San Joaquin Delta Junior College for employed dental assistants and a two-year course for dental assistants will be started at San Joaquin Delta Junior College in 1968. In general however, the Council has felt inadequate because of lack of staff and financing although all the member agencies cooperated. The Council must rely on the staff of the county medical society.

The Council has made a proposal to the Community Health Services of the United States Public Health Service, Region IX for a grant to carry on their work. The initial proposal was made in January, 1967.

Discussions with persons in Community Health Services has led us to believe that although the need for financial support of this type of program is apparent, our particular grant proposal will probably not be accepted at this time. An alternate suggestion was made to us which we would readily accept. This proposal was to study the potentiality of placing at the Medical Society's and at the Council's disposal an employee of the Public Health Department to help carry out staff functions. This person would assist in carrying out staff functions of the Health Professions Training Council and work in other areas of similar interest.

AGRICULTURAL WORKERS

The San Joaquin County Medical Society could not possibly exist in an area such as ours without being aware of and concerned for the health needs of agricultural workers. Each year we can expect approximately 12,000 migrant agricultural workers through our county. For the past ten years, through one form or another, the Medical Society has been attempting to establish a pilot program in order to not only render care to these people but more importantly, to develop means by which their needs can be analyzed and programs developed in order to meet these needs.

It was not however, until April 1 of this year that the Medical Society was able to successfully implement a program. This program receives funds from four sources: 1. Office of Economic Opportunity, $76,322.

2. United States Public Health Services, $60,901.

3. State of California, $25,000.

4. Regional Demonstration Center, Migrant Education, $18,680. These amounts are for a grant period of April 1, 1967 to March 31, 1968. The proposal is a two year proposal. The proposal for the second year is similar to the first with the exception that initial money that was initially budgeted and not funded is being requested. This additional money amounts to approximately $100,000.00 and is for private hospitalization for persons to be covered. This particular proposal is through the Medical Society's Foundation for Medical Care and in cooperation with the San Joaquin Local Health District, the San Joaquin Pharmaceutical Association, and the San Joaquin County Board of Supervisors. The project objectives are:

A. To provide comprehensive family health services for migrant agricultural workers and families through provision of:

(1) Medical outpatient clinic services at Harney Lane and Mathews Road migrant camps.

(2) Mobile outpatient clinic services in areas in which migrant agricultural workers reside, and which are far removed from other sources of medical care available to such workers and families: Acampo, Linden, Terminous, Thornton, Vernalis.

(3) Continuity of care between outpatient clinic sessions, by establishing fee-for-service arrangements with general practitioners in each of the areas in which agricultural workers reside.

(4) Hospitalization in community hospitals when inpatient care is indicated.

(5) Public health nursing, environmental sanitation, and health aide services in all areas in which migrant agricultural workers reside or work. B. Coordinate family health services provided by project staff with health services available through all other resources in the community.

C. Obtain and evaluate precise information regarding health problems of migrant agricultural workers and families:

(1) Extent and types or unmet medical needs.

(2) Volume of medical and paramedical services required to meet identified needs.

(3) Manner in which needed services can best be provided.

(4) Cost of providing the indicated services.

(5) Problems related to coordination of community health service

resources.

Accomplishment of this objective will provide the medical, sociological, and fiscal information needed in planning to meet the health needs of migrant agricultural workers on a continuing basis.

Project needs and background

San Joaquin County lies in the mid-portion of the central valley of California, near the junction of the San Joaquin and Sacramento Rivers. The economy of the County is predominantly agricultural: of the 1409 square miles, approximately 90 percent is devoted to agricultural activities; the value of agricultural commodities produced annually exceeds $224,000,000.

As of July 1, 1966, the estimated population of the County was 278,800. A little over one-third of the population resides in the City of Stockton, which is located near the center of the County; an additional 40,000-45,000 individuals live in suburban areas adjacent to Stockton. The remainder of the population resides in five smaller cities and in the unincorporated areas.

Population estimates and 1960 Federal Census reports indicate that: During the past five years, the population of San Joaquin County has increased at the rate of approximately 1.9% per year; the population includes a high proportion of young persons and an increasing proportion of older individuals; the proportion of Negroes, other non-whites and Mexican Americans is high, particularly in the City of Stockton; a high proportion of the total population is in the lower socioeconomic group; average educational level is low; and approximately twenty per cent of all housing units are substandard.

During 1965-1966, unemployment rates ranged from a low of 4.3% in September to a high of 9.6% in February; throughout the year, seasonal agricultural workers constitute a large portion of the unemployed group. Employment figures listed include domestic residents, domestic migrants, and some 4580 Mexican Nationals, and 574 other foreign contract laborers.

Method of procedure

Medical and related health services will be provided by the San Joaquin County Medical Society, through the Foundation for Medical Care and in cooperation with the San Joaquin Local Health District and other agencies as follows: A. Fixed outpatient medical clinic services are established at:

(1) Harney Lane Migrant Camp-estimated maximum capacity: 480 persons. Clinic services are provided five nights per week, Monday through Friday, 7-10:00 p.m.

(2) Mathews Road Migrant Camp-estimated maximum capacity 800 persons. Clinic services will be provided five nights per week, Monday through Friday, 7-10:00 P.M.

At both camp sites, services will be provided for an estimated 3000 persons who will be residents of the camps during the period April 1October 31, 1967, and to such other migrant workers and families living nearby who can be encouraged to utilize the health services offered. Services described below will be provided without any type of eligibility determination. Efforts will be made, however, to identify individuals who may be eligible for service under one or more of the several public medical care programs (e.g. Medi-Cal, CCS, Federal Medicare), and to assist such individuals in obtaining needed care.

B. Mobile medical clinic services will be provided for migrant workers and families living in or near Acampo, Linden, Terminous, Thornton, and Vernalis, once weekly at each location, on a regular schedule, during the period April 1, 1967 March 31, 1968. Clinic hours will be arranged to meet the needs of clients in each location.

C. Outpatient medical services will be provided in the offices of private physicians located nearest to each clinic site, to provide service at times other than regularly scheduled for clinics. Insofar as possible, private care will be provided by the same physicians who have served at clinic sessions, in order to provide continuity of care.

D. Clinical laboratory and radiological services will be provided through existing arrangements with service facilities, as established by the Foundation for Medical Care.

E. Inpatient care will be provided in seven open-staff community hospitals located in Stockton, Lodi, Manteca, and Tracy. Specific referral procedures will be developed.

F. Public health nursing, environmental sanitation, and health aide services provided in the project will be coordinated with related services

provided by the San Joaquin Local Health District and other community agencies.

The program is too new to produce any meaningful statistics or obviously any conclusions.

REGIONAL MEDICAL PROGRAMS FOR ASSESSMENT OF QUALITY OF MEDICAL CARE

The San Joaquin County Medical Society, through its Foundation for Medical Care, last month signed an agreement with the California Committee on Regional Medical Programs. The agreement calls for the cooperative efforts of the Monterey County Medical Society's Foundation for Medical Care, the Santa Clara County Medical Society's Foundation for Medical Care, and our Foundation. These Foundations have agreed to a program whereby a statistically selected sample of cases of patients treated for heart disease, cancer, stroke and related diseases will for a period of time be reviewed by a committee of physicians in the three counties and the information transmitted to the California Committee on Regional Medical Programs. Representatives from Stanford Medical School will cooperate in the program. After a review of the cases, an additional purpose of the program will be to develop programs required to supply any deficiencies in patient care which may appear as a result of such review.

SAN JOAQUIN FOUNDATION FOR MEDICAL CARE

No discussion of the review of services and the quality of medical care, utilization of medical manpower and the like would be complete without mention of the work of our Foundation for Medical Care. Established in May of 1954, the Foundation is a subsidiary corporation of the Medical Society. Membership in the Foundation is open to all practicing physicians in our county. The establishment of the Foundation arose out of public needs and desires for certainty of coverage and more comprehensive coverage. In addition, the Medical Society added the meaningful purpose of the review of quality of care rendered under any prepaid programs the Foundation might sponsor. Currently our Foundation for Medical Care is sponsoring prepaid programs that cover approximately one-half of the insured population of our county. These programs are underwritten by fifteen different insurance companies plus California Blue Shield and Blue Cross. Professional claims arising from these programs are reviewed by practicing physicians. This review has resulted in accumulated knowledge concerning quality of medical care rendered in our community. This awareness has led directly to individual education of physicians, general education of physicians through postgraduate courses and Medical Society programs and disciplinary action in cases where the educational process failed. In actuality, the Foundation for Medical Care represents a county-wide committee for medical audit, tissue, and utilization committee all rolled into one.

Our Medical Society's implementation of county-wide utilization review for extended care facilities has added another dimension to this type of actvity.

MEDICAL MANPOWER PROJECT

The U.C.L.A. School of Public Health, working through a grant from the Ford Foundation, is currently involved in a program with our Foundation for Medical Care entitled "Medical Manpower Project". The purpose-to study and to try to relate the care of users of medical care to the type of care they are actually using. In this connection the study is attempting to learn in fine detail how many hours of doctor time, nurse time and technician time are required to provide specific care during the period of the study. A Foundation group_with comprehensive coverage has been chosen for this study. The group is the International Longshoreman's Warehouseman's Union, Pacific Maritime Association Health and Welfare Program. A similar study for a similar period of time is being completed at the Ross Luce Clinic in Los Angeles.

SUMMARIZATION

In general we would conclude that our involvement in the various programs aforementioned has led directly to a realization on the part of the medical profession that we do have a definite and ever-increasing responsibility in the area of planning, health manpower and quality of medical care. There is also being

developed on the part of our general public an awareness that their local medical profession is indeed interested in their well-being.

I would hope that future challenges, as yet unknown to us, will be met with ever-increasing vigilance and vigor by us all.

REMARKS, 10TH COUNCILOR DISTRICT OFFICERS MEETING ON COMPREHENSIVE HEALTH PLANNING, DECEMBER 2, 1967

(Presented by John I. Morzumi, M.D., President, San Joaquin County Medical Society, Stockton, Calif.)

That Public Law 89-749 is currently a law of the land, that comprehensive health planning is part of the public domain, that the highly individual circumstances of a given local community or political subdivision or a grouping of contiguous and mutually augmenting geographical entities must dictate the implementation of provisions of that law seem to be a logical interpretation of the impact of that law. It is true that one can argue about the semantics of the phrase "comprehensive health planning," the precise meaning of which may be quite variable. We in San Joaquin have elected to assign as broad a meaning as is practical. This means that in any area of health problem where physicians are directly or indirectly involved, we mean to become more knowledgeable and lend our expertise.

Traditionally physicians everywhere were not only considered to be doctors to alleviate suffering, but highly educated and intelligent citizen leaders in matters of education and government civics. As American society became increasingly complex and as demand for acquisition and practical application of scientific knowledge became more intense, the individual physician unconsciously and gradually retreated from the sphere of the public health. The individual doctorcitizen became myopic and lived his life in the microcosm of his private practice. It is now time and opportunity for us to reacquire leadership in matters of health for the public commonweal. That is the challenge of Public Law 89–749.

It is obvious that some of the problems of a large metropolitan poverty population are quite different from those of a migrant agricultural group. The need for basic health care remains the same. There is immediate recognition that distance to be traveled, the type and cost of available transportation, the socioeconomic bases for the behavior patterns of such disparate groups greatly influences whether or not such persons can or do, indeed, seek medical care. Local knowledge of such determinates should dictate the directional course and alternatives that need to be discovered for reasonable solution of local problems.

We in San Joaquin County, or as a matter of fact, any other planner at the State or Federal level, are in no position to direct or implement the health care of the people of Watts. On the other hand, for example, we have recently learned what must be done for the migrant farmworkers in our area. For 10 years we attempted to establish some type of pilot program not only to render care but also to develop methods for analyzing migrant farmworker needs and programs to meet their needs. We thought that a prepaid plan with participation by growers and grower groups might permit these workers to obtain medical care. We were not successful in promoting that scheme. However, in April of this year, we successfully implemented a program. An outline of that program is in the paper submitted to the Western Conference on Future Directions and Decisions in Medical Care recently concluded in Chandler, Ariz.

We learned some lessons which need to be mentioned. It was vital in the planning stage and subsequent application of our proposal to both State and Federal agencies that we not only had acquiescense but active cooperation and participation of the local health department officer. He had certain expertise regarding the numerous funds that might be available and the form and letter of our application which would be most conducive to favorable action. His, in fact, was the agency which the previous year attempted with some success in having residents from our county hospital to man such a clinic. This year volunteer doctors from our community went at night to two fixed clinics operated at two large labor camps built and sponsored by the local political subdivision. These were maintained each week night from 7 to 10 p.m., or whatever time it took to take care of sick people. They were referred to consultants when necessary and given specific date and time appointments for special problems. Many in turn failed to keep these appointments. I am not implying, therefore, that consultants should be available at these clinics, for that would not be efficient use of medical manpower. What I am saying is that we realized that this group of people who depend on a seasonal harvest as their sole means of making money to maintain themselves

economically independent would not and could not take time off during their maximum earning hours or days to seek and obtain medical care unless they were seriously ill. They feel that they could not afford care not because of the doctor's bill necessarily, but because of loss of income time. Thus we needed to seek them out and convey medical care to them even at night. This, then, reveals the need to educate these people in prophylactic care, that it is economical to seek care earlier to prevent more serious illness which would require additional medical manpower and expense. The righteous platitude of "let them come to us" was and is inadequate if not irresponsible. So we recognize not only pure medical needs but the efficient utilization of medical manpower within the context of present times and local situations. This may not be comprehensive but it is responsible health planning. As a part of the whole problem of health planning it is comprehendible and certainly a measurable contribution to comprehensive health planning.

What I have just related is, of course, only a small segment of a recognizable hiatus in health care and planning which can be found in all communities. There are other examples of doctor and medical society involvement with the local community. Presently we are engaged in a survey in identification of the lessadvantaged population groups in Stockton and San Joaquin County. The county hospital administration has completed an independent survey of the sources of origin of its inpatient and outpatient load and is preparing an official report. Individual physicians, the medical society, the public health officer, and people residing in disadvantaged areas will be conducting surveys of the medical needs of such areas. Our county medical society is engaged in a study of the county hospital which is located 5 miles outside of Stockton from which originate the majority of the hospital patient load including those who seek emergency care and clinic visits. It is essential to collect and collate these pieces of intelligence in order to be able to come up with meaningful and integrated recommendations. Another example-an approved rehabilitation center is 40 to 50 miles distant in a mountain community because it was able to utilize facilities which used to be primarily used for the care of tubercular patients in our area. There is reason at least to question the efficient utilization of such facilities for the geographical area that it purports to serve. In a recent conversation with an old friend of mine I learned that a small, relatively isolated community in Wyoming was the site of a full rehabilitation facility with a resident physiatrist, orthotist, and other supporting personnel. Of course, the people of that community and the physicians using or wishing to utilize such a facility should influentially participate in the decision of appropriate and efficient medical utilization of that facility. When an air pollution conference was held 2 months ago in Fresno, we were fortunate enough to find a local physician who was intensely interested in that topic and who has acquired a certain expertise. He will serve as liaison and resource man between the medical community and local government agencies.

The control of agricultural cultivation to prevent peat dust problem is an area that by local ordinance is vested in the office of the district attorney in my community. Do we not need his expertise, and does he not need our knowledge and advice? Obviously example after example can be cited such as alcoholic and mental health clinics, highway safety and education, drug abuse control and education, noise abatement, and even zoning practices as affecting the totality of community health. After all, isn't this what comprehensive health planning is about?

Due to special circumstances in the organizational make-up, the executive administrative personnel and devices available in the San Joaquin Medical Society, we may be able to do a few more things than in other counties but even we cannot cope with the total problem nor do we want to. For comprehensive health planning is a function of and for the entire community and not the sole domain of doctors. Hence lay and medical thought leaders, including the local public health department, have formulated a steering committee for organizing the San Joaquin Comprehensive Health Planning Association to which interested health organizations, governmental agencies, and other interested community groups have been invited to appoint representatives. This group will select a board of directors to represent proportionately the consumer public and the health profession and will draft the articles of incorporation and bylaws. The initial support is from the medical society but in a very short while we would need financial support from the county government and anticipate a request for planning funds under the provisions of Public Law 89-749. This, then, is a summary and analysis of what Public Law 89-749 means to us in San Joaquin County. If we have assisted you in your understanding it better, let me say that we do not pretend to know it all. We also seek information and advice from others who