to another. Services were generalized so that they encompassed needs of the total family group. In this way needs of adults and children could be met in a single visit.

With passage of the Migrant Health Act in 1962, funds became available for development of migrant projects throughout the United States. The many projects which are now in operation have greatly increased our knowledge of migrant health problems and how to deal with them most effectively. Furthermore, these various projects reinforce each other so that migrants may now move from one project area to another along their various streams, and services started in one place may be continued in other locations on the way. Exchange of experience by professional workers has further added to effectiveness of these programs. One of the greatest "spin-off" values derived from these projects has been the strengthening of total public health services through reinforcement of existing programs, and acquisition of knowledge which is especially applicable toward meeting health needs of the poor.

In addition to improvement in the provision of personal health services, significant advances have been made in environmental health. Although State laws and regulations now provide standards for migrant housing and sanitation, such standards could not have been achieved without assistance from the Migrant Health Act. Palm Beach County has 136 farm labor camps with a total capacity of 26,959 individuals. In addition, there are 395 rooming houses with over 5,000 units and 1,300 other dwellings used by migrants. Upgrading these facilities, educating owners, operators, and occupants in principles of environmental health, and developing field sanitation programs could not be accomplished without augmentation of health department staff and facilities.

The Palm Beach County Migrant Health Project has now been in operation over 11 years. In the beginning a disproportionately large expenditure of effort was required to obtain minimum improvements. Health services conveyed to the migrant's doorstep might not be utilized because of ignorance, or fear. Improvement of housing and sanitation was a very slow process with inadequate laws or staff.

Now, migrants travel long distances to attend clinics. They seem eager to obtain information about health. The existence of other projects along the travel routes facilitates the exchange of information on patients. Acceptance of migrants by the communities has improved, largely due to greater involvement in service projects.

The volume of services now being provided to agricultural migrants in Florida is partly reflected by figures obtained from annual reports for the 1966-1967 season. Selected figures are as follows:

Clinic visits____

Field visits (nursing).

Sanitation visits..

Completed referrals (to other counties or States using the migrant health services referral system) --

43, 236

13, 678

10, 875

1,763

Comparisons with previous years show a marked increase in the various services. Even though the volume of health services now being provided is great, large numbers of migrants are not adequately being reached. Far too many medical conditions are in advanced stages before they are discovered; there are too many unnecessary deaths. Migrants are learning where to turn for help in treating illness, but we are only making a beginning in teaching the value of preventive measures and positive health. We have a long way to go before the environment in which the migrants live and work is brought up to acceptable standards, and it will take continued efforts to maintain these levels.

When illness is discovered which requires medical care or hospitalization, often for prolonged periods, we remain greatly handicapped in Florida. The funds available for hospitalization are completely inadequate, as are those for payment of physicians. As a result, obtaining treatment; except for emergencies, is often difficult. Hospitals and physicians do continue to provide treatment in many cases without reimbursement, but again migrants are without resources available to the resident population.

Partly as a result of the Migrant Health Act, the State and various counties have increased their efforts in behalf of migrants. However, the task exceeds local capabilities in those areas which continue to have large migrant populations. The intercounty and interstate character of these problems argues strongly in favor of continuation of migrant health programs as special services, at least until other resources become available.

An increase in funds available through the Migrant Health Act is strongly urged. Existing projects are limited in their ability to reach people needing service, or by their inability to provide a full range of medical care. Other areas would like to develop migrant projects, but are unable to do so because of inadequate funds.

Senator WILLIAMS. Certainly.

Dr. BRUMBACK. Since my home county, Palm Beach County, Fla., requires a very large number of agricultural farmworkers, we naturally have been impressed with the tremendous health needs of these people and their families.

When I first came in contact with this problem over 17 years ago, it soon became obvious that major assistance from the Federal Government was needed. Local resources were just not available for more than token support and many of the problems crossed State lines. Local health services are not adequate to meet the needs of the resident population. When 30,000 migrant workers and their family members in one county are added to this resident populationSenator WILLIAMS. What was that figure?

Dr. BRUMBACK. 30,000 workers and family members, which is a current estimate which I think is quite conservative, and these people have a disproportionately large number of problems.

It is impossible to do more than say that migrants are welcome to attend clinics if they can afford to lose a day's pay, make a 40- to 50-mile round trip, and return as often as necessary to obtain the fragmented services typically provided in most communities.

One would have to assume that the migrants are tremendously motivated to obtain health care and this was certainly not the case a few years ago.

The Palm Beach County migrant project has been in operation over 11 years. The early efforts were assisted by grants from the Children's Bureau, and through these studies and demonstrations we learned about the migrants' health problems, how they attempted to meet these problems, and the factors affecting their attempts at solution.

We learned a number of things which could be done to improve migrant health-the use of intermediary people for education and interpretation, the effectiveness of a multidisciplinary team, the family clinic concept in lieu of the traditional fragmented approach, the importance of providing services at a time and at a place most convenient to the migrant families and, most important, making the services acceptable to these people.

After over 11 years of these projects in Palm Beach County, we are now seeing the payoff of these services. Whereas formerly the services brought to the migrants' doorstep might be refused, now they will travel miles to attend clinics, and we can see the benefits in reduced illness, better nutrition, and much improved general health.

Of course, since 1962, local efforts have been reinforced by other projects. During this past year in Palm Beach County over 11,000 migrants received some type of personal health service-maternity care, immunizations, treatment of illness or injury, planned parenthood service, well child examinations, et cetera.

In addition, most of the 30,000 migrants were affected by environmental health services, improvement of housing and sanitation, and an unknown number received health information through various media.

Figures for the State of Florida obtained from annual reports for the 1966-67 season showed that there were over 43,000 clinic visits, over 13,000 nursing field visits, nearly 11,000 sanitation visits, and 1,763 completed referrals to other counties or other States.

I have some figures on the average per capita cost of personal health services in Palm Beach County. I was unable to get them for the State as a whole. But if we base this per capita information on the total number of the migrant estimated population in the county, we have a figure of $11.16 per migrant.

If we base this on the number reached, actually reached by services, the figure is $23.33. Of this the Public Health Service provided $13.40 of the cost of the service for the migrants reached and $6.66 based on the total population.

The sanitation services or environmental health services cost approximately $2.60 per individual served, of which $1.76 are grant funds. Although the volume of service rendered taxed the staff to capacity, nearly 19,000 migrants in Palm Beach County received no known personal health services. In many cases the services rendered were inadequate to meet the needs. Lack of sufficient funds to pay for hospitalization or physician services has created an increasingly serious problem in obtaining adequate diagnosis or treatment. Sometimes treatment is delayed until emergency care must be given.

We estimate that our budget of $334,813, including $200,268 of Federal money, would have to be at least doubled to provide minimum acceptable care. I am not talking about adequate or optimum, but minimum acceptable care. Much of the increase would be used for hospitalization and physician payments. The balance would be used to augment medical servicing, nutrition, education, sanitation, and social services.

More emphasis could be given to prevention of illness and disability and promotion of positive health, and I think this sometimes is lost when we talk about hospitalization and treatment for illness and injury, already present. We really haven't gotten into a program of prevention in positive health as we should with these people.

To summarize, agricultural migrants are still not receiving anywhere near the same amount of health care available to the resident population. A major portion have not been reached at all by these services. Now, this is in a county that has been providing services through special programs for over 11 years. A good beginning has been made, but much more needs to be done. The interstate character of the problems justifies a continuing partnership of Federal, State, and local agencies in working toward its solution.

The urgency and unusual character of this need requires the special attention which is given through the Migrant Health Act. If we are not to lose what we have gained through these projects, it is imperative that the act not only be extended, but that sufficient funds be authorized and appropriated to provide the needed health services to our agricultural migrants.

Thank you very much, and I will be glad to answer any questions. Senator WILLIAMS. That is a very helpful statement, I will say on behalf of the committee, Dr. Brumback. We had Dr. Wilson Sowder with us last week. He directs the State health program in Florida? Dr. BRUMBACK. Yes, that is correct, Senator Williams.

Senator WILLIAMS. And I imagine you work with the State health department.

Dr. BRUMBACK. Very closely.

Senator WILLIAMS. When it comes to applications for funds under our national program, and since you are associated with a county program you coordinate your programs with the State health department?

Dr. BRUMBACK. Yes, we do, Senator Williams. However, we continue to have a separate program. We have had a program first financed by the Children's Bureau and then from 1962 until 1966 shared by the Children's Bureau with the Public Health Service and we are at present receiving funds from the Public Health Service. We do work through the State board of health, but we have a separate program. Senator WILLIAMS. As I interpret your statement, you feel as though you made a good beginning in Palm Beach. It is Palm Beach County?

Dr. BRUMBACK. Yes, sir.

Senator WILLIAMS. You still have a long way to go and probably in terms of resources you need even today twice as much as the resources that are available?

Dr. BRUMBACK. Yes, this is true, and if this support were lost, although there would be a residual, I am sure, that would carry on, there isn't any question but what the program would be damaged tremendously. We simply would not be able to continue to support anything like the amount of services that we have and we can't see anything in the foreseeable future that would change this.

Senator WILLIAMS. Paul Rogers is the Congressman from that area. Dr. BRUMBACK. Yes, sir; that is correct.

Senator WILLIAMS. He is in a sense our counterpart on the House side, and I know that you have made your feeling known to Congressman Rogers.

Dr. BRUMBACK. Yes, very much so, Senator Williams.

Senator WILLIAMS. Well, we have had very good cooperation with the House side, through Congressman Rogers particularly. Dr. BRUMBACK. Yes; he is vitally interested.

Senator WILLIAMS. As a matter of fact, the whole program has gained such general acceptance that this committee has no controversy at all. Obviously you folks who are on the firing line are doing the work and have made the program work and it is known to be effective. It is our job to provide funds so that you can continue working in this area of dedication to people who some years back were almost wholly excluded from regular medical care.

Do you have any questions, Mr. Blackwell?

Mr. BLACKWELL. Dr. Brumback, the State contributes about a third to the program, on a statewide basis? Is that about right? Dr.BRUMBACK. Well, actually this is predominantly local contributions. The difference between our total amount expended and the amount contributed by the Public Health Service is primarily the local contribution, Mr. Blackwell. The State contributes.

Mr. BLACKWELL. Local and State contribution would be equivalent to what? Would it be as much as a third?

Dr. BRUMBACK. Our total budget at the present time is $334,000, of which $200,000 is Federal money, so there is a balance of a little over $134,000 which is primarily local.

Mr. BLACKWELL. So in your particular project the local contribution is slightly in excess of the State?

Dr. BRUMBACK. Yes, it is.

Mr. BLACKWELL. What was the per capita expenditure for persons reached in your project?

Dr. BRUMBACK. The per capita expenditure for personal health services for the migrants reached was $23.33 according to our calculation.

Mr. BLACKWELL. And you characterize that, I believe, as minimum health care?

Dr. BRUMBACK. Well, actually when it is realized that this includes hospitalization, preventive care, clinic service, home nursing visits, and all types of health care for a period of 1 year, this is certainly very submarginal as far as trying to deal effectively with the health needs.

Mr. BLACKWELL. What would be the statewide cost of extending the $100,000 in the State of Florida to the level of care that you have in your project? Would that be $2.3 million? Is that the arithmetic? Dr. BRUMBACK. I should guess that the State would want to at least double the amount expended at the present time, the same as we would.

Mr. BLACKWELL. Are you speaking of per capita, doubling per capita, or doubling total project cost?

Dr. BRUMBACK. I am talking about the total project money in order to supply minimal services to these people, because there are still a number who are not being reached, and those who are being reached are not being adequately reached. I think this is extremely conservative, Mr. Blackwell.

Mr. BLACKWELL. You are characterizing it as conservative, because the figure to double would not, on a statewide basis, result in the $23 per capita expenditure in your project? Is that what you have in mind? Dr. BRUMBACK. That is correct.

Mr. BLACKWELL. So, if your standard of care were used as the norm statewide, it would be roughly double again.

Dr. BRUMBACK. We don't consider ours optimum at all. We are not providing adequate care. We are not reaching half of the migrant population, so certainly our services are not yet adequate.

Mr. BLACKWELL. Dr. Brumback, I would guess that there is an increasing number of hospitalizations of migrant farm workers subsequent to the establishment of your program, that is, more people are reached, and more people learn about it; there are more illnesses and conditions discovered requiring hospitalization. Is that a sound guess?

Dr. BRUMBACK. Yes, it is. However, also we are cutting down on hospitalization now by being able to reach these people outside the hospital through outpatient clinics, through health education, through better environmental sanitation programs. We are cutting down on the need for hospitalization, and this we can document.

Mr. MITTELMAN. Just a few questions, Dr. Brumback.

Do you have any estimate of the amount of your budget that is spent on preventive, as opposed to remedial services?

Dr. BRUMBACK. I didn't bring figures on this. It would take a while to dig these out. Actually, I would say that we are spending a relatively small part of our budget, unfortunately, on preventive services. Most of the migrants that we see already have defects that require correction. They have illness and injury, and most of our time is spent in diagnosing and treating these things. A relatively smaller part is