the way.

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

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 donnås 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 Oregon 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, I 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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Since the work of public health in a local community is really directed, for the most part, to the lower socioeconomic levels of that community, then 20 percent of our total population missed really means that we were not being very successful with 40 to 50 percent of the population we were working with.

In a city with as large a population of migrants as Laredo, our very limited success with the migrant and his family was adversely affecting the overall public health picture of the community, of course.

With 20 percent of the population not cooperating, or cooperating very little, it was really impossible to control communicable disease; to effectively raise the immunization levels of the children of Laredo; to carry out a complete environmental health program; and what was more important, to solve Laredo's greatest problem, the high rate of tuberculosis.

There were many reasons why we were not having much luck with the migrant and his family, the two main ones being, first, the fact that the migrant was out of the city 5 to 7 months of the year, and the second one was the lack of enough personnel to fastidiously and effectively stick with the migrant and convince them to attend our clinics and improve their health and sanitation practices.

The third reason, and in many ways the most important, was the nature of the Mexican-American migrant himself.

Some of the personnel of the health department who had tried to work with the migrant before the Migrant Health Act was passed did not believe that anything could ever convince them to follow many of our recommendations.

It was not that they ever opposed the health department openly. What little effort that was directed at the migrant, and it was never enough before 1963, was usually met with a complete lack of interest.

Laredo's widely publicized environmental health demonstration program, which saw the elimination of over 5,000 privies in a period of 7 years, met its match in dealing with many of our migrants.

They refused to eliminate their pit toilets, just like they refused to immunize their children, or participate in our citywide tuberculin testing for tuberculosis. They felt that since they spent such a short time in Laredo, they did not have to obey the health code.

They would tell our nurses that they were doing all this up north, , where they were working--getting their shots, getting chest X-ray et cetera. Of course, they had no records to prove it, but there was no way of making them do it. I am sure they told the same story at the other end of the line.

The fact remained that the children were not getting immunized; the tubercle bacillus was probably being spread around the country, or maybe being brought back into Laredo. The migrant's premises were unkempt and dirty 6 or 7 months out of the year, making it difficult for the health department to make their neighbors that stayed home comply; and they were not bringing their families to receive the medical help that they needed.

As I mentioned before, the very nature of many of the migrants also played a strong part in this. The fact that the city of Laredo now, 4 years later, has a higher immunization level in preschool children, for DPT and polio, than the national average, and that the children of migrants now have the same level as the rest of the community, has been a real achievement, considering the inability a few short years ago of many of our migrants to translate from one culture to another in medicine.

As a matter of fact, this is more surprising, since many of them still have that fatalistic view point on disease--they feel that even though they are immunized against the disease, they can still catch it.

That such an about-face in the conduct of the most recalcitrant of the "hard-to-reach" in Laredo, the migrant, would ever happen would have been considered extremely unlikely a few short years ago. That it would ever happen in 3 years is unbelievable.

It happened because a small group of dedicated professional public health workers, financed by the migrant health program, centered their efforts on this 20 percent of the population.

Also, it happened because of a rather curious phenomenon which I, as a Mexican-American myself, understand perhaps better than most.

The Migrant Health Act, which allowed the Laredo-Webb County Health Department to hire two badly needed additional nurses, à sanitarian, and a health educator, also brought about a rather unexpected and very impressive change in the attitude of the migrant himself.

While some continued to be reluctant, large numbers of migrants started coming to the clinics that had never come before--because it was a program that Congress had passed for them. This I was told personally by several of them, they were now coming to the health department to get what was theirs.

As I said before, as Mexican-American, I can understand this. The reluctance of a great percentage of the so-called hard-to-reach in public health is due only to pride.

As I mentioned before, an environmental health demonstration program was started in Laredo in 1955, under the auspices of the National Communicable Disease Center and the Texas State Health Department.

Laredo had before this a very high infant mortality rate, particularly a very high infant mortality due to diarrhea, high morbidity rates in enteric diseases, a high morbidity rate in tuberculosis--as a matter of fact, a very high everything:

From 1955 to 1962, great strides in public health were made in Laredo, but then we became aware that we were not having much luck with a very large percentage of our population, composed of migrants and their families, who spent a great deal of time out of the city.

While I did not have time to break up the statistics between 1954 and 1962 as compared to now, I have here a handout which I prepared for a talk I gave in Houston last September.

This, gentlemen, is the first handout at the end of my talk in the report that I hope you have.

I can assure you gentlemen that the difference between 1954 and 1962, which is the last year we had without the migrant health grant, was not as marked as you see between 1954 and 1965.

The Laredo migrant health program added two things to our health department within a period of 2 years which gave an unbelievably sharp rise to all our progress charts, of which only a few are represented by this handout.

Those two things that were added were the family health service clinic for migrants, and the migrant environmental health program.