were experts in the specific public health subspecialty area under discussion, plus two mental health experts. To a large extent the conference was successful in obtaining the desired distribution of expertise, as noted below. The proposed vehicle for engaging the public health and mental health experts in their dialogue and curriculum development work was a “working paper” prepared and distributed prior to the conference. Thus, the initial task of the work groups would be to discuss and re- work the paper, emerging with a “refined” conceptualization and statement of the mental health aspects of that subject area. The antici- pated outcome was that teaching materials and approaches would be developed which eventually could be used within the schools of public health to advance the goal of integrating mental health concepts into public health. An outstanding roster of public health and mental health faculty members from the various schools of public health agreed to undertake the preparation of the working papers. A public health faculty mem- ber, expert in a specific subspecialty area, was paired, on consent, with a mental health faculty member as a coauthor team. Opportunities were provided for the coauthors, who were usually from different schools, to meet in order to prepare the papers on a close working basis. The coauthors were asked to address the mental health training needs of two types of public health students: the generalists, that is, those students who may take only a single survey course in an area, and the specialists, those students majoring in a particular public health subspecialty. The papers were also to include a brief overview of the scope of the subspecialty area, its mental health relatedness, identification of mental health principles, case material where ap- propriate for illustrative purposes, methods of teaching the material, and indications where the content might be presented by collaborative or team teaching with the mental health faculty. Twelve working papers were forthcoming which subsequently will appear in a separate volume to be published in early spring 1969. Shortly after the first meeting of the Advisory Committee in mid- August 1967, the deans of the schools of public health were polled to determine their reactions to the proposed conference, its purposes, format, and schedule. The response from the deans was outstandingly positive, and efforts immediately began to secure commitments from the coauthors. In early November 1967, invitations to conference participants were issued. Again, the response was enthusiastic. vi With the assistance of the Advisory Committee a final agenda and format evolved. Group chairmen were selected, and a decision was reached to cluster the 12 groups into four sections, with a section re- porter who would visit each of three groups during their deliberations and then prepare a concise feedback report during the final plenary session. To bring before the participants a critical view on issues of mental health and public health relevance from a special vantage point of wisdom, Dr. René Dubos was invited to deliver a formal address before the entire conference. As Dr. Balester indicated in his opening remarks, the list of con- ference participants reads like a “Who’s Who in Public Health.” The initial intent to secure the participation of senior faculty from the schools of public health was well-fulfilled. Of the 88 conference par- ticipants, 78 were on the faculties of the schools of public health, eight were federal officials, and two participants were representatives of interested agencies. The 78 academic participants included 51 full professors, of whom 11 were deans of schools of public health ; 18 associate professors; three assistant professors; and six lecturer-instructors. Fifty-eight of the faculty members represented the 12 public health subspecialties for which there were working groups; 20 faculty members were mental health experts. This broad representation enabled the proposed group staffing pattern to be achieved in most instances. Participants represented all 15 of the accredited Schools of Public Health in the United States, and an observer was in attendance from the University of Toronto School of Hygiene. This proceedings document, even with its graphic content, scarcely can convey the sense of commitment and productivity which charac- terized the work of the participants. To the extent that any such docu- ment can capture the feeling, tone and sense of the meeting, it would appear that the individual chairman’s reports and the section reports do so. These reports reflect the participants’ effective response to the charge presented to them in Dr. Yolles’ keynote address. In publishing these proceedings and the companion volume contain- ing the 12 working papers, our anticipation is that faculty and stu- dents in the schools of public health will use these contents as a point of departure for further clarification and implementation of mental health concepts in public health practice. StepHEN E. Gorpston, Ep. D., M.S.P.H. vii Acknowledgments Many persons contributed to the success of the National Conference on Mental Health in Public Health Training. The Conference Ad- visory Committee was of great assistance. Dr. Raymond J. Balester, Acting Director, Division of Manpower and Training, NIMH, made available considerable time and proposed invaluable suggestions throughout all stages of conference planning. In addition, support and guidance was generously provided from the following persons at the highest levels at NIMH : Dr. Stanley F. Yolles and Dr. Bertram S. Brown. Essential administrative assistance was forthcoming from Mr. Wil- liam Huber and Mrs. Betty Meenan, Division of Manpower and Train- ing Programs, NIMH. The mass of details characterizing such a national conference could not have been handled but for the efficient and capable work of Mrs. Jean Santucci. To the staff at Airlie House we extend warm appreciation, not only for a splendid conference setting but for the amenities which are of major significance. To the Association of Schools of Public Health which lent us their support, to the deans of the schools of public health, and to the partici- pants we extend a genuine thank you for the cooperation which enabled us together to move ever closer to our mutual professional goals. S.E.G. viii Opening Plenary Session Monday, p.m., May 27, 1968 Introduction to the Conference RayMoND J. BALESTER, Ph. D. Acting Director Division of Manpower & Training Programs National Institute of Mental Health I would like formally to open this National Conference on Mental Health in Public Health Training by extending a very warm welcome from the National Institute of Mental Health. We wish to express our appreciation for the time that you have taken to come to this very important conference. The list of participants reads like a dis- tinguished “Who’s Who in Public Health.” The purpose of this conference is to explore and identify mental health concepts and principles that can be integrated into the teach- ing of each of the 12 public health subspecialties represented. In essence, it is a scholarly conference on curriculum development, and it poses an extremely serious challenge to us at this time. We recognize that 214 days is a very short time in which to develop curriculum materials, but it is our hope that with the amount of brain power available here we can make a substantial dent into this problem of developing an integrated curriculum which involves mental health content. The structure of the conference involves 12 work groups meeting all day Tuesday and Wednesday. On Wednesday evening we will convene again in plenary session to hear a talk by Dr. René Dubos. The reputation of this man precedes him, and it should be a very interesting evening. There will be a final plenary session on Thursday morning, during which the findings and deliberations of the various groups will be presented and discussed. The main item on the agenda for this evening and the first major business of the conference is a keynote presentation which will place the substance and purpose of the conference into perspective. Our keynote speaker is familiar with public health problems, both by training and practice. Dr. Stanley Yolles, Director of the National Institute of Mental Health, was commissioned in the U.S. Public Health Service in 1950 and was appointed Director of NIMH in 1964. He holds an A.B. degree from Brooklyn College, an M.A. degree 1 from Harvard, an M.D. from New York University College of Medi- cine, and an M.P.H. degree from the Johns Hopkins University School of Hygiene and Public Health. Dr. Yolles completed his psychiatric residency at the U.S. Public Health Service Hospital in Lexington, Ky., and at the University of Cincinnati Department of Psychiatry. He is certified in psychiatry by the American Board of Psychiatry and Neurology. Dr. Yolles has spent many years in mental health and epidemiologi- cal settings during his tenure in Government service. His professional affiliations are as numerous as his many important positions. Dr. Yolles. Keynote Address: Public Health and Mental Health: Some Thoughts on the Nature of the Relationship StanLEy F. Yorres, M.D. Director National Institute of Mental Health Opening Plenary Session Monday, p.m., May 27, 1968 Keynote Address: Public Health and Mental Health: Some Thoughts on the Nature of the Relationship Stanitey F. Yorres, M.D. Director National Institute of Mental Health It appears to me that three events stand out as being milestones in the effort to clarify and define the nature of the special interrelation- ships between the fields of mental health and public health. Appro- priately, these three events were all conferences. The first event occurred in 1948 in Berkeley, Calif., when under the sponsorship of the Commonwealth Fund, a group of health officers came together with a faculty of mental health experts for a 2-week workshop to explore the mental health relatedness of public health work. One outcome was a report entitled “Public Health is People,” which is considered today to be a classic in public health literature. This marked a beginning at the effort to attempt to articulate the points of convergence of the two fields. Coincidentally, it was that same year that NIMH, which had just come into being, initiated a grants program to the various schools of public health to promote the mental health-public health training of students enrolled in the schools. I note with pleasure that the first recipient of an NIMH stipend under this program, Dr. Ernest Gruenberg, is here with us tonight. The second milestone occurred 11 years later, in December 1959, when the Association of Schools of ublic Health, with financing from NIMH, conducted a national conference at Arden House on mental health teaching in schools of public health. This conference focused on curriculum content and teaching methods for the mental health training of both the general public health student and community 5 mental health specialists. The majority of the participants were mental health professional people—both trainers, from schools of public health and other mental health training centers, and practitioners, who are the consumers of the trained product. However, save for a good representation by the various deans of the schools of public health, there were few other public health faculty members or other public health (nonmental health) people in attendance. So, in effect, mental health people struggled, by and large, among themselves to try and define public health relatedness and public health-mental health training issues. A splendid report was forthcoming, but the extent to which the nature of the mental health-public health relation- ship was advanced or clarified was somewhat questionable when viewed by today’s still unresolved problems. The third milestone is living history. It is here, it is now! We have before us, each of us, an unprecedented opportunity to participate in nailing down the precise relationships of mental health to public health as mental health impinges on the 12 public health subspecialty fields represented here at the conference. To a large measure, the structure of this conference represents a basic principle of the democratic process which has been brought to our attention time and time again over the past few years in our domestic struggles in the United States: namely, that those persons at whom programs are directed must be involved in the planning and implementation of these programs. To be specific, Airlie House is primarily a public health conference, not a mental health conference. Accordingly, this is reflected in the com- position of the 12 work groups in which there are three public health faculty representatives for each mental health faculty member. This conference has been organized on the conviction that only by securing the active involvement of the public health faculty (in other than mental health) can we advance the goal of integrating mental health into public health and thereby contribute to better overall public health training. The task before you is a difficult one. You are being asked to evolve curricula and content which heretofore have not existed in an ordered systematic fashion, and to help clarify a relationship between two fields that has been characterized by “fuzzy” thinking. Some observers in commenting on the nature of the relationship between mental health and public health have correctly suggested that this relationship to date is not a “marriage” between the two fields, but rather a courtship of questionable intimacy, that often borders more on an illicit affair. At the other extreme, some persons have gone so far as to state: “Public health is mental health, and mental health is public health.” I'believe this to be a mere play on words, without substance or meaning. If mental health-public health practice is subsumed under the rubric 6 of public health, it tends to be obliterated or taken for granted. Any truth that may lie in this aphorism results from the implementation of programs and activities in which mental health and public health seem to blend, rather than from any presumed “given” that each field is inextricably interwoven and based each on the other. Speaking for the mental health field, we know that there has been a limited translation of public health principles into mental health practices. The major thrust of community mental health and the success of community mental health centers lies in implementing public health principles and relating meaningfully to the community and the people to be served. One of our greatest unfinished tasks in the basic training of all mental health professional personnel is to inculcate public health principles into such training and thereby to enlarge the vista and scope of practice beyond the traditional one-to- one psychotherapeutic intervention. And yet, we are still groping with the problem of identifying clearly and precisely what these public health principles are, and how they might best be incorporated into the training of mental health workers. The apparent schism between mental health and public health is reflected in the lack of cooperation between practitioners in these two groups in implementing programs which are of mutual concern. In those many instances in which mental health services are organiza- tionally and administratively a part of state or local public health services, we see suspicion where there should be cooperation, separa- tion where there should be profitable integration. Even more so, when such services are administratively and organizationally independent, we see the same picture of nonalliance. In truth, there is no real integration of mental health into public health; it is a characteristic neither of the training of public health nor mental health professionals nor of subsequent practice. Moreover, there has been a pronounced reluctance by public health workers to be involved: in the mental health effort. For example, altheugh schools of public health provide training in hospital ad- ministration and health education, there are very few such trained Liospital administrators or health educators who venture to work in the mental health field. I would advance the argument that a key reason for this state of “separateness” lies heavily in the absence of a conceptual basis for mental health training in the schools of public health. After a period of 20 years of support for mental health training in schools of public health, we at NIMH are convinced that the existing psychiatric, psychological, and psychoanalytic models are no longer appropriate for teaching mental health in schools of public health. The basis for these models is that mental health is merely a specialty placed 7 outside the context of public health and therein more germane to psychiatry, psychology, and psychoanalytic models. The ambiguous and even amorphous status of mental health in schools of public health today is a reflection of the ambiguities of the status and relation- ships of mental health to public health on one hand and to psychiatry, psychology, and psychoanalytic thought on the other. Schools of pub- lic health which respond to such professional ideological constraints are not able to make an impact with mental health training on public health training. Their graduates are likely to be unaware or only acquiescent about mental health as a component of public health work and of the value of the mental health component of their formal education in public health. In short, mental health training for students in schools of public health can not mirror the content or curricula provided for the basic training of mental health specialists in psychiatry, psychology, and social work. If a new model is needed for mental health training in schools of public health, and I argue that it is needed, then such a model can only evolve through the integration of mental health concepts into the basic public health sub-specialty fields represented at this conference. Con- tinuing my argument, it follows that a job needs to be done, not just by mental health experts, but by mental health and public health ex- perts working together. The recent redirection of the NIMH mental health training grants program to the schools of public health to focus primarily on the integration of mental health into all relevant public health areas attests to our conviction that a more meaningful approach to mental health- public health training must evolve than we have had formerly. We at NIMH maintain the original premises upon which this program was initiated 20 years ago, namely, that schools of public health train leadership personnel in public health who, by virtue of their positions in communities and States, will assume vital roles in implementing mental health programs and practices. Further, we maintain that these personnel should be aware of interpersonal factors in their work, the nature of mental health services and facilities, and the application of public health principles to the detection, prevention, and control of the mental illnesses and the promotion of mental health. In supporting mental health training in schools of public health, NIMH’s priorities are to provide mental health training that will : 1. Enable the public health worker to perform more effectively his job as a public health worker; 2. Assist the public health worker in functioning cooperatively with mental health workers, where their responsibilities join; and } 3. Serve to enlist public health workers into full-time functioning in the mental health field. Public health approaches are increasingly a matter of importance to mental health workers. We look to schools of public health, as society in general looks to its universities, for new knowledge and new principles which we can translate into effective action on behalf of those we serve. The rapid pace of change in our technological society demands new principles and knowledge for coping with our problems. We need an interchange of public health-mental health practice, concepts, and methods for the betterment of both mental health and public health. Above all, we need to begin to clarify what these principles are and what should be taught in the schools of public health. The specific charge that I extend to you in opening this conference is threefold : 1. Identify the mental health content that is relevant to each of your public health subspecialties; 2. Identify the problems in teaching such mental health content so that we may proceed to tear down any barriers to more effective train- ing; and 3. Share with us any recommendations you may wish to offer for implementing more effective training programs. I warmly welcome you to Arlie House. On behalf of NIMH I extend both greetings and appreciation for your joining with us to tackle the important issues before this conference. Thank you. Dr. Barester. Thank you, Dr. Yolles. Dr. Yolles’ charge to this conference is clear. In its most aphoristic sense he is saying that we as parents or as tribal statesmen representing two camps should try to get our children to stop living in sin and to legalize this relationship; or in its most scholarly sense, he is saying that we must reduce the alienation between the concepts of public health and mental health and to promote the integration of mental health concepts into the body of content that we identified as public health content. This is no easy task; it’s going to take a great deal of thinking for the next 214 days to even begin to get closure. The motivation that you see is a contemporary one. If ever there was a time in the history of a society, or if there ever was a society, that needed the guidance and the assistance of public health concepts and mental health concepts, it’s our society today. Hopefully, you will begin to make some entry into the many, many problems through your deliberations here, and you will be able to light the way so that we can improve on the delivery of services in our American society. I wish you good luck. I am sure it’s a frightening challenge, but I also feel very confident that this particular group is equal to this challenge. 335-225 0—69——2 9 Group Reports Group | Public Health Administration Chairman: Joan C. Hume, M.D. The group identified the following mental health content areas in which public health administrators should have knowledge in order to understand mental health and to function appropriately in this sphere: (1) mental disorders, (2) personality development, (3) psy- chological components of physical illness, (4) social disintegration, (5) interpersonal skills, (6) determinants of health behavior, (7) orga- nization and management of mental health programs, (8) social in- stitutions and community structure, and (9) psychological and social aspects of environmental health. As a preamble to specific discussion of mental health content in cur- ricula, the group emphasized the following more general points: 1. All schools cover many of the nine mental health content areas in their existing programs although the academic department having responsibility may differ from one school to another. 2. While many schools have faculty competent to cover each of these content areas in depth, other schools may need to add staff in one or more areas to offer instruction even at an introductory level. Teaching competence may reside in a department of mental health or in other departments within a school. 3. Each school of public health has certain unique qualities and strengths, emphasizes the training of certain types of health pro- fessionals, and has a slightly different perception of its educational responsibilities. This diversity is a highly desirable characteristic and should be fostered. There should be no effort to impose conformity in curriculum development or methods in which subjects are presented. Rather, every effort should be expended to build upon the peculiar strengths of any given institution. 4. Schools and supporting agencies should encourage and foster research in the epidemiologic, administrative, social, and biologic aspects of mental health. Such activities improve the quality of teach- ing in the various departmental offerings and allow the training of students in research methodology. Where doctoral programs exist, inevitably there is consultation across departmental lines in the devel- opment of the thesis and education of the faculty (both in the sponsor- ing department and the other participating departments), in the process of review of the thesis and in the final oral examination by interdepartmental committees. 5. In any special field, not excluding mental health, the most im- portant ingredient in the development of adequate curricula for both 12 general and specialist groups is a free, two-way flow of input by faculty with general and specialized interests into the course content and curricula for both types of students. Every effort should be made to introduce appropriate mental health content into general programs. Currently, there is even more need to get general public health and specific health administration content into the programs designed to prepare mental health specialists for administrative roles in their special field. Among the most effective methods of introducing mental health content into general public health administration courses are the involvement of the general public health administration faculty in the teaching of mental health specialists and increasing involvement of mental health students in general courses. 6. For general health and mental health administrators there should be greatly increased emphasis on the use of quantitative techniques in program planning, operational decisionmaking, and evaluation. 7. Generally speaking, one of the best ways of introducing special- ized content in any field in courses designed for generalists is to use examples from the specialized fields in courses such as biostatistics, epidemiology, administration, environmental health, qualitative deci- sionmaking, and comprehensive health planning. 8. Given the time limitations currently imposed on the educational programs of schools of public health, the group felt that if required courses are to be added, existing courses must be dropped. Therefore, the group indicated that the most successful approach to the introduc- tion of specialized material is as suggested above in required courses and the offering of attractive elective opportunities for students wish- ing to explore the field in greater depth. 9. Another approach suggested to increase the opportunities for exposure of general students to specialized fields is the development of joint or interdepartmental courses. Such developments should be encouraged and should be highly successful where appropriate staff and interest exist. 10. The group believed it worthwhile to emphasize the essentiality of incorporating mental health components in comprehensive health planning courses, the participation by mental health faculty, and the enrollment of mental health students in such courses. 11. There was consensus that in view of the varied resources and educational philosophies of the faculties in the several schools, efforts to specify minimal requirements or desiderata would in all probability tend to inhibit rather than encourage the development of suitable exposure of students to mental health content. The group agreed that mental health is one important component of the overall comprehensive health program, and this concept should be emphasized in teaching. However, it was recognized that at present, in many areas, the fields are quite separate in their programs and administration. 13 Two recommendations emerged relating to the better integration and coordination of general and mental health administration : 1. That NIMH sponsor a survey of programs in schools of public health to determine what is currently being taught in the nine content areas listed above. The survey team should represent the disciplines of mental health, general public health administration, and behavioral science, and 2. That NIMH and the Association of State and Territorial Health Officers be encouraged to develop separate position papers addressed to the changing relationships between general public health and mental health and how to integrate and coordinate their administration and function more effectively. 14 Group li Medical Care and Hospital Administration Chairman: JAMES L. Troupin, M.D. The mental health aspects of medical care and hospital administra- tion should receive a high priority in the training of specialists in these fields. These mental health aspects include: (1) general appreciation of “human relationships” (aspirations, anxieties, fears, dignity, etc.), (2) knowledge of the psychological aspects of patient care and hospital administration, (3) knowledge of the mental and emotional aspects of general illness, and (4) the treatment of patients with mental disorders. Education in medical care and hospital administration, and its mental health components, should include consideration of the follow- ing issues: (1) the coordination of public and private arrangements for medical care, (2) the demand for more efficient methods of or- ganization and delivery of services, (3) the plight of the hospitals, (4) the rising cost of medical care, (5) the persistent shortage of health manpower, and (6) the crisis in medical care for the poor, including the need for a single standard of personal health services for the entire population. The group acknowledged the trend of integrating mental health ° with other health services, as evidenced by statistics indicating that a large number of psychiatric patients are now being treated in general hospitals. Another trend is away from the huge custodial mental insti- tution toward the community mental health center. Since these trends imply a new and broader scope of professional practice and concern, some mental health content should be included in the training of medi- cal care and hospital administrators. The manner in which mental health content is included in the curric- ulum should be determined individually by each school of public health. The group discussed the extent to which there was a “core” of admin- istration in the fields of public health, medical care, hospital adminis- tration, mental health, etc. Noting that hitherto there has been consid- erable fragmentation, the group recommended some integration as a method whereby closer relationships could be promoted among students specializing in each of the above-named fields. Present training of medical care and hospital administration spe- cialists should be influenced by a sound estimation of future roles in 15 the several health services, including mental health services. In addi- tion, a system of continuation education should be developed. A majority of the group agreed that, to achieve the objectives cited, the presence of a full-time faculty member with a mental health spe- cialty is desirable in every school of public health. Moreover, com- prehensive health planning and, by extension, the entire field of health services, should include mental health administration. As an important corollary to the discussions, the group suggested that there should be a medical care and hospital administration com- ponent in the training of mental health specialists. 16 Group lil Public Health Education Charrman: Rape H. BoaTrmaN, PH. D. The group suggested that the major public health problems today require radically new approaches beyond narrow disciplinary con- cerns. Curriculum development should not be limited to traditional public health structures. Some feeling was expressed that mental health and health educa- tion professionals may be interchangeable in some settings and with respect to some tasks and situations. There would appear to be a need for several definitions of mental health. To the extent that mental health refers to the proper functioning of human beings, it overlaps with all levels of training and functioning activity. Concern was expressed that universities traditionally have been separated from communities, and today there is a need for the uni- versities to be more aware of and responsive to the community and its problems, With specific reference to mental health, it was suggested that teaching methods and content should draw heavily from the community, and the focus of the school of public health would in part be a commitment to a specific community problem in which there is mainly a mental health component and which requires participation by all disciplines. The difficulty of relating the skills of clinically- oriented people to training community-oriented practitioners was cited. The group emphasized the need for concern with the growth in emo- tional maturity of the faculty and students, and an ability to see themselves and their behavior as a more mature commitment in rela- tionship to a whole range of problems and capabilities and the relation- ship of mental health to the entire curriculum for this purpose. Members of the group felt that professionalism had become almost a cult in public health practice. They saw the great need for the pro- fessional worker without an attendant cult of professionalism. There was general agreement that as professionals we are opposed to dele- gating community policy decisions to the professional who is essen- tially an enabler of community groups to make policy decisions. Prejudice against minority groups was recognized as a problem of some consequence in the professional worker himself and one which could be treated in part at least through mental health and educational efforts. It was suggested that NIMH should engage in an educational re- search program to concentrate on the problems which are blocking effective preparation of health professionals for practice. 17 Group IV Epidemiology Chavrman: W. W. ScHOTTSTAEDT, M.D. The group agreed on the difficulty of defining mental health or mental illness in clear, operational terms. Emphasis was made that the area extends well beyond a consideration of the neuroses and psy- choses to encompass affect, cognition, and sentiments both as factors in the etiology of disease and as consequences of disease. Attitudes, behavior patterns, and personality traits are included as well as social status, social mobility, status incongruity, and culture change. The scope of epidemiology of mental disorders is broad, including as it does the epidemiology of infectious diseases, accidents, poisoning, metabolic disorders, and genetic defects. Teaching in this area should instill a concern for the psychosocial and intellectual consequences of other kinds of disease—for example, of measles, arthritis, diabetes, and strokes. All students should receive basic instruction in the behavioral sci- ences relevant to public health, but only selected students need specific instruction in the epidemiology of mental and emotional disorders. The introductory course in epidemiology offered to all public health students should set the stage for more advanced courses by emphasizing general principles. Illustration of these principles may be drawn from the field of mental disorders. The course should separate the use of epidemiology as a basis for administrative decisionmaking and action from its use as a research tool. These uses require different approaches, utilizing different kinds of information under a different set of rules. The unifactorial and multifactorial models should be presented with a discussion of the issues involved and the advantages and limitations of each model. Prevention and treatment should be differentiated since theories and types of data sought differ depending on which goal underlies the study. Methods of evaluation and the assessment of in- dicators need to be presented. The student should gain an understand- ing of the importance of social factors; he should learn when and how to ask for the help of an epidemiologist. Teachers of mental health epidemiology will need to be trained before specific courses in this area can be developed generally. The training of epidemiologists at the M.P.H. level should include exercises drawn from the field of mental disorders to show that mental disorders are amenable to epidemiologic investigation. In presenting these examples, the special problems in this field need emphasis: problems of diagnosis and classifications, problems of use of records, the lack of uniformity of data from different sources, the differences 18 inherent in this part of the medical care system, and the difficulties of separating dependent and independent variables as noted above. Though these problems are not restricted to the epidemiology of men- tal disorders, they are particularly acute in this area. Attitudes, per- sonality, and behavior should be emphasized as factors in etiology. The psychosocial consequences of disease should also be presented. The use of psychologic and behavioral patterns as indicators need emphasis. Theories of mental disease should be presented to provide a conceptual framework for interpretation of data. The doctoral or research epidemiologist will require special con- sideration. Faculty with competence in the area of mental health epidemiology are needed to teach in this area. It is preferable to have persons engaged in research in this area to supervise thesis research of students specializing in the study of mental disorders. Lacking this, one can utilize joint supervision by a psychiatrist and an epidemiologist. Someone on this team must know the relevant theories, the potential pitfalls, and the state of development of the area to be studied. All the special problems noted before need reem- phasis for the research epidemiologist, whether working on the epi- demiology of mental disorder himself or not. Evaluation of educational programs in mental health is difficult and the group offered no simple solution. Program objectives are difficult to formulate. Are we providing a resource for students to use in meeting their educational needs and desires? Then asking students if their desires have been met would constitute an evaluation of sorts. Is the aim to diffuse mental health information more widely? Then a count of students taking these courses might be an evaluation. Is our objective to provide more people working in the area of mental health ¢ Then the number of students getting degrees, the number being placed in mental health positions, and the number specializing in the field would be criteria useful in evaluation. Is our goal to alter atti- tudes, level of knowledge, and behavior in respect to the field of mental health? Then we need attitude measures and tests of knowledge to determine our success. Is our aim to reduce the number and severity of mental health problems in society? Then appropriate statistics need to be gathered to evaluate whether or not this is being done. The group suggested a combination of measures to evaluate the effectiveness of mental health education by schools of public health: change in number of graduates in this field, number of placements and number remaining in the field, positions held with some concern for degree of leadership role, and research contributions. The last measure will have to be handled grossly, perhaps utilizing three categories: no research, an ordinary research output, and recognition of outstand- ing achievement by peers. The various measures suggested should be applied selectively so that the same criteria are not used for persons 19 in mental health practice and in mental health research. Program objectives should be multiple, not limited to the objectives of a funding agency nor evaluated solely by persons operating academic programs. Evaluation of such programs might be done by a team of agency members and of persons from schools having such educational pro- grams. This should not be done by application review bodies. The group offered the following recommendations to the National Institute of Mental Health to encourage developments related to the epidemiology of mental disorders: 1. Make teaching materials and exercises available for use in epidemiology courses; most faculty would welcome such materials. 2. Provide support for the staff needed to offer programs in the area of mental health epidemiology. 3. Provide stipends for students with special interest in this area, including psychiatric residents who wish a year of training in ride y. 4. A the development of special training centers for special- ists in this field. 5. Encourage attendance by psychiatric residents and staff at sum- mer sessions in epidemiology. 6. Establish field stations for epidemiologic studies. These stations should be established within university structure by a combination of contractual arrangements and assignment of NIMH staff. Training, research, and operations could be combined with joint participation of the university and NIMH, and, 7. Establish a joint group of university and NIMH personnel to develop appropriate methods for evaluation of education programs and to apply these to funded programs. 20 Group V Biostatistics Chairman: JouNn W. Fertig, PH. D. The primary mandate given to this group was to explore and identify opportunities within the Biostatistics segment of the public health curriculum for the inclusion of relevant mental health content which would be professionally meaningful to the general student body enrolled in the schools of public health. More specifically, although perhaps less felicitously, the group was instructed to identify the “mental health content of biostatistics.” The basic course in biostatistics in schools of public health covers a wide range of statistical methodology including descriptive and analytic demographic techniques, vital statistics, generic concepts of statistical description and reference, and basic research design con- siderations. The course is commonly taught to the entire student body drawing upon illustrative material from all phases of public health. Under the most favorable circumstances this broad range of topics is covered within the framework of a single semester course—approxi- mately 30 lecture hours and twice as many laboratory hours. The primary characteristic of the resulting instructional activity is heterogeneity—of student body, of statistical methodology, and of areas of application. Such heterogeneity, usually identified as sources of difficulty in the teaching of biostatistics, also provides unique opportunities for instruc- tion. Public health is increasingly an eclectic profession making use of information, techniques, and personnel from many diverse areas of specialization. The course in biostatistics is one of the few profes- sionalizing experiences shared by all students at schools of public health. It is also an academic experience which can touch upon and to some extent indicate the interrelatedness of all aspects of the profes- sion of public health. Consequently, the biostatistics faculty has a responsibility not only for teaching statistical methodology but also for contributing to the integration of diverse personnel and diverse subject matter that is so essential in the maintenance of a vigorous profession. The area of mental health with its foundations in both biological and social sciences and its emphasis on an ecologic community orien- tation could easily provide the entire broad variety of subject matter needed to illustrate the application of all principles and methods taught in the introductory course in biostatistics. In fact, many de- partments of biostatistics were including material relevant for mental health in their courses before there were formal courses or departments 21 of mental health in their school. The problem for the biostatistics faculty is one of selecting a limited amount of illustrative material from the area of mental health so as to maintain an appropriate mix of applications within the entire field of public health. The selection should be expected to vary from school to school but will, in general, be guided by several considerations: 1. How well does the problem illustrate an important statistical issue or method ? 2. Does the problem require an excessive amount of technical back- ground not already known by the student body as a whole? 3. Does the subject matter provide sufficient but not excessive op- portunity for diversion of student attention to non-statistical issues? 4. Is the problem material readily available ? 5. Will the mental health aspects of the problem be suitably rein- forced or amplified in some other segment of the curriculum ? There has been rapid expansion of work using statistical method- ology in all aspects of the field of mental health—laboratory experi- ments, clinical trials, epidemiologic investigations and program eval- uations. It should be recognized that many of the most important statistical issues related to the area of mental health go beyond the content normally included in the basic course in biostatistics for all students and provide challenges for advanced courses in biostatistics. Such examples are advanced life table methods, profile analysis, and multivariate analysis. Publications of the National Institute of Men- tal Health alone provides a rich source of good biostatistical teaching material. Topics in basic biostatistics which may be particularly well illus- trated by mental health data include life-table methods for the study of long-term illness; incidence and prevalence techniques for describ- ing the occurrence of disease in populations and the flow of patients through hospitals; indices of social characteristics of populations; problems of quality of basic data, e.g., reliability of classification of disease and completeness of census enumeration of special risk groups; familial and areal aggregation of diseases or risk factors; the inter- pretation of time series; and measurement of psychological charac- teristics including attitude scaling. While it may be encouraging to the mental health faculty to realize that such a wide variety of subjects from its field of special interest may be included in the teaching of biostatistics, two basic problems in the development of such teaching should be recognized. Firstly, mental health topics are in competition not only with statistical subject matter but also with every other area in public health for inclusion within the limited time of the course in biostatistics. Secondly, because biostatisticians are generally not expert in the field of mental health and because the instruction in the substantive aspects of the illustra- 22 tive problems must be restricted, there is a real risk of superficial or even incorrect instruction in mental health. The fundamental method of coping with both of these difficulties is the development of a strong faculty in mental health which is capable of taking an active interest in the development of statistical instruction relevant to mental health. Given such a department a variety of techniques may be used to integrate the teaching of biosta- tistics and mental health. Appropriate members of both departments should sit in on courses or more actively participate in the teaching of the other department. For example, members of the mental health faculty may function as laboratory assistants in the biostatistics course. Such shared teaching provides the basis for judicious selection of mental health material to be used in teaching biostatistics and makes more possible the reinforcement of biostatistical teaching in courses in mental health. The faculty in mental health should take major responsibility for organizing statistical data on the scope of mental health problems and on the efforts made to control and prevent mental disorders and to promote mental health. Collaboration in research activities of the departments of mental health and biostatistics will also provide a mechanism for insuring that the mental health content of biostatistics is appropriate and up- to-date. In addition to the impact upon the teaching of basic biostatistics, such interdepartmental collaboration can contribute profitably to the teaching of advanced courses in both departments and to the recruit- ing into mental health specialization of biostatisticians and other stu- dents in the general class at the school of public health. An active mental health department in a school of public health contributes to the integration of biostatistics and mental health not only through the teaching and research activities of its faculty, but also through the impact of their own students on the rest of the student body in the statistics course and elsewhere. Without such active support and interest on the part of the mental health faculty, the mental health content of biostatistics must be ex- pected to be more limited. 23 Group VI Chronic Diseases Chairman: Roy M. AcHEsoN, D.M. The group listed the mental health content pertinent to the fol- lowing topics which concern all those teaching chronic diseases in schools of public health: (1) principles and methods of epidemiology, (2) epidemiology of chronic diseases, (3) control programs, and (4) administration. Two other topics of interest to the specialist student in chronic disease, but not to the general M.P.H. student, were etio- logical research and administrative research. The following examples were identified from the field of mental illness which either bridge the gap between chronic organic disease and mental disease or are better than those presently available in the field of chronic disease : I. PrincieLes aNp MerHODS oF EpmbEMIoLocy.— (1) Centralized mental hospital records give an opportunity in some states for record linkage with death certificates, and historical research trends, (2) men- tal illness presents a vivid example of the problems in case ascertain- ment and repeatable diagnosis, (3) mental illness provides a good model for relating diagnosis to social disability, and (4) mental ill- ness provides a good example of the value of migrant studies. II. Ermemiorocy oF CuroNic Disease—The following are some diseases or conditions which are common and provide examples of particular epidemiological interest in both their physical and mental stigmata: syphilis, pellagra, birth injury, cerebrovascular disease, and epilepsy. III. ConTrOL.—(1) With respect to control procedures, those con- cerned with chronic physical disease have much to learn from those working with mental illness (examples include randomized therapeutic trials involving alteration of the social environment, and control pro- cedures concerned with the organization of services or with the modifi- cation of behavioral patterns rather than with the construction of buildings or the setting up of static organizations), (2) the group discussed the concept of community mental health centers. It was agreed that while the cost per patient in centers may be higher, per unit time, than the equivalent cost in a state mental institution, the benefit to the community derived from each was unknown. The solution to this problem is relevant to the planning of chronic disease control, (3) recognition was made that mental health planning has been separate from other aspects of public health and comprehensive planning. The group felt such division is inappropriate. This development was traced to the historical stigma associated with mental disease and more 24 recently to the emphasis in the United States on psychoanalysis and the consequent costliness of treatment. In turn, this situation has led to a failure of health insurance plans adequately to cover mental ill- ness, and (4) while “preventive” programs in mental health, such as certain student health services, are more ambitious than many pro- grams concerned with the pre-symptomatic diagnosis of chronic dis- ease, they urgently need evaluation. An instance was cited of a university program which has used screening questionnaires and is heavily overburdened with the management of minor mental illness, yet has been almost entirely unsuccessful in predicting, let alone preventing, suicide attempts. IV. ApministraTioN.—The faculty concerned with mental health, particularly its social contexts, has much to offer in teaching adminis- tration to all students of public health. In particular, mental health faculty can offer instruction in group dynamics and institutional processes. V. Ertorocicar ResearcH.—In this area examples from mental ill- ness are less fruitful and less abundant than in chronic disease. While it was recognized that case history (retrospective) studies were the simplest to execute, the following possible opportunities for cohort (prospective) studies were cited: (1) postpartum depression and psychoses, starting with pregnancy or birth certificate, (2) the epide- miology of bereavement, starting with death certificates, and (3) mental deficiency and birth weight, starting with birth certificates or hospital inpatient records. The group offered the following recommendations: 1. That teachers of chronic disease search for pertinent examples in the epidemiology and control of mental illness when such examples do not exist in their own field. The Table appended to this report lists pertinent examples indicating (a) areas where mental health is “ahead,” (b) areas in which there is a genuine common interest be- tween the two fields, and (c) areas in which mental health has probably lagged behind chronic disease. 2. That the spectrum of disease be presented to M.P.H. and special students as a continuum; conscious effort should be made to avoid treating mental illness as a separate subject. 3. That training funds be made available to support M.P.H. and doctoral students who come to schools of public health directly from college in the study and control at a community level of all disease, including mental disease. 4. That NIMH make available to faculty normally concerned with teaching chronic disease, material and bibliographies on the epide- miology and control of mental illness; this will be helpful to teachers of chronic disease who tend to be “insecure” when they use mental health material. 335-225 0—69——3 25 5. That an attempt be made to integrate the training of psychiatrists and other clinical mental health professionals with the training of public health students. In particular, mental health people should be encouraged to take courses in epidemiology, biostatistics, and adminis- tration given in the schools of public health. 6. That all M.P.H. and special students be given an understanding of the individual and social aspects of human behavior with a view to gaining insight into the impact of such behavior on the epidemiology and control of chronic disease. The group recognized the problems in selecting relevant aspects of social and psychological science, and in evaluating the ability of students, especially the M.P.H. student, to comprehend these principles in the limited time available. 7. That those concerned with screening programs and programs in pre-symptomatic diagnosis of chronic physical and mental illness develop common techniques for evaluating the efficacy of such programs. 8. That joint programs based on the identification of social disability be developed by workers in mental health and chronic disease with a view toward the establishment of effective methods of rehabilitation (e.g., the maintenance of independent status in old people). Differences of opinion were expressed in the group as to whether the overwhelming concern in the United States with psychoanalysis has interfered with the public health aspects of mental health by obscuring useful course content, and by preventing experimentation with control techniques which may be effective on a community basis. A minority felt the problem lies with the hospital-academic orienta- tion of psychiatrists. It was agreed that the mixed backgrounds and varied future goals of the usual M.P.H. class make the effective introduction of any course material extremely difficult. 26 TABLE Illustrative Areas: Mental Health and Chronic Disease MENTAL HEALTH COMMON INTEREST AND CHRONIC DISEASE © “AHEAD” PROBLEMS “AHEAD” 1. Centralized hos- 1. Diagnostic 1. Chronic pital admission records in some States (a valuable epidemio- logical resource). 2. Randomized trials of manipulation of social environment. 3. Community- based control pro- cedures, rather than those based in institutions. 4. Theory and teaching of admin- istration. 5. Use of para- medical workers in treatment and control. problems in epidemiological research. 2. Use of mi- grants for epidemio- logical studies. 3. Models for relating diagnosis to social disability. 4. Diseases with physical and mental content, e.g., cerebrovascular disease, rabies, epilepsy, scurvy, etc. 5. The problem of cost-benefit analysis in control procedures. 6. Problem of evaluating indi- vidual health outcome in screening and presymptomatic diagnosis programs. disease control and care is fully in- tegrated with com- prehensive planning and health insurance schemes. 2. Etiologic research. 3. Screening by risk factors. 27 Group VII Maternal and Child Health Chairman: RoBerTr H. LENNOX, M.D. The group recommended that some mental health teaching should be available to all candidates studying for the M.P.H. degree. Up to the present, maternal and child health teaching programs have in- cluded variable amounts of mental health material. There has been, however, an outstanding lack of mental health personnel in maternal and child health departments of schools of public health. It is anticipated that once this deficiency is recognized, a cooperative integrated teaching program between the two disciplines will result. Instructional programs in maternal and child health by experts in mental health would improve the overall caliber of the teaching program. Through on-going maternal and child health programs, mental health personnel can become acquainted with “normal” families and their developing children and adolescents. Further extension of these programs to the handicapped child or battered child offers the mental health worker a fertile field for study. In addition, maternal and child health teaching programs include new areas of concern to students of mental health, e.g., genetic counseling, artificial insemination, contra- ception, drug addiction, etc. There is an outstanding need for community teaching laboratories for schools of public health. Such laboratories would be developed by maternal and child health personnel in conjunction with mental health specialists. The use of these facilities by personnel of the combined departments would form valuable community teaching, training, and research centers. . To foster the integration of maternal and child health and mental health teaching the group recommended: (1) increased NIMH train- ing grant support for mental health faculties in schools of public health; (2) programmatic support for research projects of mutual interest to both maternal and child health and mental health faculties. 29 Group VIII Public Health Nursing Chatrman: DororHY McC. TarBoT, M.A. Public health nurses function at different levels with varying roles. Each level and role has its own competence requirements and training needs. However, the group agreed that public health nurses should have knowledge in the following mental health content areas: growth and development ; the family ; the community ; levels of social control; group processes; assessment and evaluation of health needs of indi- viduals, families, and communities ; management theory ; and research. In addition, public health nurses require understanding of the preva- lence of mental health-related problems and measures for intervention. Because nurses enter schools of public health with widely variant preparation in mental health and psychiatric concepts, such content must be highly individualized in their training programs. In addition, schools differ in the way in which they incorporate mental health con- tent into the curriculum. In most instances, three main channels are used—core (required course) content, elective courses in mental health, or integration in other courses such as maternal and child health or supervision. Whatever the pattern there should be assurance that mental health content is included. The public health nurse must be prepared to function simultaneously with individuals, families, groups and communities in matters relating to mental health. Such diversity requires different sets of skills and understandings. Moreover, public health nurses need preparation to work in critical problem areas such as poverty, with multiproblem families, and in suburban settings with a high incidence of emotional problems. Consultation skills should be considered as essential equipment for any leadership position in nursing. 30 Group IX Population Control and Family Planning Chairman: JoEN C. CUTLER, M.D. The group focused its concern on the following issues: How can mental health concepts be formulated and presented so as to be under- stood by and be useful to public health personnel working in or con- cerned with family planning? Is there clearcut evidence of a specific relationship between mental illness and family size and spacing or population density? What assistance can mental health expertise and experience offer to the public health worker who must be able to work with sex and sexual behavior in family planning programs and services, in teaching, or in planning and administering such programs? Is it reasonable to consider the mental health aspects of population and family planning as an integral part of total public health practice? These general conclusions were reached: (1) that certain types of mental illness and social maladjustment (which was considered by the group to have a large mental health component) bear a relationship to unwanted, unplanned, or untimely pregnancy; (2) that the training program of public health specialists in population should have (as an integral element) the instruction in mental health concepts and tech- niques that is required both for the use of the professional in the exercise of his career, and in his preparation to work (with maximum effectiveness and productivity) with mental health specialists whose co-operation will be required for successful operation of population programs; and (3) that health professionals such as physicians and nurses must be taught to appreciate the importance and necessity of advising and furnishing or making accessible family planning and related services in preventing progress of mental illness, in manage- ment of mentally ill patients, etc. Attainment of many mental health objectives can be assisted by family planning and the implementation of population policies. Like- wise, attainment of population policy and family planning goals can be facilitated by utilization of mental health concepts and techniques. The introduction of family planning and population programs and concepts into public health practices is so recent that teaching of workers in this field must be innovative, must draw upon experience of faculty of many other fields, and requires preparation of faculty by a variety of methods. Techniques must be developed to deal with personal attitudes and feelings related to sexual matters on the part of 31 faculty members in professional preparation for teaching in this field. In turn, the faculty needs to include attention to this problem in its teaching of students because of the influence of attitudes and feelings on the delivery of and acceptance of consultation, advice, and services in the areas of reproduction and sexual behavior. The group felt that the mental health professions should take a stand in support of family planning when it is an appropriate element of preventive or curative mental health practice. Consideration was given to the lack of sufficient experimental evi- dence required to evaluate the relationship of many elements of popu- lation density, size, distribution, etc., to mental health. Increased sup- port of research in this field is necessary to provide a basis for more effective public policy determination and resultant public health practice. As findings become available, they should immediately be integrated into training programs so that they then may be reflected in improved delivery of mental health services. The group recommended that support to mental health training programs in schools of public health be continued and increased to permit greater input of the mental health elements of family planning and population programs. 32 Group X Environmental Health Chairman: Morton S. Hmserr, M.P.H. The group felt there is a need to integrate the conceptual aspects of mental health in the teaching of environmental health. The following inputs should be considered with regard to course or content material for the environmentalist: molding public opinion or public action, public decisionmaking ; social and psychological patterns of the pop- ulation served; how to help others to help themselves; social and cultural organization ; social, cultural, political, and economic impli- cations of public health; understanding of available mental health resources as applied to environmental factors; and effect of the par- ticular environmental health service on the people served. General conclusions reached by the group included a consideration that the optimal situation would be for the environmental health fac- ulty to incorporate relevant concepts in mental health or human ecology in the teaching of environmental health. Attempts should be made in such instruction to include preventive measures in environ- mental health against mental stresses. A second strategy involves a team planning approach between the mental health or human ecology specialist and the environmentalist, the latter providing instruction. A third approach calls for separate lectures presented by a mental health or human ecology specialist. The group specifically recommended that environmental health fac- ulty be oriented to the needs and the importance of integrating concep- tual principles of mental health in the teaching of environmental health. A course or teaching content on human behavior should be based on examples applicable to environmental health. 33 Group XI Occupational Health Chairman: Jost NiNe-Curt, M.D. The group emphasized the need for recognizing the relation of the individual to his work and the community environment. Mental health specialists could contribute toward teaching this relationship and toward sensitizing students to emotional needs within the work setting. Since mental health instruction should be related to the specific public health subspecialty areas, various types of mental health instruction may be needed for different programs. Accordingly, the group felt that a diversity of teaching programs should be stimulated and encour- aged rather than conformity to a specific curriculum be required. The mental health faculty member who wishes to contribute to instruction in a public health subspecialty needs special training for such teaching. In relation to occupational health, the mental health teacher must know the specific problems of the environment as well as the intrapsychic aspects. The most favorable teaching approaches should be problem oriented rather than subject oriented. The mental health aspects of occupational health include concern with the total environment, including the social, emotional, and ethnic factors as well as physical factors. The group stressed the importance of selecting the individual for the job and fitting the job to the worker; this concept was defined as “ergonomics.” Group XII Nutrition Chairman: MERVYN G. HArpINGE, M.D. The group indicated that inclusion of mental health concepts and principles is essential in the teaching of nutrition. In nutrition courses for non-majors, the group agreed that relevant mental health concepts and principles should be introduced with the more accepted material on nutrition, and particularly in connection with special areas such as expectant mothers, infancy, adolescence, old age, obesity, etc. For nutrition specialists, additional opportunities exist to offer participa- tion experiences such as seminars, nutrition surveys, and family care. Concern was expressed about using instruction in nutrition as a vehicle for making all students aware of social and behavioral prob- lems. Obstacles inherent in large classes and limited curriculum time were cited. 34 Section Reports SECTION REPORTS Groups |, Il, and lll Section Reporter: Ricuarp K. C. Ler, M.D. As I listened in on the three groups, I found that they spent a good deal of time discussing the scope and meaning of mental health. One group tried to define mental health. Group I, chaired by Dr. Hume (Public Health Administration), identified the areas of con- cern in which individuals must have knowledge in order to under- stand mental health and to function appropriately. This group listed nine different subject areas which they identified as having mental health content: (1) psychological components of physical illness, par- ticularly the psychological determinants and consequences of physical illness; (2) personality development; (3) nature and characteristics of mental disorders; (4) social disintegration; (5) interpersonal skills; (6) organization and management of mental health programs; (7) determinants of health behavior; (8) social institutions and com- munity structure; and (9) psychological and social aspects of en- vironmental health. I am stressing these nine points because the group spent a great deal of time getting the proper listing and the language describing these areas of concern. Group II, Hospital Administration and Medical Care, also tried to describe the areas of concern, or as they described it, the mental health aspects. They listed four areas which were generally covered by the nine areas described by Group I. Group III, Health Education, found that a single definition of mental health was impossible. They believed that many definitions were needed, and that we probably shouldnt use the mental health rubric, but should state what it is we talk about in ways we can rec- ognize. They felt that mental health refers to the proper functioning of human beings, and in this sense it overlaps all levels of training and functioning activity. All three groups reviewed the working papers. One group spent a great deal of time studying and analyzing their working paper in depth. The authors of the working papers were making changes fol- lowing ideas brought out in the discussions. A common area of con- cern all through the meeting was the curriculum. Each school of public health has certain unique qualities and strengths, each emphasizing the training of certain types of health professionals. Each also has a slightly different concept of its edu- cational responsibilities. This diversity is a highly desirable char- acteristic and should be fostered. There should be no effort to impose conformity in curriculum development or methods. Rather, every 36 effort should be expended to build on the peculiar strengths of any given institution. " This feeling was a unanimous one among all the groups. One group went so far as to refer to the “poor role” played by granting agencies, when efforts were made to influence unreasonably the cur- riculum of schools. It was agreed that in any special field—not excluding mental health—the most important ingredient in the development of adequate curricula to serve both generalist and specialist groups, is for a free two-way flow to take place between faculty members interested in both groups and for this to be reflected in the course content and curricula. Every effort should be made to introduce appropriate mental health content into the general health program. It was believed there is cur- rently more need to get general public health and specific health ad- ministration content into programs designed to prepare mental health specialists for administrative roles in their special field. Among the most effective ways of introducing mental health content into general public health administration courses is the involvement of the general public health administration faculty in the teaching of mental health specialists and the increasing involvement on the part of mental health students in general administration courses. One of the best ways of introducing specialized content in any field in courses designed for generalists is to use examples from the special- ized fields in such courses as biostatistics, epidemiology, comprehenive health planning, and so on. Or one can offer attractive elective oppor- tunities for those students who wish to explore the field in greater depth. Or there may be the development of joint or interdepartmental courses. Two groups stressed that it would be most worthwhile to em- phasize the mental health components in comprehensive health plan- ning courses and participation by mental health faculty in these courses, as well as the enrollment of mental health students in such courses. Group II, Medical Care and Hospital Administration, had a news- letter from the APHA describing some current important issues in the teaching of medical care in hospital administration. They felt that mental health should be incorporated in these issues. For example, the newsletter included a description of the mixture of public and private arrangements for medical care, the demand for more efficient methods for organization and delivery of services, the plight of hospitals, the rising costs of medical care, the persistent shortage of health manpower, the crisis in medical care for the poor, and the need for a single standard of personal health services for the full popula- tion. The group felt that certainly the mental health components in these areas should be included. 37 Group III, Health Education, suggested that we could not infer from this conference structure an awareness of major concerns over public health today which reflected radically new approaches to public health problems from other than the disciplinary approach. The con- ference seeks to find answers to what should be new questions from es- sentially traditional public health structures. The group questioned the assumption that this is an appropriate way to develop curricula. This group also felt that the framework given—mental health and health education—is a dichotomy ; they were asked to point out this dichotomy and they felt that they couldn’t. They explained that in some settings the health education and mental health professionals can be and are interchangeable, whereas in other situations this is not possible. The group felt that universities traditionally have been sep- arated from communities, and today there is need for them to be more aware of and responsive to the community and its problems. With specific reference to mental health, Group III suggested that teaching methods and content should draw heavily from the com- munity. This group also felt there was too much professionalism as a cult in public health practice. The group noted that prejudice against minority groups was recognized as a problem of some consequence in the professional worker himself and could be treated in part at least through mental health and educational efforts. Group II, Medical Care and Hospital Administration, noted the trend toward integrating mental health with other health services. For example, psychiatric patients are being treated in general hospi- tals; another trend is away from the huge custodial institution towards the community mental health centers. Both trends imply that a new and broader scope of appeal may be envisaged. Therefore, some mental health content must be included in the training of medical care and hospital administrators. There were a number of recommendations to NIMH relating to integration and coordination of general and mental health administration : (1) It was recommended that the National Institute of Mental Health sponsor a survey of programs of schools of public health to determine what is currently being taught, particularly in the nine areas mentioned in Group I. It was further recommended that the survey team should be represented by several disciplines, such as mental health, public health administration, and the behavioral sciences, and that the members should be intimately acquainted with schools of public health. (2) The health education group suggested research by NIMH into factors which are blocking effective preparation of health professionals for practice. 38 (8) It wasrecommended that close relationships should be promoted among the students specializing in public health, medical care, hospital administration, and mental health. The present day training of medical care and hospital administration specialists should be influenced by a sound estimation of future roles in the several services, including mental health services. In conclusion, two items from the three groups were a continuing thread through the discussions. One is that while many schools have competence in the faculty to cover mental health content in a number of areas in depth, others may need to add staff in one or more areas to offer instruction even at an introductory level. Competence may lie in a department of mental health in one school or may be provided through other departments. The second item was that comprehensive health planning encompasses the entire field of health services. It will be an important means of bringing together the different components of health services. Training courses and comprehensive health planning should include mental health components. 39 SECTION REPORTS Groups IV, V, and VI Section Reporter: Epwarp M. Corart, M.D. I am reporting on the deliberations of the working groups in biostatistics, epidemiology, and chronic disease. All three groups, al- though they suggested some changes, essentially were in agreement with the prepared working papers. Biostatistics ‘and epidemiology had two very important things in common. One was that a basic course in each is commonly required of all students. The second was that they were concerned more with concept and method than with content. Their concern was with con- cept and method that would form the basis for the understanding and practice of public health, including mental health, rather than with the subject matter which in both courses is used primarily for illustrative purposes. By contrast, a course in chronic disease is not required as frequently for all students. Secondly, chronic disease is a subject matter field that is concerned not only with the principles and methods of epi- demiology and control, but also with descriptive epidemiology of the chronic diseases and with the administration of programs for their control. The basic course in biostatistics in schools of public health covers a wide range of statistical methodology, including descriptive and analytical demographic techniques, vital statistics, generic concepts of statistical reasoning, specific statistical methods, and considerations of basic research design. The course is commonly taught to the entire student body drawing, as I indicated, upon illustrative material from all phases of public health. Under the most favorable circumstances, this broad range of topics is covered within the framework of a single semester course, in approximately 30 lecture hours and about twice as many laboratory hours. The primary characteristic of the resulting instructional activity is heterogeneity : heterogeneity of the student body, heterogeneity of statistical methodology, and heterogeneity of areas of application. These sources of heterogeneity are usually identified as sources of difficulty in teaching. The biostatistical group felt that public health is increasingly an eclectic profession, making use of information, techniques, and per- sonnel from many diverse areas of specialization. The course in bio- statistics is one of the few professionalizing experiences shared by all students in schools of public health. Consequently the biostatistics faculty has a responsibility not only for teaching statistical method- ology but also for contributing to the integration of diverse personnel 40 and diverse subject matter that is so essential in the maintenance of a vigorous profession. The group felt that the area of mental health, with its foundations in both biological and social sciences and its emphasis on the ecological community orientation, could easily provide the entire broad variety of subject matter needed to illustrate the application of all principles and methods taught in the introductory course in biostatistics. The problem for biostatistics, then, is one of selecting a limited amount of illustrative material from the area of mental health so as to maintain an appropriate mix of applications within the entire field of public health. This selection should be guided by a number of con- siderations, among which are: How well does the problem illustrate an important statistical issue or method ? Does the problem require an excessive amount of technical background not already known ? Does the subject matter provide suffi- cient but not excessive opportunity for diversion of student attention to nonstatistical issues? Is the Problem material readily available? Will the mental health aspects of the problem be suitably enforced or amplified in some other segment of the curriculum ¢ Essentially similar comments.apply to the basic course in epidemi- ology. These are the limited time for the course, the variety of epi- demiological methods to which the student should be introduced, the heterogeneity of the student body, and the desirability of selecting examples that individually are most suitable for illustrating particu- lar epidemiological concepts or methods and in their totality are most likely to convey to the students the range of applicability of epidemiology. Some consideration was given to topics in the basic courses in bio- statistics and epidemiology and chronic disease that might be particu- larly well illustrated by mental health data. These include: life-table methods for the study of long-term illness; incidences and prevalence techniques for describing the occurrence of disease in populations and the flow of patients through hospitals; indices of social characteristics of populations; problems of quality of basic data—for example, re- liability of classifications of disease and completeness of enumeration of special risk groups; familial and areal aggregations of disease or risk factors; the interpretation of time series; the measurement of physiological and psychological characteristics, including the meas- urement of attitudes and attitude-scaling; the whole problem of atti- tudes, personality, and behavior as factors in the natural history of disease; problems in the separation of dependent and independent variables; diseases with both physical and mental components—and in this connection the psychosocial consequences of physical disease; social status; social mobility ; status incongruity and culture change; record linkage where, for example, centralized hospital data for mental hospitals can be related to death certificates; randomized trials of 335-225 0—69——4 41 manipulations of the social environment; community-based rather than institution-based control procedures; and the use of paramedical workers in treatment and control, in which it seems mental health has progressed further than have the other aspects of public health. There were other topics also. Large as the list is, it could probably be extended much beyond those topics considered by the various groups. The groups pointed out that mental health content couldn’t be used to the exclusion of other content areas. Some attempt should be made to give to each content area its proper due. It was also pointed out that the quantity and quality of teaching of mental health content in each of the disciplines I am reporting for can be strengthened by the development of a strong faculty in mental health capable of taking an interest in and contributing to the teaching in each of these other disciplines. The epidemiology group emphasized the importance of making clear to students the differences in terms of objective, in terms of the data needed, and in terms of the approaches used between employing epidemiology as a basis for administrative decision making and epi- demiology as a research tool. The epidemiologists felt that, although all students should receive basic instruction in the behavioral sciences relevant to public health, only selected students need specific instruction in the epidemiology of mental and emotional disorders. The epidemiology group also discussed the method and the appli- cation of evaluation. They recognized the difficulty and the importance of evaluating educational programs. One of the problems presented in evaluation was a lack of clarity as to objectives. What were the educa- tional objectives? A second equally crucial problem related to the indices to be chosen and measured as indicators of success in reaching the stated objectives. The epidemiology group suggested a combination of measures to evaluate the effectiveness of mental health education by schools of public health. These included change in the number of graduates in the field, number of placements and number remaining in the field of mental health, positions held (with some concern for degree of leader- ship), and, finally, research contributions. Program objectives should be multiple, they felt, and not limited to the objectives of the funding agency, nor ev usted solely by the per- sons operating the programs in academic institutions. It would seem appropriate to have a program evaluation group made up of agency members and of persons from schools having mental health programs. It was felt strongly this should not be done by study sections concerned with funding. Finally, a number of recommendations were made. One recommen - dation was that the spectrum of disease should be presented to M.P.H. 42 students as a continuum with a conscious effort made to avoid treating mental illness as a separate subject. A second recommendation was that teachers in the several areas should search for pertinent examples in the epidemiology and con- trol of mental illness. In this connection, the feeling was that most faculty would welcome teaching materials, exercises, and appropriate bibliographies made available to them by NIMH. Thirdly, all students should be given an understanding of the in- dividual and social aspects of human behavior as it relates to epidem- iology and control of illness. Fourthly, support should be provided for mental health faculty, not only in the interest of training mental health specialists but also for the impact such faculty should rightly have on the teaching of other disciplines to all students. Fifthly, in a parallel vein, the training of mental health specialists should be integrated more closely with the training of public health students in general courses, and particularly in courses in biosta- tistics, epidemiology, and administration. Another recommendation was that efforts should be made jointly by those interested in physical illness and in mental illness to develop and evaluate programs directed at case-finding and at rehabilitation. A number of recommendations were made that were more directly concerned with the mental health specialist than with the general student in public health : (1) Training funds should be made available for others besides the categories of students now eligible for support for mental health training. Special attention was called to the need to support students right out of college who might be interested in coming to schools of public health to prepare for careers in community mental health. (2) NIMH should continue to stimulate the development and opera- tion of training centers for specialists in the mental health field. (3) In the interest of furthering mental health epidemiology, NIMH should help establish field stations within appropriate univer- sity settings for the epidemiological study of mental illness, and NIMH might also provide stipend support for psychiatric residents who wish to pursue a year of training in epidemiology. The final recommendation was that a joint group of university and NIMH personnel be established to develop appropriate methods for the evaluation of mental health educational programs and to apply these methods, then, to the funded programs. 43 SECTION REPORTS Groups VII, VIII, and IX Section Reporter: Myron E. WEaMaN, M.D. I take pleasure from the fact that my two colleagues have already spelled out a number of points which will make it easier to report on our three groups. Actually, they didn’t discuss all of the things the previous six have. I am impressed at how much difference there was in terms of coverage, despite certain similarities among the three groups. There were a few points that were brought up through all of them and that I think might be emphasized at the start. There was a discussion about the balance between public health and mental health. There was agreement among all three of our groups that from the conceptual standpoint, certainly, mental health is an integral part of the total picture of human health, in the same sense as the concept of such factors as nutrition or growth and develop- ment in the total picture of human health. Any distinction in termi- nology between “public health” and “mental health” might be looked at as dealing with existing operational situations rather than concept. Any attempt—I made an attempt at one stage—to indicate some kind of dividing lines between physical health and mental health, or between the influence on host and environment of physical, social, or biological factors, was rejected by all three groups as being far too limiting. One of the common concepts in all three groups was related to the interpretation of the word “preventive” in mental health. There was common agreement that when we use the word “preventive” in mental health we think of prevention of tension, prevention of turmoil, promotion of reasonably friendly relationships, without going into implications about the possible relationship of this to the prevention of overt mental disease, a subject which we felt we could not get into at this time, and as to which there were varying degrees of knowledge and ignorance. We did, however, on the basis of at least one of the group reports, consider the subject against the framework of five levels of preven- tion or some of the other attempts to differentiate between health promotion, prevention of specific disease, early detection and treat- ment, rehabilitation, and so on. I might point out that the three groups on which I am reporting were separated for really quite different reasons. In the first place, the public health nursing group had a different charge from the other 11 groups of this conference, in that they were dealing with a closely defined group of health workers. Public health nurses have a poly- Ad valent task to perform in relationship to all areas of organized health activity, and they have the greatest opportunity for working with individuals and with families. In almost every aspect of their work and interaction with the community, there are enormous possibilities for utilizing and implementing mental health concepts. In maternal and child health, one is dealing at any given time with a group of the population, but over a period of time one is dealing with every single member of the population. The distinguishing feature at the time of major consideration is growth and development, among the most important distinguishing characteristics of mental health given the growth and development of personality and the interrelationship between physical growth and mental and emotional growth. At the same time, the maternal and child health people deal with certain special risks inherent in this growth process; one never forgets, however, the special opportunities in this period for a positive approach to introduction of mental health aspects. The maternal and child health group recognized—at least one member did—that Dr. Dubos’ speech last night really covered about everything we had to say; if I were smart I wouldn’t make a report but would just remind you to think again of what he said last night. The family and population planning group dealt with one of the newest of all of the recognized responsibilities of public health. As of this moment we vary all the way from enthusiastic engulfing of the concept of population planning to frank resistance to it. It strikes me as interesting—this was not discussed but I have to throw it in—that the attitude towards population here is poles apart from that of a century ago. The organized maternal and child health movement had its start in France because of a concern over population, because the relatively falling population of France vis-a-vis Germany and some of its political neighbors was a source of serious military concern. Child health had to be fostered in order to help the population (and the army) grow more rapidly. Now we think of population planning in terms of global population ; interaction with maternal and child health is very strong. Mental health aspects are repeatedly and constantly concerned with family size, husband-wife relationships and the whole problem of sex relations. All our groups found that the problems we were talking about over- lapped each other in some degree to all three levels of interest. We were all talking about postbaccalaureate training. Nobody wanted to go into the question of what students came prepared for in their baccalaureate training. But we did think that in the masters’ level training at schools of public health, all students ought to have some- thing related to maternal and child health and to population. Not all agreed about nursing, as distinct from working with nurses. 45 Finally there is the problem of the third level, the specialists in each group. Our various groups thought the differences between the levels was a matter of degree rather than anything else. All of our groups found that the papers from which they were working were exceedingly use- ful, quite comprehensive. A series of suggestions were made about changes, but neither in this report nor in the discussion in the groups was there an attempt to list all of the specific recommendations, in view of their prospective inclusion in the final report. The groups emphasized the reciprocal relationship of maternal and child health teaching and mental health teaching as one example. This also applied in nursing and population planning. In one school the introductory course in maternal and child health had so much overlap with the introductory course in mental health that it was to the distinct advantage of both units to combine the teach- ing into a single course. It was thought that more exploration could be made of that kind of situation. There was a strong feeling that mental health needs and mental health aspects needed to be intensified through- out the curriculum relating to three subjects, but the actual methods of how this is to be introduced will have to vary considerably accord- ing to the pattern of the individual school. All three groups emphasized—the nurses perhaps more so than the others—the peculiar advantages of the multidisciplinary enviroment in a school of public health for the teaching of the kinds of relation- ships we are talking about. For example, maternal and child health is based upon the concepts of growth and development which, however, also involve teaching in nutrition, teaching in relation to infectious disease in early childhood, and the concepts of biostatistics in measur- ing growth and development. Putting this teaching in the environment of a school of public health had distinct advantages for the teaching of mental health as an interrelated, all-pervading concept. Our nursing group was particularly emphatic on this, pointing out that for the proper training of nurses at the gradute level, a school of public health offered particular advantages that no single profes- sional school could offer. Vice versa, the contribution of nurses to the training of other health workers was emphasized as strongly. Con- tinuation and extension of this is urgent. Incidentally, in talking about the character of the environment of the school of public health, one of the groups—which I won’t identify for fear of reprisal—had good things to say about deans. As far as specific recommendations are concerned, the nursing group, for instance, had a long list, which will appear in their report, of ma- terials which they thought needed to be included in the teaching of nurses. They emphasized that they would not specify in any way where or how this material should be included in the curriculum or even 46 whether it should be in nursing courses, in mental health courses, in general administrative courses, in epidemiology, or wherever. They emphasized the need for inclusion somewhere. The population plan- ning group emphasized the overlap which occurs in such a subject as child abuse. Is this properly a subject to be limited to population planning ? Doesn’t it affect other parts of the school of public health ? The problems of child abuse certainly have close interrelations with socioeconomic factors as well as with mental health as a concept. There was emphasis in all the groups about the need in teaching pro- grams for using real-life situations. One group pointed out the con- trast between the picture of the patient who arrives in a clinic or at an institution well-dressed, giving the appearance of independence and assurance, and what the student sees in the home. To see such a person in his own environment may present an extraordinary contrast. The need for teaching in a real-life situation is not satisfied by seeing the patient in a clinic setting. By the same token, there was considerable emphasis on the impor- tance of a professor’s feelings with regard to the particular subject he was talking about and the interrelationship of this with mental health. The instance given in one group was the fact that the health worker, in talking about such subjects as abortion, is affected very seriously by his own feelings as to when life begins. Technically, the WHO defini- tion says that life begins at 20 weeks of gestation because before that a baby is not viable, even if he is born alive. Nevertheless, the indi- vidual students very so much in their attitude toward this that teachers must understand the variation in the feelings of the worker as well as the variations in the feelings of the teacher. It was recommended that various ways might be taken to improve this with the use of faculty seminars or other methods of faculty interchange. There was considerable emphasis in all three of these groups on the importance of research and particularly on the importance of prospec- tive studies. There was considerable pointing the finger at the absence of prospective studies and of critical design in the field of mental health. There was emphasis on the need for greater investment and greater stimulation of this. Finally, some words about the role of the National Institute of Mental Health. It comes as no surprise to the leadership of the Institute or to my colleagues to know that all three of the groups recommended greatly increased support. They recommended this greatly increased support with reasonable controls. There was a very strong feeling that objectives needed to be set out in terms of any granting program specifying what funds were ex- pected to buy. What changes might occur ? What kinds of people should be trained ? What kinds of training should they have? But there was a steadfast decrying of any attempt to spell out a particular pattern, 47 not alone because of the variation in the schools but because any attempt for a control group to add up courses, hours, or anything of the sort is completely futile. I add here my own prejudice by telling you what I told a student who was asked, “How much mental health or maternal and child health or epidemiology or anything else did you have in your course?” I told him to say, “I don’t know. Our course is not designed that way. We can’t tell you the number of individual courses or the number of specialized hours. If you want to, we will be glad to review the total subject matter.” I think this has important implications for the manner of supplying aid. There was a strong feeling that the objectives need to be spelled out clearly so that an evaluation could be made of them and to decry vigorously any attempt to come later and evaluate a program when the objectives had never really been set out in the first place. This is a futile exercise that won’t work. Finally, all three of the groups were very grateful for the oppor- tunity to have this interchange. They felt that the National Institute of Mental Health had made a great contribution to the mental health of at least these three groups. 48 SECTION REPORTS Groups X, Xl, and XII Section Reporter: WitLiam F. Mayes, M.D. I’m surprised at the lack of duplication and repetition in the first three reports. I think this is terrific. I am quite impressed. I will be speaking for three groups: Environmental Health, Occu- pational Health, and Nutrition. I have not attempted to repeat details that appeared in the reports of the chairmen, which will be available to staff and to others. I have attempted to follow roughly the format as suggested by the program planners of the conference, and that is to discuss in general terms some of the unique features of the three different groups, some of the major issues or problems that ran through all three of these groups, and then finally some of the recommendations that would apply. But detailed specifics and listing of examples I have not done in this report. So, in this respect, this report differs somewhat from some of the other reports. As for some of the common features—there were half a dozen of these, I think I have eight actually—all three groups attempted defini- tion of their community health subspecialty and either continued to the point of being satisfied that they could define it or they couldn’t do so, or it wasn’t appropriate to define the particular subspecialty area (en- vironmental health, occupational health, or nutrition) and mental health. They all identified these related areas in different ways, but they did identify what they considered mental health experts. There were some variations, of course. They all agreed that there should be involvement of mental health experts in their particular subspecialty teaching program, but they didn’t agree on what the nature and extent of this involvement might be. They each gave examples of mental health curricula or teaching contents that they felt to be appropriate to their particular areas of concern and responsibility. In the working papers and in the discussions all three groups de- scribed to varying degrees the actual content of these particular areas— specifically, the teaching content, research content, and service or practice content. Each of the three groups listed specific examples of preventing stress and other mental health problems within the context of that particular area of concern. They all related or attempted to re- late mental health content within that subspecialty context. They also tried to relate this content to the mental health content, within the comprehensive community health care context, but with varying degrees of success. All of the groups at one time or another discussed the artificiality and futility of trying to isolate or separate mental health from phys- 49 ical and social health, when in reality (as they felt) they were all so intricately interwoven in essential components of the total or compre- hensive health of the individual or the group or the community. They concluded that it is a useless exercise and even a disservice to the approach to the total health and well-being of the individual, family, or community to perpetuate attempts at this artificial division. These were some of the commonalities discussed in all three groups. Following are some unique features of the discussion, one or two from each group. The environmental health group had quite a concern for the “interface,” as they called it, between the internal environment of the individual and the external environment of the individual. The environmental health group also discussed the importance and role of mental health in the understanding and maintenance of the ecological balance or equilibrium of man in his world. The occupational health group had two or three unique areas of dis- cussion that didn’t occur in the others. One thing I noticed, at the be- ginning at least, was that when the occupational health group spoke of a mental health expert, they were always speaking of psychiatrists. This distinction wasn’t true in the other groups, and later in the occu- pational health discussions, when someone called attention to this, it was admitted that there were other mental health specialists, but this identity of the mental health expert as a psychiatrist had been the automatic response. A second difference in this group was their interest in the creative values of stress in the work situation. This was the only group that discussed stress in this sense. All the other groups discussed trying to avoid or prevent stress. This group saw the value in what they called “creative stress.” A third unique discussion point was the role of mental health con- cepts in the practice of a science and art of what they call “ergo- nomics,” which I understood to be the fitting of the job to the worker, or the employing of the worker for a specific job, or a combination of the two. In the nutrition group, all members viewed the nutrition educator as a change agent. The working paper had five or six pages devoted to this concept. Therefore they were very much interested in the mental health aspects and concepts and practices in the change process. The nutrition group also attempted to distinguish between the prevention of mental illness and the promotion of mental health. This was an interesting exercise; at some points the differentiation was indistinct. The nutrition group discussed another unusual subject which became exciting later in the same day. That was the possibility of using ex- perimental animals in the study of mental health as research models for the study of mental health in humans. This discussion took place before Dr. Dubos’ presentation last evening. This morning I learned 50 that the man who was discussing this approach, in the nutrition group, is a very close friend and scientific cohort of Dr. Dubos. Some of the major issues or problems that were identified in the group discussions I have pooled into three clusters. Therefore they won’t appear here exactly as they will in the reports, but they are con- sistent in content. The first of these problems that I have listed here in the summation is the question of whether all the students of every community health subspecialty should be exposed to areas of knowledge in mental health. The usual end of such a discussion was that all students should be exposed to some aspects of mental health content. But the more difficult and more directly related question had to do with how these areas of knowledge could be taught and demonstrated in the most meaningful and effective way. The second problem area was concerned with the extent and methods of involvement of mental health experts in the teaching of mental health concepts and practices in given subspecialty contexts. The third problem area was identified as the existence of a parallel of ignorance or naivete or lack of information: the mental health expert, with regard to the other health subspecialties, and the other health subspecialties with regard to the content and context of mental health. They were parallel in the sense that each possessed inadequate knowledge, appreciation, and understanding of the other content and context. In summary, I have pulled out five specific recommendations that can readily be generalized as applying to all three discussion groups. The first is that mental health concepts and practices should be incorporated in the teaching programs of all the other subspecialties to some degree. The second is that both the mental health and other health subspecial- ties’ faculties involved in such teaching should participate in this teaching program, but in varying extents, patterns, and methods, de- pending on the nature and the context of the other subspecialty. This might appear to be a biased view, but I’m reporting it as I heard it. The third general recommendation is that special measures should be taken to prepare both mental health faculties and other health sub- specialties’ faculties for this joint teaching enterprise to the extent necessary in specific instances. The fourth recommendation is that mental health content, in order to to be most meaningful, should be presented to students of another health subspecialty in terms of the specific health problems or cases drawn from within the context of this other subspecialty. The fifth, is that specific mental health input should be decided for each of the other health subspecialties’ teaching areas, through joint consultation with mental health experts, but—this again is a pointed 51 recommendation—the other health subspecialty would make the final decision as to “what” and “how much” of the mental health input should be incorporated into that particular teaching program. There are specific sample lists in the chairmen’s reports as to what the con- tents might be. In the last minute or so remaining I would like to diverge slightly from the suggested format in order to present three comments based on four aspects of my professional experience—first, as a practi- tioner of pediatrics and then public health; second, as a teacher in public health schools, in medical schools and nursing schools; third, as a commissioned public health service officer for several years in the research and training grants area; and fourth as a dean of a school of public health. In the light of this background of pertinent experience, I am taking the liberty of departing from the suggested format to add three of my own personal comments which I believe to be pertinent to the objectives of the entire conference. The first personal comment : that this conference, through the group discussion on previously prepared papers technique has been of inesti- mable communicative value. I think you have seen evidences of this in the imaginative, objective process of the identification, analysis and discussion of the most pertinent and the most complex and per- plexing problems involved in the process of incorporation of mental health content into the teaching programs of a dozen of the other health subspecialties. The second personal comment : that the five recommendations sum- marized from the discussion groups on teaching of mental health in environmental health, occupational health, and nutrition appear to this reporter to be, generally speaking, realistic, rationally sound, and academically practicable. The third and last personal comment is of a slightly different nature. From the standpoint of the stated, published mission of the United States and Canadian schools of public health—which is “to meet the expectations of society by preparing competent, imaginative work- ers for careers in preventing disease and disability, in analyzing, improving, promoting and maintaining the health of the public’— from this point of view, it appears to this reporter that, in the process of education of these health career workers, it is neither appropriate, academically sound, nor in the best interests of the public for any single health discipline, specialty, or subspecialty among the con- stellation of community health disciplines either to demand or to expect special treatment or first priority among the schools of public health, unless the teaching for that area of knowledge is specifically required in the “Criteria and Guidelines for Accrediting Schools of Public Health,” as published in the August 1966 issue of the Journal of the American Public Health Association. 52 MENTAL HEALTH TRAINING PROGRAM DIRECTORS (1) Dr. Lemkau, Johns Hopkins Uni- versity; (2) Dr. Coleman, Yale Univer- sity; (3) Dr. Broussard, University of Pittsburgh; (4) Dr. Bernard, Columbia University; (5) Dr. Williams, Univer- sity of Minnesota; (6) Dr. Roberts, University of Toronto; (7) Dr. Norman, Tulane University; (8) Dr. Wilson, University of North Carolina; (9) Dr. Leighton, Harvard University; (10) Dr. Knutson, University of California (Berkeley) ; (11) Dr. Howell, Univer- sity of Michigan; (12) Dr. Baler, University of Michigan; (13) Dr. Schwartz, University of Hawaii. At- tending but not in picture: Dr. Wilner, UCLA. 53 DEANS OF SCHOOLS OF PUBLIC HEALTH (1) Dr. Mayes, University of North Carolina; (2) Dr. Trussell, Columbia University; (3) Dr. Goerke, University of California, L.A.; (4) Dr. Schott- staedt, University of Oklahoma ; (5) Dr. Harding, Loma Linda University; (6) Dr. Goldsmith, Tulane University; (7) Dr. Cohart, Yale University; (8) Dr. Wegman, University of Michigan. At- tending but not in picture: Dr. Hume, Johns Hopkins University; Dr. Lee, University of Hawaii; Dr. Nine-Curt, University of Puerto Rico. Invited Address: Biological Determinants of Individuality and Mental Health Rent Dusos, Ph. D. The Rockefeller University New York, New York Plenary Session Wednesday, May 29, 1968 Invited Address: Biological Determinants of Individuality and Mental Health RENE Duos, Ph. D. The Rockefeller University New York, New York Session Chairman: BERTRAM S. Brown, M.D. Deputy Director National Institute of Mental Health René Dubos is a very special name and a very special man to me. It seems that all my life I have been running into him, and now I have finally met him in the flesh. In college—I went back and looked through my books—he was in my biology texts as a great pioneer in basic biology. In medical school, his textbook, “Bacterial and Mycotic Infections of Man,” was my bible. I leafed through this textbook recently as a bit of an adventure in remembrance of things past, and I came across some interesting refer- ences to Dr. Dubos I want to share with you. For instance, in the 1952 edition, in referring to the chapter on antimicrobial agents it says: “Drugs principally of historic interest. Among the substances of microbial origin, tyrocidine and gramicidin hold an honored historic position as the first drugs of microbial origin of some practical value. These substances were crystallized by Hotchkiss and Dubos from a mixture called tyrothricin obtained by Dubos in 1939 from strains of a Gram-positive sporulating soil bacillus which have been rained to grow on a medium enriched with Gram-positive organisms.” He was in the business of training bacteria back at the start ! However, that chapter wasn’t by one of his friends, and this historic place that he held wasn’t as warmly looked upon by some of the other people in the 18 references he has in his own textbook. For example, Walsh McDermott looks upon Ehrlich’s search for the magic bullet as sort of an empiric or implied empiricism and trial by error and refers back to our honored speaker, saying, “These successes,” referring to penicillin and things like that, “stand in contrast with the results of a more rational biologic and chemical approach. Thus, Dubos’s 56 ES ss mi 57 335-225 0—69——5 search for soil bacteria that utilize other bacteria as nutrients yielded only inhibitors too toxic for chemotheraputic use (gramicidin and tyrocidine).” Pretty critical. All he got was a few words of historic interest! So he has been controversial in a very pleasant way, even in his basic biological contributions which are of great importance. Then I went on to the Harvard School of Public Health, and there his word was law. As I looked through my public health textbooks, I recalled that Dr. Dubos was the only man who could make sanitary engineering philosophical. I know this deification of René Dubos is exactly what he would rebel against, for he loves to cast down myths and idols by looking at things with a fresh and creative eye. But, nevertheless, over my life I have collected Dubos quotes. I have another one that says—and this is a standard in 18 different textbooks: “In most laboratories, culture of suspected tuberculin materials will be kept 6 to 8 weeks before being discarded as negative. Quicker better results are obtained by using a medium described by Dubos.” Now, what is this Dubos magic medium that grows tuberculin bacilli and human wisdom faster than usual? I think it’s a very unique organ and intellectual heart, or a cortex that really cares. And after biology, medicine, and public health, it is fitting that he is here tonight at a meeting concerning mental health and public health. It is difficult, when deciding how to introduce a man of his stature, to know really how to do it. I found there is a bibliography of introduc- tions to René Dubos, and I have a quote from a quote when he was given an honored position at PAHO. I'd like to use this as a last quote to show the stature of the man that we are going to hear from. This quote is from 7'he Mirage of Health. “The earth is not a resting place. Man has elected to fight, not necessarily for himself, but for a process of emotional, intellectual, and ethical growth that goes on forever. To grow in the midst of dangers is the fate of the human race, be- cause it is the law of the spirit.” I am glad to introduce Dr. René Dubos. Biological Determinants of Individuality and Mental Health RENE DuBos The Rockefeller University New York, New York How We Become What We Are All human beings are related, biologically and mentally; what I shall emphasize in this essay, however, is not their resemblances but rather their differences. In practice, no two persons have exactly the same biological and mental constitution. Indeed, the individuality of any person now living is different from that of anyone who has ever lived in the past or will live in the future. We can speak of individuality in absolute terms because each person is unique, unprecedented, and unrepeatable. Individuality has of course genetic determinants. Except in the case of identical twins, each person has inherited an array of genes not found in any other person. Furthermore, the statistical chance that the array of genes possessed by a given person today has ever occurred in the past, or will ever occur again, is so small as to be practically nil. The genetic endowment, however, is only one of the factors that act in determining the traits by which we know a person. Genes do not determine these traits; they only govern the responses to environ- mental stimuli. Individuality results from the fact that each person is continuously being molded, physically and mentally, by the unique constellation of surroundings and events that evoke responses from his genetic endowment. In my opinion, environmental determinants play a role as great as, and probably greater than, genetic determinants in shaping individu- ality. Moreover, it is practically impossible to manipulate genetic constitution, whereas we can change many aspects of the environment almost at will and thereby condition the phenotypic expression of man’s nature. For these reasons, I shall direct my remarks to the effects that the environment exerts, not only on the day-to-day life of human beings, but also on the development of individuality. The environment has a dominating role in shaping individuality because most of the stimuli that impinge on a person leave on him an indelible stamp. Such lasting effects naturally condition all sub- sequent, responses of the person to other stimuli and thus give a direc- tion to his further development. 59 The conditioning of the organism by the environment begins during the intrauterine life. Even though the Dionne quintuplets were genetically identical, they were so different phenotypically that their attendants could differentiate them from the time of birth. Their biological and mental individualities became of course increasingly pronounced with age. It is probable that the relative position of the five fetuses in the uterus provided for each of them slightly different environmental conditions at critical stages of their development, thus resulting in phenotypic distinctiveness. Much evidence is now ac- cumulating that many different kinds of prenatal influences—result- ing, for example, from nutritional or hormonal factors—not to mention exposure to drugs or infectious agents—exert on the fetus at critical periods of differentiation profound effects that persist after birth and throughout life. Watsonian behaviorists and Freudian psychoanalysts commonly limit the meaning of the phrase “early influences” to the conditioning of emotional and mental characteristics by the forces that impinge on the newborn baby and on the child during the formative stages of his development. Child-rearing practices are considered of particular importance in this conditioning. Early experiences, however, do more than condition behavioral pat- terns and emotional attitudes. They also affect profoundly and lastingly other biological characteristics such as initial growth rate, efficiency in the utilization of food, anatomic structures, physiologic attributes, size and longevity, response to various forms of stresses and stimuli, in brief, almost every phenotypic expression of the adult. Furthermore, many kinds of environmental forces other than child- rearing practices play important roles in shaping individuality. These forces affect of course the organism directly ; furthermore, they impose directions and limitations to its subsequent development by acting on it early in life. From the topography of the land to climatic factors, from nutrition to education, from sensory stimuli to religious beliefs, countless are the types of influences that leave a permanent stamp on the human organism even when they have acted only during the early phases of its development. Experiments with animals have confirmed and extended the obser- vations made on human beings. The following are but a few among the many environmental factors that have been experimentally manipu- lated to affect early life: nutrition, infection, temperature, humidity, type of caging, extent and variety of stimuli, degree of crowding and of association with other animals of the same and other species. Suffice it to state here that many different aspects of the anatomy, physiology, and behavior of several animal species have been found to be pro- foundly and lastingly affected by such early influences, even when these had been very transient. 60 : : pir The experiences of early life are naturally of special importance in man because his body and especially his brain are incompletely differentiated at the time of birth and because they develop as the infant responds to environmental stimuli. As in the case of experimental animals, anatomic structures, physiologic attributes, and behavioral patterns are molded by the surroundings and the conditions experienced during prenatal and early postnatal life. The change in the rate of anatomical, physiological, and sexual maturation caused by the en- vironment constitutes one of the most striking and probably most im- portant factors in the shaping of individuality. A marked acceleration in physical growth and sexual maturation has occurred during the past few decades in all countries that have adopted the ways of life of Western civilization. The physical stature of Japa- nese teenagers since World War II, and of the children of Jewish immigrants from Central European ghettoes who have settled in Israel, provide spectacular evidence that many characteristics of a race or social group can be changed profoundly within one generation, by changing its ways of life. The factors responsible for the dramatic changes now being ob- served in the rate of physical and sexual maturation are not completely understood. Improvements in nutrition and in the control of infections have certainly played a large part in the acceleration of development during early childhood, and this change in turn has been responsible for the larger size achieved by adults. It has been suggested also that increased hybrid vigor has resulted from the greater latitude in the choice of marriage partners made possible by advances in transportation. Behavioral patterns, emotional attitudes, immunities, and allergies can be regarded as different forms of biological memory which persist in the organism through its whole life. It is important to emphasize at this point that most of the manifestations of the so-called “subcon- scious” are not pathological but in fact are a constant and universal part of the healthy state. The historical accident that Freud dealt mainly with a certain type of patient whose illness originated from subconscious mental processes has obscured the more interesting and more important truth that the past survives in all attributes of the body and the mind, in health as much as in disease. Since the biological memory of early influences involves not only mental processes but also bodily functions, it is imperative to develop systematically a science that might be called “biological Freudianism.” The body and the mind are in their most plastic state early in life, and for this reason early influences—both prenatal and postnatal— certainly play the most important role in converting genetic potentiali- ties into the biological and mental attributes of the adult. It is also true, on the other hand, that surroundings and events continue to have 62 formative effects throughout the lifespan. Many of the responses made by the adult organism to environmental stimuli become inscribed in the body and the mind, thereby altering subsequent responses to the same and other stimuli. For example, allergies and certain emotional attitudes can be lastingly acquired during adulthood. Individuality therefore reflects the evolutionary past of the person as encoded in his genetic apparatus and in all aspects of the experi- ential past that have become inscribed in the structures that store bio- logical and mental memory. Individuality might be defined as the continuously evolving phenotype, incarnating the past. Why We Behave as We Do Regarding individuality as an incarnation of the past implies biolog- ical constraints on freedom of behavior. When the process of decision- making is analyzed in all its details, step-by-step, freedom seems to disappear because all aspects of behavior are found to be under the control of genetic, experiential, and environmental factors. Yet, the awareness of personal freedom in making decisions is a straightfor- ward experience that must be reconciled with the deterministic view of individuality. Attempts to find a theoretical formulation that would be compatible with both determinism and free will have so far failed. Nevertheless, I shall accept free will as a needed and useful belief, simply because I consider the experience of it more impressive than the failure to prove its existence. As is the case for man’s other attributes, however, the actualization of free will has deterministic components. Some of these can be rec- ognized by following chronologically the various steps of mental development. From the very beginning of his life, the child responds to stimuli, stores information about the environment, and develops adaptive pat- terns of responses. It is probable, although not certain, that this initial process of coping with the environment is largely unconscious. In any case, this early phase is soon followed by a more active and conscious one during which the child attempts to create his individuality by in- tegrating his genetic endowment with the biological and mental memo- ries of early experiences. From a very early age, the child begins to “imagine” a world of his own in which he can act out his individuality. IT have used the word “imagine” in its strong etymological meaning, namely “to create an image.” This is the meaning that Shelley had in mind when he wrote in “Defence of Poetry,” “We want the creative faculty to imagine [to create an image of] that which we know.” For the child, the actualization of free will is the creative imagining of a world 63 mentally constructed out of his genetic constitution and early experiences. In normal adult human beings, behavior ideally displays an increas- ing degree of freedom in making decisions, but it also continues to depend on the past for providing the material out of which decisions are made. Mental health implies free will in eliminating, choosing, organizing, and thereby creating. Behavior always has roots in the past and is conditioned at each moment by environmental forces, but it also involves anticipations of the future that are in the final analysis the creations of man’s free will. Determinism and free will thus constitute the two complementary aspects of behavior. The deterministic aspects of behavior readily fall within the range of the orthodox biological sciences. Its manifestations as acts of freedom have largely remained in the domain of literature. Modern existentialists have affirmed the person’s right to actualize the freedom of his individuality at the moment of action. In fact, this right had been proclaimed on many earlier occasions by influential writers of the preexistentialist era. For example: F. Dostoevski: “Man only exists for the purpose of proving to himself that he is a man and not an organ-stop! He will prove it even if it means physical suffering, even if it means turning his back on civilization.” J. Ortega y Gasset: “Living is precisely the inexorable necessity to make one- self determinate, to enter into an exclusive destiny, to accept it—that is, to resolve to be it. We have, whether we like it or not, to realize our ‘personage,’ our vocation, our vital program, our ‘entelechy’—there is no lack of names for the terrible reality which is our authentic I (ego).” André Gide: “What could have been said by someone other than you, do not say it; what could have been done by someone other than you, do not do it; of yourself, be interested only in those aspects that do not exist except in you; create out of yourself, patiently or impatiently, the most unique and irreplacable of beings.” Paul Tillich: “Individualism is the self-affirmation of the individual self as individual self without regard to its participation in its world.” Under the conditions of daily life, the organism exists as a function- ing structure made up of inherited and acquired characteristics that are organically integrated. This integrated structure is more or less enduring and remains effective long after the conditions that have brought it into being have disappeared. Since each person develops such a unique, integrated, and enduring structure which is largely of his own making, his responses to environmental stimuli eventually acquire much independence of his evolutionary past and even of the culture to which he belongs. Irrespective of theories concerning the ultimate nature of free will, this independence enables man to create a future of his own choice. By the exercise of free will each person selects the set of conditions under which he operates and which thereby influence his further devel- opment by eliciting responses that become lastingly incorporated in his 64 physical and mental constitution. Even more importantly, decisions with regard to the total environment inevitably affect the development of young people exposed to this environment during the formative stages of their lives. Each individual decision thus imposes a direction and a pattern on the future, not only of the person concerned but also of his social group. In this sense man makes himself, individually and socially, through a continuous series of choices conditioned by the past, but dictated by value judgments, anticipations of the future and the myste- rious attribute that we call free will. Human Adaptability As we have seen, individuality represents at any given time the phenotypic expressions of the inherited potentialities made functional by the experiences of life. The behavioral manifestations of individual- ity are conditioned by the past and are continuously being altered by the responses that the person makes to environmental stimuli. To live is to function. Physically and mentally, human beings de- velop in the very act of functioning. Indeed, the physical and mental attributes acquired by use are so dependent on continuous environ- mental stimulation that they degenerate or at least atrophy through disuse. Mental health thus involves the conditions that favor the development of the proper kind of mental attributes and the opportu- nity to give expression to these attributes in the course of daily life. The few examples now to be considered have been selected to illustrate that both biological and psychological factors affect the establishment and the maintenance of mental health. Studies in experimental animals have revealed that malnutrition during early life interferes with the development of anatomical struc- tures in the brain and decreases learning ability. Observations in de- prived human populations suggest that similar phenomena can occur in children and that the deleterious effects may be irreversible when malnutrition extends beyond the fourth year of life. Furthermore, dietary habits acquired early in life may persist for long periods of time. For instance, rats once used to a low-protein diet tend to continue eating it even though a better diet is made available to them later. Such habituation involves both metabolic and behavioral adaptations. In this case again, epidemiological evidence indicates that human beings tend to retain throughout life dietary habits acquired during childhood. Crowding can cause disturbances of endocrine function and of behavior; its effects differ profoundly depending upon the conditions 65 under which high population density is achieved. If adult animals (young or old) obtained from different sources are assembled in one area, they commonly exhibit such aggressive behavior that a large percentage of them may die. In contrast, if animals are born and allowed to multiply together, they can reach very high population densities without displaying destructive aggressiveness because the group develops an adaptive social organization that minimizes violent conflict. As the population pressure increases, however, more and more animals exhibit a large variety of abnormal behavior. These deviants do not suffer from obvious organic abnormalities, but they tend to act as if they were unaware of the presence of their cage mates. Their behavior is asocial rather than antisocial. It is true that men are not rats; but the most disturbing aspect of behavior among crowded rats is that it resembles so much human behavior in some crowded communities. Human beings readily adapt to crowding probably because high population density is not a new experience in human life. Countless human beings have elected to live in crowded agglomerations through- out historical, and even in prehistorical, times. The neolithic settle- ments, Imperial Rome, the medieval fortified towns, and the cities of the Industrial Revolution all exhibited an intensity of crowding that has not been exceeded in our own times. Modern cities are larger, but in general they are less crowded than those of the past. It can be assumed that adaptation to crowding will become even more com- plete as human beings are increasingly exposed to urban conditions during the early phases of their development. Such adaptation may be of either genetic or experiential origin, or both. The effects of crowding cannot be measured in terms of population density. They depend on the quality of the social organization and on the nature of interrelationships between individual persons. Hong Kong and Holland are among the most crowded areas of the world, yet their populations enjoy good physical and mental health because they have slowly evolved in the course of centuries patterns of human relationships that minimize social conflicts and allow persons to retain their identity and a large measure of individual freedom. Human beings are so adaptable that they can survive, function, and multiply irrespective of malnutrition, crowding, and excessive or in- adequate exposure to sensory stimuli. But while biological adaptabil- ity is obviously an asset for the survival of Homo sapiens considered as a biological species, it is not as effective in preserving the attributes that make human life different from animal life. From the human point of view, the success of adaptation must be judged in terms of values peculiar to man. The following examples will serve to illustrate that certain adaptive processes have remote consequences that are un- fortunate from the purely human point of view. 66 People born and raised in an environment where food intake is inadequate tend to restrict unconsciously their physical and mental expenditure so as to reduce their nutritional needs. They become adapted to malnutrition by living less intensely. The physical and mental apathy and other forms of indolence commonly observed among underprivileged people are not racial or climatic in origin. In a large measure, these behavioral traits result from the fact that the physiological and mental imprinting caused by early nutritional deprivation persists throughout the whole lifespan. One could almost say that adaptation to low food intake imposes a limited social role to the malnourished person. Shortage of food is now rare in affluent countries. But malnutrition can take other forms, including perhaps excessive artificial feeding of the infant. There is some evidence that infants fed a rich and abundant diet tend to become large eaters as adults. It would be sur- prising if such acquired dietary habits, in addition to being physio- logically objectionable, did not also have unfavorable behavioral manifestations. Undesirable behavioral changes are also likely to result from man’s adaptation to extremely high population densities. The complexity of social structures will make some form of regimentation unavoid- able; freedom and privacy may come to constitute antisocial luxuries, and their attainment will involve real hardships. In consequence, the types of human beings most likely to prosper will be those willing to accept a regimented and sheltered way of life in a teeming and polluted world from which all wilderness and fantasy will have dis- appeared. The domesticated farm animal and the laboratory rodent on a controlled nutritional regimen in a controlled environment will then become true models for the study of man. Admittedly, it is possible to rear and train children in such a man- ner that they become habituated to oversocialized conditions—to such an extent indeed that they do not feel safe and happy outside a crowd of their own kind. But this does not invalidate the view that there is potential danger in even our level of overcrowding today. Children and adults can be trained or habituated to avoid everything good and healthy, to search for happiness in overeating all sorts of palata- ble but unbalanced food, in perversions, addictions, or simply unsuit- able amusements. Once habituated to these ways of life, the deprived individual feels dejected and miserable. Yet such habituations as well as the “adjustment” to crowded life may in the long run do more harm than drug addition or alcoholism. Granted that man can eventually achieve some form of adaptation— whether desirable in the long run or not—to many forms of stressful situations, it is also true that almost any kind of sudden change is detrimental to physical and mental health. As Hippocrates wrote 2500 67 years ago, “It is changes that are chiefly responsible for diseases, espe- cially the greatest changes, the violent alterations both in the sea- sons and in other things. But seasons which come on gradually are the safest, as are gradual changes of regimen and temperature, and gradual changes from one period of life to another.” The wisdom of this Hippocratic aphorism is illustrated by the fact that the traumatic effects of crowding result not so much from high population density as from the social disturbances associated with a sudden increase in density. The appalling amount of physical and mental disease during the Industrial Revolution had several different causes, but one of the most important factors was certainly the fact that immense numbers of people recently arrived from rural areas had to live and function in the crowded tenements and factories of the mushrooming industrial cities before they had had time to become adapted to ways of life that were entirely new to them. Yet, it took but one or two generations to convert these people of rural origin into urban people for whom high population density became almost an essential condition of happiness. In our own times, the rapid mobility of populations from one geo- graphical area to another is probably contributing to the patterns of diseases in technological societies. The so-called diseases of civiliza- tion are to a large extent the consequences of maladaptive responses to rapid changes in the ways of life. They are not due to the urban environment per se, but rather to the difficulties of adaptation entailed by moving rapidly from one environment to another. All over the world, mental disorders seem to increase in frequency among primitive people when they enter the first phase of industrializa- tion. A Place of One’s Own Children seem to be satisfied with “imagining” their own fanciful world and acting out their lives in the dreamland they thus create. But most teenagers want and probably need to operate in the world of reality. Their demands for a real life become more exacting as they approach adulthood. This change of requirements with age presents problems that are especially urgent in modern societies, because physi- cal and sexual maturation is now achieved much earlier than in the past. It can be assumed that changes in the rate of maturation affect not only physiological activities but also the development of self- reliance, the awareness of social needs, and in particular the eager- ness to find one’s place in the order of things. For this reason, it is biologically and socially tragic that the laws and customs in the coun- tries of Western civilization increasingly tend to treat young men and women as children, even while the conditions of life accelerate all aspects of their physical and physiological development. The attributes that we consider most attractively human and most conducive to happiness are to a very large extent a product of socialization. They emerge and take shape in the course of participation in the activities of other human beings. As used here, the word “participation” involves more than being a passive observer of the social scene, or being invited to share in the wealth and entertainments created by others. It implies taking an active and preferably con- structive part in socially meaningful enterprises. Passive exposure to information is rarely sufficient to give complete emotional satisfaction or to foster development. Information becomes really formative only when it is presented in such a manner and in such a social setting that the person can use it in some activities of his life. We build ourselves while building the world. Furthermore, the healthy integration achieved in the course of this self-building can be maintained only by continuous activity. This is true not only of physical attributes but also of mental processes; neural activity goes on all the time spon- taneously in the brain, but it becomes organized into structured patterns only in the course of responses to environmental stimuli. As mentioned earlier, most environmental factors affect mental development, especially of children. In the past, rural life was often favorable to such development, because it exposed children to an immense variety of stimuli—those from nature, those from the very diverse activities on the farm, and perhaps especially those from the chores of daily life in which they were expected to participate. During recent, years, the nonurban environment has become poorer in stimuli even in farm communities, and particularly in many suburbs. From the point of view of mental and emotional development, children brought up in wealthy manicured suburbs may be among those most severely deprived of creative sensory input. Paradoxically, their environment may be more deficient in meaningful stimuli than that of certain country and city children. Around the turn of the present century, the Lower East Side in New York was an unsanitary and uncomfortable environment; but its streets were crowded with an immense variety of ethnic groups, displaying their different trades, customs, shows, and celebrations that provided constant stimulation for the local residents of all ages, with much opportunity for active participation. The Lower East Side, despite its poverty, nurtured some of the most picturesque and original talents of 20th-Century America, not only in entertainment and the arts but also in politics, philosophy, science, and technology. Many old cities offer to children the wealth of their historical past, the charm of their traditions, their lively shops and outdoor cafes, the civilized games of life carried out in drawing rooms or parks. All these 69 manifestations of city life constitute as many different kinds of stimuli from which children can derive substance for their development. In large urban agglomerations, the great diversity of offerings in the various schools enriches still further the milieu for mental growth. Unfortunately, most modern housing developments have none of the stimuli that used to be provided by farm life or true city life. Whether of the high-rise type in the compact city, or of the Levittown-type in the sprawl city, such housing developments are featureless and offer no opportunity for those creative responses to environmental stimuli which are essential for mental development. Children growing in them are likely to be so handicapped as to become mentally and emotionally crippled. This defect is not inherent in urban life; it is only the conse- quence of a kind of planning unconcerned with the needs and wants of human beings. While it is certain that health and development require the oppor- tunity to participate creatively in the affairs of the social group, it is also true that many persons require solitude now and then in order to achieve expression of their individuality. According to legends and history, Moses, Buddha, Christ, and other religious leaders had to withdraw into the wilderness before returning to their fellowmen to fulfill their mission. In a well-managed environment, ordinary human beings should be able to achieve privacy without having to withdraw from life. The possibility to retire into a room of one’s own is a widely felt need. Fortunately, one can also achieve some measure of isolation among crowds, for example on a park bench amidst strollers, chil- dren, nursemaids, and lovers. René Descartes found the crowded streets of Amsterdam a congenial environment in which to pursue his thoughts, amidst the anonymous tradesmen who took no notice of him. Social history leaves no doubt that mental health requires both a great variety of human contacts and the possibility of achieving some form of independence in a world of one’s own. These requirements are not frills or luxuries but are as essential as biological needs. They threaten to be in short supply long before there are shortages of the materials and forces that keep the body machine going and the econ- omy expanding. The Dimensions and Limits of Freedom Adequate nutrition and adequate sanitary conditions may be suf- ficient to make a contented beast, but not a happy man; indeed, he may remain a very discontented man even if well-fed, well-protected, and provided a carte blanche for coffee, soft drinks, whiskey, and amusements. Young men riot in ghettoes or on Ivy League campuses not for the sake of their bodily needs but for causes that are often ab- stract, ill-defined, and in any case determined by highly subjective 70 value judgments. To discuss mental health profitably we must leave off talking about what people need and bestow more attention on what they want. The difficulty however is that few people know what they really want because, as we have seen, most of them adapt to what they have, even when this adaptation spells biological and mental starva- tion for their lives. Free will is part of the innate endowment of normal human beings, but it can express itself in actual acts of freedom only when con- ditions are favorable. Many people who are free in theory live in practice under such conditions that they cannot actualize their free- dom. For example, children who are denied the opportunity to experi- ence early in life the kind of stimuli required for mental development do not acquire the mental resources that would be necessary for the full utilization of their free will. It is not right to say that lack of culture is responsible for the behavior of slum children or for their failure to be successful in our society. The more painful truth is that these children acquire early in life a slum culture from which escape is almost impossible. Their early surroundings and ways of life at a critical period of their development limit the range of manifestations of their innate endowment and thus destroy much of their potential freedom. In the words of the late English geneticist, J. B. S. Haldane, “That society enjoys the greatest amount of liberty in which the greatest number of human genotypes can develop their peculiar abilities. It is generally admitted that liberty demands equality of opportunity. Tt is not equally realized that it demands a variety of opportunities.” Although the phrase “variety of opportunities” is usually interpreted as referring to political and social rights, it should imply also the biological and psychological factors that play such a crucial role in mental growth and in the maintenance of health. Since the development of all physical and mental traits is inevitably conditioned by early environmental stimuli, it is doubtful that societies can ever provide absolute freedom. To some extent, the child is pro- grammed by the conditions of intrauterine and early postnatal life over which he has no control. On the other hand, it would be unethical and in any case futile to try creating one particular type of environment optimum for all of mankind. Such a course would impose a common pattern of develop- ment on all human beings and thus would be tantamount to suppress- ing their freedom. Society should instead provide as wide a range of environmental conditions as practically and safely possible so that each human being can select the experiences most suitable to the devel- opment of his attributes and to the prosecution of his goals. Human potentialities, whether physical or mental, can be realized only to the extent that circumstances are favorable to their existential 71 manifestation. For this reason, diversity within a given society is an essential component of true functionalism; the latent potentialities of human beings have a better chance to emerge when the social en- vironment is sufficiently diversified to provide a variety of stimulating experiences, especially for the young. As more and more persons find it possible to express their biologic endowments under a variety of conditions, society becomes richer and civilizations continue to unfold. In contrast, if the surroundings and ways of life are highly stereo- typed, the only components of man’s nature that flourish are those adapted to the narrow range of prevailing conditions. Hence, the dangers of many modern housing developments—designed as if their only function were to provide disposable cubicles for dispensable people. Irrespective of their genetic constitution, most young people raised in a featureless environment, and limited to a narrow range of life experiences, will be crippled emotionally and mentally. We must therefore shun uniformity of surroundings as much as absolute con- formity in behavior. Creating diversified environments may result in some loss of efficiency; but diversity is an essential condition for enabling each person to discover what his potentialities are and thus to have more wisdom and freedom in deciding what he wants to become. Freedom is essential for human development, but the fact that man is & social animal imposes limitations to his freedom. Paul Tillich displayed ignorance of an escapable biological truth when he wrote the passage quoted above: “Individualism is the self-affirmation of the individual self as individual self without regard to its participation in its world.” It is not posible to conceive of man, biologically and mentally, “without regard to his participation in the world,” because he could not survive or even exist without being an integral part of the human world and of the environment in which other human beings function. Freedom involves not only what to do, but even more perhaps what not to do. It cannot mean complete permissiveness because some form of discipline is essential to the integration of all human societies. Total rejection of discipline is unbiologic and would inevitably result in the disintegration of individual lives and of the social order; it is incom- patible with physical, mental, and social health, indeed with the sur- vival of the human species. Familial and social structures differ in detail according to cultures, but in one form or another they are essential to human life. The uni- versal need for social organization imposes inescapable constraints to the exercise of freedom, but on the other hand it also provides the stimulus for a variety of design in human life. Design, rather than anarchy, is the characteristic of life. In human life, design implies 72 the acceptance and even the deliberate choice of certain constraints which are deterministic to the extent that they incorporate the past and the influences of the environment. But design is also the expression of free will governed by value judgments and anticipations of the future. Dr. Brown. Since January of this year, Dr. Dubos has transmitted to 75 groups information which has transformed them so they are be- yond what they were before and, I think, to the benefit of every one of those 75 groups. He has kindly consented to entertain some comments or questions. Q. I have a question on your experimental work that you mentioned at the beginning. In your experiments, were there sometimes hindrances to development, or were you optimizing the environment so as to im- prove the rats, or whatever the animals were? Dr. DuBos. “Improving” implies questions of values, but mouse and rat values are not familiar to me. So let me try to be as objective as possible. By the way, this will give me a chance to point out that knowledge of consequences may help in defining values. One always says that values are independent of scientific knowledge and beyond scientific approach; yet I believe that awareness of the likely con- sequences of a course of action is always involved in the formulation of values. From this point of view, what applies to a mouse or a rat may not be irrelevant to man. It is easy to arrange that the diet fed the mother (mice or rats) during gestation and during lactation be of such composition that the young will be a very large animal at weaning time—as large as we have known a weaning mouse to be. On the other hand, by restrict- ing the amount of food given the animal during gestation and lactation, or more conveniently by changing the composition of its food, one can produce animals that are very small at weaning time. The differences are of the order of 40 percent, let’s say, 9 grams as against 15 grams. Now, suppose that all the weaned animals are fed the richest diet that we know. The animal that was small at weaning time will remain small thereafter; the animal that was large will remain big there- after. Furthermore, the difference will increase with time. So if you are interested in the body weight of the mouse, to sell it as a chicken or as a pig, there is no doubt that being large is better. But on the other hand, we have observed repeatedly that if we keep the animals for their whole lifespan, most of the large animals, whose mothers were fed a very rich diet, become obese later in life, and they die before the small animals. None of the animals whose mothers received the deficient or limited diet became obese; they usually live longer. So here the problem of value is fairly clear: Do you want to live long, or do you want to be big? 73 Another kind of experiment is based on the fact that some mice or rats are better mothers than other mice or rats. By this I mean they are good at making nests, they attend to their young very carefully; whereas others are not nearly so good at mothering. In a particular experiment we took 360 mice all born the same day from mothers of the same age. The newborn mice were reallocated at random to foster mothers so that there was no question of difference of genetic endow- ment of the young. The ones that were given to good mothers became larger and remained larger thereafter. Moreover, the good mothers teach their young good mothering habits, so that the large weight is the result of a cultural habit that is transmitted. In another type of experiment, the lactating mother is treated with a substance having a certain flavor that passes into the milk, so that the young is habituated to the taste of that substance during lactation. From then on the young will select food flavored with this substance by preference over other food; in contrast, an animal not habituated to that taste during lactation may completely reject food flavored with this substance. These experiments point to all sorts of possibilities of habituation, which may be good or may be bad, depending upon certain kinds of environment in early life. Furthermore, there is much evidence that one can profoundly change the behavioral patterns, the number of brain cells, and even the histological arrangement of the neural system, by manipulating the behavioral richness of the environment. In the final analysis, the answer to your question, “better or worse,’ really depends upon what we want to become or what we want the mouse to become or the rat to become. In general, our society does not accept that values be decided by scientists, but what the scientist can do in practice is to show that certain courses of action have certain kinds of consequences. Awareness of these consequences, in turn, helps society to formulate its values. Q. Dr. Dubos, your argument for determinism is very persuasive, but your retention of the notion of individual free will seems to sug- gest a kind of faith and a wishful philosophy. I wonder if you wouldn’t think that the question of free will or the notion that free will operates is more a question of lack of data on the infinite number of stimuli, en- vironmental and genetic, needed to make a determination. Dr. Dusos. IT am aware of the weakness of introducing free will without any evidence other than that I believe that I have free will. But you happen to believe it, too. Indeed, I am sure that there is no one in this room that does not believe it. Nevertheless, I am aware of the intellectual dilemma. And the only thing to do is to take shelter behind statements made by one of the most illustrious scientists of our time, namely, Nils Bohr. As you know, Nils Bohr was the proponent of the theory of complementarity ; under ’ 74 certain conditions, you study the electron as a particle and under other conditions you study it as a wave. There is no possibility of reconciling the two approaches. Nils Bohr was as concerned as you are and as I am with the problem of determinism and free will ; he wrote a most extraordinary article in which he tried to defend the view that free will and determinism are the equivalents of wave-particle complementarity in physics. I realize that analogy is not proof. Dr. Brown. Dr. Dubos, I feel that you have taken basic biology and raised it to its highest human qualities, and I want to thank you for all of us. 75 Appendixes > Conference Planning Group . Section Reporters and Chairmen . Work Groups . Conference Schedule . List of Participants m OO W APPENDIX A Conference Planning Group Conference Director Stephen E. Goldston, Ed. D., M.S.P.H. Special Assistant to the Director National Institute of Mental Health Division of Manpower and Training Programs Raymond J. Balester, Ph. D. Acting Director, Division of Manpower and Training Programs National Institute of Mental Health Advisory Committee Viola W. Bernard, M.D. Clinical Professor of Psychiatry Division of Community Psychiatry Columbia University School of Public Health and Adminis- trative Medicine 630 West 168th Street New York, New York 10032 Edward M. Cohart, M.D. Chairman, Department of Epidemiology and Public Health Yale University School of Medicine 60 College Street New Haven, Connecticut 06510 77 Paul V. Lemkau, M.D. Professor of Mental Hygiene School of Hygiene and Public Health Johns Hopkins University 615 N. Wolfe Street Baltimore, Maryland 21205 Philip Margolis, M.D. Professor of Psychiatry Neuropsychiatric Institute University of Michigan Ann Arbor, Michigan 48104 James L.. Troupin, M.D. Director of Professional Education American Public Health Association New York, New York 10019 Myron E. Wegman, M.D. Dean, School of Public Health University of Michigan Ann Arbor, Michigan 48104 Section A (I, IT, III) Section B (IV, V, VI) Section C (VII, VIII, IX) Section D (X, XI, XII) APPENDIX B Section Reporters Richard K. C. Lee, M.D. Edward M. Cohart, M.D. Myron E. Wegman, M.D. William F. Mayes, M.D. Group Chairmen Group I John C. Hume, M.D. Group II James L. Troupin, M.D. Group III Ralph H. Boatman, Ph. D. Grour IV W. W. Schottstaedt, M.D. Grour V John W. Fertig, Ph. D. Group VI Roy M. Acheson, D.M. Grour VII Robert H. Lennox, M.D. Group VIII Dorothy M. Talbot, M.A. Group IX John C. Cutler, M.D. Group X Morton S. Hilbert, M.P.H. Group XI José Nine-Curt, M.D. Group XII Mervyn G. Hardinge, M.D. 78 APPENDIX C Work Groups Grour I Public Health Administration Grour II Medical Care and Hospital Administration Group III Public Health Education Group IV Epidemiology Grour V Biostatistics Group VI Chronic Diseases Group VII Maternal and Child Health Group VIII Public Health Nursing Group IX Population Control and Family Planning Grour X Environmental Health Group XI Occupational Health Group XII Nutrition APPENDIX D Conference Schedule Monday, May 27, 1968 Registration 5 p.m. Dinner 0 p.m. OprENING PLENARY SESSION Session Chairman: Raymond J. Balester, Ph. D. Acting Director, Division of Manpower & Training Programs 6:4 8:3 National Institute of ental Health Orientation to the Conference Structure Welcoming Remarks: Mr. Middleton Administrator, Airlie House Stanley F. Yolles, M.D. Director, National Institute of Mental Health Keynote Speaker: Tuesday, May 28, 1968 7:30-8:00 a.m. Breakfast 9:00 a.m.—Noon Group Meetings 10:30 a.m. Coffee 12:15 p.m. Lunch 2:00-5:00 p.m. Group Meetings 3:15 p.m. Coffee 6:30 p.m. Dinner Evening Open 79 Wednesday, May 29, 1968 7:30-8:00 a.m. Breakfast 9:00 a.m. Group Meetings 10:30 a.m. Coffee 12:15 p.m. Lunch 2:00-4:30 p.m. Group Meetings 3:15 p.m. Coffee 5:30 p.m. Dutch Treat Social Hour 6:30 p.m. Dinner Evening Session Chairman: Bertram S. Brown, M.D. Deputy Director, National Institute of Mental Health Invited Address: ~~ René J. Dubos, Ph. D. Topic: Thursday, May 30, 1968 7:30-8:00 a.m. Breakfast PLENARY SESSION Session Chairman: Bertram S. Brown, M.D. 9:00 a.m. 10:30 a.m. 12:15 p.m. The Rockefeller University “Biological Determinants of Individuality and Mental Health” Summary of Group Meetings: Section A: Section B: Section C: Section D: Coffee Floor Discussion Lunch Adjournment (Groups I, II, and III) Richard K. C. Lee, M.D. Dean, School of Public Health University of Hawaii (Groups IV, V, and VI) Edward M. Cohart, M.D. Chairman, Department of Epidemi- ology and Public Health Yale University (Groups VII, VIII, and IX) Myron E. Wegman, M.D. Dean, School of Public Health University of Michigan (Groups X, XI, and XII) William F. Mayes, M,D. Dean, School of Public Health University of North Carolina APPENDIX E PARTICIPANTS IN THE NATIONAL CONFERENCE ON MENTAL HEALTH IN PUBLIC HEALTH TRAINING Group |—Public Health Administration Chairman: Joun Hume, M.D. Guillermo Arbona, M.D. Professor of Public Health University of Puerto Rico Department of Public Health School of Medicine San Juan, Puerto Rico 00905 Herman E. Hilleboe, M.D. Professor of Public Health Practice School of Public Health and Administrative Medicine Columbia University 600 West 168th Street New York, New York 10032 Paul V. Lemkau, M.D. Professor of Mental Hygiene Johns Hopkins University School of Hygiene and Public Health 615 N. Wolfe Street Baltimore, Maryland 21205 Ralph Sachs, M.D. Professor of Public Health University of Hawaii School of Public Health 2540 Maile Way Honolulu, Hawaii 96822 385-225 O—69——1T7 Andrew P. Haynal, M.D. Associate Professor of Public Health Practice Loma Linda University School of Public Health Loma Linda, California 92354 John Hume, M.D. Dean, School of Hygiene and Public Health Johns Hopkins University 615 N. Wolfe Street Baltimore, Maryland 21205 Irwin M. Rosenstock, Ph. D. Professor of Public Health Administration University of Michigan School of Public Health Ann Arbor, Michigan 48104 Waldo L. Treuting, M.D. Professor of Public Health Practice Graduate School of Public Health University of Pittsburgh Pittsburgh, Pennsylvania 81 Group ll—Medical Care and Hospital Administration Chairman : James L. Troupin, M.D. Alfred W. Childs, M.D. Associate Clinical Professor of Medical Care Administration University of California School of Public Health Berkeley, California Milton I. Roemer, M.D. Professor of Public Health University of California School of Public Health Hilgard Avenue Los Angeles, California 90024 Cecil G. Sheps, M.D., M.P.H. General Director Beth Israel Medical Center 10 Nathan D. Perlman Street New York, New York 10003; and Lecturer Columbia University School of Public Health and Ad- ministrative Medicine Ray Trussell, M.D. Director Columbia Universit School of Public Health and Administrative Medicine 600 West 168th Street New York, New York 10032 Peter Putnam, M.D. Training Specialist Division of Manpower and Training Programs National Institute of Mental Health 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 David Sanders, M.D. Lecturer in Public Health Psychiatry University of California Hilgard Avenue Los Angeles, California 90024 James L. Troupin, M.D. Director of Professional Educa- tion American Public Health Associa- tion 1740 Broadway New York, New York 10019 Group llI—Public Health Education Chairman: Raver H. BoarMAN, PH. D. Ralph H. Boatman, Ph. D. Professor of Public Health Ed- ucation University of North Carolina School of Public Health Chapel Hill, North Carolina Jerome Grossman, Ph. D. Professor of Public Health University of Hawaii School of Public Health 2540 Maile Way Honolulu, Hawaii 96822 82 Robert N. Wilson, Ph. D. Professor of Mental Health University of North Carolina School of Public Health Chapel Hill, North Carolina 27514 Mortimer Brown, Ph. D. Assistant to the Director State of Illinois Department of Mental Health 401 S. Spring Street Springfield, Illinois Lowell S. Levin, Ed. D. Associate Professor of Public Health Yale University Department of Epidemiology and Public Health 60 College Street New Haven, Connecticut 06510 Guy Steuart, Ph. D. Associate Professor of Public Health University of California School of Public Health Hilgard Avenue Los Angeles, California 90024 Group IV—Epidemiology Chairman: W. W. Scuorrstaept, M.D. John Cassel, M.B.B. Ch. Professor of Epidemiology University of North Carolina School of Public Health Chapel Hill, North Carolina Alexander H. Leighton, M.D. Professor of Social Psychiatry Harvard University School of Public Health 55 Shattuck Street Boston, Massachusetts 02115 Leonard M. Schuman, M.D. Professor of Epidemiology University of Minnesota School of Public Health Mayo Memorial Building Minneapolis, Minnesota 55455 Mervyn W. Susser, M.B.B. Ch. Professor of Epidemiology Columbia University School of Public Health and Ad- ministrative Medicine 600 West 168th Street New York, New York 10032 Ernest M. Gruenberg, M.D. Professor of Psychiatry (Epide- miolo Columbia University School of Public Health and Ad- ministrative Medicine 600 West 168th Street New York, New York 10032 W. W. Schottstaedt, M.D. Dean, School of Health University of Oklahoma Oklahoma City, Oklahoma Reuel Stallones, M.D. Professor of Epidemiology University of California School of Public Health Berkeley, California 94720 Group V—Biostatistics Chairman: Joan W. Ferrie, Pu. D. Lenin Baler, Ph. D. Associate Professor School of Public Health University of Michigan Ann Arbor, Michigan 48104 Morton Kramer, Sc. D. Chief, Biometry Branch National Institute of Mental Health Barlow Building 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 Robert B. Reed, Ph. D. Professor of Biostatistics School of Public Health Harvard University One Shattuck Street Boston, Massachusetts 02115 John W. Fertig, Ph. D. Professor of Biostatistics Columbia University School of Public Health and Administrative Medicine 600 West 168th Street New York, New York 10032 Jan Kuzma, Ph. D. Assistant Professor of Biostatistics Loma Linda Universit; School of Public Health Loma Linda, California 92354 Group VI—Chronic Diseases Chairman: Roy M. Acuzrson, D.M. Roy M. Acheson, D.M. Professor of Epidemiology and Medicine Yale University Department of Epidemiology and Public Health 60 College Street, New Haven, Connecticut 06510 Maureen Henderson, M.B., D.P.H. Professor of Preventive Medicine University of Maryland School of Medicine Baltimore, Maryland ; and Lecturer in Chronic Diseases Johns Hopkins University School of Hygiene and Public Health 615 N. Wolfe Street Baltimore, Maryland 21205 Jules V. Coleman, M.D. Clinical Professor of Public Health and Psychiatry Department of Epidemiology and Public Health Yale University 60 College Street New Haven, Connecticut 06510 Brian MacMahon, M.D. Professor of Epidemiology School of Public Health Harvard University One Shattuck Street Boston, Massachusetts 02115 Charles E. Schoettlin, M.D. Assistant Professor of Epidemi- olo University of California School of Public Health Hilgard Avenue Los Angeles, California 90024 Group Vil—Maternal and Child Health Chairman: Roper H. LENNOX, M.D. Elsie Broussard, M.D. Associate Professor Graduate School of Public Health University of Pittsburgh Pittsburgh, Pennsylvania Donald A. Cornely, M.D. Professor of Population and Family Health School of Hygiene and Public Health Johns Hopkins University 615 N. Wolfe Street Baltimore, Maryland 21205 84 Andie L. Knutson, Ph. D. Professor of Behavioral Sciences University of California School of Public Health Berkeley, California 94720 Donald C. Smith, M.D. Professor of Maternal and Child Health University of Michigan School of Public Health Ann Arbor, Michigan 48104 Erwin Crawford, M.D. Associate Professor of Maternal and Child Health School of Public Health Loma Linda University, Loma Linda, California Ira W. Gabrielson, M.D. Assistant Professor of Public Health and Pediatrics Yale University Department of Epidemiology and Public Health 60 College Street New Haven, Connecticut 06510 Robert H. Lennox, M.D. Professor of Maternal and Child Health Tulane Universit, School of Public Health and Tropical Medicine 1430 Tulane Avenue New Orleans, Louisiana 70112 Helen M. Wallace, M.D. Professor Maternal and Child Health School of Public Health University of California Earl Warren Hall Berkeley, California Group VIlII—Public Health Nursing Chairman: Dororay McC. TaLBor, M.A. Nora F. Cline, R.N., M.L. Associate Professor of Mental Health School of Public Health University of North Carolina Chapel Hill, North Carolina 27514 Miss Esther A. Garrison Chief, Psychiatric Nursing Training Branch National Institute of Mental Health Barlow Building 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 Dorothy McC. Talbot, M.A. Associate Professor School of Public Health and Tropical Medicine Tulane University 1430 Tulane Avenue New Orleans, Louisiana 70112 Ruth B. Freeman, Ed. D. Professor of Public Health Administration Johns Hopkins University School of Hygiene and Public Health 615 N. Wolfe Street Baltimore, Maryland 21205 Roger W. Howell, M.D. Associate Professor Mental Health University of Michigan School of Public Health Ann Arbor, Michigan 48104 George E. Williams, M.D. Associate Professor University of Michigan School of Public Health Mayo Memorial Building Minneapolis, Minnesota 55455 85 Group IX—Population Control and Family Planning Chairman: Joan C. CurLer, M.D. Viola W. Bernard, M.D. Clinical Professor of Psychiatry Columbia University School of Public Health and Administrative Medicine 600 West 168th Street New York, New York 10032 William A. Darity, Ph. D. Professor of Public Health University of Massachusetts Department of Public Health Amherst, Massachusetts 01003 Melvin Zelnik, Ph. D. Associate Professor Division of Population Dynamics School of Hygiene and Public Health Johns Hopkins University 615 N. Wolfe Street Baltimore, Maryland 21205 John C. Cutler, M.D. Director, Population Division Graduate School of Public Health University of Pittsburgh Pittsburgh, Pennsylvania Arnold Schwartz, M.D. Professor of Public Health School of Public Health University of Hawaii 2540 Maile Way Honolulu, Hawaii 96822 Group X—Environmental Health Chairman: Morton S. Hwsert, M.P.H. Nelson Biaggi, Ph. D. Professor of Environmental Health University of Puerto Rico School of Medicine Department of Public Health San Juan, Puerto Rico 00905 Dorothea C. Leighton, M.D. Professor of Mental Health University of North Carolina School of Public Health Chapel Hill, North Carolina Thomas McGowan, M.D. Associate Professor University of Oklahoma School of Health 800 Northeast 13th Street Oklahoma City, Oklahoma 73104 Edwin Fair, M.D. University of Oklahoma School of Health 800 Northeast 13th Street Oklahoma City, Oklahoma 73104 86 Morton S. Hilbert, M.P.H. Associate Professor of Environ- mental Health University of Michigan School of Public Health Ann Arbor, Michigan 48104 Frank W. Macdonald, Dr. P.H. Professor of Environmental Hy- iene Tulane Universit, School of Public Health and Tropical Medicine 1430 Tulane Avenue New Orleans, Louisiana 70112 Morris A. Shiffman, D.V.M. Associate Professor of Environ- mental Sanitation School of Public Health University of North Carolina Chapel Hill, North Carolina 27514 Group XI—Occupational Health Chairman: Jost Nine-Curr, M.D. Anna M. Baetjer, Sc. D. Professor of Environmental Medicine Johns Hopkins University School of Hygiene and Public Health 615 N. Wolfe Street Baltimore, Maryland 21205 Florence G. Liben, M.D. Associate in Psychiatry Columbia University School of Public Health and Administrative Medicine 600 West 168th Street New York, New York 10032 David Minard, M.D., Ph. D. Professor of Occupational Health Graduate School of Public Health University of Pittsburgh Pittsburgh, Pennsylvania Daniel Wilner, Ph. D. Professor of Public Health University of California School of Public Health Hilgard Avenue Los Angeles, California 90024 Jean S. Felton, M.D. Professor of Occupational Health University of California School of Public Health Hilgard Avenue Los Angeles, California 90024 Harold J. Magnuson, M.D. Professor of Industrial Health University of Michigan School of Public Health Ann Arbor, Michigan 48104 José R. Nine-Curt, M.D. Head, Department of Public Health School of Medicine University of Puerto Rico San Juan, Puerto Rico 00905 David A. Fraser, D. Sc. Associate Professor of Industrial Hygiene School of Public Health University of North Carolina Chapel Hill, North Carolina 27514 87 Group XlI—Nutrition Chairman: Mervy~N G. Harpinee, M.D. Grace Goldsmith, M.D. Dean, School of Public Health and Tropical Medicine Tulane University 1430 Tulane Avenue New Orleans, Louisiana 70112 Edward Norman, M.D. Professor of Public Health Psy- chiatry Tulane University School of Public Health and Tropical Medicine 1430 Tulane Avenue New Orleans, Louisiana 70112 C. A. Roberts, M.D. Executive Director Clarke Institute of Psychiatry 250 College Street, Toronto 2B, Canada (Representing University of To- ronto School of Hygiene) Bacon F. Chow, Ph. D. Professor of Biochemistry Johns Hopkins University School of Hygiene and Public Health 615 N. Wolfe Street Baltimore, Maryland 21205 Mervyn G. Hardinge, M.D. Dean, School of Public Health Loma Linda University I.oma Linda, California 92354 John R. K. Robson, M.D. Associate Professor of Nutrition University of Michigan School of Public Health Ann Arbor, Michigan 48104 Other Participants REPORTERS Section A (Groups 1,1, and 111) Richard K. C. Lee, M.D. Dean, School of Public Health University of Hawaii 2540 Maile Way Honolulu, Hawaii 96822 Section B (Groups IV, V,VI) Edward M. Cohart, M.D. Chairman, Department of Epi- demiology and Public Health Yale University School of Medicine 60 College Street New Haven, Connecticut 06510 Section C (Groups VII, VIII, IX) Myron E. Wegman, M.D. Dean, School of Public Health University of Michigan Ann Arbor, Michigan 48104 Section D (Groups X, XI, XII) William F. Mayes, M.D. Dean, School of Public Health University of North Carolina Chapel Hill, North Carolina 27514 L. S. Goerke, M.D. Dean, School of Public Health Universit Hilgard of California venue Los Angeles, California 90024 INVITED SPEAKER René J. Dubos, Ph. D. Professor The Rockefeller University 66th & York Avenue New York, New York 10021 NIMH Participants Not Assigned to Groups Stanley F. Yolles, M.D. Director National Institute of Mental Health 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 Bertram S. Brown, M.D. Deputy Director National Institute of Mental Health 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 Raymond J. Balester, Ph. D. Acting Director Division of Manpower and Training Programs National Institute of Mental Health 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 Stephen E. Goldston, Ed. D., M.S.P.H. Special Assistant to the Director National Institute of Mental Health 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 Richard H. Williams, Ph. D. Assistant to the Director for Special Projects National Institute of Mental Health 5454 Wisconsin Avenue Chevy Chase, Maryland 20015 Mgrs. JEAN SANTUCCI Conference Secretary Mgzs. Mary DIP1eTRO Conference Secretary 89 U.S. GOVERNMENT PRINTING OFFICE: 1969 O—335-225 “% Public Health Service Publication No. 1899 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION NATIONAL INSTITUTE OF MENTAL HEALTH wii (029318596