objectivity is masculine and care is feminine, and the former is always valued more than the latter.

Let me offer a perspective on mental health issues that differs somewhat from the analysis presented by Dr. Pechura in “Healing the Mind–Body Split.” I begin by emphasizing a critical but often ignored point, namely, that chronic disabling illness is the central health problem facing American society. By definition, chronic disorders are unlike acute bacterial infectious diseases. The latter are short-lived and generally curable; the former are of long duration, often impair the functions of organs and cause disability, and usually require a judicious combination of treatment and care that minimizes (but does not necessarily eliminate) the underlying pathology and the disabilities that follow. Such disorders as schizophrenia, for example, erode the ability of people to deal with “personal hygiene and self-care, self-direction, interpersonal relationships, social transactions, learning and recreation,” which in turn prevent them from becoming economically self-sufficient.1 Since there is no “magic bullet” to cure schizophrenia and eliminate the disabilities that follow, we rely on a judicious mixture of psychiatric interventions (e.g., drugs) and systems of care. The same comments apply as well to many chronic conditions, including those associated with cardiovascular disorders and malignant neoplasms.

Health policy as it relates to the severely and chronically mentally ill, therefore, must be conceptualized within a framework that includes the traditional emphasis on prevention and treatment, but accepts as well the need for care. Indeed, severe mental disorders require the integration of health policy and social policy. The challenge to the IOM is to promote the kind of broad-based studies that will enable us to modify our health care system to accommodate the varied needs of those who suffer from chronic disorders that involve disability. Beginning with this observation, let me offer a somewhat different perspective on mental health policy in the decades following the end of World War II.

After World War II mental health policy underwent a dramatic transformation. In mid-nineteenth-century America the asylum was widely regarded as the symbol of an enlightened and progressive nation that no longer ignored or mistreated its insane citizens. The justification for asylums appeared self-evident: they benefited the community, the family, and the individual by offering effective medical and psychological medical treatment for acute cases and humane custodial care for chronic cases. In providing for the mentally ill, the state met its ethical and moral responsibilities and, at the same time, contributed to the general welfare by limiting, if not eliminating, the spread of disease and dependency.

After World War II, by way of contrast, mental hospitals began to be perceived as the vestigial remnants of a bygone age. Increasingly, the emphasis was on prevention and the provision of care and treatment in the community.



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