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families do very well, and you can now see very beautiful little homes that they have. They painted them up, spruced them up.

They take care of them during the time they are gone. Their yards are clean, and a very large percentage of these migrants are certainly not a blight on the community now.

Mr. BLACKWELL. What proportion of that migrant population do you think you are reaching? Twenty percent? Thirty percent?

Mr. GONZALEZ. We feel that it is between 30 and 40 percent that are coming to the clinics, that are following our clinical recommendations.

Most migrants have been approached by our health educator, sanitarian, and his assistant. Almost all have been seen and visited. They are participating in the services that we have for them.

We think that 40 percent would be a good figure to say that are taking advantage of what we have now.

I could be wrong in this, but many, many of them now don't even go to our clinics. They will go see their own private physician.

Mr. BLACKWELL. The migrants in Laredo settled in what, generally speaking, is part of an urban area in the fringe of Laredo, or in the city?

Mr. GONZALEZ. Inside the city limits; yes.

Mr. BLACKWELL. In Hidalgo they are more scattered throughout the rural areas?

Mr. GONZALEZ. Yes; it is out in the country, not so much in the city, but then Hidalgo, like I said, has an enormous number of migrants, and their families. They have approximately 25,000, just that county alone.

Mr. BLACKWELL. So it is obviously easier to reach the migrant settled inside the city limits?

Mr. GONZALEZ. Definitely.

Mr. BLACKWELL. So your 30 or 40 percent would be how much higher than in a county like Hidalgo, for example?

You could not logically expect them to have the same success in reaching them as you have in Laredo.

Mr. GONZALEZ. I believe so.

I am not too acquainted with the Hidalgo County program, but I think that they are having more success.

Mr. BLACKWELL. But your success is better than generally throughout the rural counties?

Mr. GONZALEZ. Let me say it is easier.

Senator WILLIAMS. Thank you very much, Mr. Gonzalez. Your presentation has been a big contribution to our deliberations here. Mr. Gonzalez, do you know whether there is a health program under this act in Starr County?

Mr. GONZALEZ. I believe that that is covered by the statewide program, Senator. I do not think that they have a local program.

I know Zapata County just south of us does have a program now. I am not sure if Starr County is included in the Hidalgo County program. It may be a multicounty program. I think it is under Dr. Copenhaver. He may be in Zapata and Starr Counties also.

If not, then it is covered under the State program.

Senate WILLIAMS. Thank you very much.

We will now hear from Dr. Robert Locey, the director, migrant health program, in three counties in Michigan.

We kept you waiting a long time, Doctor, but better late than

never.

Dr. LOCEY. I hope I have enough calories to continue, here.

Senator and staff members of the Subcommittee on Migratory Labor, I am very pleased to be able to represent the southwestern corner of Michigan to you.

When I introduced myself, I did not mention the names of the towns, and I think if I mentioned the names of any of the towns in our area, I doubt if you would recognize them.

Senator WILLIAMS. Oh, we have been there.

Dr. LOCEY. Well, I am glad to hear that.

Senator WILLIAMS. That is good cherry country, too.

Dr. LOCEY. Yes, and you made reference to strawberries at one time.

I think with all due respect to Florida, that you really ought to come see ours sometime. Our area is one of the most diversified crop areas of the country, and the growing season opens up in May with asparagus and closes with grapes and apples in the late fall.

Our particular agricultural industry requires large numbers of seasonal farmworkers, and thus we rely heavily on migrant laborers. The U.S. Department of Agriculture lists one of our counties, Berrien, as the Nation's third-ranking county in the utilization of migrant workers, and another of our counties, Van Buren, in the eighth ranking position.

Our peak utilization time is usually the middle of June, when some 23,400 migrants are on hand, 19,800 of which are of working age.

We generally maintain 6,000 to 10,000 seasonal workers during the 8-month harvest period, which covers some 25 different crops. To house this large influx of people, we have approximately 700 camps. When I first became director of the associated health departments in November of 1964, I was charged to do something about "the migrant problem."

Being new to the area, I did not know what this problem was. However, I soon discovered it was a situation of grave concern, and one about which the community was quite ashamed. In fact, it may have been a very strong factor in finally organizing an approved health department in our area.

În talking with doctors, dentists, hospital administrators, pastors, growers, city folk, and heads of civic and voluntary agencies, 1 found the community divided in itself, each willing to blame the other, and no one willing to take the leadership to solve this problem.

This was not surprising, in view of the magnitude of the situation. Because our communities are largely agricultural, the tax base was not felt to be sufficient to undertake a program that would meet the needs of these people.

Our ratio of doctor to resident population is low, and that same ratio for dentists is even lower. Paramedical manpower is at a premium. The many small political jurisdictions acted as so many fences, each enclosing a typical rural or semirural conservative people. Yet, the fact remained that the migrant suffered during his tenure with us, and that unnecessarily high medical bills for migrant medical care were being paid by the taxpayer, due to lack of preventive care, and of early care in cases of illness.

Data obtained for the year 1964 showed that area hospitals had a loss of some $90,000, due to uncollected bills for migrant care. The Berrien County Welfare Department reported a cost of approximately $38,000 in 1964 for outpatient visits.

Because the migrant worker waited until he was very sick before seeking help, it taxed our already hard-pressed medical manpower.

The doctors were not so distressed at the additional hours they had to put in for migrant care, but were more concerned about the followup on these people. They were concerned about the migrant's ability to obtain the prescribed medications that he should have, and about the living conditions that their sick patients had to be returned to.

Dentists in our area could handle only emergency care. No thought was given to the remedial aspect for migrants.

Organization was the only answer to the problem, and organization could only be attained through use of the Migrant Health Act of 1962. Since we were dealing with an interstate problem, we felt it was a fair and just use of Federal funds.

We were more than willing to put in our 25 percent. In fact, our contribution greatly exceeded that amount.

We knew that somehow we would have to develop some kind of educational program to stimulate migrants to seek care in the early stages of illness, that we would have to urge growers to afford adequate housing and a decent environment, to have safe water supplies, proper sewage disposal facilities, and suitable provisions for personal hygiene, laundry, and recreation; that we must somehow educate the migrant into the proper use of the facilities furnished by the grower; and that we must coordinate the health activities of official and voluntary agencies that were then providing assistance to migrants.

In looking at the map of the tricounty area, you can see, too, that we would have to provide facilities in the area where the camps were most prevalent.

In this case, the camps are indicated by red dots, the medical facilities in blue, and the dental facilities in green, and you can see that these facilities are not in the area where the migrants are most prevalent, and so we then established the three facilities that you see in a triangular fashion.

After months of planning and organization, we came up with a project that would cost approximately $1.28 per migrant per biweekly period for 13 biweekly periods. This is based on a biweekly average of 8,657 migrants from April 15 through October 15.

This is a very small amount, it is true. However, we tried to keep it practical in terms of the medical manpower we had available, our ability to recruit additional personnel, and the little experience that we had.

We would have been content that first year with just holding our own, while we were working out the bugs in the system and recruiting qualified personnel. However, our medical program was busy from the very outset. The number of outpatient visits supported in total or in part by the migrant health project for 1966 was 2,469.

The doctors working in the clinics, and again I make reference to our medical societies. I feel that congratulations are in order to them.

We have a hundred doctors. About a third are specialists, which reduces the number practicing—well, not practicing, but doctors seeing private patients-to 66, and 44 of them are in these migrant clinics.

87-443-68-8

But they were enthused about the quality and continuity of care given, and the followup of these cases in the field.

Administrators at the local hospitals noticed a decrease in hospitalization of migrant workers, and members of their families. Physicians having offices nearest to the growing areas and physicians on call for hospital emergency rooms said that emergency calls for migrants had lessened considerably.

Growers felt that lost time in the fields due to illness was lessened, giving them more man-hours of work, and there were indications that many of the laborers would return next year because of the respect afforded them at the clinics.

As one migrant put it, "This is the first time I felt treated like an equal human being."

Our division of environmental health licensed 634 of the estimated 700 camps. Within this number of camps, 2,108 item violations were noted, and orders were issued for their correction.

Because of the shortage of personnel, only 93 camps were visited a second time. Among these 93 camps, 224 violations were listed at the time of the initial visit. At the time of the second visit, 147 corrections had been made, for a percentage correction of 65.6 percent, which was much better than the compliance rate for the State of Michigan as a whole, which was 39.9 percent.

I believe that this in some way reflects the value of a complete project. If the grower sees that the doctors, dentists, health department, civic and voluntary agencies are pitching in in one united effort, then he is more likely to go along.

At the time of the initial camp visit for licensure inspection in 1967, the number of violations recorded dropped by 58 percent, to 1,224. By the end of the 1967 season, our records show that over $110,000 had been put into improvements and new housing by the growers.

It is very difficult to compile, analyze, and compare data regarding costs and losses for medical care on seasonal laborers, due to several factors, including the present rapid rise in cost of medical care, and differences in the definition of migrant laborers among medical facilities, in policies of welfare departments, and in the number of migrants from year to year.

However, it is possible that any lowering of outpatient and inpatient costs for migrants could be related to the availability of facilities for early diagnosis and treatment of disease, to health education, and to the improvement of housing.

From the standpoint of outpatient cost, it is worth noting that in Berrien County the average cost per outpatient visit recorded by the department of social services in 1964 was $12.78, while, in spite of rising medical costs, the cost per outpatient visit recorded by the migrant family clinics in 1966 averaged only $7.22. For referrals made by project field personnel directly to private physician offices or hospital emergency room, the cost was only $9.36.

Also worth noting is the comparative data on direct relief medical payments made by the Berrien County Welfare Department, both before and after the project started.

In June, July, and August of 1965, the cost was $6,488.34. In these same months of 1966, the cost was only $3,079.30, or a reduction of $3,409.04.

The total cost for outpatient services during these same 3 months dropped from $9,898.32 in 1965 to $9,050.60 in 1966.

Although the difference is not striking, it is a definite break in the trend of increasing medical care costs for the indigent.

In terms of hospitalization during these same 3 months of 1965, $45,886.94 was spent on noncategorical hospitalization, which included migrant labor medical care costs. In 1966, the first year of the project, the cost for noncategorical hospitalization was only $39,521.95, or $6,345 less.

However, if you compare the first 5 months of 1965 and 1966 for noncategorical hospitalization, 1966 shows an increase in cost over 1965 by almost $30,000. Thus, the cost for noncategorical hospitalization had actually taken a sudden change from an increasing to a decreasing trend during the time the family health clinics for migrants were operating.

Such figures as the preceding ones, which are used as indexes to evaluate the progress of the migrant health program, cannot give the entire picture. Yet, they do give an indication that preventative care and early care is less costly.

Such early care is afforded the migrant through the program developed by our communities as a result of the Migrant Health Act of 1962.

The savings in terms of outpatient care and hospitalization in no way make up for the total cost of the project, but this is more than made up by a more knowledgeable migrant, a healthier migrant, and one who is more productive, and who is less of a burden on the taxpayer. The value is immeasurable in terms of the migrant's dignity. One of the greatest fears at the beginning of the project was that migrants who had higher than average capabilities for that class of people, and who were more stable from year to year than most seasonal workers, would abandon paying for their own care, as they had done in the past.

This proved to be untrue. Private physicians have reported that through the first and second years of the project those migrants who had been previous patients and were paying for their care were continuing to come to their office, and were continuing to pay their bills.

Our report for 1967 is being compiled, but is not yet completed. However, from observation, we know that our program has improved significantly. This year we had an outbreak of diphtheria, which we were able to handle efficiently and effectively.

After the situation was cleared up, I shuddered when I reflected on what we would have done had we not had the migrant health project.

Although we have made a great deal of progress, I am sure that you realize how difficult it is to develop something of this proportion in a 2-year period of time. We had hoped to be sufficiently organized by the time our project ran out, on June 30, 1969. Even then we will need some continuing financial support.

To say, or give the impression, that our current program will be sufficient at the end of 3 years, would be misleading. We still would not have sufficient environmentalists to inspect all camps at least twice during the season. We still would not have sufficient nurses and health education aides to make the meaningful personal contacts. necessary in many problem areas.

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