A Cross-Cultural Format for National Mental Health Program Analysis Bernard L. Bloom, Ph.D., S.M.Hyg. Wayne R. Bartz, Ph.D. Johanna M. Brawley, Ph.D. James R. Holmes David L. Jordan, Ph.D. Edward W. Pomeroy, Ph.D. Michael Ziegler, Ph.D.
ABSTRACT:With the growing interest in community mental health programs outside of the United States on the part of American mental health professionals, a cross-cultural format has been developed to assist in making a comprehensive analysis of any national mental health program. The format itself, together with initial experiences with its utilization in the study of six different mental health programs, is presented. While continued revisions of the format can be expected, it has already proved useful in comparative analyses of a variety of mental health program components. One of the particularly useful by-products of the growing interest in the provision of community-based mental health services in the United States has been the increased interest in mental health services in other countries. It has often been alleged that while the United States may generally be superior in the treatment provided for acute and atypical illnesses, other countries often have better organized services for chronic illnesses, including psychiatric disorders. Furthermore, many of the ideas basic to the American community mental health philosophy seem to owe a great deal to programs outside the United States. This is particularly true of ideas regarding the coordination, delivery, and financing of mental health services. One aspect of the growing interest in international mental health is the rapidly expanding literature appearing in American journals regarding mental health programs outside the United States. Within recent years international surveys of progress in mental health programming have appeared (see, for example, Krapf and Moser, 1962 ). European programs have been described by Anderson (I965), Furman (1965), Hurder ( i 9 6 i ) , Lunn (1966), Maclay (i958), Mandelbrote (1965), Morrice (i966), Mueller (I965), and Rajotte and Denber (i964). Through the writings of Field and Aronson (~964, 2965), Lazure (1964), and Rao (1966), among others, American readers are Dr. Bloom is professor, Department of Psychology, University of Colorado, Boulder, Col. 8o3o2. The co-authors are graduate students in the department. Community Mental Health Journal, Vol. 5 (3), 1969
227
228
Community Mental Health Journal
learning more about mental health activities in Asia and in the Soviet Union. There is also an occasional article about mental health activities in Central and South America (see, for example, Guanche-Cadron and TorresCastro, 2966, and Keenan, 2966 ) as well as in Africa (Lambo, I964 and 1966, and Toker, i966 ). Paralleling this growing literature is an increase in the availability of descriptions of general health and welfare services outside the United States (Chen, 1966, Jellinek, 2963, Strornberg I966, and WHO, I96o ). Tunley (I966) has recently described several national health programs to a lay audience. If efforts are to be made to compare national mental health programs systematically, however, in addition to learning about particular features in certain countries, a general format or guide would be desirable. Such a format would need to be reasonably comprehensive and at the same time sufficiently broad and flexible so that it would be applicable to most, if not all, national mental health programs. The virtues of such a guide would be that similar kinds of questions could be raised regarding each national program, and countries could be compared regarding many facets of their mental health activities. Such a format would also serve to alert investigators to areas in which they do not have adequate information about mental health activities in other countries. The format for the analysis of a national mental health program presented here was the outcome of a project undertaken to determine what kinds of information would be needed about any country in order to have a full understanding of its mental health activities and their social and geopolitical contexts. Following the preliminary development of a format by each author working independently, the various proposals were reviewed and integrated into the form presented in Table 2. Continued revisions of the format will undoubtedly be desirable, although in its present form it has been reasonably satisfactory. In order to examine the usefulness of the format, it has already'been applied to six national mental health programs: Canada, Great Britain, the Soviet Union, Israel, Liberia, and Ireland. National mental health programs in Norway, Haiti, and Nigeria are currently (January, 2968 ) being studied. In each case it was difficult to get information, although within a period of three months a surprising amount was uncovered. In every case more information was available than was thought probable at first, although there was considerable variation in both the quantity and quality of information obtained. Initial requests for information were made of the appropriate embassies, United Nations delegations, ministries of health, and of the World Health Organization. After that, whatever leads were uncovered were followed. The most difficult components of the analysis format to complete included Section VI (Specialized Mental Health Services), Section VIII (Mental Health Forensics), Section IX (Cost and Financing), Section XI (Volunteer Mental Health Activities) and Section XII (Research). In spite of these difficulties, however, the analyses are informative and substantiate the notion
Bloom, Bartz, Brawley, Holmes, Jordan, Pomeroy, Ziegler
229
TABLE
Format for the Analysis of a National Mental Health Program I. Relevant Background Information A. General 4. Geopolitical organization of country i. Brief orientation to country and rele5. Literacy rate, health level, and other vant history relevant general population charac2. Demographic, political, geographic, teristics ethnic, and economic features relevant to an understanding of the mental health program context B. Mental Health 3. Contemporary political climate and i. History of efforts to provide mental relatively enduring cultural values of health services importance in understanding mental 2. Previously existing surveys of mental health program health program II. Conceptions of Mental Illness, A. Definition of the field and the patient-- C. who is considered mentally ill; what phenomena are considered within the field of mental illness D. B. Community and national definitions of deviant behavior
Insanity, and Treatment Paths to mental health facilities, e.g., voluntary petition, commitment, usual patient history General ideas of causation of mental illness and relation to prevailing treatment methods
III. Context of Mental Health Program A. Description of related programs z. General health services 4. Interagency and interprogram collab2. Welfare and financial assistance prooration grams B. Activities of the above programs in men3- Education tal health field IV. Organization and Description of relation to population served B. Role of each geopolitical unit C. Statistical information, e.g., admissions, prevalence, etc. D. Specific program descriptions ~. Inpatient services 2. Outpatient services 3. Transitional services, e.g., halfway houses, day or night hospitals, foster and nursing home placement, homemaker services, emergency services, diagnostic services Ao Locations, in
Public Sector Mental Health Program 4. Rehabilitative services, sheltered workshop, employment programs, expatient social clubs 5- Primary prevention programs, including mental health education 6. Use of nonheahh facilities, e.g., jails, as mental health program resources 7. Variations in availability of services within country E. Interagency, intergeopolitical unit, and interprogram relationships F. Nature of ongoing program analysis and evaluation G. Program planning activities
V. Organization and Description of Private Sector Services D. Interrelationships within private sector A. General health services and between private and public sector B. Mental health services C. Missionary services
A. B. C. D. E. F. G.
VI. Specialized Mental Health Services H. Mental health aspects of chronic disease Rural areas services I. Migrant workers Urban areas services J. Emotionally disturbed children Special education Alcoholism and drug abuse K. Special programs for chronic mental illness Juvenile delinquency L. Other special programs Adult correction M. Unusual or unique treatment techniques Aging
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TABLE I (continued) VII. Mental Retardation Programs C. Other programs A. Inpatient services B. Community outpatient programs VIII. Mental Health Forensics D. The patient as a witness A. Legal definitions of insanity E. Other forensic considerations B. Types of legal commitments C. Pleading insanity IX. Cost and Financing of Mental Health Programs A. Budget and source of funds C. Analysis of expenditures B. Expenditures by category and by source of funds X. Manpower and Employment A. Employment practices (e.g., merit system, E. Training of manpower--universities and other training facilities salary) B. Availability of manpower and ease of re- F. Professional societies--programs and degree of vitality cruitment C. Types of manpower utilized and nature G. Mental health-related manpower programs, e.g., clergy, recreation of their responsibilities 2. Use of folk-practitioners or other in- H. Standard-setting policies and procedures digenous workers I. Interprofessional relationships, and staD. Formal role of family in treatment protus differentials cedures XI. Voluntary Mental Health Activities A. Volunteer clinical and related activities B. Voluntary agencies (equivalent to a mental health association) XII. Research A. Areas of activity and research interest D. Publication B. Specific scientists and studies channels C. General level of support and sources of support for research
and other dissemination
XIII. Evaluation of Mental Health Prcrgram A. Strengths and weaknesses of the national mental health program A. In English language
XIV. Annotated Bibliography B. In native language (if other than English)
XV. Glossary of Special Terms Used in Country that some components of the c o m m u n i t y mental health model as it is developing in this country have been prevalent for m a n y years in the countries studied and that c o m m u n i t y mental health concepts are particularly useful where n e w l y developing programs are being planned or implemented. It has become customary in the United States to use the phrase " c o m m u nity mental health" in two quite separate contexts. Social scientists tend to use the term to refer to that b o d y of research and practice dealing with the "mental health" of the c o m m u n i t y and with the identification of forces in the c o m m u n i t y that enhance or detract from the emotional well-being of its
Bloom, Bartz, Brawley, Holmes, Jordan, Pomeroy, Ziegler
231
members. Medically trained practitioners and administrators and planners of community mental health facilities tend to use the term to refer to improved systems for the organization and financing of traditional mental health services. It is in this latter sense that community mental health programs outside the United States appear to have the most to teach Americans. Preventive services and social system analyses and modifications are not common in the countries studied, nor does there seem to be an unusually high priority assigned to their development. Rather, there appears to be a concern with reaching all the appropriate members of a catchment area, making a full range of services available to all without regard to financial considerations, and with utilization of indigenous manpower or traditional manpower in innovative ways. In general, community mental health programs of those countries studied outside the United States are within the general medical health services model and they focus on treatment rather than prevention. In contrast to most American community mental health programs, even within quite recent years, programs outside the United States are generally oriented toward the provision of comprehensive services without concern for financial or other eligibility requirements. The format which has been developed and presented here has been unusually helpful in understanding the historical antecedents of various mental health programs as well as in studying national differences in mental health program philosophies, objectives, components, and techniques. It would be most appropriate if the development of such a format could be continued by many persons with the goal of improving upon the version presented here.
REFERENCES Anderson, R. W. British community psychiatry and its implications for American planning. Community Mental Health Journal, i965, I, 223-232. Aronson, J., and Field, M. G. Mental health programming in the Soviet Union. American Journal of Orthopsychiatry, i964, 34, 913-924 9 Chen, K. P. Medicine and public health in transition in Taiwan. Harvard Public Health Alumni Bulletin, 1966, 23, 6-I2.
Field, M. G., and Aronson, J. Soviet community mental health services and work therapy: a report of two visits. Community Mental Health Journal, 1965, 1, 8i-9o. Furman, S. S. Community mental health services in northern Europe. National Institute of Mental Health. Washington, D.C. : Gov. Ptg. Office, i965. Guanche-Padron, J., and Torres-Castro, J. Psychiatry in Yucatan. Hospital Community Psychiatry, i966, 17, I62-163 .
Hurder, W. P. (Ed.) European mental health programs as viewed by mental health specialists and legislators. Southern Regional Education Board. Atlanta, Ga., i96I. Jellinek, E. M. Government programs on alcoholism: a review of activities in some foreign countries. Rep. Series Memo. No. 6. Mental Health Division, Dept. of National Health and Welfare, Ottawa, Canada, i963 . Keenan, Betty. The hospital Ayala, M6rida. Hospital and Community Psychiatry, i966, I7, I64-i66. Krapf, E. E., and Moser, J. Changes of emphasis and accomplishments in mental health work, i948-196o. Mental Hygiene, 1962, 46 , I63-i92. Lambo, T. Adeoye. Patterns of psychiatric care in developing African countries. In Ari Kiev (Ed.), Magic, faith, and healing. New York: Free Press, 2964.
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Community Mental Health Journal
Lambo, T. Adeoye. Socioeconomic change, population explosion and changing phases of mental health programs in developing countries. American Journal of Orthopsychiarty, 1966, 36, 77-83. Lazure, D. Politics and mental health in new China. American Journal of Orthopsychiatry, i964, 34, 925-933 . Lunn, V. Some features of Danish forensic psychiatry. Comparative Psychiatry, 1966, 7, 69-80. Maclay, W. S. Experiments in mental hospital organization. Canadian Medical Association Journal, i958, 78, 9o9-916. Mandelbrote, B. M. Running a British mental hospital Mental Hygene, I965, 49, 2o8-219. Morrice, J. K. W. Dingleton l~ospital's therapeutic community. Hospital and Community Psychiatry, 1966, 17, 14o-I43. Mueller, H. W. Germany's hospitals develop broad programs. Mental Hospitals, 1965, I6, 2o4-2o8. Rajotte, P., and Denber, H. C. B. Two remarkable achievements of social therapy: the French psychiatric hospitals of Saint-Alban and Lannemezan. Mental Hygiene, i964, 48, 537-543. Rao, S. Caste and mental disorders in Behar. American Journal of Psychiatry, I966 , I22, lo45-1o55. Stromberg, K. South of the border. Univ. of Colo. Medical School Quarterly, I966, 7 (Winter), I- 3, Toker, E. Mental illness in the White and Bantu populations of the Republic of South Africa. American Journal of Psychiatry, 1966, I23, 55-65. Tunley, R. The American health scandal. New York: Harper & Row, 1966. World Health Organization. Health services in the USSR. Public Health Papers No. 3. Geneva: WHO, I96o.
ABSTRACT:With the growing interest in community mental health programs outside of the United States on the part of American mental health professionals, a cross-cultural format has been developed to assist in making a comprehensive analysis of any national mental health program. The format itself, together with initial experiences with its utilization in the study of six different mental health programs, is presented. While continued revisions of the format can be expected, it has already proved useful in comparative analyses of a variety of mental health program components. One of the particularly useful by-products of the growing interest in the provision of community-based mental health services in the United States has been the increased interest in mental health services in other countries. It has often been alleged that while the United States may generally be superior in the treatment provided for acute and atypical illnesses, other countries often have better organized services for chronic illnesses, including psychiatric disorders. Furthermore, many of the ideas basic to the American community mental health philosophy seem to owe a great deal to programs outside the United States. This is particularly true of ideas regarding the coordination, delivery, and financing of mental health services. One aspect of the growing interest in international mental health is the rapidly expanding literature appearing in American journals regarding mental health programs outside the United States. Within recent years international surveys of progress in mental health programming have appeared (see, for example, Krapf and Moser, 1962 ). European programs have been described by Anderson (I965), Furman (1965), Hurder ( i 9 6 i ) , Lunn (1966), Maclay (i958), Mandelbrote (1965), Morrice (i966), Mueller (I965), and Rajotte and Denber (i964). Through the writings of Field and Aronson (~964, 2965), Lazure (1964), and Rao (1966), among others, American readers are Dr. Bloom is professor, Department of Psychology, University of Colorado, Boulder, Col. 8o3o2. The co-authors are graduate students in the department. Community Mental Health Journal, Vol. 5 (3), 1969
227
228
Community Mental Health Journal
learning more about mental health activities in Asia and in the Soviet Union. There is also an occasional article about mental health activities in Central and South America (see, for example, Guanche-Cadron and TorresCastro, 2966, and Keenan, 2966 ) as well as in Africa (Lambo, I964 and 1966, and Toker, i966 ). Paralleling this growing literature is an increase in the availability of descriptions of general health and welfare services outside the United States (Chen, 1966, Jellinek, 2963, Strornberg I966, and WHO, I96o ). Tunley (I966) has recently described several national health programs to a lay audience. If efforts are to be made to compare national mental health programs systematically, however, in addition to learning about particular features in certain countries, a general format or guide would be desirable. Such a format would need to be reasonably comprehensive and at the same time sufficiently broad and flexible so that it would be applicable to most, if not all, national mental health programs. The virtues of such a guide would be that similar kinds of questions could be raised regarding each national program, and countries could be compared regarding many facets of their mental health activities. Such a format would also serve to alert investigators to areas in which they do not have adequate information about mental health activities in other countries. The format for the analysis of a national mental health program presented here was the outcome of a project undertaken to determine what kinds of information would be needed about any country in order to have a full understanding of its mental health activities and their social and geopolitical contexts. Following the preliminary development of a format by each author working independently, the various proposals were reviewed and integrated into the form presented in Table 2. Continued revisions of the format will undoubtedly be desirable, although in its present form it has been reasonably satisfactory. In order to examine the usefulness of the format, it has already'been applied to six national mental health programs: Canada, Great Britain, the Soviet Union, Israel, Liberia, and Ireland. National mental health programs in Norway, Haiti, and Nigeria are currently (January, 2968 ) being studied. In each case it was difficult to get information, although within a period of three months a surprising amount was uncovered. In every case more information was available than was thought probable at first, although there was considerable variation in both the quantity and quality of information obtained. Initial requests for information were made of the appropriate embassies, United Nations delegations, ministries of health, and of the World Health Organization. After that, whatever leads were uncovered were followed. The most difficult components of the analysis format to complete included Section VI (Specialized Mental Health Services), Section VIII (Mental Health Forensics), Section IX (Cost and Financing), Section XI (Volunteer Mental Health Activities) and Section XII (Research). In spite of these difficulties, however, the analyses are informative and substantiate the notion
Bloom, Bartz, Brawley, Holmes, Jordan, Pomeroy, Ziegler
229
TABLE
Format for the Analysis of a National Mental Health Program I. Relevant Background Information A. General 4. Geopolitical organization of country i. Brief orientation to country and rele5. Literacy rate, health level, and other vant history relevant general population charac2. Demographic, political, geographic, teristics ethnic, and economic features relevant to an understanding of the mental health program context B. Mental Health 3. Contemporary political climate and i. History of efforts to provide mental relatively enduring cultural values of health services importance in understanding mental 2. Previously existing surveys of mental health program health program II. Conceptions of Mental Illness, A. Definition of the field and the patient-- C. who is considered mentally ill; what phenomena are considered within the field of mental illness D. B. Community and national definitions of deviant behavior
Insanity, and Treatment Paths to mental health facilities, e.g., voluntary petition, commitment, usual patient history General ideas of causation of mental illness and relation to prevailing treatment methods
III. Context of Mental Health Program A. Description of related programs z. General health services 4. Interagency and interprogram collab2. Welfare and financial assistance prooration grams B. Activities of the above programs in men3- Education tal health field IV. Organization and Description of relation to population served B. Role of each geopolitical unit C. Statistical information, e.g., admissions, prevalence, etc. D. Specific program descriptions ~. Inpatient services 2. Outpatient services 3. Transitional services, e.g., halfway houses, day or night hospitals, foster and nursing home placement, homemaker services, emergency services, diagnostic services Ao Locations, in
Public Sector Mental Health Program 4. Rehabilitative services, sheltered workshop, employment programs, expatient social clubs 5- Primary prevention programs, including mental health education 6. Use of nonheahh facilities, e.g., jails, as mental health program resources 7. Variations in availability of services within country E. Interagency, intergeopolitical unit, and interprogram relationships F. Nature of ongoing program analysis and evaluation G. Program planning activities
V. Organization and Description of Private Sector Services D. Interrelationships within private sector A. General health services and between private and public sector B. Mental health services C. Missionary services
A. B. C. D. E. F. G.
VI. Specialized Mental Health Services H. Mental health aspects of chronic disease Rural areas services I. Migrant workers Urban areas services J. Emotionally disturbed children Special education Alcoholism and drug abuse K. Special programs for chronic mental illness Juvenile delinquency L. Other special programs Adult correction M. Unusual or unique treatment techniques Aging
230
Community Mental Health Journal
TABLE I (continued) VII. Mental Retardation Programs C. Other programs A. Inpatient services B. Community outpatient programs VIII. Mental Health Forensics D. The patient as a witness A. Legal definitions of insanity E. Other forensic considerations B. Types of legal commitments C. Pleading insanity IX. Cost and Financing of Mental Health Programs A. Budget and source of funds C. Analysis of expenditures B. Expenditures by category and by source of funds X. Manpower and Employment A. Employment practices (e.g., merit system, E. Training of manpower--universities and other training facilities salary) B. Availability of manpower and ease of re- F. Professional societies--programs and degree of vitality cruitment C. Types of manpower utilized and nature G. Mental health-related manpower programs, e.g., clergy, recreation of their responsibilities 2. Use of folk-practitioners or other in- H. Standard-setting policies and procedures digenous workers I. Interprofessional relationships, and staD. Formal role of family in treatment protus differentials cedures XI. Voluntary Mental Health Activities A. Volunteer clinical and related activities B. Voluntary agencies (equivalent to a mental health association) XII. Research A. Areas of activity and research interest D. Publication B. Specific scientists and studies channels C. General level of support and sources of support for research
and other dissemination
XIII. Evaluation of Mental Health Prcrgram A. Strengths and weaknesses of the national mental health program A. In English language
XIV. Annotated Bibliography B. In native language (if other than English)
XV. Glossary of Special Terms Used in Country that some components of the c o m m u n i t y mental health model as it is developing in this country have been prevalent for m a n y years in the countries studied and that c o m m u n i t y mental health concepts are particularly useful where n e w l y developing programs are being planned or implemented. It has become customary in the United States to use the phrase " c o m m u nity mental health" in two quite separate contexts. Social scientists tend to use the term to refer to that b o d y of research and practice dealing with the "mental health" of the c o m m u n i t y and with the identification of forces in the c o m m u n i t y that enhance or detract from the emotional well-being of its
Bloom, Bartz, Brawley, Holmes, Jordan, Pomeroy, Ziegler
231
members. Medically trained practitioners and administrators and planners of community mental health facilities tend to use the term to refer to improved systems for the organization and financing of traditional mental health services. It is in this latter sense that community mental health programs outside the United States appear to have the most to teach Americans. Preventive services and social system analyses and modifications are not common in the countries studied, nor does there seem to be an unusually high priority assigned to their development. Rather, there appears to be a concern with reaching all the appropriate members of a catchment area, making a full range of services available to all without regard to financial considerations, and with utilization of indigenous manpower or traditional manpower in innovative ways. In general, community mental health programs of those countries studied outside the United States are within the general medical health services model and they focus on treatment rather than prevention. In contrast to most American community mental health programs, even within quite recent years, programs outside the United States are generally oriented toward the provision of comprehensive services without concern for financial or other eligibility requirements. The format which has been developed and presented here has been unusually helpful in understanding the historical antecedents of various mental health programs as well as in studying national differences in mental health program philosophies, objectives, components, and techniques. It would be most appropriate if the development of such a format could be continued by many persons with the goal of improving upon the version presented here.
REFERENCES Anderson, R. W. British community psychiatry and its implications for American planning. Community Mental Health Journal, i965, I, 223-232. Aronson, J., and Field, M. G. Mental health programming in the Soviet Union. American Journal of Orthopsychiatry, i964, 34, 913-924 9 Chen, K. P. Medicine and public health in transition in Taiwan. Harvard Public Health Alumni Bulletin, 1966, 23, 6-I2.
Field, M. G., and Aronson, J. Soviet community mental health services and work therapy: a report of two visits. Community Mental Health Journal, 1965, 1, 8i-9o. Furman, S. S. Community mental health services in northern Europe. National Institute of Mental Health. Washington, D.C. : Gov. Ptg. Office, i965. Guanche-Padron, J., and Torres-Castro, J. Psychiatry in Yucatan. Hospital Community Psychiatry, i966, 17, I62-163 .
Hurder, W. P. (Ed.) European mental health programs as viewed by mental health specialists and legislators. Southern Regional Education Board. Atlanta, Ga., i96I. Jellinek, E. M. Government programs on alcoholism: a review of activities in some foreign countries. Rep. Series Memo. No. 6. Mental Health Division, Dept. of National Health and Welfare, Ottawa, Canada, i963 . Keenan, Betty. The hospital Ayala, M6rida. Hospital and Community Psychiatry, i966, I7, I64-i66. Krapf, E. E., and Moser, J. Changes of emphasis and accomplishments in mental health work, i948-196o. Mental Hygiene, 1962, 46 , I63-i92. Lambo, T. Adeoye. Patterns of psychiatric care in developing African countries. In Ari Kiev (Ed.), Magic, faith, and healing. New York: Free Press, 2964.
232
Community Mental Health Journal
Lambo, T. Adeoye. Socioeconomic change, population explosion and changing phases of mental health programs in developing countries. American Journal of Orthopsychiarty, 1966, 36, 77-83. Lazure, D. Politics and mental health in new China. American Journal of Orthopsychiatry, i964, 34, 925-933 . Lunn, V. Some features of Danish forensic psychiatry. Comparative Psychiatry, 1966, 7, 69-80. Maclay, W. S. Experiments in mental hospital organization. Canadian Medical Association Journal, i958, 78, 9o9-916. Mandelbrote, B. M. Running a British mental hospital Mental Hygene, I965, 49, 2o8-219. Morrice, J. K. W. Dingleton l~ospital's therapeutic community. Hospital and Community Psychiatry, 1966, 17, 14o-I43. Mueller, H. W. Germany's hospitals develop broad programs. Mental Hospitals, 1965, I6, 2o4-2o8. Rajotte, P., and Denber, H. C. B. Two remarkable achievements of social therapy: the French psychiatric hospitals of Saint-Alban and Lannemezan. Mental Hygiene, i964, 48, 537-543. Rao, S. Caste and mental disorders in Behar. American Journal of Psychiatry, I966 , I22, lo45-1o55. Stromberg, K. South of the border. Univ. of Colo. Medical School Quarterly, I966, 7 (Winter), I- 3, Toker, E. Mental illness in the White and Bantu populations of the Republic of South Africa. American Journal of Psychiatry, 1966, I23, 55-65. Tunley, R. The American health scandal. New York: Harper & Row, 1966. World Health Organization. Health services in the USSR. Public Health Papers No. 3. Geneva: WHO, I96o.
