for appointments. Some migrants asked the project workers to recommend area dentists for continued remedial work when they were notified of the limited time available through the project program."

One crew was observed at its next location after it left the project area. The crew members showed generally improved health conditions. Vitamins were still being taken as directed. The crew members had found discarded building materials and spent their first days in repairing doors, windows, and screens. Care was used in preparing baby foods and formulas. Mothers expressed gratitude over the fact that the new location provided a safe supply of drinking water.

A sanitarian reported: "A surprising number did remember what I taught them. *** Some claimed most of the people in a given camp try desperately to keep things clean but that only a few are the culprits. This I found to be true." Specific health benefits resulting from projects included:

The discovery and treatment of several thousand persons requiring medical care who might otherwise have continued without attention, at least until their conditions became emergencies. One community reported a reduction of 75 percent in the hospitalization of migrants, and no deaths for the first time in at least 3 years.

The immunization of several thousand children and adults, some of whom had never before received immunization of any kind.

Dental examination and treatment, especially of children.

An increase in the number of migrants carrying a health record, so that treatment can be continued without duplicated effort in diagnosis and identification of effective therapy.

Improvements in the camp environment of thousands of workers and their families. One project, for example, reported that 75 percent of the camps in the area met local regulations at the end of the season compared with 5 percent at the beginning. Few projects made this outstanding a record, but many made a substantial start.

A start toward identifying the counties of origin and the destination counties of migrants, as a step toward linking the health services of one project area with those provided the same individuals elsewhere.

Other benefits were also attributed to project operation:

Less violence in the migrant labor camps.

An opportunity for migrants to realize their own potentials through assisting in a community project; for example, a Puerto Rican migrant girl assisted nurses and physicians in

one project by volunteering as an interpreter for other Spanish-speaking migrants. For her own career, she hopes to become a nurse. In another project area, two Negro teenagers assisted as aides in night clinics. One plans to become a social worker and the other, a nurse. The community is helping them realize their educational goals.

Improved community understanding and acceptance of migrants, public-voluntary cooperation, and working relationships between State and local health department staff members on behalf of migrants. In one area, the experience in public-voluntary cooperation in a migrant health project has led to exploration of ways to continue this cooperative effort on behalf of local needy people.

A clearer view of health efforts as part of a larger picture. Thus one project report observed: "These people have been dumped into an area by virtue of a mechanical cotton picker, which has left them without income, with squalid housing, without transportation, and lacking employment opportunities. Our job is * *to get these people back into a productive capacity ***. Health will be the entering wedge We believe that our interests * * * will be shared by a number of other agencies and by the ranchOur knowledge of these migrants indicates to us that the vast majority are ready to avail themselves of * * * opportunities, but cannot get over the hurdle of being stranded *** with little employment and no means of transportation."

ers

* *

When grant funds first became available in 1963, migrants were already arriving in many project areas. An immediate start was urgent if people were to be served before they moved on. The pressure to get started complicated the already complex problems of a new project.

Delay in obtaining grant funds made recruitment of staff even more difficult. In some cases, key staff members could not be recruited, and the original project plan had to be modified.

Time was lacking for proper orientation of staff members to their jobs or to the migrant situation.

Recruitment and training of volunteers to perform key tasks was also difficult.

There was little time for working out effective relationships between paid staff and volunteers, among the different organizations with a potential contribution to make to the project and with interested individuals.

Available health education materials proved inadequate in the migrant situation.

Poor crop conditions in 1963 added to the problems encountered by some new projects.

Migrants were more than normally mobile as the result of drought, poor crops, and lack of local work opportunity in some project areas. There was even less than the usual

opportunity to work with a person or family over a period
of time. Yet building rapport as a basis for acceptance of
health services-as many project reports commented-takes
time, especially with a group which has built up distrust
based on past community rejection.

The fact that there was less than usual work opportunity
also created problems related to health and health care.
For example, some families lacked funds to purchase food,
yet could not qualify for surplus food under the local mech-
anism for its distribution. This created additional problems
for projects in teaching good nutrition practices.

In spite of their multiple problems, many projects also reported factors contributing to success in their first year:

Support and active cooperation of local physicians, dentists, hospital administrators; employment service; civic organizations; local migrant committees; and other groups.

Cooperative relationships with welfare workers in gaining access to needed social services. and successful working relationships with hospitals, leading to ready acceptance of migrants as patients.

Relatively small turnover in the local migrant labor force. (One large employer attributed the small turnover of his employees to the standards set by the organization "First, we demand that they work, and, second, we demand that they live as human beings should * * *")

Effective rapport with migrant mothers, teenagers, crew leaders, and other members of the migrant group who assisted in readying clinic quarters, cleaning up after each clinic session, and encouraging other migrants to use project services.

Assistance of health aides, in some cases drawn from among migrants or ex-migrants, in creating better understanding, and in identifying persons requiring health care and bringing them to the attention of project nurses.

The favorable attitude of some growers who looked upon project services as a "fringe benefit" for their workers and believed that keeping them in good health made them a better work force.

The involvement of community volunteers, which greatly enhanced community understanding and acceptance of migrants. Church groups, especially, stimulated interest in project development, recruited volunteers including professional health workers, and provided a link between migrants and the local community.

Suggestions for future program development were made by migrant health projects, based on their first year's experience:

STAFF AND STAFF TRAINING

Selection of staff on the basis of sincere interest and willingness to work toward bettering the migrant situation. The

director and other staff members should have a comprehensive view of the national migrant situation.

Early recruitment and preseason orientation of all personnel, including volunteers, to provide for clear understanding of duties and to whom to report regarding problems.

Involvement of personnel from the cultural group to be served, especially where language is a barrier to communication.

Carryover of staff from year to year to the extent possible, in order to minimize problems of establishing rapport.

SPECIFIC SERVICE NEEDS

Recognition that migrants are most in need of the type of health care provided by general practitioners, plus dental care and provision for acute emergencies that cannot be delayed until the project nurse revisits a camp or until the next clinic session.

Greater availability of services beyond those that can be provided in a makeshift setting; e.g., hospital outpatient and other diagnostic and laboratory services; hospital carepossibly at the discretion of the project medical director.

Recognition of the need for transportation for many migrant patients.

Repeated visitation of camps to bring service to migrants' attention in recognition of the fact that they are in a strange rural area.

Exploration of welfare services as a possible adjunct to clinic services.

Legislation to establish and enforce housing and sanitation regulations where these do not exist; better definition of migrant and camp owner responsibility in the housing situation.

Project reports also emphasized other needs:

With migrants

IMPROVED COMMUNICATION

Recognition of migrants' need to have an opportunity to express their own health concerns.

Improvement of teaching methods and materials; increased emphasis on health education effort in prenatal care, infant and child care, nutrition, money management, and camp maintenance.

With community groups

Much more interpretation of the need and the program to farmers, hospital administrators, and others whose cooperation is essential. Encouragement of growers to advise project staff about the migrants they will employ, when they will arrive, how long they will stay, their work schedules,

and other matters pertinent to the development of a sound
health program.

Expanded use of community volunteers, establishment of
local committees, and use of other measures to improve
community understanding and attitudes toward migrants
and toward the health project.

With other health or related activities in the same area and elsewhere

Improved coordination of effort within the project staff, and between the project and other community activities on behalf of migrants; early planning to work out relationships and schedules, and to define responsibilities held by different persons and groups.

More consistent use of personal health records carried by migrants, and recognition of those that migrants present; more definite solutions to the problems of interarea referral and means of providing health care for people on the move.

IMPROVED PLANNING AND EVALUATION

Initiation of project planning and preparation well in advance of the crop season, and allowance of time for evaluation at the end.

Better evaluation measures for health education and other services.

Encouragement to employers to provide identification cards to migrants listing the names and birth dates of family members, and the name and address of the farmer who employs them.

Recognition that health effort is part of a larger picture involving help to stranded people to make them part of the normal community.

THE MIGRANT HEALTH BRANCH

To implement the grant program, the Public Health Service estab lished the Migrant Health Branch. The staff includes consultant in medicine, nursing, sanitary engineering, health education, rura health, and public administration. The Migrant Health Branch ha headquarters in Washington, D.C., and nine field representative stationed in regional offices of the Department of Health, Education and Welfare.

The staff places major emphasis on--but its consultative role is no limited to grant implementation. In connection with the projec grant program, the Branch staff has

Prepared program guidelines based on congressional intent; developed application and funding procedures.

Set up a cooperative reporting and evaluation procedure in which grant-assisted projects and the Public Health Service share in a joint effort to measure progress under the migrant health grant program.

Made information and consultation services available to interested persons and groups.