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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 À for insertion in the record. (App. A follows:)
PROVISION OF COMPREHENSIVE HEALTH SERVICES FOR MIGRANT AGRICULTURAL
WORKERS AND FAMILIES IN SAN JOAQUIN COUNTY-SAN JOAQUIN COUNTY MEDICAL SOCIETY PROGRESS Report, As of NOVEMBER 30, 1967
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 Hatthews 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. 11. 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: Number of clinic sessions.
148 Number of individuals served. Number of clinic visits.
3, 133 Average attendance per clinic session.
21. 2 B. Matthews Road Migrant Camp.--Services initiated on May 15, 1967, five evening clinics per week, 3 to 4 hours/session: Number of clinic sessions...
133 Number of individuals served..
764 Number of clinic visits..
2, 193 Average attendance per clinic session --
16. 5 C. Mobile Medical Clinic.- Services initiated on July 10, 1967, one night per week at each of five locations, 3 to 4 hours/session: Vernalis : Number of clinic sessions..
19 Number of individuals served.
293 Number of clinic visits....
532 Average attendance per clinic session.
28.0 Terminous: Number of clinic sessions
21 Number of individuals served.
105 Number of clinic visits..
249 Average attendance per clinic session..
Number of clinic sessions...
215 Number of clinic visits.
478 Average attendance per clinic session.
22.8 Linden: Number of clinic sessions
20 Number of individuals served..
154 Number of clinic visits..
342 Average attendance per clinic session..
17.1 Acampo: Number of clinic sessions
19 Number of individuals served.
119 Number of clinic visits -
202 Average attendance per clinic session.
10.6 Total, Mobile Clinic Unit: Number of clinic sessions.
100 Number of individuals served.
886 Number of clinic visits...
1, 803 Average attendance per clinic session..
D. Total, All Clinic Services.Number of clinic sessions.
381 Number of individuals served
2, 693 Number of clinic visits.
7, 129 Average attendance per clinic session -
18.7 Medical services at the Harney Lane and Matthews Road clinics were terminated on November 10 and November 17, respectively, when the camps were closed for the season. Mobile clinic services were terminated at Acampo, Terminous, and Vernalis on November 17, by which time most migrant families had departed from these areas. The mobile medical clinic continues to visit Linden and Thornton once weekly.
E. In-Office Medical Services.-In-office services were initiated during July, 1967, after funding of all components of the project was assured. As of November 30, 533 referrals had been made, 310 (58.2%) of which were successfully completed:
Reports on referrals continue to be received. Some patients deliberately delayed acceptance of referral until they were no longer working. The final proportion of successful referrals (on which reports will be received) will undoubtedly be higher than the 58% presently recorded.
F. In-Hospital Care.--The hospitalization component of the original comprehensive plan was not funded. All patients in need of hospital care were therefore referred to San Joaquin General Hospital. During the period April 1-November 30, 89 patients were referred for in-patient care:
Recorded referrals and admissions for hospital care do not adequately reflect the need of migrant families for such care, for the following reasons:
(1) The Harney Lane camp operated at capacity for less than seven months; Matthews Road camp was occupied for six months, but operated at full capacity for less than four months. The mobile clinic service was provided for less than five months; no service was provided in outlying areas during the months of April, May, June, during which months San Joaquin County experiences the largest influx of migrants (cherry season).
(2) San Joaquin General Hospital staff may not admit all referrals, particularly some for whom, in the opinion of clinic physicians, elective procedures are indicated. The number of such patients has not yet been documented.
(3) Inpatient care was provided at San Joaquin General Hospital for some migrant individuals who received no clinie services at the camps, but went directly to the Hospital. Efforts are under way to identify and of services rendered, are not yet available. Preliminary review of clinic records indicates that comprehensive services have been provided for a wide range of conditions:
these individuals. III. Conditions For Which Medical Services Were Provided.--A statistical record was prepared for each service provided in the program. Analysis of these records is now in progress, and detailed tabulations of conditions diagnosed and treated
Adults served at the clinics were found to have a wide range of chronic conditions: anemia, arthritis, diabetes, other endocrine problems, hypertension, chronic respiratory disease, obesity, minor and major surgical problems.
Approximately 17% of all clinic visits were for diagnosis and treatment of respiratory infections.
Obs.-gyn. services included prenatal care, family planning, diagnosis and treatment of g.u. infections and other gynecologic problems. Obs.-gyn. services were provided regularly by qualified gynecologists at each clinic location; these sessions were conducted in addition to the general medical clinic sessions. Special efforts were made by Health Aides to promote client acceptance of prenatal and family planning services:
Approximately one-half of all clinic visits were made by children. Services included not only care for acute illnesses, but also examination and counselling of well infants, preschool, and school age children. Qualified pediatricians staffed each clinic at least once weekly. Although children having acute problems were seen daily, effort was made to refer children to the pediatrician whenever possible.
Immunizations were provided at all clinic sessions. Some 3304 immunizations were administered (DPT, DT, Polio, Measles, Smallpox). The numbers of completed series of the several immunizations have not yet been tabulated. Particular effort was made to immunize adults as well as children.
Tuberculin skin tests were done routinely for children and for as many adults as possible. The Health District and Bret Harte clinic provided chest x-rays and other indicated examination for tuberculin reactors. To date, followup has been completed for 72 of 106 such referrals. One case of active tuberculosis was diagnosed. One adult male "converter” and seven tuberculin positive children were placed on INH prophylaxis after receiving complete evaluation. Local, intrastate, and interstate followup on other tuberculosis suspects continues. Although tuberculosis case-finding efforts have not yet been evaluated adequately, the prevalence of tuberculosis among migrant families does not appear to be as high as that observed among single male transients in this County. (In a continuing case-finding program which has been conducted since 1953, the active tuberculosis case rate among these men has ranged from a high of 20.2 cases per 1,000 men examined in 1955 to a low of 3.4 per 1,000 in 1966.)
IV. Public Health Nursing, Health Aide, and Related Services.—Detailed reports on Public Health Nursing and Health Aide services are not yet available. Public Health Nurses and Health Aides served at each clinic location five nights per week, as provided in the project plan. In addition, Public Health Nurses and Health Aides paid from regular Health District budget provided services daily to all camps and the two day care centers, during regular working hours.
Amblyopia screening and audiometric screening were provided for children attending the two day care centers during the summer months. Public Health Nurses provided followup for children found in need of further examination.
Two Health Educators on Health District staff assisted physicians, other members of clinic staff, Public Health Nurses, and Health Aides, in providing health education services. Educational materials were provided in Spanish as well as English. Although project staff participated in some group activities, person-toperson contact was emphasized.
Medical, nursing, and related services were coordinated with the activities of a Federally funded migrant education project conducted in the two fixed camps. Particular effort was made to ensure that preschool and school age children received medical evaluation and other preventive medical services.
V. Population Served.--Accurate figures regarding the population served are not available at this time. However, estimates derived from several sources