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With a feeling of frustration, we engaged in a radically different approach in 1960 when members of the society voluntarily staffed a clinic for migrant agricultural workers in proximity to a soup line and used clothing depot. Three years later it was apparent that we were reaching too few people by waiting for those who were forced to us through hunger or nakedness.

At this time, we inaugurated the policy of going to the people in the fields and their camps on the riverbanks, using the trunk compartment of automobiles as dispensaries.

To the question "Why don't you go to the county hospital?”, the answer was, "We don't belong there. They don't like us, but we know that you like us because you have come to us when you did not have to do so." To the confession, "We are bringing you very poor medical care," the answer was, "We know that, but at least someone is at last trying to do something."

While out among the people, we observed the activity of the local public health nurses and sanitarians. It was a normal evolutionary development that when we wrote a program seeking to bring comprehensive medical care to these people that it should be a joint effort of the San Joaqun Medical Society and the San Joaquin local health district. We submitted a budget of $315,000 this year and received grants from the following sources:

1. Initial grant from California State Department of Public Health, $76,322.

2. U.S. Public Health Service, $60,901.

3. California State Department of Public Health, another grant of $25,000.

There are two migrant housing facilities in the county: one situated in the northeast portion adjacent to the county dump, Harney Lane Camp, containing 100 units. The other is in the south-central portion adjacent to the county hospital, Matthews Road Camp, with 144 units. Two fixed clinics were operated at the camps Monday through Friday from 7 p.m. until all patients were seen.

The Harney Lane Clinic operated for 6-months; The Matthews Road Clinic, with 44 occupied units for 6 months, and with 144 occupied units for 4 months.

Obviously, the great majority of the migrant workers are living elsewhere and it was for this reason that we became interested in the mobile clinic concept.

A mobile clinic traveled 5 nights a week to outlying areas with particularly high farmworker populations, for a period of 4 months. We missed the cherry harvest, with a peak employment of 9,300. Our statistics cover a period to November 1, 1967. These variable intervals were necessitated by delays in construction and lack of funds.

Senator WILLIAMS. What does that mean exactly, Dr. Gianelli, when you say that you missed the cherry harvest?

Dr. GIANELLI. The cherry harvest occurs in May. The people come into the area about March and April. They come in early. If I may digress, if you have the time, the people that are going to pick cherries come into the area much earlier than the harvest season. I asked one woman why she was so far in advance of the harvest season and she said, "My husband and I cannot afford to miss the picking of cherries because it represents a large part or the largest part of our annual income."

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I said, "Where are you from?" She said she was from the Bakersfield area. I said, "Why didn't you step into the farm employment office and find out when the cherries were ripening in San Joaquin County?" The reply was the only information they had available is for their own immediate use.

She said, "It is necessary for us to come up here ahead of time because there is such a competition that we have to line up the grower well in advance or somebody else will get the job."

1 said, "Economically, what does this mean to you?" She said, "Well, in the Bakersfield area my husband and I, working full days at the best, the best day we had, was $9 earnings for both of us, whereas in cherries the two of us working together can earn $50 a day." So this year we were not funded early enough to man our clinics during cherry season; 2,693 patients were served with 7,129 visits in 379 sessions; 201 patients were referred to the offices of specialists in private practice, 93 to dentists, and 239 to private clinical laboratory and X-ray departments. There were 98 women given prenatal care and 183 took advantage of family planning and other gynecological services such as Papinicolau smears. They were served by Boardcertified or Board-eligible gynecologists.

Children not only were treated for acute illnesses but also were seen for counseling, well-baby checkups, immunizations, and tuberculin skin testing.

While on the subject of tuberculosis, it should be noted that skin testing was a routine for adults also and those who reacted positively had chest X-rays. We found only one case of active tuberculosis. One adult whose skin test converted is receiving treatment. Seven children who had positive skin tests are undergoing treatment. We think this demonstrates that tuberculosis among migrant agricultural families is not the problem that it has been among the single migrant


Four children were seen suffering from malnutrition, and 15 children and six adults with anemia.

Since our request for private hospitalization was disallowed because of lack of funds, patients were hospitalized at the county hospital. There were 36 such, of which 12 were maternity and five were newborn. There were 31 additional patients whom referring physicians felt should be hospitalized but who were not accepted by the county hospital because of the lack of continuity of care; that is, physicians in training overruled the judgment of senior physicians who had been following the patients, and the other reason is the elective procedures, as now there is a residence requirement in the county for what is termed or thought to be an elective procedure, and this elective procedure is a bugaboo in California at the moment, and I am sorry that Senator Murphy is not here with you this morning. If I can make myself clear on that, for example, a gynecologist might see a woman and decide that she has an ovarian tumor. To this man with experience this could very well represent a cancer. To him this is an emergency procedure. But a house officer at the county hospital can examine the woman and decide that she has a benign cyst which can be taken out in some other county and so the woman is turned away, so that we feel that hospitalization is a very important part of our program because without it it is difficult to keep the morale of the physicians participating at the proper level.

From the foregoing, it is evident that we saw approximately 20 percent of the migrant farmworkers in our area. In anticipation of the question, "Why can't these people be seen under title XIX?" there are several points for consideration. As I have intimated above, these people are so thoroughly alienated from the rest of society that they will not seek out the medical services that are available. Secondly, they are not sophisticated enough to seek care for minor ailments, and least of all, for preventative care. Thirdly, during the major peak harvest period, their income makes them ineligible, according to regulations, for categorical aids.

In practice, we have found that it is necessary for bilingual health aides and nurses to contact the people during the daytime, ferreting out those who are ill, urging them to attend the clinics, doublechecking to ascertain that they have done this, making the appointments for specialist referrals and checking to see that the patients go to the physicians' offices.

We should not assume that upon entering a community these people will follow the usual custom of contacting a physician for a routine physical checkup and making arrangements for emergency care if it should arise. Moreover, they are reluctant to take time off during the peak harvest season. As one cherrypicker remarked to me when asked why he worked while ill, "During the 3 to 4 weeks of the cherry harvest, I earn a large part of my annual income." Experience has taught us that the medical needs of these people cannot be met in the usual manner. The clinic, operated in the midst of the migrant agricultural workers, is tailored to their needs. This concept has been acceptable to the physicians. At no time did we suffer from a lack of competent professional involvement. The major physician criticism was the inability to follow through with hospital care when it was indicated. If funds are available, suggested improvements have already been tabulated for the coming season.

Another major area of deficiency is dental care. Because of limited funds, we restricted this to those in need of emergency treatment. We would like to greatly enlarge dental coverage. Of 150 dentists canvassed, 56 agreed to participate under the program.

Government funds are dispensed through the aforementioned foundation. The clinic physicians are paid on an hourly basis. The claims of those seen in private offices on fee-for-service basis are all reviewed by physicians and dentists.

Drugs usually are dispensed by the clinic doctor, but since the formulary is limited, arrangements were made to have prescriptions filled in private pharmacies. These claims were reviewed by a committee of the San Joaquin Pharmaceutical Association. Prescriptions written in private offices are also handled in this manner.

Until 1965, we had braceros in California who were furnished well-integrated medical care by international agreement. This was good. However, our own people have had to obtain their medical services on a "catch as catch can" basis. Their chief protection has depended on a thin line of committed people with meager economic resources upon which depends the awful responsibility of ultimately defending the honor of a nation before God and before humanity.

Some additional facts have been discerned. Medicine is a pluralistic discipline. No one scheme of action will serve all the people. With regard to migrant agricultural workers, close cooperation between

the county medical society and the local health district has proved fruitful. We feel that these organizations should work out their unique problems together on the local level.

It has been said that these patients will not use private facilities, but 496 of the 2,693 did just that. As of this moment, we have received followup reports concerning 60 percent of this group and more are expected within the next few weeks.

We are developing statistics that hopefully will be used to develop prepayment plans for the health care of agricultural workers. In the meanwhile, we have publicly stated that we believe it is the duty of Government to give assistance when the private sector cannot or will not cooperate. Migrant health funds are in essence a farm subsidy whereby the farmer receives healthier, happier, and more productive personnel and the physician is allowed to live with his conscience.

We feel that health education occurs whenever an aide, nurse, or physician, sees a patient. We do not believe that scheduling a health education lecture and movie in the evening, when these people are available, but when the children are fussing and the parents are tired after a day of hard labor, accomplishes its objective.

Our critics have said, "This program seems to work in your area, but it won't work in ours." We have no secret formula, but we would remind you that these people have been dehumanized as evidenced by such terms as "Wino," "Fruit-bum," "Okie," "Arkie," and "Spic." They can be rehumanized by the interest and love of their fellow man.

There is just one point in it that I would like to call to your attention that you might miss otherwise, and that is the emphasis is being placed upon the health of the migrant families. We have said practically nothing, just one reference, to single men who are also engaged in agriculture and are migrants and this is a forgotten group. It is in this group that we have found most of our TB, for example, although I think we have made progress. In 1955 the morbidity rate was 20 per 1,000. In 1966 it was 3.6 per 1,000. We are formulating plans to adequately or at least more adequately incorporate this group, which is sizable, in our next year's program if we can afford it. I would like to introduce exhibit A for insertion in the record. (App. A follows:)



During the period April 1-November 30, 1967, health services for migrant agricultural workers and families were provided as proposed in the original comprehensive plan, with the exception that inpatient care in community hospitals could not be provided, because this portion of the project was not funded.

I. Administrative Accomplishments during the period April 1-November 30, 1967, included:

A. Execution of agreements for support of the project and provision of services:

1. Contract No. 664 with the California State Department of Public Health, for support of fixed clinic services at Harney Lane and Matthews Road Camps ($76,322).

2. USPHS Grant No. MG-157 (67) for support of mobile clinic services ($60,901).

3. Contract No. 140 with the California State Department of Public Health for additional support of fixed and mobile clinic services ($25,000).

4. Agreement with the San Joaquin Local Health District for provision of public health nursing, clinic nursing, health aide, and clerical services at migrant medical clinics and in migrant camps.

5. Agreement with Regional Demonstration Center, Migrant Education (Tricounty Migrant Education Project), for provision of medical, public health nursing, and related services for children included in the migrant education project.

B. Development of plans for implementation of the project, including specific procedures for clinic operation, referral and consultation, coordination of in-office and clinic services, records.

C. Recruitment of medical, dental, and ancillary personnel:

1. 112 physicians from all areas of the County agreed to provide in-office service and/or to staff the medical clinics.

2. 41 dentists from all areas of the County agreed to provide dental services.

3. Five clinical laboratories, five pathologists, and seven radiologists agreed to provide clinical laboratory and radiological services.

D. Design, procurement, and equipping of a mobile medical clinic unit. II. Medical Services.-During the period April 1 to November 30, 1967, medical services were provided at

A. Harney Lane Migrant Camp.-Services initiated on April 17, 1967, five evening clinics per week, 3 to 4 hours/session:

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B. Matthews Road Migrant Camp.-Services initiated on May 15, 1967, five evening clinics per week, 3 to 4 hours/session:

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C. Mobile Medical Clinic.-Services initiated on July 10, 1967, one night per week at each of five locations, 3 to 4 hours/session:

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