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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, 1 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 ut 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?

you have

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 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

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spent on preventive work, promotion of positive health, and doing the job that we would like to do. If we did a better job along these lines it would require more immediate expenditures. I think in the long run certainly we would save money.

Mr. MITTELMAN. If you receive more money either from Federal, State, or local sources, would you spend it primarily on more remedial care, or do you think that you could make a more substantial effort

, in the preventive care area?

Dr. BRUMBACK. I think we can make a substantial effort in preventive services and promotion of positive health. We certainly would set this up as an objective, to expend quite a bit more effort in these directions; that is, toward prevention and promotion of positive health, better nutrition, better general health, better sanitation, and so forth.

Mr. MITTELMAN. Have you made any studies or estimates of the effectiveness of the money spent on preventive care, whether it really produces any significant results at all?

Dr. BRUMBACK. Yes, we have, and we can demonstrate that there has been a marked reduction in illness, particularly certain types, the diarrheal diseases, illness due to poor environmental health. There has been a reduction in preventable disease, and actually we are just beginning now, we feel, to receive the full benefit of programs that have been in effect now for over 12 years.

Mr. MITTELMAN. Thank you.

Mr. BLACKWELL. Doctor, just one final question in the same category. Do you have any findings on reduction of loss of time from work?

Dr. BRUMBACK. Yes. I think Mr. White will speak to this specifically from his point of view; that is, the farmer's point of view, Mr. Blackwell.

Senator WILLIAMS. Fine. Would you stand by while we hear from Mr. Leonard White, vice president of Flavor-Pict Co-Op., Inc., Delray Beach. Mr. White?



Mr. WHITE. Yes, sir, it is Flavor Pict Co-Op. It is actually a family cooperative, but we are still farming as a family, incorporated, in order to market our products in volume.

Senator WILLIAMS. Do you grow mostly citrus?

Mr. WHITE. No, sir; our main item is tomatoes. We shipped about 27 million pounds out of Palm Beach and Martin Counties last year, of the one item. We produce some other vegetables, but our main crop is tomatoes.

Senator WILLIAMS. So it is not citrus at all? Your operation is vegetables?

Mr. WHITE. That is correct.

Senator WILLIAMS. How about strawberries? Do you have any fruits?

Mr. WHITE. We were in the strawberry business several years ago, but due to a few problems we finally decided to get out of it.

Senator Williams. I think you were wise. We have spent a little time down in strawberry country. I think you made the wise decision. That is rough business, isn't it?

Mr. WHITE. Yes, it is.


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Senator WILLIAMS. We have some city boys up here sitting at this committee table, but we have spent a lot of time in the field, and Fred Blackwell and I particularly spent a lot of time in strawberries in Florida, and we concluded that if people can afford to lose that amount of money in strawberries, they would be well advised to get out.

Mr. WHITE. I think if they could afford to lose it, they wouldn't be farming.

It is a pleasure to be here.

Senator WILLIAMS. You mentioned you do a big business in tomatoes. What is the name of the tomato that you grow?

Mr. WHITE. We have the Flavor-Pict registered trademark which you probably have seen on tomatoes.

Senator WILLIAMS. What breed of tomato do you grow?

Mr. WHITE. We grow a trellis or a stake crop, a trellis-grown tomato, which is pruned by hand and only a crown fruit is harvested, It is not the bruised type tomato, that you see a lot of, grown for processing or green harvest. This is a vine-ripened fresh tomato shipped in cardboard cartons, in one- or two-layer cartons, to keep the quality standards where they need to be for fresh consumption.

Senator WILLIAMS. A Florida-developed tomato?

Mr. WHITE. Yes, the varieties that we use were developed by the experiment stations and the university in Florida, and I have worked very closely with experiment stations and these varieties were tried on our farms before they were released.

In the last 10 years we have upgraded our quality and varieties by, I would say, a change of varieties about three times in the last 10 years, and it has added a lot to the quality I think that you receive in the northern markets in the wintertime.

Senator WILLIAMS. Tomatoes are an annual planting. You have a planting each year, don't you?

Mr. WHITE. We plant each year, that is correct..

Senator WILLIAMS. I get a little provincial here. I come from New Jersey, and we have an extension service, and we have Rutgers University. Have you ever heard of the Rutgers tomato?

Mr. WHITE. Yes, I have heard of it, but it doesn't grow well in

Senator Williams. It is a good tomato for some parts of the country.
Mr. White. That is why it was grown in New Jersey.
Senator WillIAMS. Forgive the interruption. We are honored to have

you come all the way here to aid us in our deliberations.

Mr. WHITE. I have an outline here of some few remarks. I may deviate from them just a little.

For the background, I am a farmer and I spend most of my time on the farm, about 12, 14 hours a day. The Migrant Health Act needs to be extended from my point of view, if we are to make any progress for the underpriviliged migrant agricultural worker and because of his residential requirement for one thing and the transient nature of his occupation, it sometimes doesn't let him stay in one county maybe more than 2 or 3 months or sometimes even a few weeks. The migrant usually lives in a rural labor camp, or in our case, most of our migrants on the farm have housing furnished by the farmer.

Due to this, he does not have access to the programs designed to meet the needs of the local residents. And in addition to the labor that is housed on the farms, we have our day-haul crews which we are all familiar with, and I believe this is where most of our problem arises.


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