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experience similar and comparable problems and who have sought and found solutions.

Dr. GIANELLI. Then I just happen to have a few pictures of our newest addition, a mobile clinic. They are just snapshots. If I can have one minute I will explain it briefly.

Senator WILLIAMS. Can we look at them while you are talking, Doctor?

Dr. GIANELLI. You may. This is how we are spending our money for the U.S. Public Health Service. We are representing this unit. Senator WILLIAMS. This picture shows a trailer.

Dr. GIANELLI. This is a trailer. We are renting it because our actuary said that this was the best way to handle it and also in the off season we remove the partitions and it doubles as a blood bank collecting unit. We have a four-county area and we will take this around and secure blood donations from the other counties.

Senator WILLIAMS. You have one trailer in this mobile unit?

Dr. GIANELLI. We have one trailer. It goes to five different locations in the counties. People enter at one end and are processed. There are five forms that have to be filled out. They can go down a narrow corridor to the nurse's station at the other end if that is indicated, such as in children who are there just for immunizations and do not have to see the physician. The central area contains doctor's consultation room, examining room, toilet, and wash basin. Senator WILLIAMS. You mentioned skin testing for TB. Is that part of this mobile unit's activity?

Dr. GIANELLI. Yes, sir.

Senator WILLIAMS. The TB test is called a Tine test, is it not?
Dr. GIANELLI. Right.

Senator WILLIAMS. It is just a little pin prick?

Dr. GIANELLI. Nothing much to it, and the nurses do it.

Senator WILLIAMS. Did you hear the presentation of our last witness, Mr. White?

Dr. GIANELLI. Was that the last speaker?

Senator WILLIAMS. Yes.

Dr. GIANELLI. I couldn't hear him too well. I heard some of his remarks. I didn't hear the early part of his presentation.

Senator WILLIAMS. He has about 1,200 workers at peak season. He is obviously trying to make available to his workers the various health services that are now becoming available under the Migrant Health Act. It is not complete by any means.

Are you getting that kind of cooperation from the growers in your community?

Dr. GIANELLI. We are not.

Senator WILLIAMS. Is there anything you could do to persuade them that it is good business to have workers who are in good health?

Dr. GIANELLI. Well, as I indicated, we spent 6 years trying to do this. They are living in a different world, a world that we have left behind, of noninvolvement, and of individual identification rather than group identification. You just can't get these people to change overnight. They feel as though it is somebody else's responsibility.

I made a remark to the California Farm Bureau Federation meeting which I was asked to address a couple of months ago. The statement was made after my presentation by one of the growers that they didn't see where this was their responsibility and I pointed out to them that

this past winter through redevelopment we had torn down nine blocks of central Stockton which housed the single men that were engaged in agriculture primarily, and because we had an exceptionally wet winter for California that these people were hungry and cold, and ill, and they organized themselves and marched upon the mayor's residence asking for help. His remark too was, "The city of Stockton has no responsibility toward you."

About 3 months ago we recalled the mayor so that perhaps there is some hope.

Senator WILLIAMS. That is by petition of how many people? How do you do that?

Dr. GIANELLI. You have to sign up a certain percentage. I don't know what it is offhand.

Senator WILLIAMS. Then it goes on the ballot?

Dr. GIANELLI. And it went on the ballot, right.

Senator WILLIAMS. I am not going to ask which party was involved. We will leave well enough alone.

Dr. GIANELLI. It is possible.

Mr. BLACKWELL. Dr. Gianelli, in your statement you refer to this current budget request of $315,000. My arithmetic indicates that you received about $162,000 of your request. Is my arithmetic correct? Dr. GIANELLI. Yes, sir.

Mr. BLACKWELL. The men in your profession generally are not known to be big spenders so I am assuming that your original figure was a fairly large request, is that correct?

Dr. GIANELLI. The largest item that was not funded was the request for hospitalization and this was not allowed because of lack of funds.

Now, we had to more or less guess at the amount that we would need for hospitalization. Actually I am surprised that the figure was only some $11,000, as you saw. I mean we had 36 patients, as the record shows, who were hospitalized and their hospitalization cost is $11,000. Of course, it would cost more if they were in private hospitals, not from the standpoint of hospital cost, but there would be a fee for service charge of the private physician because these people were taken care of by house officers in the employ of the county. But it is a good deal for the county to work with. I mean we have a commitment from the county board of supervisors for matching funds. California is on a 50-50 basis matching funds to $50,000. It is good business for them, too. They have 100-percent coverage for these people now. If we put them in a private hospital they drop their cost by 50 percent. But they know, of course, we are not going to let these people who need hospitalization and treatment get away.

Mr. BLACKWELL. Do you have an estimate on the number of the migrant population that you did reach with your project services? Dr. GIANELLI. Well, from the figures that I have given you it is roughly 20 percent.

Mr. BLACKWELL. Are you speaking in reference to the 14,000 migrants?

Dr. GIANELLI. Somewhere along 12,000 or 14,000. I was talking about 12,000.

Mr. BLACKWELL. Do you know the per capita investment in persons reached?

87-443-68- 7

Dr. GIANELLI. As you can see, this report is up through November 1. Now, we are still in the process of receiving bills. We just don't have that figure for you. The doctors take anywhere from 2 to 6 months to submit their bills. Maybe you haven't had that experience, but overall we have had experience that they are a little bit lax and I tried to get this figure for you yesterday because I thought it might be asked. I don't know how much we have spent. But we have played it conservatively feeling that it would be much better to end up with excess money than to have to abandon the project somewhere along the way.

Mr. BLACKWELL. Could you give us an estimate of the amount needed to provide your present level of care to all of the migrants in your county reaching roughly 20 percent of 12,000?

Dr. GIANELLI. I don't know. Certainly the major percentage or the amount per person will decrease as time goes on. I mean after all, our clinic investment is there. I mean we pay so much rent per month for the trailer and it is used more. We pay no more rent for it so the cost will drop down.

We have another budget in, or shortly will be submitting it. We are asking for $350,000 for this coming year. With this amount I think we could do a much better job in not only getting more people, but also extending the services as I have mentioned-hospitalization, dental care, and a larger formulary. This is another area that is a thorn in the side of physicians, that they are working with a very abbreviated formulary.

If you know anything about physicians, they are sort of prima donnas when it comes to prescribing medicines. It might be the same drug under a different name, but they have to have their own brand, this type of things.

As I say, we have to take this into consideration when we are working with a large group of men who are doing this on a voluntary basis. Mr. BLACKWELL. What in your opinion is the effect on the individual from this lack of funding for hospitalization? Does he have much prospect of shopping around in another county?

Dr. GIANELLI. I don't think so. I can't speak with any authority for the rest of the State of California, least of all for Ŏregon and Washington, but I think most counties have a minimum residence requirement, and I believe it is a year in most places. I don't know of any that is less offhand, which means that these people are not going to get this because they are not going to be 1 year in one place, I don't believe. Some of them will, of course, and some won't.

Mr. BLACKWELL. So there will be a lack of hospital care although, in the professional opinion of a physician, it is needed?

Dr. GIANELLI. Right.

Mr. BLACKWELL. That is all the questions that I have.

Senator WILLIAMS. I will state that Senator Murphy, of California, did regret very much that he couldn't be here. This is the windup week for this session of Congress and the major business before us now is conferences with the House to iron out differences in bills and he had to be at the joint conference with the House on the education bill that the Senate passed in somewhat different form than the House. I think he has a couple of amendments to the education bill that he will try to persuade the House to accept.

You are a member of the American Medical Association?

Dr. GIANELLI. Yes, sir.

Senator WILLIAMS. Are you getting cooperation from your colleagues in the association on this migrant health program which you so eloquently described?

Dr. GIANELLI. At what level?

Senator WILLIAMS. The practicing doctors.

Dr. GIANELLI. We are getting good cooperation at the county level as I have indicated. At no time, as I mentioned, have we suffered from a paucity of competent professional involvement. At the State level we are getting good cooperation. At the national level-well, I think perhaps you should understand the structure of organized medicine, that there is a great deal of county autonomy, county medical society autonomy, and we have no directors from AMA saying that we have to do this or we have to do that. The fact of the matter is we do pretty much as we please. We have not been reprimanded. At least at the State level they are very happy with us.

It might be interesting, if I can digress just a moment. The State of California is having a little argument over Medi-Cal. We have been selected to run a pilot program starting the first of January 1968 wherein we are providing Medi-Cal recipients medical care at so much a month, will be paid a premium of so much a month per recipient, and we will then take the risk. We are limited in risk to 10 percent. If we lose more than that the State says it will come to our aid, but our figures that we gave for prepayment runs about one-third under what it cost this previous year per recipient and we have been in this business for quite a while. You say we are poor businessmen, but we are still in business. We don't expect to lose this challenge.

Senator WILLIAMS. You certainly obviously devote a great deal of time to this work is bringing better health care to farmworkers. It must be a demanding situation for you to meet your regular private patient obligations and still do all this work.

Dr. GIANELLI. I have two very good partners who grumble some, but so far haven't thrown me out of the partnership.

Mr. MITTELMAN. I just wondered, Doctor, whether any other medical societies have chosen to copy, to emulate your wonderful example in California or in any other place that you might know of?

Dr. GIANELLI. Oh, yes, they have in California. There are other county seats that might not be doing it the same way we are doing it, but certainly are involved in the care of migrant agricultural workers. There are other counties and perhaps somebody is more knowledgeable here than I am on that. We certainly won't take all the credit for it. What we will take credit for, though, is for originating the foundation concept which is serving as a vehicle for the implementation of the migrant health program and also is serving as a vehicle for the pilot study for Medi-Cal. So that is a very useful instrument.

The foundation concept is rather general in California, at least in the Central Valley, and San Diego County-we skip over Los Angeles County-and it has spread even as far east as New York State so it is not unknown in medical circles.

Mr. MITTELMAN. I would just like to congratulate you and your society for instituting this program It is certainly a remarkable example of what public-spirited citizens can really do to make an impact on a severe problem of this kind. I only wish that there were a great many more like you.

Dr. GIANELLI. Thank you very much.

Senator WILLIAMS. Well, we will do our best to cooperate with your great efforts, Doctor. We will try to pass this bill as soon as we can. Dr. GIANELLI. With enough money for hospitalization, 1 hope. Thank you.

Senator WILLIAMS. Do you want to stand by while your colleagues make their statements?

Dr. GIANELLI. Yes, sir.

Senator WILLIAMS. We will now go to the director of the LaredoWebb County Health Department, Mr. Jose Gonzalez. Is that the name of the county, Laredo?

Mr. GONZALEZ. No, sir, Laredo is the city. Webb is the county. Ours is a city-county health department. I just happen to have a little map with me that shows the work that we did in Laredo this past year.

Senator WILLIAMS. Thank you. We can see it.

Mr. GONZALEZ. Mr. Chairman and gentlemen, first of all, it has been real gratifying for me to know that the migrant has persons like Dr. Gianelli at the other end of the line. I represent the opposite end, the home base area, or one home base area.

Laredo was one of the first programs after Congress passed the Migrant Health Act in September 1962. I believe I am right in saying that there are now approximately 100 projects in about 40 States and Puerto Rico receiving grant assistance.

I believe that Laredo was the sixth to apply for and receive a grant, back in early 1963-and thanks to a demonstration program started by the National Communicable Disease Center and the Texas State Health Department in Laredo in 1955, with continuous evaluation studies being made, we in Laredo are in perhaps a better position than most other migrant grant locations to measure the effectiveness of the migrant health program.

A health index survey made in 1966, with the aid of statisticians from Atlanta and Austin, confirmed previous findings that a large "pocket of resistance" made up of the Laredo migrants and their families, approximately 20 percent of the city's population, and impervious to repeated health department efforts prior to 1963, is now finally on a par with resident citizenry in respect to the immunization level of children; adult response to tuberculosis heaf testing; enteric disease morbidity, previously much higher among migrants, and compliance with sanitation regulations in their homes and premises. This is unequivocally and entirely due to the work being performed directly with migrants and their families since 1963 by the nurses, sanitarian, and health educator of the Laredo migrant health program.

When it was first announced that Laredo would start a program that would bring public health to our migrants, there was a very obvious and a very widespread awareness that the Migrant Health Act was a real godsend-a real pioneering act of the Congress to remedy years of neglect of a very significant number of American citizens.

Laredo is a home base of anywhere between 12,000 to 15,000 migrants and their families, who leave the city each year, and these make from 17 to 20 percent of the population.

In a situation which I believe typical of all the home base areas, particularly the large ones, a dynamic local public health program was actually being ineffective, because it was not touching 20 percent of the population.

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