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Executive Planning Committee  4444444444444

Executive Planning Committee

T o each of the Executive Planning Committee
members of the National Hispanic/Latin0 Health
Initiative, I applaud your tireless efforts and commend
you from the heart. By speaking and acting as one to
address our most critical issues, you have fostered the
health and well-being of Hispanics/Latinos in commu-
nities across America. For all of this, I thank you.
A cada miembro de1 Comite Ejecutivo de
Planificacion de la Iniciativa National de Salud
Hispana/ Latina, les felicito de todo corazon por sus
incansables esfuerzos con respect0 al bienestar de
nuestra comunidad. Al hablar y actuar coma
representantes de nuestra sociedad, han fomentado
la salud y el bienestar de 10s Hispanos/Latinos en
comunidades en todos 10s Estados Unidos. Y por
todo esto les extiendo mi sincere agradecimiento.

Helen Rodriguez-Trias, M.D.
President

American Public Health Association
Brookdale, CA
Co-Chair: Los Angeles Regional Health Meeting

(PHS Regions IX and X)

Raul Yzaguirre, 6.5.
President
National Council of La Raza
Washington, DC

Ahtonia Coello Novello, M.D., M.P.H.
Surgeon General

U. S. Public Health Service

Lydia E. 5oto-Torres, M.D., M.P.H.
National Coordinator
Surgeon General's National Hispanic/Latin0

Health Initiative

Washington, DC,

Charter Members
Castulo de la Rocha, J.D.
President and Chief Executive Officer
AltaMed Health Services Corporation
Los Angeles, CA
Co-Chair: Los Angeles Regional Health Meeting
(PHS Regions IX and X)

Jane L. Delgado, Ph.D.
President and Chief Executive Officer
National Coalition of Hispanic Health and Human

Services Organizations
Washington, DC

In Memoriam
Rodolfo 6. Sanchez
President
Sanchez and Associates
Arlington, VA


4444444444444  Executive Planning Committee

Sanding Members
Marilyn Aguirre-Molina, Ed.D.
Assistant Professor
Robert Wood Johnson Medical School
Piscataway, NJ
Co-Chair: New York/Newark Regional Health

Meeting (PHS Regions I, II, and III)
Mari Carmen Aponte, J.D.
Attorney
Gartrell, Alexander, Gebhardt and Aponte
Washington, DC

_

Rosamelia de la Rocha, B.A.
Director
Office of Equal Employment and Civil Rights
Food and Drug Administration
Rockville, MD

Eunice Diaz, Ph.D., M.P.H.
Commissioner
National AIDS Commission/Infant

Mortality Commission
Santa Barbara, CA

John W. Diggs, Ph.D.
Deputy Director of Extramural Research
National Institutes of Health
Bethesda, MD

Robert G. Eaton, J.D., M.B.A.
Associate Administrator for Program Development
Health Care Financing Administration
Washington, DC

Carola Eisenberg, M.D.
Consultant

Harvard Medical School
Cambridge, MA

Anna Escobedo Cabral, M.S.
Executive Staff Director
U.S. Senate Republican Task Force

on Hispanic Affairs
Washington, DC

George R. Flores, M.D., M.P.H.
Public Health OfBcer
Sonoma County public Health Department
Santa Rosa, CA

John Flares
Past Director

White House Initiative on Education Excellence

for Hispanic Americans
U.S. Department of Education
Washington, DC

Aida L. Giachello, Ph.D.
Assistant Professor
University of Illinois-Chicago
Chicago, IL

Co-Chair: Chicago Regional Health Meeting

(PHS Regions V and VII)

Paula 5. Gomez
Executive Director
Brownsville Community Health Center
Brownsville, TX
Co-Chair: San Antonio Regional Health Meeting

(PHS Regions VI and VIII)

Robert Gomez, B.A.
President

National Association of Community Health Centers
Tucson, AZ

lleana C. Herrell, Ph.D.
Associate Administrator
Of&e of Minority Health
Health Resources and Services Administration
Rockville, MD

Peter Hurley

Associate Director for Vital and Health Care

Statistics Systems
National Center for Health Statistics
Hyattsville, MD

Sharon Katz, M.P.A.
Special Assistant
Centers for Disease Control and Prevention
Washington, DC

Leonard R. Klein
Associate Director for Career Entry
Office of Personnel Management
Washington, DC

Laudelina Martinez, M.A.
President

Hispanic Association of Colleges and Universities
San Antonio, TX

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Executive Planning Committee  444444444444+4

Father Vidal Martinez, 0.6.M.
Pastor

La Asuncion Catholic Church
Perth Amboy, NJ

Janie Menchaca Wilson, Ph.D., R.N.
Immediate Past President
National Association of Hispanic Nurses
San Antonio, TX

Enrique Mendez, Jr., M.D.
Assistant Secretary for Health Affairs
U.S. Department of Defense
Washington, DC

Hermann Mendez, M.D.
Associate Professor of Pediatrics
State University of New York
Brooklyn, NY

Carlo5 Perez, M.P.A.
Area Administrator
Ofice of Health Systems Management
New York State Department of Health
New York, NY
Co-Chair: New York/Newark Regional Health

Meeting (PHS Regions I, II, and III)

Luisa del Carmen Pollard, M.A.
Director

RADAR Network
Center for Substance Abuse Prevention
Rockville, MD

Michael E. Ramirez, B.S.W., M.P.A.
Personnel Officer
D.C. Office of Personnel
Washington, DC

Mario Ramirez, M.D.
Vice Chairman
University of Texas System Board of Regents
Rio Grande City, TX

Jaime Rivera-Dueno, M.D.
Executive Director
San Juan AIDS Institute
Santurce, PR

Blanca Rosa Rodriguez
Acting Executive Director
White House Initiative on Educational Excellence
for Hispanic Americans
U.S. Department of Education
Washington, DC

Rene Rodriguez, M.D.
President
The InterAmerican College of
Physicians and Surgeons
New York, NY

Ramon Rodriguez-Torres, M.D.
Chief of Staff
The Mary Ann Knight International Institute
of Pediatrics
Miami Children's Hospital
Miami, FL
Co-Chair: Miami Regional Health Meeting
(PHS Region IV)

Raul Romaguera, D.M.D., M.P.H.
International Health Officer
Ofice of International Health
Rockville , MD

Margarita Roque
Executive Director
Congressional Hispanic Caucus
Washington, DC

Jose M. Saldana, D.M.D., M.P.H.
President
University of Puerto Rico
San Juan, PR

5hiree Sanchez
Assistant Director
Office of Public Liaison,
The White House
Washington, DC

Ruth Sanchez-Way, Ph.D.
Director

Division of Community Prevention and Training
Center for Substance Abuse Prevention
Rockville, MD

Maria D. Segarra, M.D.
Associate Director for Policy and Internal Affairs
Ofice of Minority Health
Rockville, MD

Belinda Seto, Ph.D.
Deputy Director
Of&e of Minority Programs
National Institutes of Health
Bethesda, MD


a+++4444444444  Executive Planning Committee

Ciro V. Sumaya, M.D., M.P.H.T.M..
Associate Dean for Affiliated Programs and
Continuing Medical Education
University of Texas Health Science Center
San Antonio, TX
Co-Chair: San Antonio Regional Health Meeting
(PHS Regions VI and VIII)

5ara Tort-es, Ph.D., R.N.
President

National Association of Hispanic Nurses
Tampa, FL
Co-Chair: Miami Regional Health Meeting

(PHS Region IV)

Fernando M. Trevino, Ph.D., M.P.H.
Dean, School of Health Professions
Southwest Texas State University
San Marcos, TX

5teve Uranga Mcbne, D.M.D., M.P.H.
Program Director
W. K. Kellogg Foundation
Battle Creek, MI
Co-Chair: Chicago Regional Health Meeting

(PHS Regions V and VII)

Frank Vasquez, Jr., M.B.A.
Executive Director
Hidalgo County Health Care
Corporation
Pharr, TX

Richard A. Veloz, J.D., M.P.H.
Staff Director

Select Committee on Aging
U.S. House of Representatives
Washington, DC

Marcelle M. Willock, M.D., M.B.A.
Professor and Chairman
Department of Anesthesiology
Boston University Medical Center
Boston, MA

Alternates for the
April 22-23,1993, Meeting
Esther Aguilera
Legislative Assistant for Health and Judiciary
Congressional Hispanic Caucus
Washington, DC

Olivia Carter-Pokras
Public Health Analyst
Office of Minority Health
Rockville, MD

Evelyn Day
Chief, Diverse Education Division
Of&e of Personnel Management
Washington, DC

Lily 0. Engstrom, M.5.
Assistant Director
Office of Extramural Research
National Institutes of Health
Bethesda, MD

Carlos Espatza
Director of Federal Liaison
Hispanic Association of Colleges and Universities
San Antonio, TX

Adolph P. Falcon, M.P.P.
Senior Policy Advisor
National Coalition of Hispanic Health and

Human Services Organizations
Washington, DC

Patricia M. Golden. M.P.H.
Special Assistant to the Director
Division of Epidemiology and Health Promotion
National Center for Health Statistics
Hyattsville, MD

Amelia Gutierrez Ramirez, Dr.P.H.
Assistant Director for Administration and

Community Health
South Texas Health Research Center
San Antonio, TX

Christina Lopez, M. Ed.
Director, Health and Elderly Component
National Council of La Raza
Washington, DC

William C. Parra
Deputy Associate Director for HIV/AIDS
Centers for Disease Control and Prevention
Atlanta, GA

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Contents  4 4 4 4 4 4 4 4 i 4 4 4 4 4 4 4 4 4 1 4

Contents

Message from the 5urgeon General o 2

Chapter 1: Introduction + 5

Chapter 2: Charge to Participants + 9

Chapter 3: Hispanic/Latin0 Health Issues Panel--Background
Ewnmary Paper5 o 15
Improving Access to Health Care in Hispanic/Latino Communities o 15
Improving Data Collection Strategies o 17
Increasing the Representation of Hispanics/Latinos in the Health Professions o 19
The Development of a Relevant and Comprehensive Research Agenda to Improve
Hispanickatino Health o 2 1

Health Promotion and Disease Prevention o 23

Chapter 4: National bbrkshop Recommendations* 27
Access to Health Care o 27

Data Collection o 31

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Research Agenda o 3 3
Health Professions o 36

Health Promotion and Disease Prevention o 40

Chapter 5: Fbesentation of National Workshop
Recommendations+ 45

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Access to Health Care o 45

Data Collection o 49
Research Agenda o 5 1
Health Professions o 54

Health Promotion and Disease Prevention o 57


a4444444444444444444   Content5

Chapter 6: Closing Remarks + 61
Chapter 7: Regional Health Meetings + 67

Introduction o 67

The Miami Hispanic/Latin0 Regional Health Meeting o 70
The Chicago Hispanic/I-&no Regional Health Meeting o 72
The San Antonio Hispanic/Latin0 Regional Health Meeting o 74
The NewYork Hispanic/Latin0 Regional Health Meeting o 76
The Los Angeles Hispanic/Latin0 Regional Health Meeting o 78

Chapter 8: Priority Recommendations + 81
Cross- Cutting Issues o 8 2
Access to Health Care o 83

Data Collection o 88
Research Agenda o 92
Representation in Health Professions o 95
Health Promotion and Disease Prevention o 97

Appendix A

National Workshop Participants o 10 1

Appendix B
National Workshop Agenda o 117

Appendix C

Regional Health Meetings-Executive Planning Committees and Agendas o 12 1

Appendix D

Regional Sponsors and Co-Sponsors o 149

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Appendix E
National Workshop Speakers o 15 1


Artist:
Vito Oporto
Original Concept:
TODOS Hispanic Student Organization
Ohio State University
Design Contributions:
Executive Planning Committee
Surgeon General's National Hispanic/Latino
Health Initiative

T he symbolic elements of this logo reflect the
mission of the Surgeon General's National
Hispanic/Latino Health Initiative. The colors of the
United States of America represent the effort to
unite all Hispanics/Latinos, regardless of their
diverse backgrounds and roots, under our flag. The
Bald Eagle, the traditional symbol of "supreme
power and authority," uses its great wingspan, keen
eyesight, and ability to soar over great distances to
protect and embrace its territory. The eagle
embodies the Office of the Surgeon General, whose
%ingsn protect th ose in need. The people repre-
sent all Hispanics/L.atinos: the individuals and
families, the young and the elderly, all those who
need that protection. The circle was used in many
ancient civilizations as a symbol representing the
Sun, life itself, and the aim to achieve perfection, to
do everything right, to live in good health, and to
prolong our existence. As a graphic symbol for
health, the circle represents the well-being of the
body and the freedom from physical disease or pain,
not only for the individual or for a people, but for
the Nation. The powerful words "organized" and
"solidarity" are designed to stir positive reactions
beyond the borders of this Nation, bringing to-
gether all Hispanics/ Latinos . Finally, the small
squares and the borders show the artistic traditions
of the Hispanic/Latin0 Heritage.

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Message from the Surgeon General o o o o + o + + + + +

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MessaaefromtheSgeon General

               4
I n this melting pot called America, \w Hispanics/
Latinos--soon to hccomc the largest and youngest oE
its ethnic minorities  h a\ c mereI\- remained on the
outside of the pot looking in. Following the path of
least resistance, \ve haw let the status quo sustain us for
the last 500 years. Rrandcd as one amorphous group,
ST haw pcrswcred, but JVC` ha\-c ncwr rcallv been
accounted for or counted in collecti\-clv as one . .
until now. Speaking \\.ith one loud voice, MY can begin
to make America listen to us as ncwr b&i-e. Onlb
then can \vc Hispanics/Latinos tinall\. lx@ to come
into our ov,n.

  Toda!., HispanicsILatinos make up 22 million
hardworking members of'thc .Amcrican tBmil\-, and
by the !-ear 2000, th crc \vill bc 3 I million of us.
Pal-crty, undcrcmphn mcnt, absence of true data,
lo\\ educational attainment, cultural dislocation,
and limited access to health cart and inzurancc ha\ c
set man\- of us apart t;om mainstream .-\meric,a ant1
jeopardized our health.

  To begin to co&ont the challcngc\ that
Hispanics/Latinos fhcc in this county, and to dc\ slop a
plan to address our complex harricr5 to qualit\ hc>alth
care and w-1 ices, the Surgeon Gencral"r landmark
Hispanic/ Latino tlcalth Initiatiw 11 as born. 7% (al--
reaching Initiatiw, dcsicgncd to unite the &n-t\ ot`
diwrse Hispanic/Latino groups nation\vidc thrc y+
the Of&c oE the Surgeon Gcncral, \\ as charactcri,c~I
lx three main goals:

  m To gather information on the health ncctl,,
  concerns, and priorities of Iiispanic/Latino
   .Imcricans.

* To proposc cffccti\.e and rcalihtic rccommcn-
dations fbr addrrshing thew needs.
                 6

* To lx-o\ idc a clear focus t;)r coordinating the-
activitich of the Ijcpartmcnt of Health and
Human Scrviccs with thaw ot'thk- Hispanic/
Latin0 communit\-.

antonia Coello Novello, M.D., M.P.H.
Surgeon General
U.S. Public Health Senicc

  `l-hi> report documents the activities and
tinding\ of the Initiatiw. AS an unprcccdentcd
c~ompcntlium of infbrmation, the report dcscribcs
the *tatus of 1 lispanic/Latino health in t'i\c regions
ot'thc Llnitcd State\, dcfincs the challcngcs and
I)riorlt\- isuci cncompassine out- ercatcst disparities
                    L c
ant1 harrier\, and lists the rccc,mmcn~lations rclatcd
to ~lizpa"ic/L.atino health priorities.
  The Initiati\c and thih report wvrc madc
pos\ihlc through the support ofthc U.S. IIcpart-
mcnt of Hcxalth and Human Scrviccs, Public Health
Scr\ ice. Ott`icc ot`.Minoritv Health. The Initiati\ c
I\ ah guided lx an Excc-uti\ c f'lanninc Committee
   c                       c
ma& up of48 HispanicILatino leaders from
throughout the countr\..
    c
  In Scptemher 1992, in V+`ahhington, D.C.,
I\ c hcltl the first c\ cnt of the Initiatii c -the Surgeon
Gcvwral's Sational \Vorkahop on Hispanic/Latino
Hc,alth. hlorc than 200 Hispanic/L.atino Icaclcrs


concerned with the health and well-being of the
Hispanic/Latin0 community came together to speak
at this landmark Workshop.
  They shared their experience and expertise in
developing recommendations for addressing five
health concerns critical to Hispanic/Latin0 Amcri-
cans. These issues remained as the central focus of
our Initiative efforts:

. Improved access to health care.
* Improved data collection strategies.

. Increased representation in the science and
health professions.

. Development of a relevant and comprehcn-
sivc research agenda.

. Health promotion and disease prev-cntion
efforts.

  Subsequently, in March and April 1993, x1-c
held five Regional Health Meetings in U.S. cities
with large Hispanic/Latin0 populations-New
York, Miami, Chicago, San Antonio, and Los
Angeles. At these intensive Z-day meetings,
hundreds of Hispanic/Latin0 leaders and health
professionals pooled their expertise to identifv
Hispanic/Latin0 health issues specific to each
region, to formulate partnerships for action at the
State and local levels, and to develop appropriate,
communitv-based recommendations.
       ,
  Following the regional meetings, the Execu-

tive Planning Committee members met in
Washington, D.C., for a comprehensive, 2-da)
followup session at the end of April. At that time,
MC reviewed all the recommendations proposed at
the National Workshop and the five Regional Health
Meetings for possible implementation. This report
summarizes the most pertinent recommendations
developed by the group in addressing the five
critical issues in improving the health and vvell-being
of the Hispanic/Latino communitv.
                        i
  The recommendations come at a time when the

Sation is examining health care for all Americans. It
`\-as tbc hope of the group that these recommendations

could be used by Federal, State, and communitv leaders
as thev plan for the health and well-being of Hispanics/
Latinos. When these recommendations were made to
the Surgeon General, it was the group's consensus that
thev could be used to empower communities and close
the gaps between the "haves" and the Uhave-nots."

  As a result of working together and speaking
with one voice, I am confident that we are on the right
track and are beginning to make a real difference in
dealing with these complex issues. Our collective
efforts in cam-ing forth the aims of this Initiative are
critical to the health of everv Hispanic/Latin0 Ameri-
can. For only with a new, more cohesive, it-depth,
and realistic profile of this Nation's Hispanics/Latinos
can we trulv begin to plan for the future as true equals
in this lancl of opportunity. As we proceed to work
together for good health, let us make TODOS (all of
us) our watchvvord for vears to come.

Antonia Cocllo Novello, M.D., M.P.H.
Surgeon General

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44444444444444444   Introduction

Chapter 1: Introduction

Background

H ispanics/Latinos constitute one of the fastest
growing ethnic minorities in the United States. Today,
there are 22 million Americans of HispanicILatino
descent in this country, making up about 9 percent of
the Nation's population. Bv the vear 2000, Hispanics/
                  _ .
Latinos will become the largest-  and one of the
youngest--of America's ethnic minoritv groups, with
an estimated 3 1 million members. B\- 2050, the
Hispanic/Latin0 population is projected to be
8 I million people or about one-fifth of the predicted
American population.

  More than two-thirds of Hispanics/Latinos no\\
living in the United States arc nativ-c citizens; however,
they do not share in America's bountv. Their
per-capita income is disproportionately lower than that
of African Americans or non-Hispanic/Latin0 whites,
and more than one-third of them do not ha\-e health
insurance even though Hispanics/Latinos are the most
highly employed minority. The disparity in health
status between the Hispanic/Latin0 and non-Hispanic/
Latin0 populations in the United States is a recognized
problem, and research has been conducted to detcr-
mine the magnitude and causes of this disparity.
However, the problem defies any generic approaches
for solutions because of the diversity of the Hispanic/
Latin0 population in national origin and cultural
heritage, economic status, geographical distribution,
and demographic characteristics.

  Numerous groups within the Hispanic/Latin0
community have attempted to address the diverse
and complex problems of Hispanic / Latin0 health
status. Recognizing the need to address this
problem in a united and unified effort, the

Congressional Hispanic Caucus, national Hispanic/
Latin0 leaders, and several Hispanic organizations
recommended that the Public Health Service (PHS)
launch an initiative to develop solutions; they also
rccommendcd that Surgeon General Antonia Coelfo
No\-ello lead the initiative. Thus, the Surgeon
General's National Hispanic/Latin0 Health Initiativ-e
was formed. This report documents the activities of
the Initiative.

  The Initiativ-e is dcsigncd to meet three
critical goals in support of the Department of Health
and Human Services (DHHS) commitment to
health for all Americans: to reduce the health
disparities of all people in this country, to improv-e
delivcrv of health set-v-ices to those in need and
those at risk, and to cnsurc access to health care for
all. More specifically, the Initiative addresses five
crucial health objectiv-es pertinent to the Hispanic/
Latin0 population:

. To improve access to health care for all.              One

* To improve the collection of health data for
Hispanics/Latinos across the board.                 Voice

  o To develop a relevant and comprehensive
  research agenda.

  . To increase Hispanic/ Latin0 representation in
  the science and health professions.

  * To expand community-based health promotion
  and disease prevention outreach activities.
  To assist her in planning the activities of the
Initiative, the Surgeon General enlisted Hispanic/
Latin0 leaders from across the Nation who have
expertise in Hispanic/Latin0 health issues. The
members of the Executive Planning Committee are
listed in the front of this report.

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Introduction  44444444444444++4*

Events of the Initiative

National Workshop on HispanicLatin
Health: Implementation Shategies
l- his Workshop \vas the critical first step in meeting
the goals of the Initiative. Held September 28-30,
1992, at the ANA Westin Hotel in Washington, D.C.,
the Workshop w-as hosted by Dr. No\-410 and \vas
sponsored by the Office of the Assistant Secretan. for
Health (OASH), Office of Minority Health, and
co-sponsored by the National Institutes of Health,
the Centers for Disease Control and Prevention,
and the Substance Abuse and Mental Health Services
.\dministration.

  The Workshop brought together more than
200 Hispanic/Latin0 leaders from di\.crse back-
grounds and organizations in a unique forum that
pooled their strengths and leadership abilities to
             c
promote the health and well-being of the Nation`s
                        c
Hispanic/Latino population. The purpose of the
Workshop x,-as to document the status of Hispanic/
Latino health and to begin de\-eloping strategies to
meet the identified needs. Its specific goals \vc>r(

* To gather information about the health nectls,
concerns, and priorities of Hispanic/Latin0
.imcricans

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. To propose effecti\.c and realistic rccommcn-
dations for meeting those needs.

. To pro\-idc a clear focus for coordinating the
Department's efforts with the efforts of the
Hispanic/Latino communitv.
To prepare the \\`orkshop participants to

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address the issues in each of these arcas, the Surgeon
General commissioned a set of Background Sum-
mar? Papers. These Background Summar\- Papers
outline the problems in each area, summarize
proposed solutions from existing literature, and
offer suggestions for implementation strategies.
They \\ crc sent to the participants before the
\Vorkshop and were presented at the M'orkshop b\
the IIispanic/I.atino Health Issues Panel, composed

of the fi\-e corresponding authors. The papers laid
the groundwork for and served as a prelude to the
important work that occurred at the Workshop.
The Background Summary Papers are to be pub-
lished in Public Health Reports, the journal of PHS.
  During the Workshop, the participants were
assigned to Work Groups, kvhich were charged with
de\-eloping implementation strategies for improving
the health and xv&being of the Nation's Hispanic/
Latin0 population. Each Work Group was tasked
\vith meeting three objectives:
. To identify between 5 and 10 priority
  problems or issues for the assigned topic
  (access to health care, data collection,
  research agenda, representation in the health
  professions, and health promotion and disease
  prc\ ention efforts) and to rank them accord-
  ing to their priority.
     c

  * For each problem or issue, to identify at least
   one aim or desired end.

  . To tlcvelop a list of implementation stratcgics
  for reaching each aim. As strategies were
  tic%\ eloped, some groups also identified at
   u hat Ic\-el  Federal, State, or local---and 1~).
   11 hich sector -public, private, or public
  pi-i\-ate partnerships -~these implementation
  strategies should be undertaken.
  On the final da!- of the Workshop, a spokes-
person for each IVork Group presented the Work
Group's finding\ to LVorkshop participants; to a
Rcyondcr Panel composed of kc\. leaders of Federal
accncics; and to local, State, and Federal policvmakers.
&

Regional Health Meetings
The findings of the National Workshop provided the
basis for the second phase of the Initiative, the Regional
Health Meetings, held in the spring of I993 in cities
across the country--Ne\\- York, Miami, Chicago,
San .\ntonio, and Los .L\ngcles. The Regional Health
Meetings dre\\- approximately 1,000 participants from
tlivrse Hispanic/ Latin0 populations to address health
problems \\-ithin their communities.


  The objcctivc of each Regional Health
Meeting was to identify and focus on the specific
needs of the regions and to dc\ clap stratcgich for
          c
creating partnerships for action at the local and State
levels, \\-hcrc lacking, and for atrcngthcning the
linkages that alreadv exist to promote Hispanic/
Latin0 health and \vcll-being. Folio\\-ing a format
similar to the National U'orkshop, groups ot
participants dcvrlopcd stratcgics for each critical
area of concern and prcscntcd the findings to the
entire gathering.

  This report contains a chapter summarizing
the Regional Health Meetings. The full proceeding>
for each mcctinq arc` to bc published in wparatc
           L
reports.

Executive Planning Committee Meeting
On .\pril 22 and 23. 1993. just da\-5 after the la\t ol`thc,
Regional Health M cctings took place, the Exccuti\ c
Planning Committee for the Initiative met in
Washington, D.C., to rc\-iv\\- the findings of thr
National Workshop and the Regional Health Meetings
and to draft a national plan of action for impro\-ing the
health and well-being of Hispanic/Latino r\mericans.
              L
This national plan s~ntbcsizcs and prioritizes the
strategies devclopcd at all of the other \\-orkshops; its
purpose is to address the divcrsc health needs of the
Hispanic/Latin0 communitv.

About This Report

This report is published in t\vo versions. The first
version, entitled Recornmendntior~s fo the Surgeorl
General To Improve HispanidLrrtino Health. contains
a summary of the Executix-e Planninq Committee
                          c
meeting held on April 22 and 23, 1993, and the
implementation strategies identified at the meeting
as crucial for prompt action, Bccausc this report is

a svnthcsis of the findings from all of the activities
of the National Hispanic/Latino Health Initiative
and prioritizes the recommendations dcvclopcd, it
sc'r\.c's as an action plan for the Nation to begin
addressing the critical issues related to the health
\tatus of the Hispanic/Latin0 population.

  The second 1 crsion of the report, cntitlcd One
I'oice. Our Vi.siorl-RoL.orl?rlzell~i~lfiOlls to the Surgeon
Getwrd To lwprm~e Hisllcrrric//Lcttirrn Hedth. docu-
mcnts all cycnts of the Initiative with emphasis on
the National M'orkshop held in September 1992.
Chapter 2 contains Dr. No\-cllo's charge to the
participants at the Sational 1Vorkshop. Chapter 3 is
the prcscntation of the Background Summarx
Papers. Chapter -F lists the implementation
\tratc$cs dc\-clopcd at the National Workshop, and
Chapter 5 ic the presentation of those implemcnta-
tion stratcgic5. Chapter 6 contains Dr. Nowllo's
closing remarks from the National CZ'orkshop.
Chapter 7 providcb a summarv of the Regional
Health Meetings, with highlights of the implemcnta-
tion stratcgics dc~elopcd at the meetings. Chapter 8
contains the priorit! recommendations devclopcd at
the lipril 22- 2 3, 1993, Executi\,c Planning Com-
mittee Meeting.
Appendix .% lists the participants of the National
Workshop. (Participants of the Regional Health
Mwtings arc listed in separate proceedings docu-
mcnts for each meeting.) Appendix B contains the
agenda for the National Workshop. Appendix C
provides the Executiw Planning Committee
members and the agenda for each Regional Health
Meeting. Appendix D lists the regional sponsors
and co-sponsors for each Regional Health Meeting.
Appendix E contains the remarks of goyemment
and communitv leaders \\.ho took part in the
National Workshop.

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Chapter 2: Charge to Participants

Antonia Coello Novello,
M.D., M.l?H.

Surgeon General

Buenas tardes y bienvenidos. It is my great pleasure
to welcome you all to this landmark National
Workshop on Hispanic/Latin0 Health: lmplemen-
tation Strategies. As you know, our motto for this
important event is TODOS, and it has been
precisely in the spirit of togetherness and unity, of
solidarity and a vision for a healthier future, that we
have been working so hard in the past months to
make this Workshop a reality. A heartfelt thank
you to everyone on the Executive Planning Com-
mittee-and especially to the original five individu-
als (Rudy Sanchez, Raul Yzaguirre, Jane Delgado,
Helen Rodriguez-Trias, and Castulo de la Rocha).
Without the Committee's tireless and diligent
efforts, there would be no .workshop today.

  This group meeting here toda! for the first
time is very similar in composition to the Hispanic/
Latin0 population as a whole-multicultural and
multidisciplinary. We come from throughout the
United States, we can trace our heritage back
centuries, and we come from multiple Hispanic/
Latin0 groups. We come from the public and
private sectors: we consist of national, State, and
local officials; community leaders; and health
professionals-clinicians, physicians, researchers,
and educators. Whether participant or observer,
we are all in this together and have come to mark a
great new beginning for Hispanic/Latin0 health.
  This Workshop will bring to the forefront-
  * The links between having good health and
  having a good life.

B The reality of farnil! ties that not onlv bind
our immediate households and relatives but
that go back five centuries.

= The true meaning of lost of country, love of
heritage, and love of learning.

  = The application of knowlcdgc to move
  forward-con rcspcto, confiannza, y honor.
  Above all, the Workshop will strcngthcn the
conviction that, in the words of Pablo Ncruda, "All
paths lead to the same goal: to convcv to others what
we are." Basically, we plan to get to the heart of what
it means to bc a Hispanic/Latin0 man, woman, or
child in this country. That is why wc are here.
  In this historic meeting, it is rn: hope that we
will filter out the noise of our separate realities and
make our many voices heard in one choir-a choir
of voices that will make America listen as never
before. TODOS, together, with one voice, we
Hispanics/Latinos will live up to the single most
important goal positioned for the future: that people
from eve? cultural and ethnic group shall be empow-

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ered to contribute, not OII(V to themselves but to the
common good of all Americans.

In that spirit of empowerment, we shall meet
here for the next 3 days. These 3 days may bring
moderate success for some and laurels for a few on
which to rest in the coming months, or they ma? bring
unprecedented achievements that will resonate for
years to come and well into the next centur>-.
As the Surgeon General for all Americans,
I ask you to rise to the challenge and aim for the
unprecedented achievements that will make it
feasible for each one of us to have a future. In doing

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so, make it happen not only for yourselves but for
each member of the Hispanic/Latin0 community.
  In these critical days, I ask you to use not only
vour experience and intellect, but Tour feelings.
Bring not only your care and concern but, if
necessary, your anger and frustration, your sense of
empathy, justice, and fair play. Adding feeling to
intellect will temper our data and theories with a
healthy dose of reality. At the same time, I am
asking you not to let your emotions and feelings
overpower you to the extent that we become
splintered and lose sight of our overriding goal in
this spirit of empowerment: to develop implemen-
tation strategies that can cut through talk and result in
action. We want to "get real," but in doing so, we
must address our pressing concerns with realistic,
feasible solutions. I am asking you to bring your
honest perceptions of what can help our families and
children to be healthier and better prepared for the
new age upon us, while allowing us to face our
many barriers objectivelv.
  We have all heard a great deal about
Hispanics/Latinos; we have been inundated with
statistics that paint a complex and often gloomy
picture of what it is to be Hispanic/Latin0 in
America. Let me share some of those with you
todav.
   ,

  * WC know that, by the vear 2000, the
  22 million Hispanics/Latinos of today will
  become almost 3 1 million, yielding the single
  largest and >-oungcst ethnic minority in the
   United States.

* The majoritv of Hispanics/Latinos-67
pcrccnt-were born in the United States.

= Hispanics/Latinos live in virtually every part
of the Nation but are hcavilv concentrated in
the four States of California, Texas, New
York, and Florida. Most of our population
live in urban arcas.

m The Hispanic/Latino population includes
many tliffcrcnt nationalit! groups. The

majority (63 percent) identify themselves as
Mexican Americans; 11 percent are Puerto
Rican; 5 percent are Cuban; 14 percent are
Central or South American; and 8 percent arc
f rom other Hispanic/Latin0 subgroups.

* Although Hispanics / Latinos comprise the
fastest growing segment of the elderly
population, as a group they are younger than
other Americans. They have the highest birth
rates in the country and have larger families
than non-Hispanics/Latinos; 20 percent of
these families are headed by a single female.

* Hispanics/Latinos have the lowest levels of
educational attainment of any major popula-
tion group. Only about one-half of adults are
high school graduates, and fewer than 1 in 10
has completed college.

* The per-capita income for Hispanics/Latinos
is disproportionatclv lowcr than for African
                I
Americans or whites. In fact, Hispanics/
Latinos arc less likclv to bc homeowners than


other Americans, and more than one-fourth

live in poverty.

. Hispanics/ Latinos die from various causes.
.-\mong the major ones are accidents, diabe-
tes, cirrhosis of the liver, homicide, AIDS,
and perinatal conditions.

m Thhqdu-ee percent of Hispanics/Iatinos lack
health insurance, despite the fact that there may
well be an adult worker in the family.

  These facts portray our sociodemographic and
c*conomic realities and show who we are today.
1 hclieve that many of the problems we face as
Hispanics/Latinos reflect the educational and
economic disparities we all know. Yes, we have
problems, but they are not insurmountable.
&cause we also have great resources and
strength-not the least of which is our strong work
ethic and our sense of justice.
  Your commitment and that of the organiza-
tions and institutions you represent is critical to our
success in this Workshop. With that kind of mutual
commitment, we can bring the very best knowledge
and resources to bear for each of the five critical
issues we will discuss-this time with eves toward
                             ,
the future.

For example, during our Workshop--

m In our discussion of improving access to
health care, it means removing cultural
barriers that perpetuate fear, mistrust, and
misunderstanding. It means access that is
culturallv sensitive and culturallv responsible.
It means bridging the language gap-r
should 1 sav the inability to communicate
between those who speak English and those
who do not. It means encouraging women
who seek out medical care last because of
family obligations to put themselves first for
once. It means access that is community-
based, family-centered, and under one roof.
* Increasing representation in the health
professions mrans hccoming more in\-olvcxl in

our education, eliminating illiteracy, increas-
ing the number of college graduates, and
reducing the time it takes to get a degree. It
also means getting on in the world of bio-
technology and science and aspiring to be the
best, whether young or old. It means
education for everyone. It means encouraging
not only our young people but also our adults
to get in school and continue to learn. It
means aspiring to and preparing for careers in
professions that we did not feel were open to
us in the past. It means empowering our
youth to have a say in their futures. It means
having the power to set the educational
agenda that fits our needs and not walking
around blindfolded to opportunities.

* When we talk about improving data collec-
tion strategies, it means responsiveness to all
ethnic groups and subgroups and account-
ability to the truth. It means that our
population of 22 million people needs to be
accounted for and counted in. It means
getting comprehensive data, identifying what
is and is not appropriate, and making accurate
assessments and reasonable predictions about
the real status of Hispanic/Latino health.

* Developing a comprehensive research agenda
goes hand in hand with collecting better data.
We cannot expect to understand where we
are headed and where we ought to be in terms
of health until we understand, first, where we
are today. It means finding a way by which
we benefit from what science has to offer by
tailoring its benefits to our needs. It means
focusing on the diseases that kill us and
putting priorities on research aimed at
Hispanics/ Latinos and other minorities-in
the areas of HIV/AIDS and sexually transmit-
ted diseases; alcoholism and other drug abuse;
infant mortality and perinatal addiction; child
abuse; cancer. tuberculosis. diabetes, and

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heart disease; homicides, suicides, accidental
injury; and the links between these diseases
and the "disease" of poverty.

o When we talk about health promotion and
disease prevention, it means that promoting
health for Americans must be planned to
encompass the views, needs, and feelings of
the people who require it. Health promoters
and policy makers must step, as it were, into
the shoes of the unfamiliar if they are to
develop programs that are responsive to the
needs of those entrusted in their care. It
means bilingual, culturally sensitive, and
culturally competent programs, materials,
and training that address the diverse needs of
our pluralistic high-tech society. It means
promoting the involvement of everyone to
empower their own health and the health of
their families. It means, in a sense, making us
a part of getting better-by empowering us
to understand why getting better is impor-
tant, not by patronizing us but by enlightening
us and enticing us.

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  If we are to succeed in this coming century,
we must work to bridge our differences, uniting in a
common bond and speaking with a common voice.
We must learn not only to get a piece of the pie but to
have a say in how it is baked. Most importantly,
we must earn the trust but not arouse the fear of other
minorities like us who seek a piece of the same pie.
In doing so, we must strive for the following:

  * We must secure a place for our children in
  the explosive new century. And while
  securing their place, let's not forget to
  include them in the planning process. Being
  young is no reason for exclusion.

  o We must also get involved. I would like to
  hear less of "I want, I need, and I deserve,"
  and more of "What can 1 do? How can I help?
   When do we start?'

* We must foster acceptance of our population
and promote our incorporation into a true
multicultural society. I would like to see US
help mainstream America understand and
accept our Hispanic/Latin0 culture with its
centuries of knowledge; encourage our
contributions; and value our diversity.  It is
time we put an end to cultural stereotypes
once and for all.

* We must learn to develop partnerships, not
only among ourselves but also among States,
local community groups, and businesses.
Such partnerships will extend our resources,
combine our skills and specialties, and ensure
more comprehensive services.

* We must also seek help when help is needed.
We need help to overcome the difficulties and
stress of cultural dislocation and assimilation

into American life. These problems can leave
wounds that can last a lifetime.

  *  We also must not overlook the silent cries of
  our children, who are watching us and
  emulating our behavior. They do what we
  do, not what we tell them to do. We must
  set the example of a healthy lifestyle and help
  them see through the mixed messages about
  false glamour, affluence, popularity, and the
  so-called "good life." For how can we expect
  to raise our children to value our traditions
  and customs, to respect the cultural traits that
  shape our individuality, when we ourselves
  lose our identity and self respect?
  Now, let me return to remind you of what we
all can do together at this Workshop. As health       .

practitioners and advocates, you have a chance to
become the leading architects and designers of our
agenda for the future. It will be up to you to make
these Work Group sessions meaningful and con-
structive. It will be up to you to develop sound
objectives and implementation strategies by relying


,=4.4444444444444  Charge to Participants

,,iI the shared expertise and collective wisdom of
voiir colleagues in so many fields. I am relying on
>ou all to work hard, pull together, and develop a
truly lvorkable, useable plan of action-a plan that
\vill be the blueprint of our national Hispanic/
Iatino health agenda for years to come.

In closing, let me stress that our challenges
are far from easy. We must retain our pride
jvithout lingering at the altar of personal ambition.
me must transform without transgressing, share
without imposing, and integrate without interrupt-
ing. We must also remember that it is not solel!
the responsibility of the Government to sustain us
and find a place for us in the next century.
Ultimately, no government, no community
organization alone, is responsible for our future.
We must take command in shaping our destin:.

  As we work together to solve some of our
most pressing problems, let us rely on our strong
values and traditions for guidance. Let's rebuild
where it is needed, maintain what is essential, learn
new skills and strategies, and seek help--if help is
what is needed most.

Accordingly, do not refrain from speaking out to
our leaders-communicate, reach out, be proactive.
Let us not fail out of fear of displeasing a few. After all,
we empowered our leaders bv our votes; it is our
righttul place to seek cmpowcrmcnt in rctum.
  I believe the time to act is upon us, for we
have precious little time to rehearse. A generation

is waiting in the wings, and how well the 3 I million
are received in the next 8 years depends on how
well we perform our roles during the next 3 days.

  Let me close by reminding you that the
Hispanic/ Latin0 community is diverse, very family
oriented, very strong, yet, at times, vulnerable.
Hispanics/Latinos have succeeded against tremen-
dous odds time and again. As a group, we have
contributed to making this country strong and
diverse, and we have enriched the lives of young
and old alike through our many talents in every
field. America, it is time you do not forget us!
Together, as Hispanics/Latinos and -as

Americans, we can make a difference, starting
today. For, in the words of the great sage, Hillel,
who lived in the 2nd century, "If we are not for
ourselves, who are we? If we are only for our-
selves, what are we?" As part of this glorious
mosaic that is our Hispanic/ Latin0 family, I urge us
all to make our minds and hearts converge on one
important goal: to remember who we are, and to
show America what we are.. As we navigate the
uncharted paths ahead, let us remember that
intellect alone cannot be our compass; without
knowledge, there can be no change, but without
heart, there can be no dignity.

  Lideres de1 futuro: 1 urge you to think
clearly, act decisively, and care tenderly.
  Gracias. Adelante TODOS!

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Health Issues Panel

Chapter 3 : Hispanic/ Latin0
Health Issues Panel-
Background Summary Papers

-I- he Background Summarv Papers were commis-
                    ,
sioned to prepare participants for the National
Workshop by summarizing the existing literature on
the Hispanic/Latin0 health status-the problems
identified and solutions recommended. Participants
rcccivcd the papers before the Workshop took place
so that they could arrive at the Workshop read\- for
the task of developing implementation strategies.
This chapter contains the presentation of the
Background Summary Papers at the Workshop b!
the corresponding authors.

Improving Access to Health
Care in Hispanic/ Latin0
Communities

Robert Valdez, Ph.D., M.H.5.A.
  In the next few minutes I'm going to try to
summarize some of the highlights of this working
paper, "Improving Access to Health Care in
Hispanic/Latin0 Communities," by reviewing the
literature on the financial, structural, and institu-
tional barriers that Latinos face in acquiring care.
Many of these barriers, of course, arc buttrcsscd b!
low standards of living in our community, where
basic public health and sanitation practices arc not
adequately maintained or provided. Next, I'm
going to talk about some of the proposed rccom-
mcndations, or summarize some of the proposed
recommendations, that have hccn offered by health
policy analvsts from national Latino organizations.
                            c
from academia, and from other communitv organi-
zations. Last, we'll talk ahout some of the concerns
or considerations as \ve hegin to th4ihcratc implc*-

mentation strategies by highlighting some of the
issues that I think we need to keep in the forefront
of our thinking if we are to improve access to health
care for Latinos.

  Let me first focus on the fmanciaf issues. Most
Americans finance their health care through health
plans offered as a fringe benefit of their employment,
but that link betlveen employment and health
insurance is much weaker for Latinos. Generally,
employment reaps very low wages and few fringe
benefits, as exemplified by the health insurance data.
These data on health insurance coverage, or the lack of
health insurance coverage-the uninsured-illustrates
that Latinos are three times more likely to be
uninsured than the Anglo population, and about
60 percent more likely to be uninsured than the black
or Asian and other populations.

  As you recall, about 7 million Latinos are
uninsured, but that 7 million is spread out differrn-
tially among the various Latin0 ethnic groups.
Mexican Americans and Central and South Amcri-
can populations appear to have a greater problem in
this area.

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Access to

Health

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  Part of the problem arises from the fact that,
despite v-et-y high cmplovment participation, Latinos
arc very unlikely to rcccive fringe benefits, including
hcaltb insurance, as compensation for their work.
   Let mc turn novv to some of the structural
issues. Some of the structural issues that I want to
talk about are reallv those concerns about how the
              I
svstcm in the United States is put together or not
put together, as it were. Part of that system has to
do with the public programs that are offered to
provide financial coverage, and the major program
is Medicaid, a poor program for some of the poor.
Manv of the structural problems with Medicaid
revolve around pavment fees and procedures that
basically, reduce eligibility of the Latin0 population
to participate.

  The system as a whole-that is, the health
cart svstcm as a vvholc--is generally characterized
as culturallv insensitive and fracgmcntcd, as many of
you have tried to put together your own system, by
choosing a phvsician who then chooses other
     c ,
rcfcrral phvsicians, who then choose hospitals to use
on a haphazard basis. The quality of your health
care system depends on the qualitv of vour
                         ~ ,
physician's ability to socialize with other colleagues.
  Finally, wc touch on the structural issues.
The structural issues have to do with the fact that
much of our concern focuses on medical cart and
ignores the issues of public health. Many of our
communities lack clean. safe water and basic
sanitation. And clearly. thcrc isn't the kind of focus
on reducing violence that is necessary to make
headway in the morbidity and mortality in our
communities,

  Let me turn to some of the institutional issues,
or institutional ban&s. Man\- of them are the
rcflcction of the stereotvpes and racial problems that
exist in our current system and that have led to the
exclusion in some communities of Latinos from
lcadcrship roles. Many of the current reform proposals
that focus primarilv on the financial barriers closr out
Latino husincss opportunities and community dcvclop-

ment opportunities. These arc at the heart of the
barriers that we see affecting Latinos.
  Let me summarize, or at least highlight, a few
of the recommendations in the report, Clearly,
they can be broken up into three areas: ( 1) modify-
ing governmental (Federal, State, and local)
policies; (2) expanding the supply of culturally
competent providers, either through increasing the
number of Latin0 providers or assisting non-Latin0
providers to become much more attuned to the
concerns and the issues that affect our communities;
and (3) creating incentives for public health and
primarv care.

  As we begin to think about implementation
strategies, there are a whole host of strategies that
we could come up with. Some of them needn't be
mutuallv exclusive. We could follow several
diffcrcnt strategies at one time.
   Some of the considerations that I think we're
going to have to deal with have to do with the fact
that our populations are highly concentrated locally
and in particular States. One implementation
strategv would suggest that we concentrate our
     2
efforts for change in the 12 States with the largest
Latin0 populations; alternatively or in conjunction,
we could focus on the 20 largest urban areas,
We've seen a reflection of what it means to ignore
the urban arcas in Los Angeles with the recent "fit-c
sale," or riots, that occurred there in Mav.
                              ,
  The other thing that we have to keep in mind
is the development of advocacy among our national,
State, and local leaders and our officials. It's our
responsibilitv to educate the newly clectcd Latin0
                         ,
offtcials who will be joining Congress, who will bc
joining the State Houses, and who will bc joining
citv councils all across the country. Unless wc take
it upon ourselves to educate these offtcials, it's
unlikely-given the kinds of community dcvelop-
mcnt issues that most of us have to deal with-that
health cart will bc on the top of their agenda.
  Last, wc need to consider how we arc going
to portrav oursclvcs to the national media, to the


4444444444444444   Health Issues Panel

national public. There appears to bc a lack of Latin0
images, and this lack inhibits our ability to make
changes anti gain access to the power that's ncccs-
sat-v for increasing access to medical cart and health
care for Latinos.

Improving Data
Collection Strategies

Jane Delgado, Ph.D.

First, I avant to thank my coauthor, Dr. Leo
Estrada, and the COSSMHO [National Coalition of
Hispanic Health and Human Services Organizations]
staff, who \vere wry important to this paper. I
want to start off \\ith a littlc bit of history, which is
critical to giw us a pcrspcctivc on this subject.

  In 1970, the Census first used Spanish origin
as an identifier. In 1976 Public Law 94-3 1 I was
enacted, instructing Fcdcral agcncics to collect data
on ".Amcricans of Spanish origin or dcsccnt ." In
1977, as cvrrvonc knows, the Hispanic Health and
Nutrition Examination Survey was cstablishcd.

Later, you'll see that data \vas not actually collected
until 198 I. In 1978, OMB [Office of Managcmcnt
and Budgctl issued Dircctivc 15, which set the
standard for Federal agent? data collection rclatcd
to persons of Hispanic origin. As you can see, in the
1970s \ve had t\vo things: WC had legislation, and
we had an OMB directive.

   Data
Collection

  Moving on, \vc see that by 1980 the Census
started to USC Hispanic idcntificrs for the first time.
In 1986, the Hispanic Health Rcscarch Consortium
was cstablishcd. In 1987, the National Medical
Expenditure Survey began to oversample for
Hispanics, In 1988, GAO [U.S. General Account-
ing Offcc] released a report on Hispanic health data
collection; 1989 \vas a landmark year for us as a
community, because that's the scar the national
model birth and death certificates began to incluclc a
Hispanic identifier with specificity for subpopula-
tions.

  One of the factors related to Hispanic health that
this timetable rcvcals is that, until wry recently, wc
didn't know how many Hispanics were dying. This
explains wh:, for so long, infant mortalitv has driven
all of our national health policy, \vhcn in fact that's not
an issue affecting Hispanics.

  Now, looking into the 1990s: Congress
passed the Disadvantaged Minority Health Improvc-
mcnt Act. This Act is vcrv important, bccausc it is
the first health legislation that focuses on the specific
needs of Hispanic communities and instructs people
to look at us as a unique community, rather than in
a "minority community" model. In addition, DHHS
rclcascd 300 Healthy People 2000 objcctiscs. Thcrc
arc onlv 25 Hispanic objcctivcs bccausc all of the
objcctivcs had to have a basclinc. Because \vc did
not have a baseline, thcrc lt.crc not Hispanic
component objcctivcs in sonic arcas \vhich arc`
important: alcohol abuse, substance abuse. mental
health, sexually transmitted discascs, c`tc.

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Data

Coflcction

includes Hispanic and Hispanic subpopulation health
data. In 1992, the Hispanic Health Research
Consortium awarded grants to establish five
university-based research teams focused on Hispanic
women's health.

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  These events are the significant ones in the
history of our data collection. We have a very short
history, and I think that's part of the problem. So,
when we look at recommendations in the area of
Hispanic health, I think that the first thing we have
to look at is data collection.
  What are the things that we need in data
collection? First of all, we need to include a statistically
valid sample for Hispanfcs and major Hispanic sub-
population groups in major national data collection
systems. If you look at the Background Summarv
                                  1
Paper, we have a listing of all the major data sources
within DHHS, and it indicates which sources include
samples for us. Most of them do not.
  The second critical factor is the need to
redesign samples to collect data with more popula-
tion specificity in the Central and South American
and other Hispanic subpopulations. Computer
technology has made coding pretty straightforward.
It is also important to assess the validity of current
data collection instruments and procedures for data
collection in Hispanic communities.

  A third key issue is to establish Hispanic
component objectives for Healthy People 2000.
Man) of our communities at the State and focal
level know States are using Healthy People 2000 to
drive their local agendas. Because we didn't have
baseline data, we are left out of a lot of Hen/thy

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Vision

incorporate Hispanic/Latin0 communities into
Healthy People 2000 objectives at the State and focal
levels.

  In terms of data anafvsis, it is critical to
support the Hispanic health research infrastructure
to anafvzc Hispanic-specific information. Wc
should provide technical assistance to CBOs

[community-based organizations] and Hispanic
researchers for research grants for data analysis
award, include Hispanic researchers in development
of RFAs and RFPs, and also submit an annual report
on progress made toward improving Hispanic health
data collection and percentage data analysis dollars
granted to Hispanic focus programs.
  In addition, it is critical that we include rating
criteria that would give people points on being able
to demonstrate they can work in our community. It
should not be controversial that, if you are dealing
with a bifingual/bicuftural community, somebody
on your team should be able to do that, too.
Considering that we are the g&up with the least
amount of information about us, we should be
getting not only our proportionate share but more,
so we can catch up for all the lost time we've had. f
think that's one of the things that we have to be
much more aggressive about. We are way behind in
data collection research. We don't know what our
community is dying of. We know it's not infant
mortality. We know that we tend to five longer
than non-Hispanic whites. There are other things
we are dying of, though. We need to be able to
document that and make sure people are getting
research monies for that.

  The final issue, which is also crucial, is the whole
idea of data dissemination. We need to educate people
about who we are as a community. It's good to do
research, but make sure that the data we get and the
data we collect are then disseminated.

  We need to be included in every issue of
Health U.S., which is a document that non-Hispanic
health communities use as their data bible. The
categories should not be "White/Other." Thev
should not read, "White, Black, Other." We need
to have a category that holds our information,
because our communities are different. WC have
different issues, and it's a disservice to health
planners across the country not to provide that
information. Also, we have to make the data more
accessible to people. If people want to know us, \\`C


have to give them the information. Those are the
recommendations that we started off with in the
area of data collection.

Increasing the
Representation of
Hispanics / Latinos in the
Health Professions

Fernando Trevino, Ph.D., M.t?H.

  I would like to thank my coauthors, Dr. Ciro
Sumaya, Magdalena Miranda, Laudelina Martinez,
and Jose Manuel Saldana, without whom we would
not have been able to put this paper together.
   The issue we want to talk about is health
professions. Very few career choices exist for
students that are more competitive and more
demanding than the health professions. In addition,
they require a very long educational period. You
have to studv and successfully complete anywhere
from 12 to 16 years of an education before vou even
                                ,
begin to study health.

  For us, this is a problem, because the sad thing is
that, at the present time, somewhere between 60 and
75 percent of our young students never go to college
at all and, of those that do go to college, fewer than
10 percent will graduate. The problem is that
90 percent of our students are in urban schools, which
sufTer from a limited tax base and have to deaf with all
the additional problems of society that we're ail too
familiar with. .4ltfiough school segregation fias
decreased for blacks and whites, it has actualI\
                               I
increased for the Hispanic population.

  Our parents do everything they can to
support us, but all too many of them have ver\
limited experience with educational svstcms and can
offer only limited help to us. So w-c need to look to
the teachers and the administrators and others to
guide us along. Yet, unfortunatcfy, when vou look
         L
at this, vou find that fcwcr than 3 fjcrccnt of all the
tcachcrs in the llnitctf Statrs arc Hispanic. Tfic\

o o o o   Health Issues Panel

result is that too many of our students (approxi-
mately 75 percent) who do stay in school are
focusing on nonacademic tracks that will not
prepare them for the health professions.

  Only 5 1 percent of Hispanics older than the
age of 25 have completed high school, compared
with 8 1 percent of non-Hispanics. Between 1975
and 1990, high school graduation rates increased by
12 percent for black students and 2 percent for
white students. Yet they actually decreased
3 percent for Hispanic students. As of 1989,
Hispanics were approximately twice as likely as
black students to drop out of school, and almost
three times as likely as Anglo students.

  Hcafth
Professions

0I-W

  At the current time, about 9.7 percent of
Hispanics older than the age of 25 have a college
degree. If you look at it by national origin, you see
that Cuban Americans have the best experience.
Approximately 18.5 percent of Cuban Americans
older than 25 have a college degree. Now this is
the best that any of our people have been able to
do. That's still below the rate for non-Hispanics.
It drops all the way down to 6.2 percent of
Mexican Americans. Not only is the situation bad;
it's getting worse. In 1976, 36 percent of Hispanic
high school graduates went on to college. Ten
vcars fatcr, in 1986, we had lost 7 pcrccnt. WC

Voice
*
  .





One



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Health Issues Panel  444444444444444.4`

Hcafth

Professions

went to 29 pcrccnt of our students who arc going
to coffcgc.
  Our group fookcd at the work force that wc
currcntf~ have, and we found that there is not a
singfc ticftl \vhcrc we haw achieved cxpccted
rcprcscntation, based on our population. Wc come
cfosc in things fikc radiologic technofogv and in one
        c
that won't surprise you-health aides. We come
cfosc to \vhat wc shoulcf be at that point, but \ve
tfrop consitferablv as the cducationaf level increases
for a given profession.

  We've had some succcsscs, though. I think it
was in 1968 \vhen the effort to educate minority
professionals really kicked in, and it was needed. At
that time - f968-minoritv students composed
onfv 3.6 pcrccnt of all U.S. medical students.
Now, three-fourths of these minority students were
black, antf three-fourths of them were enrolled at
two prctfominantlv African American schools,
Mcharry antf Howard Medical Schools. There were
practically no minoritv students in any of our other
metficaf schools. So the Fcderaf government rcafh
kicketf in and devcfopctf some programs and, as you
can tcfl, thcv'w had some success.

0nc

  Of interest to mc is the fact that, in 1968,
nursing hatf the best rcprescntation for Hispanics,
antf vet that's the one field that tfidn't rcaffv do

Voice

much. It sort of pfatcaucd out thcrc. The others
incrcasctf tframaticaffy, as YOU can tcff. In 1968,
thcrc wcrc onfv 23 Hispanic first-war mcdicaf
stutfents in affopathic mcdicaf schools. In 1988.
20 wars fatcr, wc hatf 949. So wc'\c matfc great
increases. Unfortunatcfy, thcv stiff rcprcscnt onf!

Onr

5.6 percent of all first-scar mctficaf students.

In tfcntistry, in 197 1 wc hatf 40 Hispanic first-

Vision

war tfcntaf students. In 1988, wc had 316,
constituting 7.6 pcrccnt of'thc total in that ficfd.
   Data aren't availabfc on first-war cnroffmcnts
in the ficftf of optomctr~, fwt in I97 I total Hispanic
stucfcnts constituted 1 fw-cent of all ofatomctr\
sttufcnts in tfac Nation; 20 vc'ars later, tfwv consti
tutccf 3. I fw-cent. In tact, thci-c arc onfv t\\`o

schools of optometry in the entire United States that
have more than 5 percent Hispanic enrollment.
One is in California, and the other is in Texas.
  BY the nay, I should mention that all thcsc
f_gurcs exclude the island of Puerto Rico and all their
schools because, obviously, that is a different situation.
  I can go on and on. Pharmacy: 3.4 percent
of our first-year students are Hispanic. Podiatry:
3.6 pcrccnt. Veterinary medicine: 2.8 percent.
And again, nursing: Rcgrettabfy, in 1971,
2.5 percent of all students admitted to any RN
program at whatever level were Hispanic. In 1985,
that increased 0.2 percent, going to 2.7 pcrccnt of
our nursing students.

  In public health we've tafkcd a lot about the
need to address prcvcntion efforts and rcafly focus
on cfcvcfoping delivery systems, and I'm a littfc
conccrnecf . If you exclude the island of Puerto
Rico's School of Public Health (and you need to,
because the University of Puerto Rico School of'
Public Health employs one-half of all Hispanic
public health faculty in the country and it's graduat-
ing t\vo-thirds of all Hispanic public health gradu-
ates), YOU \vifl find that all the other schools of
public hcafth put togcthcr have a student body of'
onlv 3.2 pcrccnt that is Hispanic.

  .\fficd health (this is a big, broatf ficltf that \\c
fumf> togcthcr antf lvhich constitutes 60 pcrccnt ot
     L
all of' our .\mcrican hcafth cart workers) has no


database to speak of. We could not find any one     people who arc not going to bc well prepared to
unified database for the field of allied health. So all    find a suitable and productive career. We think the
t1-c \vcrc able to find was data from 26 disciplines    health profession, if you look at it, is one of the
that arc accredited by CAHEA. In 1989, these     professions that's growing, and thcrc's going to hc
26 disciplines had a Hispanic participation rate of     continued demand. This could produce some
5.7 percent.                  productive contributing citizens for us.

  Why should we be worried about educating
Hispanic health professionals? Well, first, it's the
right thing to do. But that hasn't gotten us very far.
Second, and I credit my colleague, Bob Montoya,
for this one-he has shown very clearly that this is a
vcrv cost-effective way of meeting the health needs
of our country.

  Last, I do want to tell you there are some
positives. The hope for us reallv is the fact that
most surveys have repeatcdlv found that, of the
Hispanic college students and Hispanic students
who are planninq to go to college, a health career is
            L
one of their top three professional choices.

  We hear all the time that maybe n-e have a
surplus of phvsicians in other categories. We kno\\
well, and these figures show, that we don't have a
surplus of Hispanic health professionals. .\ Federal
survey found that fewer than 10 percent of Anglo
medical students stated that they planned to practice
in a critical manpower shortage area. Less than
10 percent were even thinking about it. B!
contrast, the research done by Bob Monte\-a and
others has found that 75 percent of Hispanic
medical students-in this case, it was Mexican
American medical students-go back and provide
care to minorities. They go back and provide care
in critical shortage areas. They are more likely to
accept Medicaid payment and all the kinds of things
that we're talking about doing.

The Development of' a S.
Relevant anld
Comprehensive Research
Agenda To Improve
Hispanic / Latin0 Health
Gerardo Marin, Ph.D.

  This paper was developed with the collabora-
tion of Hortcnsia Amaro, Carola Eisenberg, and
Susan Opara-Stitzer.

  Bob Montoya has made a good argument.
That is, should we as a Federal Government or State
government inwst ~350,000 to ~400,000 for the
education of a single physician who's going to go in
a surplus area, or should we be investing the same
                             L
S400,OOO to produce the kind of physician or other
health provider who is going to go serve where wc
need them as a country?

  The two words that arc critical in dewloping
a relevant and comprehensive research agenda arc
"relevant" and "comprehensive." The dcvclopmcnt
of a relevant and comprehensive behavioral and
biomedical research agenda must address at least
three arcas, and I was very pleased to hear Sccrctar\
Sullivan saying that earlier today.

  Ra? Marshall, former Sccrctars of Labor, has
estimated that 90 percent of the growth in the work
force that is going to occur in the United States
from 1990 to the war 2000 \vill bc composed ot
women and minoritics. WC ha\c large numbcw of

  First, there is the need for the rcscarch infra-
structure that is central to the design, implcmcntation,
and support of research programs. Second is the need
for appropriate research instrumentation that provides
valid and reliable information about Hispanics. The
third area is the definition of rcscarch priority arcas that
arc based on the kind of data that we alrcadv have

about our health status.

  As the basis of this, there arc three other
important concerns: ( 1) that Hispanics, Hispanic
rcscarchc'rs, must bc in\-olvcsd in this process;

Research
Agenda

one

Voice

One .

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Health Issues Panel  444444444444444444
                                                                           I

One



Voice









One

Vision

&search
Agenda

(2) that we need an increased representation of
Hispanic and Latin0 professional staff within DHHS;
and (3) that our research must include an analysis of
the realities and needs of all Hispanics, including
those living in Puerto Rico.

   Let me mention some of the issues relevant to
the three major areas that we feel should be
addressed. In terms of a lack of appropriate
research infrastructure, more than 6 years ago the
Surgeon General's office produced a report on
minority health, and yet now we find that very little
funding goes to Hispanic issues. Less than 2 per-
cent of DHHS research funding is spent on Hispanic
health research issues or in support of Hispanic
researchers. By the same token, very few Hispanics
work for DHHS, and very few Hispanics are part of
the process to make decisions about research.

  Unofficial data provided to us by PHS show
that this year only 83 of the 2,342 members of IRGs
are Hispanics. That's about 3 percent. Given this,
it's difficult to understand how an IRG can under-
stand the cultural significance and appropriateness
and relevance of the proposals being submitted.
  The issue of appropriate research instrumen-
tation was mentioned before, and we want to
reinforce that very significant need, as we see
research that is being carried out without attention
to our cultural characteristics, to group-specific
attitudes, perceptions, norms, and values, or even
to the requirements of an appropriate translation.
  Priority areas of needed research have been
mentioned throughout the day. So in the interest of
time, I won't mention them here, but rather I'm
going to list some of the suggestions that we have
made for dealing with some of these issues.

  In terms of increasing the research infrastruc-
ture, as I mentioned before, there's a very signih-
cant need to increase the representation of
Hispanics in health-related research. I'd like to
suggest that those who make decisions about RFAs
and RFPs and about funding take into consideration
the kind of research that's being carried out in the

States that have high Hispanic representation and
demand that Hispanics be included in those samples.
I'd like to suggest that oversampling of Hispanics/
Latinos be required of proposals in critical areas of
health concern for Hispanics. There is a need to
educate members of IRGs, and this needs to be
done by DHHS. There is a need to prepare IRGs,
again, to be competent in making appropriate
decisions about funding.

  In order to increase the number of Hispanic/
Latin0 researchers, there is a need to provide pre-
infrastructural training for Hispanic researchers in
behavioral and biomedical research. Programs
directed at senior Hispanic/Latin0 researchers must

                           .., .
be developed to allow them to become better
equipped and to improve their methodological
expertise. There is a need to educate the young
researchers coming this way, to provide grantsman-
ship and workshops, to provide training that will
help them be competitive.

  We need to improve the train@ and cross-
cultural competence of non-Hispanic researchers. It's
very clear that we cannot do all the research that we
need to do. We need help from other researchers, but
they need to be educated about how to conduct
culturally appropriate research with our populations.

  To increase the number of Hispanics participat-
ing in the funding process, we suggest again that
sign&ant effort be made to identify Hispanics who can
serve in IRGs, as ad hoc reviewers, at national advisory
councils and scientific councils, and as program staff at
PHS and, certainIy, in the Centers for Disease Control
and Prevention. We'd like to suggest that IRGs try to
include at least one Hispanic member to properly
assess the appropriateness of proposals, and that special
recruiting efforts be developed in order to bring some
of the expertise that is in the field to the Federal
government.

  The dearth of appropriate instruments is a very
dilficult issue to address, but it something that needs to
be taken care of. Again, there's a need to create a kind
of a repository where all of the data, as well as the


4444444444444444  Health issues Panel

instnunents, and the procedures that can be used to do
appropriate research, can be found.
We also suggest that, to define a specific
research agenda, at least five steps be taken:
  . That we pay attention to a proper understand-
ing of the issues related to the kind of health
problems that we mentioned are critical to
our population--diabetes, HIV, cancer, and

    so on.

* That a high-level committee be appointed to
follow through on the results of the Surgeon
General's Initiative.

o That special funding programs or initiatives be
developed to fund research on factors such as
acculturation, poverty, national origin or
background, and migrational history, and the
effects they have on Hispanic health.

= That special programs be developed to study
the health status of Hispanics who work in
particular environments such as migrant
agriculture, assembly plants, service profes-
sionals, and other industrial concerns.

* That special health services research be
addressed in order for them to file character-
istics of the health care delivery, personnel,
utilization, and effectiveness.

Health Promotion and
Disease Prevention
Marilyn Aguirre-Molina, Ed.D.

All of the presentations that have preceded mine
provide a framework for understanding why Latinos
face so many problems in the area of health promo-
tion and access to preventive services. I think it's
probably safe to assume two things. The first is that
the reduction of one or two risk factors for the
leading causes of morbidity and mortality can add
years to a person's life and reduce medical costs.
The second assumption is that the most cffcctive

way to reduce risk factors is through health promo-
tion and disease prevention strategies. It's generally
accepted that, for many sectors of U.S. society,
these two assumptions are true. People are
accessing preventive services, and we are beginning
to see the resuItsi.e., changes in morbidity and
mortality patterns in the United States.

  Health

Promotion
and Disease

Prevention

  When it comes to Latinos, it's a very different
situation. Nevertheless, if you look at the leading
causes of morbidity and mortality among Latinos,
there's another thing we'll agree on, that indeed we
can add years to people's lives or keep them alive
through prevention, and the leading causes of
morbidity and mortality can truly be influenced by
health promotion and disease prevention programs.

  The real question here is, why are Latinos not
sharing the benefits of health promotion and disease
prevention to improve their well-being? There are
a number of factors. We don't want to ignore the
fact that, nationally, prevention is probably a very
low priority. That can be measured by the amount
of resources allocated to prevention efforts. A
recent CDC report indicates that in 1988,
$3 2.8 billion were allocated to prevention.
Although that may seem like a lot, it represents only
3 percent of the total health care expenditures, or
only 0.7 percent of the gross national product.
We don't know what percentage-how many of
those dollars-are allocated to Latin0 programs,
but again, it's safe to assume that they are not
enough.

Voice

Other factors that prevent Latinos from
accessing preventive care services include the
following. Latinos have poor or low access to the
health or medical care settings where these
preventive services are likely to be offered. As
indicated in other presentations, Latinos are just not
approaching-much less fully utilizing-those
systems. Shortage of primary care providers and,
most importantly, the lack of Latin0 and cross-
culturally competent care providers partially
explains this phenomenon, Additionally, there's a

Vision


Health Issues Panel  44444444444444444

Health

Promotion
and Disease

Prevention

shortage of primary care facilities servicing Latinos.
Therefore, if those services and those facilities are
not available, those institutions that would be the
most appropriate sources for providing preventive
services are not available to the Latin0 community.

  There are also financial barriers. My
colleagues have already addressed financial barriers,
and the impact they have on access to regular
sources of care. Things like inadequate insurance
and Medicaid coverage complicate and reduce
access to settings where health promotion services
are offered.

One



voice









One

Vision

  There's another important issue to address,
and this is the participation of Latinos in the labor
force. Latinos are overrepresented in secondary
labor markets, for example, in agricultural and
manufacturing industries. Unfortunately, these jobs
provide the lowest rates of health insurance and
fringe benefit packages, thus having an impact on
access to health care and health promotion and
disease prevention services. An added concern tied
to these occupational settings is the high risk and
rates of on-the-job injury. One must note that all
those wonderful corporate health promotion
programs that many of us have learned to enjoy and
appreciate are just not available to a large majority
of working people in the Latin0 community.
   We also need to look at institutional or
systemic barriers. A 1991 report by the Health
Resources and Services Administration clearly
describes the problem. Let me read a quote from
this report to you: "The health care system in this
country has been designed to serve the majority
population and possesses limited flexibility in
meeting the needs of populations that are poor or
may have different illnesses, cultural practices,
diets, or languages. Barriers faced by Latinos/
Hispanics in receiving primary and preventive care
are magnified due to their special linguistic and
cultural differences." In other words, institutions
are just not adequately geared up to serve the needs
of our communities.

  I think other presenters did an excellent job of
demonstrating the glaring disparity and the lack of
bilingual/bicultural and cross-culturally competent
health care personnel who can effectively deliver
health promotion and disease prevention services. I
want to underscore the need: bilingual, bicultural,
and cross-culturally competent professionals. They
are in critical need.

  Let me just mention other institutional
barriers worthy of consideration. One of them is
bureaucratic patient intake processes, many of
which produce fear of deportation among people
who are undocumented. Some of these institutions
also have incredibly long waiting periods for
appointments, and, when one a&ally gets an
appointment, the waiting period to receive services
is excessive. In many of these institutions, service
hours do not respond to the needs of the communi-
ties they serve. Professionals may be able to afford
to take a day off for a doctor's appointment, but the
vast majority of our population cannot. They will
not be able to receive services unless they are
provided in the evenings or on Saturdays. All of
these conditions constitute what can be described as
non-user-friendly environments which discourage
patient access. As a result, Latinos ignore early
warning signs, and do not utilize screening services.
Therefore, Latinos end up in emergency rooms.

  The last two points that I want to make deal with
the programs themselves. We've talked about financial
considerations and institutional considerations. We
also need to discuss programmatic issues.

  In sum, culturally appropriate and competent
programs are in short supply. Most health promo-
tion and disease prevention programs of proven
effectiveness are mainstream programs. An
effective mainstream program, however, may not
necessarily work in the Latin0 community. Some-
times we see programs that are translated into
Spanish, which go on to become disasters in our
communities, proving that translations are not
enough. That's a central problem with many of the


444444444444444  Health l&sues Panel

prevention programs that are transported into
Latin0 communities. Many programs are devoid of
cultural competence. For example, there's a
complete misperception of the role that family and
the social support systems play or can play in
promoting health and preventing disease among
Latinos . Successful programs cannot ignore
important cultural traits that are specific to Latinos.

  Some existing programs are totally inadequate
when it comes to outreach activities. They ignore,
for example, that the church is a very important
institution for Latinos. Additionally, programs
often lack expertise on how to use the Hispanic
media effectively for outreach purposes.

  Often, those responsible for designing
programs ignore important variables. One is the
intergenerational variation that exists among
Latinos. We really have to take intergenerational
variations into account when designing programs.
We also need to look at degrees of acculturation-
that is, to what extent an individual is adapted to the
U.S. culture. There seems to be a monolithic
notion of a generic Latin0 individual, when in
reality, we must acknowledge the intergroup
diversity. As we al1 know, a Puerto Rican is not a
Cuban. A Dominican is not a Central American.
The result is that many of the existing programs are
based on poor information and poor understanding
of our communitv.
            i
  I will highlight only a few recommendations.

First of all, as a nation, we have to reshift our
priorities and start to think about prevention as a
critical component of our community's health. It's
less costly. It's easier. It's better. Of course,
among other things, this will imply political
advocacy to ensure this shift in priorities.

  Data is another key element. We must be
able to identifv gaps in health promotion and disease
          ,
prevention data, data for minority groups to
determine health disparities, the USC of alternate
care svstcms, the cxtcnt of morbiclitv and mortality,
                          ,
and so forth.

  We want to, of course, increase and improve
access to primary and preventive care. This topic
will be addressed by another work group.
   Institutional barriers must be removed.
That's where our advocacy capabilities must be
directed. There are a lot of concrete things that can
be discussed in our workshops to increase and
enhance institutions and, in particular, community-
based organizations' capacity to deliver effective
preventive programs. I say community-based
organizations, because CBOs play an important role
in our communities. They started out as social
clubs and moved on to become more comprehen-
sive health and human services organizations that
now have credibility and the ability to reach our
communities. We have to upgrade their ability to
deliver health promotion and prevention services
and help them move away from funding by sectors
of the disease-promoting corporate world. That's
one of the big problems that we face in our commu-
nities: contradictions. Much'can be done by Federal
incentives in the way of financial incentives. We
must also prepare individuals to be able to enter
these institutions.

  Health

Promotion
and Disease

Prevention

  I'm hoping that the health professions group
will help us define the direction and implementation
strategies for increasing the pool of people who are
going not just into medical care but into public
health. We have to begin to make these lucrative
and attractive career tracks.

One



Voice

   I believe that much of what the different
working groups will be exploring and discussing is
going to overlap. Topics are interconnected; our
ability to gain access to prevention is based on our
ability to gain access to the systems where preven-
tion services are provided and on having personnel
in those systems who are prepared and cross-
culturally competent to design the kinds of pro-
grams that will be effective and respond to our
community's needs.

One



Vision


Chapter 4: National Workshop
                                                            1

Recommendations

P uring the National Workshop, the participants
met in seven Work Groups to address the five key
areas of concern for Hispanic/Latin0 health-two
groups each for access to health care and for
representation in the health professions and one
group each for data collection, research, and health
promotion and disease prevention. The Work
Groups were charged with ( 1) identifying priority
problems/issues for each area and (2) developing
aims and implementation strategies for addressing
each problem/issue. This chapter lists the strategies
developed by the Work Groups.

Access to Health Care

Lack of universal health coverage.
Desired Aim

To establish a universal health plan that provides
comprehensive coverage to every resident of the
United States. Such a plan should include the
following provisions:
* Be affordable.

* Offer a basic package of services (to include
prevention) across the United States.

* Give choice of providers.

= Allow for a regular source of care and
facilitate continuity of care.

* Integrate systems of care; combine public
health, community health, and private
providers.

* Strive for innovative health care financing that
spreads the burden across all sectors of

.





*





*







*





?





*





?





*





?


?

society. To achieve this equity, tax mecha-
nisms-such as income tax (for persons
earning more than 250% of poverty level),
asset tax, value-added tax, and other mecha-
nism-hould be considered.,    _, -
Ensure coverage eligibility regardless of U.S
residency and employment status.
Offer easy enrollment and service procedures
that facilitate participation.
Provide measures of cost containment, quality
assurance, improved efficiency, and account-
ability to service recipients.
Allow service recipients to participate in the
governance of plans.

Offer rewards for providing services to
underserved and unserved populations.
Provide incentives for coverage of preventive
services.

Enforce uniform procedures for reimburse-
ment while recognizing regional differences.
Provide outreach activities to increase
awareness and use of available programs.

Be c&u-ally competent.
Address other needs unique to the Hispanic/
Latin0 population (i. e . , language, transporta-
tion, child care, other support services).

Implementation Strategies
o Establish health advocacy coalitions involving
public and private providers in each State with
significant Hispanic/Latin0 populations.

o Establish a methodology for accurately estimating
the cost of universal coverage.

One

Voice

Vision


Workshop Recommendations +

Access to

Health

Care

Inadequate coverage by Medicaid for Hispanics/
Latinos .

Desired Aim

To provide full coverage by Medicaid for compre-
hensive services for HispanicsILatinos.

Implementation Strategies
o Reduce (or eliminate) categorical and other
eligibility restrictions for Medicaid coverage,
eliminate asset tests, enforce presumptive eligibility
for pregnant women and children.

o Require Medicaid and Medicare reform to
address the unique needs of the Hispanic/Latin0
population; programs should support primary care
and shift from an emergency hospital care approach
to a comprehensive community-based care approach
(that includes preventive services).

One

Voice

One

Vision

Government and institutional policies are unrespon-
sive to the health needs of Hispanics/Latinos.
Desired Aims

To establish an integrated and coordinated
service-delivery system that links public
health, private providers, and community/
migrant health centers; foster collaboration.
To establish policies that provide for linguisti-
cally and culturally competent programs.
To support health professions education for
Hispanics/ Latinos in order to increase the
number of culturally competent health care
providers.
To accurately define the health needs of
Hispanic/Latino communities and provide
resource allocations necessarv to meet those
                    ,
needs.

Implementation Strategies
+ Convene all stakeholders to explore ways to
collaborate and interface. (Federal, State, local-
public and private)

o Recognize that categorically funded programs do not
always meet the needs of the intended populations;
review criteria for categorically funded programs that
support health centers; infhrence the decision-making
process for placement of health centers and their
modes of operations so that they better serve the
unique needs of the Hispanic/Latino comnmnity.
(Federal, State, local-public and private)

o Ensure that more Hispanics/Latinos are in key
policy decision-making positions. (Federal, State,
local-public and private)

+ Define the Yminorityn label. Programs and
policies should include all minority groups, includ-
ing Hispanics/Latinos. (Federal, State, local-
public and private)

* Develop standards for cultural competency.

Lack of health care facilities in Hispanic/Latin0
communities.

Desired Aim

To develop an infrastructure in Hispanic/Latin0
communities that ensures accessibility to health care
providers.

Implementation Strategies
o Enhance the health care infrastructure and
provide funds for construction of health facilities in
Hispanic/ Latin0 communities (legislation).

o Reformulate the criteria for appointing physicians
and other health providers to medically under-
served areas.

o Offer economic incentives to practitioners for
.

locating practices in Hispanic/Latin0 communities.


4 + + + 4 4 4 4 4 4 4 4 4 Workshop Recommendations

o (`reatc community-based health training centers
thJt provide training and job opportunities in the
b&h professions (legislation).

Exclusion of important subsegments of the
Hispanic/Latin0 population from health programs.

Desired Aim                     Desired Aim

To establish a health care system that meets the
needs of all Hispanics/Latinos, including undocu-
mented residents, migrant and seasonal workers,
rural residents and other subsegments of the
Hispanic/Latino population.

Implementation Strategies
o Include intervention activities in the public health
arena to meet the needs of special subsegments of
the Hispanic/Latin0 population (i.e., migrant and
seasonal farmworkers, children, homeless people,
people in rural areas, immigrants, and undocu-
mented residents).

To create a strong Federal, State, and local public
health system that has the ability to monitor and
influence the planning and policy development of
health initiatives and interventions. ,    __, _
Implementation Strategies
o Allocate 6 percent of health expenditures to fund
public health programs and infrastructure.

o Make the public health system accountable for
meeting the health needs of the Hispanic/ Latin0
population; establish health goals (indicators) for all
public health interventions.

o Require that health-care institutions, programs,
and initiatives ensure health-care delivery that meets
the needs of special populations (i.e., migrant and
seasonal farmworkers, children, homeless people,
people in rural areas, immigrants, and undocu-
mented residents).

o Promote HI p
        `s anic/Latino participation at all
levels of public health decisionmaking,

Omission of health care as an integral part of
economic and regional development planning.
Desired Aim
To include Hispanic/ Latin0 health issues in regional
development strategies.

Lack of health objectives for the Hispanic/ Latin0
population.

Desired Aim

To include a Hispanic/Latino agenda in Healthy
People 2000; to develop detailed health objectives
that are specific to the Hispanic/Latin0 population.

Implementation Strategies
o Review the Hea1th.v People 2000 plan to identify
gaps and develop objectives and implementation

strategies to address the health needs of the
Hispanic/Latin0 community. (Federal)

Access to

Health

   Care

A public health system and an infrastructure that are
inadequate and unresponsive to Hispanic/ Latin0
health needs.

One



Voice

Implementation Strategies
o Include Hispanic /Latin0 health issues in all social

One '

and economic development programs.

Vision

Lack of Hispanic/ Latin0 participation in the
development and review of publicly funded
proposals to ensure that programs meet the health
needs of the Hispanic/Latin0 population.


Access to

Health

Care

One

Voice

Workshop Recommendations 4444444444444

Desired Aim
To achieve equitable representation of Hispanics/
Latinos in the development and review of Requests
for Proposals throughout PHS.
Implementation Strategy
o Use legislative mechanisms and the regulation
process to increase Hispanic/Latin0 representation
in the proposal process.

o Create a national coalition that lobbies on behalf of
Hispanic/Latino health issues (e.g., National Hispanic/
Latino Coalition for a Healthy USA).




Lack of Hispanic/Latin0 access to DHHS policy
decision makers.

Desired Aim
To develop rapport and fluid channels of comnmni-
cation with DHHS policy decision makers.

Lack of proven models for alternative primary care
financing responsive to Hispanic/Latin0 community
needs.

Desired Aim

To explore innovative primary care financing and
delivery systems.

Implementation Strategies
o Fund pilot prof `ects that explore alternative
primary health care financing and delivery systems
(analogous to Health Care Financing
Administration's SHMO demonstrations).

o Include Hispanic/Latino-specific initiatives in the
Request for proposal process to foster models of
primary/managed care that meet the health needs
of the Hispanic/Latino population.

Implementation Strategies
o Meet regularly with the Secretary, (or a representa-
tive) regarding Hispanic/~atino health issues.

o Establish an Advisory Committee to the Secretary of
Health and Human Services to advise the Department
on policies affecting Hispanic/Latino populations.

o Provide advocacy for Hispanic/ Latin0 participa-
tion in the decision-making process. The number of
Latinos in decision-making positions should be
proportional to the size of the population they
represent.

o Foster policies that encourage Hispanic/Latino
representation on boards, commissions, and
advisory committees.

One

Vision

Lack of \vcll-planned, coordinated lobbying efforts
on Hispanic/ Latin0 health issues.
Desired Aim

Underrepresentation of Hispanics/Latinos in the
Of&e of Minority Health and other top-level
positions of DHHS.

Desired Aim

To create a strategically planned and coordinated    To achieve an equitable representation of Hispanic/
lobbying structure that advocates the advancement    Latin0 representation in top-level positions of
of a Hispanic/Latino health agenda.              DHHS.

Implementation Strategies
o Enlist the interest and support of health organizations
around the country to participate in a unified effort.

Implementation Strategy
o Increase representation of Hispanics/Latinos in
the Office of Minority Health and all departments of
DHHS, to include top-level representation. To the


extent possible, Hispanic/Latino issues should be
addressed by Hispanic/Latin0 representatives.

Lack of participation by Hispanics/Latinos in
leadership appointments in DHHS.
Desired Aim

To involve Hispanics/Latinos in the leadership
starch process within in DHHS.

Implementation Strategy
o Involve HispanicsILatinos in the expert talent
search process and selection for leadership positions
in DHHS.

Data Collection

There are 22.4 million HispanicsLutinos living in the
50 States and the District of Columbia and 3.5 million
persons who reside in Puerto Rico-a total of
25.9 million people. More than two-thirds of all
Hispanic/L&no Americans were born in the United
States, yet it was not until 1989 that the model birth and
death cerrificates included a Hispanic/Latin0 identifier.

  Too ofren, organizational priorities and funding
decisions are established without taking into account
Hispanic/Latin0 data. Adequate planning is not
available without the appropriate availability, utilization,
and interpretation of Hispanic/zatino data Therefore,
resources porn government (Federal, State, and local)
foundations, nonprofit and for-profit corporations, and
education institutions are not allocated consistently with
the nee& of the HispanicLutino community. As we
approach the year 20&I and beyond, the need for
HispanicLntino data will only increase. Given the
imperative to effectively target resources to maximize
bet@ and eficiency, the six areas described below are
the minimal set of issues that must be addressed to serve
the health needs of the Nation.

Inclusion: the need for inclusion of Hispanics/
Latinos in data systems.
Desired Aim

To include data on Hispanics / Latinos in all data
systems.

Implementation Strategies
o Include Hispanic/Latin0 and Hispanic/Latino
subgroup identifiers in all surveys and forms.

o Determine sample sizes for Hispanics/Latinos
that are adequate for analysis.

o Enforce OMB Directive I5 and Public Law

94-3 11. Educate agencies about the use of OMB
directives for inclusion of Hispanics/Latinos (and
Hispanic/ Latin0 subgroups) in data systems and in
federally funded intramural and extramural research
programs.

o Develop and maintain an advisory board to the
O&e of the Surgeon General to over&e F&&al,
State, and local Hispanic/Latino data issues.

   Data

Collection

Local and regional data: lack of data on specific
Hispanic/Latin0 health issues at the local and
regional levels.
Desired Aim

To reduce gaps in Hispanic health data and improve
the overall availability of data at the local and
regional levels.

Implementation Strategies
o Develop guidelines and standard procedures within
all agencies and provide technical assistance on data
collection for Hispanic/Latino population groups at the
local, State, and regional levels.

One

Voice

o Focus on HispanicILatino-specific issues. For
example, data that just enumerate the number of
gunshot wounds is not useful unless information is
also available on the community support programs.
+ Use a series of local pilot studies that identify
patterns and trends to justify future activities.

o Establish Healthy People 2000 and baseline data for
those objectives at the State and local levels.

One 4



Vision


Workshop Recommendations 44444444444444

Data

Collection

Quality: lack of quality, accurate, timely, and
culturally sensitive data system design, data collec-
tion, and analysis.

Desired Aim

To develop a foundation of high-quality, valid, and
timely information on Hispanic/Latin0 data,
equivalent to that of other ethnic/racial groups.
Implementation Strategies
o Include Hispanics/Latinos in the design, implemen-
tation, analysis, and dissemination of health assessment
and health monitoring data systems and in funding
decisions a&cting these systems.

o Assess data collection and research designs to
include considerations of the heterogeneity of the
Hispanic/L&no population. Oversampling has
been identified as a feasible method for highly
concentrated Hispanic/Latin0 subgroups; other
methods need to be developed to sample geographi-
cally dispersed Hispanic/L&no subgroups.

o Test and validate data collection and research
instruments for cultural competence and linguistic
appropriateness.

One

Voice

One

Vision

o Foster collaboration between the Census Bureau
and the National Center for Health Statistics
(NCHS) to identify existing and emerging research
issues; address problems such as procedures for
assigning race, use of surname as a proxy,
adequateness of "Other Race" and `Other Hispanic"
categories, etc. Involve Hispanic/L.atino research-
ers in seeking resolution to these issues.

o Studv the problems associated with changes in
ethnic self-identification.

o Establish guidelines for the coding and keying of
data on birthplace, work history, generation status,
socioeconomic status, language use, family relation-
ship, etc., all of which may be powerful indicators
of the health status of Hispanics/Latinos.

o Develop data release plans that meet priorities
and the needs of users for timeliness.

Analysis: the need to identify (inventory) and
analyze existing data. Available data can be instru-
mental in understanding Hispanic/Latin0 health

concerns.

Desired Aim

To increase the analyses of Hispanic/Latino health
data at the Federal and State levels and by academia
and to increase the number of Hivpanic/Latino
researchers involved in this process.

Implementation Strategies
o Include Hispanics / Latinos and researchers with
specific knowledge of the health status, living
conditions, and culture of Hispanic/ Latin0 popula-
tions in the development of health theses and
conceptual frameworks.

o Identify existing data sets and determine their
accessibility to researchers.

o Develop a network of Federal/State, university,
and community-based analysts with a primary focus
in health data analysis.

o Provide funding for technical assistance to
researchers who are involved in Hispanic/Latino
health issues.

o Increase the technological capacity of researchers
to conduct more advanced analysis (i.e., Geographic
Information Systems).

o Encourage collaborative, interdisciplinary
research that bridges quantitative and qualitative
methods.

o Identifv a person in each agency/organization to
      i
serve as the principal point of contact for Hispanic/
Latin0 data analysis.


Dissemination: lack of availability or inaccessibility
of existing data, which are in critical demand.
Desired Aim

To maximize the availability of Hispanic/Latin0 data
to Hispanic/Latin0 and non-Hispanic/Latin0 policy
decisionmakers, funding sources, practitioners,
community-based organizations, and researchers.
Implementation Strategies
o Encourage public agencies to provide information
on existing data (i.e., perform more data analysis)
so that data can be used by broader audiences,
including Hispanic/L.&no community-based
organizations. Dissemination efforts should include
informational packets, audio-visual materials,
videos, etc.

o Train community-based organizations in access
and use of data.

* Provide training and technical assistance on data
analysis so communities can draw their own
conclusions.

o Fund regional clearinghouses on Hispanic/ Latin0
health in areas of high Hispanic/I&no concentration.
o Make data available to Hispanic/Latin0 constitu-
encies as well as non-Hispanic health groups that
may play a role in the health status of the Hispanic/
Latin0 community.

Coordination: lack of coordination between
Federal and State agencies on Hispanic/Latin0
health data collection and analysis.

Desired Aim

To enhance and expand the development of
Hispanic/ Latin0 data by public agencies.

Implementation Strategies
o Use existing data systems (e.g., Census Bureau
and NCHS data) to establish cooperative agree-
ments with States to develop standard State and
local health status profiles for Hispanic/Latin0
communities.

o Establish an inventory of existing Federal, State,
and local data resources; identify gaps and areas for
improvement.

o Provide government support for a network of
community-based health data collection efforts to
serve as an "early warning" system for se$ng health
policy priorities.

o Maintain an advisory board with the Office of the
Surgeon General to oversee the implementation of
recommendations.

o Establish a Federal interagency task force on
Hispanic/Latin0 health-related data with input from
appropriate nongovernmental Hispanic/La&o
advisors.

Research Agenda

Lack of appropriate infrastructure and capacity to
conduct research.

Desired Aim A

To increase the number of behavioral and biomedi-
cal Hispanic/Latin0 scientists.
Implementation Strategies
o Develop specific support programs in PHS for pre-
and post-doctoral training of Hispanics/Latinos in
behavioral and biomedical research to eliminate their
underrepresentation in health-related research.

o Develop programs directed at Hispanic/ Latin0
researchers to allow them to become better
equipped and to improve methodological expertise
in health-rclatcd research.

Research
Agenda

One

Voice

Vision


Research
Agenda

o Target and intensify efforts to recruit Hispanics/
Latinos into PHS's existing research and training
programs.

* Develop and fund distinguished research career
programs within PHS to allow Hispanic/Latino
researchers to concentrate on research, writing, and
mentoring and to free them from the multiple
requirements and responsibilities commonly faced
by minority academicians.

o Conduct grantsmanship workshops such as those
developed by the Hispanic Cancer Control Program
at the National Cancer Institute (NCI), where
Hispanic/L&no researchers have the opportunity
to improve proposal-writing shills and have their
pre-proposals reviewed by agency program review
staff. These programs must be made available at the
National Institutes of Health (NIH), the Centers for
Disease Control and Prevention (CDC), and other
Federal agencies concerned with health issues.

o Expand and evaluate specific initiatives within the
Department of Education and the National Science
Foundation to ensure that Hispanic/Latino middle
and high school students take courses essential for
pursuing science careers.

One

o Assess the results of programs such as the
Minority Behavioral Research Supplement, Minority
Access to Research Careers, Health Careers

Voice

One


Vision

Opportunity Programs, and the Minority High
School Apprenticeship Program with respect to
Hispanic/ Latin0 students.
o Encourage professional associations to stimulate
the involvement of Hispanic/ Latin0 students in
research careers.

o Develop special initiatives to fund research
proposals submitted by new and established
Hispanic/L&no investigators.
o Increase and enhance the capacity for institution-
alized Hispanic/L.&no health research through the
establishment of Hispanic/Latino health research

centers and through support of individual Hispanic/
Latin0 investigators.
o Orient PHS program staff to Hispanic/Latino
health and related methodological issues.

Desired Aim B

To improve cultural competence and sensitivity of
Hispanic/Latino and non-Hispanic/Latino scientists.
Implementation Strategies
o Develop requirements by regional and professional
accreditation agencies that Hispanic/Latino health
research issues be incorporated into curricula,

o Develop and institute courses++eminars, and
conferences by educational, institutional, profes-
sional associations, and PHS on methods for
conducting research on Hispanic/Latino
populations.

o Orient members of IRGs on the procedures
required for culturally competent research that
targets Hispanics/Latinos and on the evaluation of
proposals with respect to appropriate sampling,
instrumentation, methodology, and cultural
sensitivity in the development of research protocols.

o Provide appropriate training and guidelines to
reviewers of proposals so that IRGs will be compe-
tent in the evaluation of Hispanic/Latin0 research.
This initiative is consistent with and enhances the
recent NIH guidelines for including women and
minorities in study populations.

Desired Aim C

To improve communication and interaction among
HispanWLatino scientists.
Implementation Strategies
o Centralize and expand the existing PHS databank
on Hispanic/ latino researchers and on
non-Hispanics/Latinos conducting research on
Hispanic/Latino populations.
o Encourage professional associations to facilitate
networking among Hispanic/Latino researchers.


* + + o 4 4 4 o o 4 o + 4 4 Workshop Recommendations

Dearth of research relevant to the health of
Hispanics/Latinos.

Desired Aim A

To develop a health research agenda that is relevant
to and focused on Hispanics/Latinos.

Implementation Strategies
o Commission a number of research efforts within
the Office of Minority Health that critically analyze
the literature on Hispanic/Latin0 health in each of
the areas identified by previous reports as deserving
attention (e.g., child and adolescent health,
women's health, diabetes, HIV, cancer, substance
abuse, depression, violence, accidents, and uninten-
tional injury). These reports will present a review
of the current knowledge base on each of the areas
covered by Healthy People 2000, clarify objectives,
and identify research needs.

o Appoint a high-level committee within the Office of
Minority Health with appropriate Hispanic/ Latin0
health expert involvement to rcvicw the outcome of
the activities of the first year of the Hispanic/Latin0
Health Initiative and the information obtained from the
state-of-the-art reviews cited above. This panel must
be charged with developing an outline of priorities for
research with Hispanics/Latinos.

o Develop special funding programs or initiatives at
the Federal level to fund research on the role of
factors such as acculturation, national origin or
background, socioeconomic status, and migrational
history on the health status of Hispanics/Latinos.

o Require large-scale, cross-sectional, and longitu-
dinal research with Hispanics/Latinos funded by
Federal and State initiatives to include the effects of
acculturation, national origin or background,
socioeconomic status, and migrational history on
the health status of Hispanics/Latinos as possible
moderators of the findings.

o Develop special program initiatives at the Federal
level to analyze the health status of Hispanics/
Latinos working in high-risk environments such as
migrant agriculture, assembly plants (including
border maquiladoras), service professions, and other
industrial environments.

o Conduct health services research to identify the
characteristics of health care delivery, including the
characteristics of personnel and structure of services
that facilitate access, utilization, and effectiveness of
health services among Hispanics/Latinos. At least 25
percent of the funds allocated for evaluation at the
Substance Abuse and Mental Heahh Services Adminis-
tration (SAMASA) and Health Resources and Services
Administration (HRSA) should be targeted for services
research to investigate questions pertaining to Hispan-
ics/Latinos. The Office of Health Planning and
Evaluation should also direct funds for research on
health services utilization by Hispanics/Latinos.

o Create an Office of Hispanic/Latin0 Health
within the Office of Minority Health, Office of the
Assistant Secretary for Health, to coordinate
Hispanic/Latin0 health-related initiatives and to
oversee their implementation within the Federal
Government. The Office must be properly funded
and must include an advisory board on Hispanic/
Latin0 health research to review its activities on a
quarterly basis. In addition, the Office of Minority
Health should issue a biannual report to Congress
detailing progress on the Hispanic/Latin0 health
agenda and the progress within PHS in meeting the
mandates in the Disadvantaged Minority Health Act
as they relate to Hispanics/Latinos.

o Fund research within PHS that is specifically
targeted at providing baseline data to enable
formulation of Hispanic/Latino-specific objectives
for Healthy People 2000.

* Develop mechanisms to obtain and incorporate
community input into the formulation of a research
agenda.

Research
Agenda

One

Voice

One

Vision


Health
Professions

Lack of culturally appropriate research theories
and methods.

Desired Aim A

To increase the number and improve the availability
and validity of research instruments and measure-
ment tools used in investigations on Hispanic/
Latin0 health.

Implementation Strategies
o Develop Federal programs to fund research that
tests the usefulness of current instruments and to
develop new, culturally appropriate instruments
that meet applicable standards of validity and
reliability.

o Fund a repository of Hispanic/ Latino
health-related instruments within PHS. This
repository must be managed by Hispanic/Latin0
organizations or researchers who can properly serve
as the caretakers of these files and report on the
issues dealing with Hispanics/Latinos.

One

Voice

Desired Aim B

To study the applicability of existing constructs and
theories to Hispanic/L&no populations.

Implementation Strategy
o Fund research within PHS to develop new
behavioral models and theories and to test the
validity of existing ones.

One

Vision

Underrepresentation of Hispanics/Latinos in PHS.

Desired Aim A

To ensure proportional representation of Hispanic/
Latin0 researchers on scientific advisory boards,
national advisory councils, and IRGs and technical
evaluation groups.

Implementation Strategies
o Survey national ag encies concerned with
Hispanic/Latino health issues, as well as researchers,
universities, or research institutes, on a yearly basis
to identify qualified individuals who may be willing
to serve in this capacity. Results of those surveys
should be published in a yearly updated directory
and made available to Federal and State agencies
funding health-related research.

o Include Hispanic/Latino representation on IRGs
within technical evaluation groups, national
advisory councils, and scientific advisory boards.

Desired Aim B

To ensure proportional represent&on of
Hispanics/Latinos on the staff of PHS.

Implementation Strategies
o Expand short-term service initiatives that allow
Hispanic/Latino researchers and academicians to
serve within PHS without severing ties with their
home institutions.

o Implement special efforts to recruit, retain, and
promote Hispanics/La&OS at ail levels of PHS
scientific and administrative staff.

Health Professions

Insufficient numbers and inadequate preparation of
Hispanic/L&no students by the educational system
(kindergarten to undergraduate) for pursuit of
health professions education.

,Desired Aim

To increase the number of Hispanics/Latinos in the
education pathway toward health professions
education so that, by the year 2000, the number of
Hispanics/Latinos admitted to health professional
schools reflects the size of the Hispanic/Latin0
population by State.


Implementation Strategies
o Increase parental involvement in their
children's education through family counseling,
dissemination of information, and enhancement of
established programs sponsored by the school,
community-based organizations, the private sector,
and the media.

o Assist low-income families in planning their
children's education.

o Ensure that Hispanic/ Latin0 children gain
English-language competency at an early age; early
childhood programs can play an important role.
o Stimulate private-sector investment in inner city
schools, colleges, and universities with high
Hispanic/Latino student bodies.
o Stimulate private sector and government investment
in scholarships and awards to Hispanic/ Latin0 students
in inner city schools, colleges, and universities with
large Hispanic/Latin0 student bodies.
o Expand the scope and funding of Health Careers
Opportunity Programs.

o Encourage Hispanic/Latin0 health professional
organizations to develop and participate in
mentoring programs at all levels.

Poor infrastructure and lack of funding to promote
greater participation of Hispanic/Latin0 students in
the health professions.
Desired Aim A

To increase the number of Hispanic/Latino
full-time equivalent faculty and students in universities
and health professions schools to reflect the percentage
of Hispanics / Latinos in the population of the area.
Implementation Strategy
Provide additional Federal funds, student loans, and
assistance to schools that have significant full-time
equivalent Hispanic/Latin0 facult? and students.

Desired Aim B                           Health

To improve the coordination of organizations and to
build a better infrastructure that will augment the
pool of Hispanic/Latin0 students eligible to pursue
the health professions.

Professions

Implementation Strategies
o Expand health professional clinical training at
community- based sites.

o Bridge health professions training of two- and
four-year colleges, including training of administra-
tive managers because they make day-to-day
decisions on service delivery to populations.

o Develop formal linkages between Federal, State, and
private organizations serving Hispanics/Latinos.

Obstacles to entry, retention, and graduation from
professional health education programs faced by
Hispanic/Latin0 students.
Desired Aim A
To increase the number of Hispanics / Latinos
entering health professions schools by a minimum of
10 annually for the next 10 years; the ultimate
minimum goal is a doubling of the number of
students currently enrolled.
Implementation Strategies
o Establish a consistent definition of HispanidLatinos
in the criteria for admission to the health professions.

o Set standards at the Federal and State levels for
increased Hispanic/Latin0 student enrollments;
these standards must be tied to funding.

o Incorporate qualitative measures in school
admissions criteria.

o Increase Hispanic/Latin0 participation in the
admissions process.
o Train admissions personnel in cultural diversity and
the health needs of the Hispanic/ Latin0 community.

One

Voice

  a
One

Vision


Health     o Credit students for diverse personal and educa-
Professions   tional experiences.

Desired Aim B

To increase the number of HispanicKatino students
who graduate from professional health programs.
Implementation Strategies
o Develop, expand, and fund retention programs
that would enable Hispanic/Latin0 students to
graduate from professional education programs
(i. e . , health career opportunity programs, peer
support groups, financial assistance programs,
National Service Corps activities, and other
educational initiatives targeting retention).

o Foster mentorship activities at health professions
schools.

o Assess standardized testing procedures; address
any biases that may atfect the performance of
Hispanic / Latin0 candidates.

Desired Aim C

One



Voice

To make health professions education financially
accessible for Hispanics/Latinos.
Implementation Strategies
o Expand scholarships, low interest loans, and loan
repayment programs available to Hispanics/Latinos.
o Increase the proportion of grant monies (versus
loans) in financial aid programs targeted at
Hispanics/Latinos pursuing health professions
education.

o Expand financial assistance programs to incorpo-
rate the support of hospitals, communities, and
other private or public organizations.

One

Vision

o Ensure thorough dissemination of fmancial
assistance information to Hispanic/Latino students;
ensure that the format and delivery of this informa-
tion are appropriate to the target audience.

Desired Aim D

To expand the funding and scope of Hispanic/
Latin0 Centers of Excellence to include all health
professions.

Implementation Strategies
o Influence the legislative process.

o Ensure equitable distribution of funds to
Hispanic/L&no Centers of Excellence relative to
the total funding allocated to such initiatives.

o Evaluate the performance (outcomes) of
Hispanic/Latino Centers of Excellence.

Need for greater coordination between the private,
local, State, and Federal sectors to improve the
support to Hispanic/Latin0 health professionals.

Desired Aim

To ensure provision of technical assistance and
financial resources to Hispanic/Latin0 health
professionals.

Implementation Strategies
o Enhance programs and improve coordination of
initiatives within DHHS.

o Review Department annual fiscal reporting
mechanisms; delineate funding for activities
targeting Hispanic/Latino health professionals;
specify DHHS funding going to Hispanic/I-&no
researchers; increase the number of Hispanic/
Latin0 researchers.

o Increase postgraduate training opportunities in
the health professions through private- and
public-sector funding.

o Increase the participation of Hispanic/L&no
health professionals in program and policy evalua-
tion committees, task forces, and oversight entities.


Need for an increased number of Hispanic/Latin0
health professionals in faculty, advanced career
positions, and decision-making bodies.
Desired Aim A

To increase the number of Hispanic/Latin0 health
professionals in management, policy, and research
positions in DHHS/PHS and other Federal and State
agencies.

Implementation Strategies
o Develop a substantive plan to develop and
promote Hispanics/Latinos in management, policy,
and research positions.
o Hold government institutions and programs
accountable for promoting Hispanic/Latin0 health
professionals' development.
o Enact legislation that requires all directors to be
evaluated on an annual basis on the following
criteria, among others:
a. Recruitment and retention of Hispanic/
   Latin0 staff.

b. Representation of Hispanics/Latinos on
review committees.

c. Grants awarded and programs established
with a Hispanic/Latin0 health focus.
d. Grants awarded to Hispanic/Latino principal
investigators.

e. Grants awarded to universities with
significant Hispanic/Latino graduation rates.
+ Implement a reporting and review system of the
implementation and outcomes of the above plan.

Desired Aim B
To increase the number of Hispanic/Latin0 faculty
in health professions schools.

Implementation Strategies
+ Develop effective methods for addressing
deficiencies in hiring and promotion policies
affecting Hispanic/Latin0 faculty in health profes-
sions schools.

o Develop legislation that would add funding to the
Disadvantaged Minority Health Improvement Act
for Hispanic/ Latin0 faculty positions in health
professions schools.

o Reconsider the balance between research,
training, and community and clinical service needs;
implement promotion mechanisms accordingly.
o Earmark funding of New Investigator Awards to
Hispanic/Latino researchers.
o Track the number of grants/contracts by
Hispanic/Latino researchers that have been submitted,
approved, and i%nded by DHHS.
o Provide technical assistance to support Hispanic/
Latin0 researchers as needed.`

Desired Aim C

To encourage mentoring of junior Hispanic/Latino
faculty.

Implementation Strategy
o Provide opportunities to establish mentoring
relationships with senior faculty.

Desired Aim D

To increase Hispanic/Latin0 representation on
local, State, and Federal grant review groups,
panels, task forces, and advisory committees.
Implementation Strategy
o Develop and maintain a centralized information
bank of talented Hispanic/Latin0 health professionals.

  Health

Professions

One

Voice

One

Vision


Workshop Recommendations o

Health

Promotion
and Disease
Prevention

Lack of culturally relevant (HispanicILatino) input
in the licensing/certification process and the
accreditation of health professions schools.
Desired Aim A

To encourage accrediting bodies to use cultural
diversity standards relevant to Hispanics/Latinos.
Implementation Strategies
o Communicate the need for use of cultural
diversity standards in the accreditation criteria of
health professional education programs.

o Provide awareness training on cultural diversity
issues to students and faculty at colleges/
universities and other educational programs.

Desired Aim B

One

Voice

One

Vision

To increase the number of HispanicsKatinos
participating in the development of licensing and
certification tests and procedures.

Implementation Strategies
o Promote Hispanic/Latin0 health professionals
within accrediting agencies to ensure Hispanic/
Latin0 representation.

o Work with the individual health professions
examination boards to determine the appropriate-
ness of tests, and to address cultural biases.

Desired Aim C

To enhance the entry of foreign-trained Hispanic/
Latin0 health professionals into the health service
delivery system.
Implementation Strategy
o Develop innovative programs and funding mecha-
nisms to assist/(re)train foreign-trained Hispanic/
Latin0 health professionals so that they can practice
in the United States.

Lack of data on practice characteristics of Hispanic/
Latin0 health professionals for planning purposes.
Desired Aim

To obtain data on practice characteristics of all
Hispanic/Latino health professionals.

Implementation Strategy
o Request that health professionals organizations
gather and analyze data on the practice characteris-
tics of Hispanic/ Latin0 professionals.

Health Promotion and
                   .-

Disease Prevention

Underlying all of the issues listed below are policy,
communication, cultural behaviors, resource develop-
ment, and community intervention factors.

Insufficient data and research on Hispanic/Latin0
health issues: .

Lack of research on health promotion and
disease prevention (HPDP) efforts that target
subgroups of the Hispanic/Latin0 population.
Lack of data on awareness, attitudes, behav-
iors, and use of screening services by
Hispanic/Latin0 subgroups
Lack of baseline data on morbidity and
mortality; lack of Hispanic/Latino-specific
HPDP year 2000 health objectives.

Desired Aims

* To gather and maintain adequate data on
Hispanic/Latin0 health issues.

= To initiate, enhance, and/or expand research
programs for the various Hispanic/Latino
subgroups. This research should be initiated,
used, and disseminated at the community level.


m TO facilitate the development of appropriate
Hispanic/L&no-specific year 2000 objectives.

Implementation Strategies
o Establish and maintain a comprehensive and
uniform database on HPDP efforts (comparable to
non-Hispanic/Latin0 databases) that accommodates
different Hispanic/Latin0 subpopulations. (Federal,
State, local)

o Establish a body that will monitor the implementa-
tion of Hispanic/Latino HPDP initiatives and advocate
on behalf of community-based organizations and
funding for HPDP programs. (Federal, State, local)
o Monitor public agencies responsible for data
collection and hold them accountable.

o Include Hispanics/Latinos on review panels,
study sections, PHS advisory councils and working
groups. (Federal, State, local)
o Establish culturally appropriate methods and
standards for data collection.

o Foster initiatives that will target and fund
Hispanic/Latino-specific HPDP activities (new
funding and reallocation of existing funds).
(Federal, State, local)

o Establish, implement, and monitor Hispanic/
Latino-spmif?c objectives in ail Healthy People 2ooO
prevention priority areas with a specific focus on those
affecting Hispanic/Latino youth. (Federal, State)
o Establish culturally sensitive and appropriate
methods for Hispanic/Latino data collection
methods and processes, (Federal, State, local)
o Establish, expand, and share data networks that
assist all research activities and community-based
organizations. (Federal, State, local)

Lack of Hispanic/Latin0 health professionals in
HPDP decisionmaking and leadership positions and
in the field.

Desired Aim

To increase the recruitment, training, and retention
of Hispanic/L&no health and other related
professionals in the administration and management
of HPDP programs in the private and public sectors.

Implementation Strategies
o Establish a comprehensive Hispanic/
Latino-specific HPDP mentorship program for
research, teaching, and community interventions.
(Federal, State, local)

  Health

Promotion

and Disease

Prevention

o Secure scholarships for training Hispanic/Latin0
leaders in HPDP. (Federal, State, local) `. .

o Increase funding for Centers of Excellence for
Hispanic/Latino health professions with emphasis in
HPDP and increase the number of Centers.
(Federal)

o Enforce existing Federal and State mandates to
ensure Hispanic/Latin0 opportunities in higher
education (faculty and boards), decision-making
positions (boards), and the workplace (manage-
ment). (Federal, State, local)

o Encourage PHS to develop incentives for primary
care providers serving hardship and underserved
areas. (Federal)

One

Weak organizational development of prevention
providers and lack of organizational development,
education, and training programs:

  x Lack of HPDP curriculum in schools.


  * Lack of multidisciplinary approaches to HPDP
  curriculum development.

  u Lack of formal HPDP training for Hispanic/
   Latin0 leaders.

u Institutionalized and individual racism as a
barrier to service delivery and professional
development.

Voice

   i

One

Vision


Workshop Recommendations o + + o o + o o + e q + +

Health

Desired Aims                    Desired Aims

Promotion        .

and Disease

Prevention

To develop and evaluate Hispanic/Latino-
specific models and approaches (e.g., clinics
on wheels, bilingual outreach programs) to
prevention programs.
To develop grass-roots community-based
programs.

8

To develop a short- and long-term prevention
strategy for communities at risk of environ-
mental hazards, communicable and chronic
diseases, etc.

s

To develop a HispanicKatino-specific
cross-cultural and multidisciplinary curricu-
lum to address the HPDP needs of the
Hispanic/ Latin0 population.
To expand the pool of qualified Hispanic/
Latin0 HPDP providers; to conduct aggres-
sive recruitment and retention programs of
HispanicKatino HPDP professionals.
To enhance the capabilities of non-Hispanic/
Latin0 HPDP professionals to better serve
Hispanic/Latin0 communities.
To increase the capacity of Hispanic/ Latino
community-based organizations to provide
prevention/ service programs.

Implementation Strategies
o Build on nontraditional m,+ods of access to care
(i.e., nurse practitioners, dental hygienists, etc.).
(Federal, State, local)

Implementation Strategies
o Develop partnerships among training institutions,
community-based organizations, and national
Hispanic/Latino agencies to better provide HPDP
services.

One

Voice

One

Vision

o Mandate all public organizations and institutions
receiving Federal, State, and local HPDP funding to
(1) develop a cross-cultural, multidisciplinary
HPDP curriculum and (2) recruit, train, and retain
Hispanic/Latin0 HPDP professionals to practice in
underserved communities.

o Provide incentives (tuition, loan forgiveness
programs, financial benefits) to providers for serving
I-hpanic/Latino and underserved communities.

o Develop training and other sensitivity initiatives
to address issues of cultural diversity and racism.

o Develop attractive HPDP continuing education
programs for health professionals in the delivery of
preventive health services to Hispanics/Latinos.

o Establish linkages among community-based
organizations, universities, the private sector, and
lay people in the community. (Federal, State, local)

o Leverage public health initiatives with support of
community-based organizations and community
coalitions. (State, local)

o Emphasize the importance of awareness, educa-
tion, early identification, and intervention through
HPDP programs via community coalitions.

o Ensure that organizations serving Hispanics/
Latinos have at least 12 months of experience in
working with the Hispanic/Latin0 community, and
that at least 50 percent of their board is Hispanic/
Latino with HispanicsAatinos in key administrative
and program staff positions. (Federal, State, local)

Lack of comprehensive and systematic approaches
to clinical and preventive services; lack of appropri-
ate screening and diagnostic procedures for
Hispanics/Latinos.

Lack of culturally sensitive and population-specific
primary prevention programs.


Desired Aim

To develop, implement, and, where appropriate,
reinstitute culturally relevant and comprehensive
preventive services.

Implementation Strategies
o Increase the use of community settings for the
delivery of primary care/preventive services (i.e.,
churches, community centers, schools, community
clinics). (Federal, State, local)
o Train staff in cross-cultural issues (i. e . , involve-
ment of family members, use of culturally relevant
screening, and diagnostic procedures, etc.) in the
delivery of services. (Federal, State, local)
o Recruit and use community leaders and
"Promotores de Salud" effectively to conduct
outreach and deliver services. (State, local)

o Require that evaluation be built into service
delivery programs to ensure adequacy of services.
(Federal, State, local)

Lack of public-private partnerships in support of
HPDP goals for Hispanics/Latinos.
Desired Aim

To increase collaboration between private and public
organizations in the development of HPDP initiatives.

Implementation Strategies
o Create a solid Hispanic/Latino HPDP information
network and clearinghouse via a public-private
partnership. (Federal, State)

o Develop regulations that require private and
nonprofit institutions (including universities)
serving Hispanics/Latinos to include adequate
Hispanic/Latin0 representation at decision-making
and program levels. (Federal, State, local)

o Encourage the creation of a national Hispanic/Latino
philanthropic federation that includes representation of
grass-roots organizations. (Federal)

o Establish guidelines for Hispanic/Latino

Health

community-based organizations and national
organizations for accepting corporate contributions;
corporations' products and services must be
compatible with HPDP goals.

Promotion
and Disease

Prevention

o Obtain corporate sponsorship and funding of
HPDP programs for Hispanics/Latinos from
industries that do not promote disease.

Lack of cooperation among nations in addressing
health issues.                 I `.*_

Desired Aim

To develop, expand, and maintain cooperative
efforts in environmental and HPDP areas among
countries in the Americas (the United States,
Mexico, Central/South America, Caribbean).

Implementation Strategies
+ Foster close collaboration between Latin Ameri-
can countries and the United States regarding HPDP
issues. (Federal, State, local)

o Make health and prevention (including environ-
mental issues) critical elements in the regulations
and implementation of the free-trade agreement.
(Federal, State)

One

Voice

Lack of a constituency for Hispanic/Latin0 political
advocacy.
Desired Aim

To build a political constituency for HPDP.                One

Implementation Strategies
o Build rapport and working relationships with
Hispanic/Latino, other appointed/elected officials,
and national organizations. (Federal, State, local)

Vision

o Develop a Hispanic/Latin0 constituency to
counter disease-promoting industries. (Federal,
State, local)


Health

Promotion
and Disease

Prevention

o Develop a consensus within the Hispanic/Latin0
community for acceptable universal standards of
primary care.

Lack of diffusion of culturally appropriate HPDP
models:

* Lack of consistency in defining
community-based HPDP interventions.

w Lack of community resources for the replica-
tion of successful Hispanic/Latino HPDP
models.

Desired Aims

* To identify, showcase, and disseminate
successful Hispanic/Latino HPDP models.

m To develop strategies to fund successful
HPDP models.

Implementation Strategies
o Establish mechanisms and procedures by which ah
prevention RFPs have Hispanic/Latino comnumity
input. (Federal, State)

o Appoint Hispanics/Latinos to the proposal review
process for research, training, and services.

back of media involvement and sensitivity to
Hispanic/Latin0 health and HPDP issues.
Desired Aim

To increase media's awareness of HispanicLatino
health issues and the media's role in disseminating
information on HPDP.

Implementation Strategies
+ Develop an agenda/workshops/training for
media representatives to participate in HPDP
programs. (Federal, State, local)

o Develop community-based.ting programs in
media advocacy.

o Use paid media to complement other HPDP efforts.

One

Voice

Viion


Chapter 5 : Presentation of National
Workshop Recommendations

A representative from each Work Group at the
National Workshop was chosen to present the
recommendations developed by the Work Group.
This chapter contains the presentation of the
recommendations, which are listed in Chapter 5.

Access to Health Care

Castulo de la Rocha, J.D.

President and Chief Executive Officer
AltaMed Health Services Corporation

Access to health care is probably the most important
issue facing Latin0 communities today, and I am
certain it will be the most important issue facing this
community for the remainder of this decade.
Nearly one-third of all Latinos are uninsured or
underinsured. We're the poorest, the youngest,
and the least educated of major ethnic groups. We
depend less on the welfare system, and we have a
strong work ethic and strong family values. Our
population is increasing rapidly. We have high
visibility. But at the same time, the needs of our
community also continue to expand very rapidly.
The current focus of public debate regarding health
care reform has focused on issues such as cost
containment, the impact of business, governance,
fmancing, and the role of the private sector in health
care reform,

  What has been missing in this debate are the
financial, structural, and institutional barriers and
obstacles that we have to face as Latinos. What we
are attempting to do is to outline these barriers.
We will focus on the lack of health care financing;
Government policies that have been unresponsive to

needs; the structure of the health care system,
which inhibits opportunities and the appropriate use
of health services; and institutions and their inability
to care for our population.

  The specifk recommendations are the following:
First, health care reform must eliminate `disin'&&ives
that work to cause the linkages of lack of public health
coverage and unemployment, specifically focusing on
the Medicaid system. Second, require Medicaid and
Medicare reform to specificahy address the needs of the
Latin0 community by supporting primary health care
services and shifting from the emergency hospital care
to comprehensive community-based care, inchrding
preventive services. Third, develop demonstration
models within HCFA [Health Care Financing Adminis-
tration] that look toward alternative health care
systems that are responsive to Latin0 community
needs. This includes managed care systems. Fourth,
even if we had adequate health care financing, there is
no assurance that our population, based on historical
practices, would be able to access those institutions.

Access to

Health

  Care

Voice

   a
One

Vision


Access to
Health

Care

One

Voice

One

Vision

Work Group Presentations

Thus, we strongly recommend the improvement of the
inkmructure and access to working capital for the
construction of health care facilities in Latin0
communities and the development of economic
incentives to provide and to place medical practices
within Latin0 populations.

   We should also reformulate the administrative
rules for designating physicians and other health
manpower in shortage areas and medically
underserved areas. The present indicators and
determinants for medically underserved areas are,
in fact, discriminatory and prejudicial to the Latin0
population. I strongly urge that we move aggres-
sively in the direction of redeftig those indicators.
  We strongly support the funding of public
health programs and infrastructure by the provision
of at least 6 percent of health expenditures that
must be accountable to the needs of the Latin0
community. What has happened over the years is
that the attention has been moved away from public
health services. We view this as an integral part of
having an effective system of health care in the
delivery of services to Latin0 populations.
  We should require Latin0 participation in
proportion to the total population in the
decisionmaking process and in positions that affect
policies in DHHS [Department of Health and
Human Services], spec&cally in boards, commis-
sions, and advisory committees, and in the RFP
[request for proposal] process, development, and
review. It is equally important that Latinos be
involved in the search and selection of leadership
within DHHS. An advisory committee to the
Secretary of Health and Human Services should be
established to advise the Department on policies
affecting Latin0 populations. It's critically impor-
tant that we have some way of monitoring and
holding people accountable for the recommenda-
tions that we have developed.
  Finally, we strongly recommend the forma-
tion and the development of a national effort aimed
at lobbying for legislative issues that are important

to the Latin0 community. This is parti&arly
important in light of the recommendations that we
will receive today. We also recommend the
development of a national Latin0 coalition for a
healthy U.S.A.

Aida L. Giachello, Ph.D.

Assistant Professor
Jane Addams College of Social Work
University of Illinois-Chicago

The main problems/issues identified by our group
have to do with the fact that we feel that there is no
universal health coverage,that-Fould facilitate entry
into the health care system. And there were all
kinds of discussion in terms of what the ideal system
is. Portability and affordability are essential. The
people, regardless of where they are in the United
States, should be able to have entry into the system.
There should be a basic package of services where
prevention would be emphasized. The consumer
should have a choice of providers and comprehen-
sive coverage allowing for continuing of care. It
should be an integrated system of care where you
would have a public sector, community health
services, and the private provider that, in most
instances, w-ill usually be included in any kind of
meaningful discussion. The system should provide
progressive health care fmancmg that spreads the
burden across all sectors of society based on level of
personal wealth. Eligibility would not be based on
residency status, or employment status for that
matter, or on any preexisting condition. It should
be easy in terms of enrollment and participation; it
should have measures of cost containment, quality
assurance, improved efficiency, and accountability
to recipient; and it should allow the recipient and
the consumer to be active agents in the process of
planning any implementation of services.
  Another element that was discussed is that
the system should reward providers who develop
services for the underserved and unserved


&+*+++++++++  Work Group Presentations

populations. It should provide incentives for
coverage for prevention services and have a uniform
procedure for reimbursement that recognized
regional differences.

  In terms of the strategy, we felt very strongly
that there should be some kind of advocacy
coalition, involving the public and the private
sectors, in every State with a significant Latin0
population. There should be some kind of method-
ology of assessing the cost of universal coverage that
factors in preventive measurements. We felt that
Government and institutional policy right now have
been unresponsive to Hispanic/ Latin0 health needs.
Therefore, there should be policy that would
integrate service delivery systems and coordinate
referral mechanisms linking the different sectors-
the public, the private provider, the community,
the migrant health centers, and the mental health
centers. There should also be policy that would
consider linguistic and cultural issues. The system
should foster collaboration among all parties and
target health profession education funding to
increase a number of primary care providers. It
should determine the unique health needs of
Hispanic/Latino communities and provide resource
allocation necessary to meet those needs.

  In terms of implementing strategy for this
particular issue, we need to bring together all
parties to explore areas of collaboration and
partnership. We also need to recognize that the

categorically funded programs as they stand now
do not meet the needs of the different populations
that they're supposed to serve; all kinds of examples
were given of how the many assistance programs
do not address the basic needs in our community.
We also need to establish guidelines to review those
categorically funded programs such as HIV
programs and maternal and child health programs,
to figure out a way of supporting Centers of
Excellence, which would best meet the needs of the
Hispanic/L&no community at all levels. And then
we need to ensure that greater numbers of the
Hispanics/Latinos are in key policymaking   , -
positions. Allocation of resources and the relevance
of services to our community are better handled
when you have people in key positions who would
be able to advocate and bring the concerns to the
discussion table.

   The third area has to do with the fact that
right now, the Latin0 community does not have
access to the full array of health services. Examples
were given in services such as primary care and
preventive services, acute hospitalization, emer-
gency services, dental services, drug and alcohol
abuse prevention and rehabilitation, occupational
health and rehabilitation, mental health services,
social service, nutrition and health education,
prescription drug, and visual and hearing services.
These are some of the many areas of priorities that
any comprehensive package should include and
make available to our community.

  We also acknowledged the fact that Latinos
are not linked to`a reguiar source of care. Accord-
ing to a recent report by the Robert Wood Johnson
Foundation, one-third of our Latino population do
not have a point of entry. One of the biggest
barriers is that if you do not have that point of
entry, you end up going to the hospital emergency
room because you just do not know where to go
when you become ill. Therefore, we feel that we
need to address this issue.

Access to

Health

Care

One

Voice

One

Vision


Work Group Presentations  +++e+++++++*+

One

Voice

One

Vision

Access to

Health

Care

  We also feel that, in terms of an ideal system,
we want to eliminate language and cultural barriers.
We want a system that can provide service to
mobile populations like seasonal migrant farm
workers, the homeless, refugees, and border and
other transient populations. We want to reduce
fragmentation and poor communication and
coordination among services providers--linking the
private provider with other local public and private
sectors and community and mental health facilities.

  We want reimbursement for services, for
public information and public education and
transportation, as well as provision for child care
and social services. We believe that to be able to
begin linking consumers to the available sources of
care, we need to engage, particularly at a local
level, in a series of outreach and marketing
strategies that would increase consumer knowledge
about what is available and how to enter a system.
We also discussed the whole issue of interpreters,
and we were concerned about the fact that the role
of the interpreter may affect the quality of care.
We were concerned also about the issue of confi-
dentiality. There are ethical issues involved when
you use interpreters and so the lack of guidance, the
lack of training, the lack of really establishing
protocols to serve providers was a clear concern of
the group.

   We also felt that we need to introduce
legislation. There should be policy and guidance to
promote bilingual and culturally competent,
relevant services. We need to develop standards
for those services; we need to revise criteria of
eligibility for funding for community and other
health programs to ensure responsiveness to
Hispanic/L.atino health needs; and we need to
assess service delivery. There were discussions
about the fact that the clinics available, public or
private, don't have flexibility of hours or services.
The services are organized to the convenience of
the provider, not to the convenience of the

consumer. And the only way that we would be
able to change this is by assessing the policy that
every clinic follows, by seeing how we can make it
more responsive to the specific needs of a given
community.

  People expressed concern that if you are
under Medicaid and you move to another State,
what you have is not portable. You cannot really
access another system from another State. There
has to be a guideline or policy; we need to explore
how can we make programs more helpful, more
useful, in addition to decreasing the number of
Latinos who are left out because of the existing
criteria.          . `-,.

   I also want to mention the need to address

and assess the needs of Hispanic women. Somehow
the discussion of meaningful policy planning in
general left out the health needs of Hispanic
women, and please keep that in mind.

   The final issue I want to address concerns
the labeling of minority. There was concern among
members of the Work Group that sometimes when
the label "minority population" is used in allocation
of funding, the term is not identified specifically
with Asian American, Native American, or
Hispanic/Latin0 American. Perhaps we should be
more specific when we are stating policies in the
allocation of resources.


++++++e++e+-  Work Group Presentations

Data Collection
Manuel R. Modiano, M.D.

Director, Arizona Cancer Center
Minority Cancer Control

We must not underemphasize the importance of
data; without them, access to care, health profes-
sions, health promotion, etc., will never happen.
There are 22.4 million Hispanics living in the 50
States and D. C., and 3.5 million people living in
Puerto Rico, for a total of 25.9 million Hispanics in
the United States. More than two-thirds of all
Hispanics were born in the United States, yet it was
not until I 989 that the model birth and death
certificates included a Hispanic identifier.

  Too often, organizational priorities and
funding decisions are established without taking
into account Hispanic data. Adequate planning is
not available without the appropriate availability,
utilization, and interpretation of Hispanic data.
Therefore, resources from governments (Federal,
State, and local), foundations, nonprofit and for-
profit corporations, as well as educational institu-
tions, are not allocated consistently with the needs
of the Hispanic community.

As we approach the year 2000 and beyond,
the need for the Hispanic data will only increase.
Given the imperative to effectively target resources
to maximize benefit and efficiency, the six areas
that I am going to describe are the minimal set of
issues that must be addressed to serve the health

needs of the Nation.

  The first issue is inclusion. There is a need
for inclusion of Hispanics in all data systems. Our
aim is to increase the mainstream inclusion of
Hispanics in all systems, and the strategies for
implementation are the following: First, all surveys
and forms must include Hispanic and Hispanic
population subgroups identifiers. Second, there
must be suflkient numbers of Hispanics and Latinos
included for analvsis. Third, enforce OMB [Office
of Management and Budget] Directive 15 and

Public Law 94-3 11. Educate the agencies about the         Data

use of the OMB Directive for inclusion of Hispanic
and Hispanic/L&no subpopulation groups and data
systems. Similar policies should be set for State,
regional, and substate levels as well as for non-
Federal purposes. And fourth, all agencies must
report progress on inclusion of Hispanics and
Latinos and their subgroups in data systems as well
as in federally funded, intramural, and extramural
research programs.

Collection

  The second issue is local and regional data.
There is a need for data relevant to the identified
Hispanic health issues at the local and regional levels
for specific subpopulations. We hope to be'able to
do this by improving the availability and reducing
the gaps in local and regional Hispanic health data
through the following implementation strategies.
First, all agencies need to develop guidelines and
technical assistance to be used by State or regional
groups to collect data for Hispanic population
groups at the local or local-regional level, including
emerging Hispanic populations. Second, focus on
Hispanic-specific generated issues. For example,
collected data that only enumerate a number of
gunshot wounds in a specific community would
be useful only if they are made available to the
community and if they are integrated with other
data that already exist in that community. Third,            One
develop a new series of local pilot studies to identify         Voice
patterns and strengths that will justify the use of
further activities in the same community and
outside. And fourth, establish new objectives for
the year 2000 and baseline data for those objectives  a
at the Federal, State, and local levels.

There is a need for quality, precise, timely,

One 2

and culturally sensitive data design, collection, and
analysis. We hope to do this through the develop-
ment of a foundation of high quality, valid, and
timely information on Hispanics equivalent to or
better than that existing in other ethnic or racial
groups. The strategies for implementation are the
following: First, include Hispanics in the design,

Vision


Work Group Presentations  44444444444444

Data
Collection









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One

Vision

implementation, analysis, funding, decisions, and
dissemination of health assessment and health
monitoring data systems. Second, assess the data
collection research designs to include considerations
of the heterogeneity of the Hispanic population.
Third, oversampling has been identified as a feasible
method of inclusion, but other methods need to be
developed to efficiently locate less concentrated and
dispersed Hispanic subgroups. Fourth, validate data
collection and research instruments for cultural
competency and linguistic appropriateness for use
within Hispanic population and subpopulation
groups. Fifth, bring the Census Bureau and NCHS
together to identify the existing and emerging
research issues with denominator and numerator
problems, such as the rules for assigning race, using
surname as a proxy, and the usefulness of other
races and, quote, "other Hispanic categories." It is
imperative that we involve Hispanic researchers in
seeking the resolution to these issues. Sixth, study
the problems associated with changes in ethnic self-
identification. Seventh, establish guidelines for the
coding and keying of data on birthplace, work
history, generation status, socioeconomic status,
language usage, family relationship, etc., which
have been shown to be predictive of Hispanic health
status. And finally, develop data release plans that
meet priorities and the timeliness needs of users.
  On the issue of analysis, there is a need to
identify and inventory the large amount of available
data. These data need to be analyzed for use in
understanding the Hispanic health concerns. To do
this, we need to increase the analysis and produc-
tion of Hispanic health data at Federal, State, and
academic levels, and to increase the number of
Hispanic researchers involved in these processes.
  The strategies for implementation include the
following: First, research on the health status,
living conditions, and culture of the Hispanic/
Latin0 populations should be included, in the
development of hypotheses and conceptual fmme-
works. Second, identify existing data sets and

determine their access to the researchers, Third,
support a network of Federal, State, university, and
community-based analysis and analysts with a
primary focus on health data analysis. Fourth,
provide support for technical assistance to research-
ers who are involved in the urgent health issues for
Hispanics. Fifth, increase the technological capacity
of researchers to conduct more advanced analysis-
for example, the geographic information system.
And finally, encourage collaborative interdiscipli-
nary research, which bridges quantitative and
qualitative investigation.

  In the area of dissemina,tion, there are data
that are unavailable or inaccessible, but are in
critical demand. Our goal is to maximize the
availability of Hispanic data to Hispanic and non-
Hispanic policymakers, funding sources, practitio-
ners, community-based organizations, and research-

ers. The data must be made accessible by training
community-based organizations to access the data in
training others in data cultural competency. The
data produced by public agencies through public
funds need to be made available to the community
by providing information packets that include
audiovisuals, slides, and other materials for
community-based organizations.

  We need to provide assistance on how to
analyze data so that people can draw their own
conclusions. The data should be balanced to include
not only the negatives but also the important
strengths of the Hispanic/Latino community and
other issues. Federal regional offices should fund
statetide clearinghouses on Hispanic health in high-
impact States. There is a need to provide informa-
tion to a broad range of groups, Hispanic civic
advocacy groups and non-Hispanic white groups,
and we need to identify in each agency and
organization a person or people to serve as principal
point of contact on Hispanic health data.

  There is a need for coordination between
and among Federal and State agencies in Hispanic
health data collection and analysis. The aim is to


+ + 4 o o o + + o + + o +  Work Group Presentations

enhance and expand the development of Hispanic
data by public agencies. We hope to do this by
using the existing Federal data systems to establish
cooperative agreements with States for developing
standard State and local health status profiles for
Hispanic communities. Second, establish an
inventory of existing Federal, State, and local data
resources to identify gaps and areas of improve-
ment. Third, provide government support for a
network of community-based health data collection
efforts to serve as an early warning system for
setting of health policy priorities. Fourth, maintain
an advisory board to the O&e of the Surgeon
General to help oversee Federal, State, and local
Hispanic health issues. And finally, establish a
Federal interagency task force on Hispanic health-
related data with input from appropriate, non-
governmental Hispanic advisors.

Research Agenda

Hortensia Amaro, Ph.D.

Associate Professor

Boston University School of Public Health

Research data provides the knowledge base for
forming policy and developing programs. We
identified four major problems in the development
of a Hispanic health research agenda and developed
aims and implementation strategies targeted to
specilic Federal and private sector institutions.

  The first major problem that we identified
was the lack of an appropriate infrastructure and
human and physical resources or capacity to conduct
research. We developed three aims in this area.
The first aim is to increase the number of behavioral
and biomedical Hispanic scientists. We developed
11 recommendations for implementation strategies
related to this aim.

  First, to accomplish this aim, PHS [Public
Health Service] should develop specific support
programs for pre- and postdoctoral training for
Hispanics in behavioral and biomedical research to

Research
Agenda

eliminate their underrepresentation in health-
related research. Second, PHS and other `IXleral
agencies must develop programs directed at
Hispanic researchers to improve methodological
expertise in health-related research. Third, PHS
should target and intensify efforts to recruit
Hispanics into its existing research and training
programs. It was recognized that PHS has excellent
research and training programs currently, and we
need to actively recruit Hispanics to these pro-
grams. Fourth, PHS should ddvelop and fund
distinguished research career programs to allow
Hispanic researchers to concentrate on research,
writing, and mentoring to free them from the
multiple requirements and expectations commonly
faced by minority academicians. Fifth, NIH
[National Institutes of Health], CDC [Centers for
Disease Control and Prevention], and other Federal
agencies should conduct grantsmanship workshops
where Hispanic researchers have the opportunity to
learn proposaLwriting strategies and have their
preproposals reviewed by ad hoc IRGs. Sixth,
expand and evaluate specific initiatives to ensure
that Hispanic middle and high school students take
courses essential for entering science careers. We
think the Department of Education, and especially
the National Science Foundation, should play a
leading role in this effort. Seventh, as was noted
this morning, there is a need to improve and to
assess the effectiveness of existing programs, such as

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Work Group Presentations  4444+44+++44+

Research
Agenda









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Voice

the Minority Biomedical Research Support Pro-
gram, the MARC [Minority Access to Research
Careers] program, and the minority high school
apprenticeship program, for recruiting and assisting
Hispanic students to complete research and training
careers. Eighth, we need to encourage professional
associations to stimulate the involvement of
Hispanic students in research careers. Ninth, PHS
and other Federal agencies should develop special
initiatives to fund grants submitted by new and
established Hispanic investigators. We need to
engage Hispanic researchers and encourage them to
take advantage of these opportunities. Tenth,
increase and enhance institutional capacity for
Hispanic health research through the establishment
of Hispanic health research centers and through
support for individual Hispanic investigators. While
it is clear that research centers are needed, it was
also recognized that many Hispanic researchers
make invaluable contributions as individual re-
searchers, and they must be supported. Finally,
PHS should provide orientation to public health
program staff on Hispanic health and related
methodological issues, so that they can better guide
program initiatives and review group scientists in
these areas. The goal here is to increase the
commitment and knowledge of Hispanic health
issues on the part of program staff who can be so
influential in funding decisions.
  A second aim related to the lack of a research

infrastructure is to improve cultural competence
and sensitivity of Hispanic and non-HispanicIlatino
scientists. The recommendations for implementa-
tion strategies are, first, that regional and profes-
sional accreditation agencies should require that
Hispanic health research issues be incorporated
into existing curricuhnn. Second, educational,
institutional, and professional associations and PHS
should develop and institute courses, seminars, and
conferences on methods for conducting research on
Hispanic populations. Third, members of internal
review groups must be instructed on the procedures

One

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required for culturally competent research that
targets Hispanics. The evaluation of proposals should
include specific points assigned for culturally appropri-
ate research methods. And fourth, staff should provide
appropriate training and guidelines to reviewers in
order to improve the ability of IRGs [Internal Review
Groups] to evaluate research on Hispanic health We
see this as being consistent with the NIH [National
Institutes of Health] guidelines for including women
and minorities in study populations.

   A third aim related to the lack of a research
infrastructure is to improve communication and
interaction among Hispanic scientists. The first
implementation strategy is to centralize and expand
the existing data bank on Hispanic researchers at
PHS and to add non-Hispanic researchers conduct-
ing research on Hispanic health. The data bank now
focuses primarily on individuals who have received
grant awards, and we think that this needs to be
expanded to other researchers as well. Second, we
need to encourage professional associations to
facilitate networking among Hispanic researchers.

  The second major problem area we identified
is the dearth of research relevant to the health of
Hispanics. The first aim here is to develop health
research that is relevant to the Hispanic population.
The first recommended implementation strategy is
that the Office of Minority Health commission a
number of state-of-the-art papers that critically
analyze the literature on Hispanic health in each of
the areas identified by previous reports and assess
gaps in knowledge. These papers would present a
review of current knowledge in each of the areas
covered by Healthy People 2000. The papers
should be used as guides for funding by PHS
agencies. Second, a high-level committee with the
appropriate Hispanic health expert involvement
must be appointed by the Office of Minority Health
to review the outcome of the activities of the Brst
year of the Hispanic/Latin0 He&h Initiative and the
information obtained from the state-of-the-art papers.
This panel must be charged with developing an outline


of priorities and initiatives for research with
Hispanics. Third, special funding programs or
initiatives must be developed by the Federal
Government to fund research on the role of factors
such as acculturation, migration, national origin,
socioeconomic status, and their impact on the health
status of Hispanics. As part of this, large-scale,
cross-sectional, 1ongItudinal studies with Hispanics
funded by Federal and State initiatives must be
required to include these factors as possible
moderators of health status. Fourth, special
program initiatives must be developed by the
Federal Government to analyze the health status of
Hispanics working in high-risk environments, such
as migrant agricultural environments, assembly
plants, service professions, and other industrial
environments, to better understand environmental
health risks. Fifth, health services research must be
conducted to identify the characteristics of health
care delivery, including personnel and facilities that
facilitate access, utilization, and effectiveness of
health services among Hispanics and Latinos. A
meaningful proportion of services research set-aside
funds, especially those related to mental health,
alcohol, and substance abuse, should be targeted to
investigate questions pertaining to Hispanics. Sixth,
create an Office of Hispanic Health within the
Office of Minority Health in the Office of the
Assistant Secretary for Health, to coordinate
Hispanic health-related initiatives and to oversee
their implementation within the Federal Govem-

ment. It is critical that this office be properly
funded and that it include an advisory board that
would review its activities on a quarterly basis. The
Office of Minority Health should issue a biannual
report to Congress detailing the progress on the
Hispanic health agenda and the progress within PHS
in meeting the mandates of the Disadvantaged
Minority Health Act as they relate to Hispanics.
Seventh, PHS should fund research targeted at
providing baseline data to enable formulation of
Hispanic-specific objectives for the next Healthy

People report. Eighth, PHS should develop mecha-
nisms to obtain meaningful community input into
the formulation of a research agenda.
  The third major problem area we identified is
lack of culturally appropriate research theories and
methods. The first aim is to increase the number,
availability, and validity of research instruments
used in investigations on Hispanic health. To
achieve this aim, the Work Group recommended
that Federal programs fund research to test the
usefulness of current instruments and to develop
new culturally appropriate instruments that meet
                           I `...
applicable standards of validity and reliability.
Second, PHS must fund a repository of Hispanic
health-related instruments to facilitate the use of
these instruments by scientists.
  A second aim related to the lack of culturally
appropriate theories and methods is to study the
applicability of existing health constructs and
theories that currently guide research and assess
their appropriateness to Hispanic populations. PHS
should fund research to develop new behavioral
models and theories and to test the validity of
existing models.

  A fourth major problem area that was
identified is the underrepresentation of Hispanics in
PHS. The first aim is to ensure proportional
representation of Hispanic researchers on scientific
advisory boards, national advisory councils, and
IRGs as well as technical evaluation groups that
review contracts. The recommended implemen-
tation strategy.is that a yearly survey be conducted
to identify qualified individuals willing to serve in
these bodies. Results of those surveys should be
published yearly, and an updated directory should
be made available to Federal and State agencies that
fund health-related research. It is recommended that
the internal review groups, technical evaluation groups
for contracts, national advisory councils, and scientific
advisory boards within PHS and other Federal agencies,
should include Hispanic representation.

Research
Agenda

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Work Group Presentations   o

Health

Professions

  The second aim related to the underrepresen-
tation of Hispanics in PHS is to ensure proportional
representation of Hispanics on the staff of PHS.
One implementation strategy is to expand the
short-term service initiatives that allow Hispanic
researchers and academicians to serve within PHS
without severing ties with their home institutions.
Finally, PHS should develop and target efforts to
recruit, retain, and promote Hispanics at all levels
of the scientific and program statTat PHS.

Health Professions

Rene E Rodriguez, M.D.

President

Inter-American College of Physicians and Surgeons

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Voice

In our area, we identified four problems. The first
problem was inadequate education of Hispanics to
move toward the health profession. Our desired
aim is to increase the numbers of Hispanics in the
education pathways toward the health profession so
that, by the year 2000, the number of Hispanics
admitted to health professional schools reflects the
percentage of Hispanic population by State. The
implementation strategies are (I ) to increase
parental involvement in children's education
through family counseling, dissemination of
information, programs like ASPIRAS established by
the school's community-based organizations,
private sector media campaign, and assisting and
monitoring low-income families in planning earlier

for later schooling of their children; and (2) to
move children into English language competency as
soon as possible through early childhood programs.
  The second problem is lack of accountability.
Our desired aim is that all PHS agency directors
should be evaluated annually based, in part, of the
following: (1) recruitment and retention of
Hispanic staff; (2) representation of Hispanics in
review committees; (3) grants, awards, and
programs with a Hispanic health focus; (4) grants
awarded to Hispanic principal investigators; and

One



Vision

(5) grants award to universities with significant
Hispanic graduation rates.    ' x *
Our implementation strategies will be to

enact legislation that will require all PHS directors
to be evaluated annually based on the criteria
mentioned above, or to secure an Executive Order
that will achieve the same goals and objectives.

  The second desired aim is to significantly
increase, by the year 2000, the number of Hispanic
full-time equivalent faculty and students in universi-
ties and health professional schools to reflect the
percentage of Hispanic population in the area. The
implementation strategy will be that the schools
showing sign&ant increases in full-time equivalent
Hispanic faculty and students will receive additional
Federal funds, student loans, and assistance.

   Our third desired aim is to address the lack of
adequate resources for success in preparation of
Hispanic students for health professions. Our
desired aim is to significantly increase, by the year
2000, the resources assigned to inner city schools,
colleges, and universities with large Hispanic
student bodies. The implementation strategies will
be (I ) to stimulate the private sector to invest in
supporting inner city schools, colleges, and univer-
sities with large Hispanic student bodies; (2) to
stimulate the private sector and Government to
invest in scholarships to Hispanic students in inner
city schools, colleges, and universities with large


Hispanic student bodies; (3) to increase funding
and the scope of the health career opportunity
programs; and (4) to stimulate Hispanic health
professional organizations to develop and participate
in mentoring programs on all levels.

  The fourth desired aim is to address the lack
of data on the practice characteristics of Hispanic
health professionals necessary for planning
purposes. Our desired aim is to have updated,
analyzed data on the practice and characteristics of
all Hispanic health professionals to be disseminated
for planning purposes. The implementation
strategy will be to request that health professional
organizations gather and analyze data on the practice
characteristics of Hispanic professionals.

Ciro % Smaya, M.D., MXt-l.T.M.
Associate Dean for Affiliated Programs and
Continuing Medical Education
The University of Texas Health Science Center
at San Antonio

Why do we need more Hispanic health profession-
als? First, let us 1-k at the moral issue. There is
talent in the community that, if better tapped, could
be an effective resource for addressing health needs
of the country and its large Hispanic community. If
one looks at the economic side, it is clear that an
increase in the number of Hispanic/Latin0 health
professionals would enlarge the proportion of
people that are educated and economically sound.
And if we look at the cost containment issue, there
is evidence indicating that Hispanic/Latin0 health
professionals are more likely to provide care for
Hispanics/Latinos and other minorities in the
community, addressing health problems in these
underserved populations that, if ill treated, would
lead to more costly treatments and increased
human suffering.

  Yet significant barriers exist in the educational
system that impede an increase in the number of
Hispanic/L&no health professionals, i.e., barriers
that are economic in nature or deal with academic

preparation, cultural differences, the admissions/
retention process in health professional schools, etc.
This presentation will cover some of the more
important issues, aims, and implementation
strategies proposed by our Work Group. A
complete listing of these fmdings will appear in the
written proceedings of the Workshop.

  Health
Professions

  Our initial aim is to increase by a minimum of
10 percent per year the number of Hispanics
entering health professions schools over the next
10 years. One of the principal implementation
strategies to accomplish this aim is to bring more
qualitative evaluations and measures into the
admissions process. Individuals should beevaluated
as a whole, not merely looking at their aptitude
tests and grade point averages. What obstacles has
the individual had to surmount to reach the applica-
tion stage? What values can the individual bring to
society? What are society's needs? It is most
important and relevant that students be credited for
their personal and diverse educational pathways.
Additional needs include increasing Hispanic/L&no
participation in the admissions process. Also,
cultural diversity should be brought to the attention
of the admissions committee, and establishing more
consistent definitions or identification of Hispanics/
Latinos as part of the admission criteria for health
professions schools.
  The second aim proposed by the Work Group
was the graduation of all HispanicNatino students
enrolled in health professions schools. In other
words, students that are admitted need to complete
their education. A number of effective retention
and support programs that address this aim do exist,
but there is a major need to expand the existing
ones and to develop them in schools in which they
are weakly structured or lacking.

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  The Work Group also stipulated that the
Federal Government and the States should set
standards for increased representation of Hispanics/
Latinos in the health professions and that these
standards be tied to funding/appropriation levels.


Work Group Presentations  4444444444444

Health

Professions

  More research is needed in analyzing
standardized test bias and lack of predictability of
these tests in determining future medical perfor-
mance of medical school graduates. In plain words,
how well do these test predict future performance
of these individuals in the community and in the
provision of needed health care, particularly for the
more vulnerable populations?

  The Hispanic Centers of Excellence, as
recently legislated, are a most important concept in
the entry and advancement of health professional
students and faculty. These Centers need our
strong support and appropriate Federal funding.
It was specifically noted that there should be an
equitable distribution of monies to Hispanic Centers
of Excellence in relation to the total amount
allocated for such initiatives through the Minority
Disadvantaged Health Improvement Act. These
Centers should also be broader in scope, covering
not only the discipliies of medicine, dentistry, and
pharmacy, as applicable currently, but also nursing
and allied health. Moreover, there should be a
critical evaluation of the Centers in terms of
outcomes and products that can enhance their

success.

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Voice

One

  Measures to make health professions
education afTordable are imperative. Yet there
currently exists insut&ient fmancial support for
Hispanic/Latino students pursuing health profes-
sions and sciences. This situation overly affects
Hispanic/Latino students because they are more
likely than non-Hispanics/Latinos to come from    '

lower economic circumstances. There are immedi-
ate needs for more or expanded scholarship
programs, low-interest loans, and effective loan

  Another aim proposed by this Work Group
was the equitable allocation of technical assistance
and financial resources to Hispanic/ Latin0 health
professionals within DHHS, and, by extension, to
the State health agencies. Implementation strategies
considered for this aim include a mechanism for
reviewing and revising DHHS fiscal reporting to
enable a clearer picture of Hispanic/L.&no health
professional employment practices and monies
targeting Hispanic/Latino health issues and His-
panic/Latino researchers. There must be increased
participation of Hispanics/Latinos in study groups,
advisory boards, councils, and task forces within
DHHS.

Vision

repayment programs. Scholarships, in particular,       Our next important issue was career develop-
have a greater impact for low-income Hispanics/    ment and faculty advancement. The aim proposed
Latinos, because they require no payback. The     here is an increased representation of Hispanics/
availability and accessibility of these measures or     Latinos in advanced career and faculty level posi-
programs should be readily disseminated to indi-     tions in health professional schools and other health-
viduals, their families, and their teachers. Further,    related organizations. To this end, a well-defined
this information needs to be given in a format that is   plan to promote Hispanics/L.atinos in upper

easily understood by the target audienceLunfortu-
nately an audience that is likely to be overly familiar
with a low-income lifestyle and, as a corollary,
whose family heads have lower levels of education.
  Coordinated efforts among the private sector
and local, State, and Federal groups to improve the
academic preparation of Hispanic/ Latino students
can have a profound effect on the number of
Hispanic/L&no students entering and successfully
completing health professional training and
education. Examples of these efforts include
kindergarten through 12th grade (K- 12) science
education taught in part by health professionals,
sessions between health profess@als and students
along with their parents and teachers/counselors,
site trips by K-undergraduate students to health
centers or clinics, student-faculty/private practitio-
ner mentorships, medical research laboratory
training programs, articulation between 2- and 4-
year colleges with health professional schools, and
on and on.


, 4 4 4 4 4 4 o o o o 4 4 4  Work Group Presentations

,,,anagement, policy, and research positions, with
d11 accompanying reporting and review system,
&ould be implemented.

  Effective methods for addressing deficiencies
in he hiring and promotion policies affecting
Hispanics/htinos in schools for the health profes-
sions are needed. The Disadvantaged Minority
Health Improvement Act should incorporate funded
programs that assist in increasing the currently very
Iow numbers of Hispanic/Latin0 faculty in health
professions schools. These programs can include
preparation enhancement as well as incentives to
the schools. With a changing focus of faculty
responsibilities in the 199Os, there also is a need to
rectify the balance among research, training, and
service in relation to the tenure and promotion
process for faculties. Community and clinical
service should carry with it valid credit towards
faculty tenure and promotion. Equitable research
funding should target Hispanic/ Latin0 health issues
and Hispanic/Latin0 researchers, i.e., New
Investigator Awards to Hispanic/Latin0 researchers.
The latter will require the tracking of the number of
grants and contracts by Hispanic / Latin0 researchers
that have been submitted, approved, and funded by
DHHS, along with the amount of technical assis-
tance provided by the granting agencies. An
effective mentoring system for junior Hispanic/
Latin0 faculty members should be routinely
available and accessible.

  In addition, there is a major need for in-
creased Hispanic/L.atino representation across the
hoard in local, State, and national policy and
decision making groups such as panels, task forces,
COUP&, and advisory committees. This aim can be
implemented more effectively by the development
of a current, centralized information bank of
talented Hispanic/Latin0 health professionals that
would serve on the above groups.   \
  The hi issue to highlight deals with licensure

and institutional accreditation. It is readily apparent
that there is a lack of culturally relevant input in the

licensing/certification process and in the accreditation
of health professions schools. One of the aims targeting
this issue argues for the incorporation of cultural
diversity standards relevant to HispanicsLatinos in the
accreditation process. The implementation of this aim
is in three steps: communication of these needs to the
accrediting body; placement of culturally diverse issues
in the curriculum and before faculty forums; and a
monitoring of implementation strategies in terms of
action and outcomes. Another aim is to increase the
representation of I-Iispanics/L.atinos in the test develop-
ment processes that are used for licensing and certifica-
tion of the various health professions. This aim can be
implemented by having listings of Hispanic/Latino
health professionals that can be selected by accrediting
and licensure committees, working constructively with
the health professions examination boards to determine
culturally biased and inappropriate test questions. The
last aim for this issue points to the enhancement of
entry of foreign-educated Hispanic health professionals
into the health service delivery system. Implementation
of this aim can be generated from innovative programs
and funding mechanisms to assist, train, and retrain
foreign-educated Hispanic/Latin0 health professionals
to practice in the United States.

   Health

Promotion
and Disease

Prevention

Health Promotion and
Disease Prevention

Elsa M. Garcia, R.N., M.H.A.

Humana Michael Reese Health Plan

Problem/issue one is that there is a lack of data on
knowledge, attitudes, practices, and utilization of
screening services by the Hispanic subgroups, and a
lack of research on new HPDP [Health Promotion
and Disease Prevention] strategies targeting Hispanic
subgroups. So we need some information on
mortality and morbidity, and that must be imple-
mented keeping in mind two aims. One, we want
policies that would establish and maintain a compre-
hensive and uniform Federal, State, and local

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Work Group Presentations   + 44444444444

Health

Promotion
and Disease

Prevention

database on HPDP, comparable to non-Hispanic/
Latin0 databases, by various Hispanic/Latino
populations. Two, research programs that are
initiated, utilized, and disseminated at the commu-
nity level for various Hispanic populations must be
established and expanded. The strategies are ( 1)
establish a body that will monitor and implement
the goals of HPDP and advocate community-based
organizations and funding for such programs;
(2) monitor agencies that are responsible for data
collection and hold them accountable by including
Hispanics on review panels, study sections, public
health services, advisory councils, and work groups;
(3) specifically target Hispanic/Latino funding
initiatives, and that may mean new funds and
reallocation of present funds; (4) establish, imple-
ment, and monitor Hispanic-specific component
objectives in all Heafrhy Peopfe 2ooO prevention
priority areas with a specific focus on those affecting
Hispanic youth-they are our future; (5) establish
culturally sensitive and appropriate methods for
surveillance and for other data collection processes;
and (6) establish, expand, and share the data
networks that assist all research and community-
based organizations.

  Problem/issue two is the lack of organiza-
tional development, education, and training
programs; lack of HPDP curriculum in local
schools; lack of multidisciplinary approaches to
HPDP curriculum development; lack of leadership
training in HPDP; and institutionalized and indi-
vidual racism, which is a barrier to delivery of
services and professional development.

  The desired aims are to (1) increase the
capacity of Hispanic CBOs [community-based

organizations] to provide prevention service
programs; (2) develop Hispanic-specific educational
curricula and role models in prevention and primary
care and in teaching and research, and recruit and
retain an emerging majority in the HPDP field; (3)
develop a Hispanic cross-cultural and multi-
disciplinary curriculum in HPDP; (4) increase the

pool of Hispanic preventionists and increase the
capacity of non-Hispanics to better serve Hispanics.
  The strategies to meet those aims are
(1) develop partnerships among training institu-
tions, CBOs, and national Hispanic agencies to
empower communities in the area of HPDP and
service programs; (2) mandate all public organiza-
tions and institutions receiving Federal, State, and
local funding to develop cross-cultural, multi-
disciplinary HPDP curricula to recruit, train, and
retain Hispanics and other appropriate role models
who will teach and conduct research in HPDP and
return to provide HPDP services in their communi-
ties; (3) provide incentives such as tuition and loan
forgiveness programs, and fmanc& benefits for
Hispanics in underserved communities; (4) develop
training and sensitization work groups to deal with
the "isms" (e.g., racism) on individual and institu-
tional levels; and (5) develop continuing education
programs for health professionals delivering
preventive health services to Hispanics.
  Problem/issue three is the lack of culturally
sensitive and population-specific primary prevention
programs. Our aims are (1) to develop and evaluate
Hispanic models and approaches: clinics on wheels,
bilingual outreach programs, prevention programs
focused at traditional and nontraditional families and
targeted Populations; (2) to develop community-
based programs; and (3) to develop a short- and
long-term prevention strategy for communities at


+ + 4 4 4 4 4 4 4 4 4 4  Work Group Presentations

risk of environmental hazards and/or communicable
.,J &onic diseases. The strategies are (1) to build on
~~ontraditional methods to access care-nursepracti-
tionen ti the field, dental hygiewd tap into
hog resources; (2) to establish linkages of CBOs with
universities and the private sector and lay people in the
community; and (3) to identify, educate about, and
intervene in public health issues early through
coInmunity coalitions.

  Problem/issue four is the lack of systematic
response to the full range of preventive services to
Hispanics. The aim is to develop, implement, and,
where appropriate, reinstitute culturally relevant
and comprehensive preventive services. The
implementation strategies are, first, to increase the
use of community settings, such as churches,
community centers, and schools, for delivery of
primary care and preventive services; second, train
bilingual and other staff to be culturally sensitive
and competent in the delivery of services, and this
involves the family; third, recruit and use commu-
nity leaders, including HIV-infected individuals who
want to go back and talk to their communities about
what they've gone through; and fourth, require
evaluation to be built into the service delivery
programs and ensure that evaluation is conducted by
Hispanic professionals.

Frank Beadle de Palomo, M.A.
Director, NCLR Center for Health Promotion
National Council of La Raza

Continuing with that, we have the ftith problem/
issue statement, which is a lack of public and private
partnerships in HPDP programs for Hispanics/
Latinos. We're constantly hearing about the
shortage of money in the public sector, that there is
a scarcity, and that there is not enough funds
allotted for us to do the kinds of programs we want,
so we need to encourage and get private industry to
become more involved.

  Our implementation strategies for this aim
would be (1) to establish guidelines for Hispanic/
Latin0 CBOs and national organizations for accepting
corporate contributions that are compatible with
HPDP programs; (2) to obtain corporate, non-disease-
promoting industry sponsorship and funding of HPDP
programs for Hispanics/Latinos, who represent a
significant sector of their market; (3) to create and
enhance a strong Hispanic/Latino HPDP information
network and clearinghouse via public and private
partnerships; (4) to develop regulations that mandate
private and nonprofit institutions, including universities
serving Hispanics/Latinos, to ensure participation in
decision and policymakiq and service implementation;
and (5) to encourage the creation of a national
Hispanic/L.atino philanthropic federation with
representation of the grassroots level of the Hispanic/
Latin0 community.

  Health

Promotion
and Disease

Prevention

  The sixth problem/issue statement deals with
the lack of Hispanic/L&no health professio,nals in
decisionmaking and leadership positions and in the
fields. We cannot affect policies and we cannot
change the current system unless we're able to
make those decisions. Our aim is to increase the
recruitment, training, and retention of Hispanic/
Latin0 health professionals in the administration and
management of HPDP programs in the private and
public sectors. Our strategies are (1) to establish a
creative, comprehensive Hispanic/Latino-specific
HPDP mentorship program for research, teaching,
and community interventions and for training
mentors; (2) to procure scholarships for training the
Hispanic/Latino leaders in HPDP programs; (3) to
increase the number of and funding for Centers of
Excellence for Hispanic/Latino health professions
with an increasing emphasis in HPDP; and (4) to
enforce existing Federal and State mandates to
ensure Hispanic/L&no opportunities in higher
education, such as faculties, boards, and manage-
ment. To do this, we would encourage PHS to
develop incentives for primary care providers

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Health

Promotion
and Disease

Prevention

One

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Work Group Presentations  4444444444444

serving hardship areas and to ensure that organiza-
tions serving Hispanics and Latinos have at least 12
months' experience in working with the Hispanic/
Latin0 community and that at least 50 percent of
their board members are HispanicLatino, with
Hispanics/Latinos in key administrative and
program staff positions.

  The seventh problem/issue statement deals
with a lack of binational United States-Mexico
health cooperation. Our desired aim is to develop,
expand, and maintain cooperative efforts in envi-
ronmental and HPDP areas among countries in the
Americas: Mexico, Central and South America, and
the Caribbean.

  Implementation strategies are ( 1) to target all
HPDP strategies that apply to Hispanic/Latino
prevention efforts to the aim of this issue and (2) if
the North American Free Trade Agreement
becomes policy, make health, including environ-
mental issues, a critical element in the regulation
and implementation of such policy.

  The eighth problem/issue statement-there's
a lack of constituency for Hispanic/Latino political
advocacy in the health arena. We need to build a
political constituency for HPDP programs to exist.
Our strategies would be (1) to build community
and working relationships with Hispanic/ Latin0 and
other appointed elected officials and national
organizations, (2) to develop and build a Hispanic/

Latin0 constituency to counter disease-promoting
industries, and (3) to develop a consensus with the
Hispanic/L.&no community for acceptable univer-
sal standards of primary care.
  The ninth problem/issue statement-there's
a lack of diffusion of culturally relevant HPDP
programs. There might be some fantastic programs
that exist in one State or in one community, but
other places don't know about those. Or, it's
difhcult to replicate these programs. Therefore,
our aims are to identify, showcase, and disseminate
successful HispanicLatino HPDP models, and to
develop strategies to fund these successful models.
Our strategy is to establish mechanisms and
procedures by which all prevention-related RFPs
have Hispanic/ Latin0 community input and to
appoint Hispanics/Latinos to review proposals.
  And our last issue is the lack of media
awareness and sensitivity to Hispanic/L&no health
and HPDP issues. Our desired aim is to increase
media's awareness of the Hispanic/Latino health
issues and the media's role in disseminating infor-
mation on HPDP. Our strategies are, first, to
develop an agenda for workshops and training for
media representatives to become actively involved
in health promotion and disease prevention; second,
to develop community-based training programs in
media advocacy; and third, to capitalize on market-
ing media and health promotion.

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o + 4 4 4 4 4 4 4 4 4 4 4 4 4 4  Closing Remarks

Chapter 6: Closing Remarks

Antonia Coello Novello,
M.D., MXH.

Surgeon General
Public Health Service

U.S. Department of Health and Human Services

Buenas tardes. Here we are, fmally, after 3 days of
intensive participation at this landmark National
Workshop on HispanicLatino Health: Implemen-
tation Strategies. To say that it has been quite a
Workshop is an understatement. It has been for
me, and I hope equally for you, 3 of the most
memorable and productive days of my term as
Surgeon General-

m Three days in which all of us have discussed
and debated, analyzed and strategized,
synthesized and prioritized.

o Three days in which you have risen to the
challenge I gave you on Monday, that is, not
to "let the laurels rest with a few" but to strive
for unprecedented achievements for us all.

* Three days in which we have been TODOS
UNIDOS, as one, for the very first time, and
it is my hope that it will be for always.

  m Three days in which, to "cut through talk and
  get us action," you brought your feelings and
  anger where they were needed, left your egos
  at the door, made use of the best we all have
  to offer, and spoke with one voice.
  In these 3 days, we have also been informed
and enlightened as never before. Our invited
speakers have responded to both our collective
identity and our badges of individuality. We have
heard from the top experts in this country on
everything from who we Hispanics/Latinos are,

where we come from and where we live, to how
much we have grown, how old we are, who goes to
school, what we do and what we earn, and how
many of us fall into the "haves" and how many fall
into the "have nets." And we have listened with the
urgency of those who, knowing our reahties for so
long, must acf nuIw to secure a place for oul;selves,
our communities, and especially for our children.
  For the longest time, we have been
told that-

m We Hispanics/Latinos number 22 million
(10 percent of the U.S. population), and by the
year2OOO,therewillbe31millionofus-the
single largest and youngest ethnic minority in the
United States. Yet amazingly, it was not until
1989 that the model birth and death certihcates
included a Hispanic/Latino identifier.

* Sixty-seven percent of us were born in the
United States, and we represent many nationali-
ties. Weliveinvirtuahyeverypartofthis
country (primarily in urban areas) but are
concentrated in seven States. In California and
Texas, one in four people are Hispanic/L.atino.

* We also compose 5 percent of the elderly
population, have the highest fertility rates in
the country, and have larger families than
non-Hispanics/L.atinos. Many of these
families are headed by a single female.

B  We have the lowest educational attainment in
the country, we are among the country's
poorest people, and we are less likely to be
homeowners than others.

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8 We suffer disproportionately from many
diseases and medical conditions, and about
one-third of us lack health insurance, even in
the presence of an employed adult in
the family.

  As I have said, these facts portrayed our
sociodemographic and economic realities and
showed who we were only yesterday. These facts
underscored the point that many of the problems
we face as Hispanics/ Latinos reflect the educational
and economic disparities that we have heard about
throughout this Workshop, and throughout
our lives.

  Now, you might say, `What's new?" I can tell
you that the latest data we have learned in just these
past 3 days have done more than corroborate what
we knew only yesterday. Aside from being clearer,
broader, varied, and more precise, they have also
added a sense of urgency in that we have very little
time left to rehearse--an urgency to remind the
American people that Hispanics/ Latinos are
22 million voices who need to be accounted for and
counted in!

8 For example, by the year 2050 the Census
Bureau predicts that the Hispanic/ Latin0
population will increase to between 74 and
96 million people, which means that almost
one-fourth of the people in this country will
be of Hispanic/Latin0 descent.

o Next, as a group, we are becoming the
youngest minority: 35 percent of Hispanics/
Latinos in this country are under 18. In
contrast, only 26 percent of non-Hispanics/
Latinos are under 18.

a ln 1992, 11.3 percent of HispanicsILatinos
were unemployed (as opposed to 7.5 percent
of non- Hispanics/ Latinos and 6.5 percent of
whites), with Puerto Ricans, Mexicans, and
those of Central and South American descent
having the highest unemployment rates among
Hispanics/Latinos.

u Hispanics/Latinos are more likely to be
employed in lower pay&g, less stable, and

more hazardous occupations than
non-Hispanics/Latinos.

* Among Hispanic/Latino men, a large number
(28 percent) are operators of equipment and
machinery, and only 11 percent are in the
managerial/professional. fields. Among
non-HispanicILatino men, only 19 percent
are equipment operators and 27 percent are
in the managerial/professional fields.

m Among Hispanic&&no women, the majority
(40 percent) fall into the technical/sales
fields, which is not far behind the 4.5 percent
of non-Hispanic/L&no women in those
fields. However, only 16 percent of
Hispanic/L&no women hold managerial/
professional positions, in contrast to
28 percent of non-Hispanic&&no women.

m Sadly, too many of our families and our

children live in poverty. The median family
income for Hispanics/Latinos is $23,000,
compared with $37,000 for non-Hispanics/
Latinos in general and $39,000 for
non-Hispanic/Latino whites.

o In 199 1, 26.5 percent of Hispanics/ Latinos in
this country were living in poverty, compared
with only 10 percent of non-Hispanics/
Latinos and 7 percent of non-Hispanic/Latin0


lvhites. Puerto Ricans were found to be the
poorest, with 35.5 percent living below the
pove~~ line, and Cubans are the least poor.

. Close to 41 percent of Hispanics/Latinos
under 18 years of age live in poverty, in
marked contrast to only 13 percent of
non-Hispanic/Latin0 youth. And 2 1 percent
of Hispanic/Latin0 adults, including the
elderly, also live in poverty.

. 0~ school dropout rates are cause for concern:
only 5 3 percent of Hispanics/ Latinos have
completed 4 years of high school, in contrast to
82 percent of non-Hispanics. And only
9 percent of Hispanics/ Latinos have attended
4 or more years of college, as opposed to
22 percent of non-Hispanics/latinos.
* Currently, only 850,000 Hispanics/Latinos
are enrolled in colleges and universities.
About half are enrolled in Hispanic-serving
institutions of higher education. Of the total
number of Hispanic/Latin0 college students,
22 3,000 are enrolled in California; 148,000
in Texas; and 150,000 in Puerto Rico. This
means we actually have only 229,000 enrolled
in the remaining States.

  We also learned that, because of limited
resources, the forthcoming National Health and
Nutrition Examination Survey (NHANES III) will
report only on non-Hispanic/L&no blacks,
non-Hispanic/Latin0 whites, and Mexican Ameri-
GUS. In other words, we have made progress-
now there is some Hispanic/Latin0 representation in
the National Survey, but two categories covered in
the previous HANES, Cuban American and Puerto
Rican, will not be covered.

  In the same vein, the lack of Hispanic/Latin0
identifiers in 20 States, uncertain reporting in
30 others, samples too small to use for analysis, and
a I O-year gap between data collection worsen the
picture. Moreover, we have learned that, ironi-
cally, those of us under the poverty line who happen

to be staying together as a family put ourselves at
risk for Medicaid coverage. And sadly, many of us
still use the entrances of emergency rooms rather
than the doorways of primary care providers.

  My friends and colleagues, these are the grim
facts as we know them today; they provide an
urgent reminder that we can't wait until tomorrow
to take action. During this Workshop, we have
strived to address these realities and to find the best
solutions to secure our futures. In the presence of
so many negatives, let us not forget that all is not
bad-regardless of the stereotypes that so many
have used as artificial barriers to keep Us fro&-what
is rightfully ours. For, contrary to what others
may say-

We are not found "sleeping under a palm tree
or dancing the night away." In the last
7 years, the number of Hispanic/Latin0
elected officials has increased by 30 percent.
They are represented in States nationwide-
on school boards, in city councils, in State
legislatures, and in Congress, where
13 members are Hispanic / Latino. And
contrary to the perceived "machismo,"
22 percent of our elected officials are Latinos.
We come from many countries, but America is
our home. Patriotism is one of our strongest
traits, along with a strong work ethic, loyalty to
family, and religious faiLvalues that are
identified as typically American. I remind you
that Mexican Americans have the highest
proportiorrof Congressional Medal of Honor
winners of any ident&ble ethnic group.
We are much more than Chiquita Banana and
Juan Valdez, I assure you. If anyone has any
doubt, just tell them to take a good look
around at the faces, the credentials, and the
achievements of the men and women in

this room!

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Colegas, let us now get to the heart of why

we have worked so earnestly in these past 3 days:


Closing Remarks  4444444444444444

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to develop the blueprint of our national Hispanic/
Latin0 health agenda for years to come. What have
we concluded? Which of these concerns are our
greatest priorities? What are our aims? How do we
overcome some of these disparities? What imple-
mentation strategies will have repercussions for
decades to come? Where do we start?
  We came to this Workshop to discuss five key
issues: access, data collection, representation,
research, and health promotion and disease
prevention.

  Let me now highlight for you some of your
key findings regarding these issues.

a With respect to access, we should aim to
develop more comprehensive health insurance
coverage that promotes an integrated system
of care and service delivery--coverage that is
affordable, accessible, open to choice, secure,
with easy enrollment, nonbiased to preexist-
ing conditions, with broad coverage eligibil-
ity, and most important, culturally responsive
and culturally responsible. In addition, health
care centers and primary care services must
be linked to consumer and community needs.

= With regard to data, you attested to the fact
that data for HispanicsKatinos are either
unavailable or inaccessible, but data are in
critical demand. You expressed the need to
include all subgroups of HispanicsKatinos in
all pertinent Hispanic/L&no data. These
data should be high-quality, precise, timely,
and culturally sensitive in their design,
collection, and analysis. They must be
analyzed and standardized for use in under-
standing Hispanic/Latino health concerns,
and they must be coordinated appropriately
among Federal and State agencies.
Regarding representation, you agreed that
there were insufficient numbers of people,
programs, and finances for the entry,
retention, and graduation of Hispanic/Latin0

health professionals. You also expressed the
need to increase the participation of
Hispanic/Latino professionals in the
admissions process, train such personnel in
cultural diversity, and employ consistent
definitions of Hispanics/Latinos for admission
criteria to health professions. Moreover, we
must increase, where appropriate (or include,
where lacking), the number of Hispanic/
Latin0 health professionals in faculties, at
advanced level career positions, on
decision-making bodies, in the licensing
certification process, and in health
professional school accreditations. Likewise,
all PHS programs should'be e&luated on the
basis of recruitment, retention, and
representation of Hispanics/Latinos in
independent research grants. We must also
increase the number of Hispanic/Latino
Centers of Excellence to broaden their base,
and we must evaluate them accordingly. We
must provide greater support early in the
process to our families, teachers, and students
and offer more in the way of mentorships.

n In addressing research, you agreed that
research relevant to the health of Hispanics/
Latinos is extremely scarce. We must
develop the appropriate infrastructure and
capacity to conduct such research, as well as
culturally appropriate research theories and
methodologies. We need greater numbers of
Hispanics/Latinos in all fields of research, and
we must recruit, train, and retain Hispanic/
Latin0 scientists throughout PHS.

* With regard to prevention, you agreed that
we lack a systematic response to the full range
of preventive services for Hispanics/Latinos
and that we must have more Hispanic/Latino
professionals in decision-making and leader-
ship positions in the prevention field.
We also lack data on knowledge, attitudes,


practices, and utilization of screening services
by Hispanic/Latin0 subgroups. In addition,
the Healthy People 2000 objectives have
neglected to address multiple health issues
that are relevant to Hispanics/Latinos. YOU
agreed that our efforts in health promotion
and disease prevention must be culturally
relevant. Also, we need to awaken the media
to increased awareness and sensitivity to
Hispanic/Latin0 health and prevention issues.

  Although these are only highlights of what you
have produced, TODOS, together, our many voices
arc already speaking in one choir to amplify our
single most important goal: that people from every
cultural and ethnic group shall be empowered to
contribute, not only to themselves but to the
common good of all Americans. More important,
our mutual efforts speak to the fact that government
a/one cannot be responsible for our future. We
must chart our own destiny. And today, proceed-
ing as one body, we have taken the first steps to
secure a place for the next generation.
  In 3 days, we have communicated, reached
out, spoken out, and learned to pool our collective
wisdom and skills in a proactive, unified effort. As a
group, we have contributed to making this country
even stronger, and we have enriched the lives of
those who may not even know of our existence.

  When we leave here later today and disperse
across this country, let us remember this day, not as
the end of a Workshop but as the beginning of a
new solidarity, a new tradition of caring for all, a
new opportunity to involve leaders at all levels of
government, a renewed sense of empowerment to
let us claim our most basic needs, and an overriding
goal for all Hispanics/Latinos: to convey to
America who and what we are.
  My friends, the time to act truly is now. A
generation is watching and waiting. We must act
while we have the support of those at the top, the
support of our colleagues in all professions and
disciplines, and the support of our con&m&fees,
our families, and our friends. And come what may,
mis queridos colegas, you will always have the
support of your Surgeon General.
  As we work together in the coming months
and years, let knowledge, imagination, dignity, and
fairness chart our path for the future. But let us also
remember that, without our health and without our
education, we will have very little to offer to this
country in the years to come.
  Lideres de1 futuro: Let us move forward,
toward a future brimming with health. In the end,
I can tell you, we shall also overcome. May God
bless you all.

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Chapter 7: Regional Health Meetings

Introduction

Tbe Regional Health Meetings, conducted as the
second phase of the Surgeon General's National
Hispanic/Latino Health Initiative, were planned
with the recognition that, if the Initiative is to
achieve its goals, action must be taken at the
regional, State, and local levels as well as at the
national level. Thus, the Surgeon General selected
five geographically dispersed sites in cities that
have high concentrations of Hispnic/Lati~
Populations-Miami, Chicago, San Antonio,
New York/Newark, and Los Angeles-to hold the
meetings. These sites were chosen to focus on the
specific needs of Hispanics/Latinos in all 10 Public
Health Service (PHS) regions of the country (see
map), to reach the largest possible number of
Hispanics/~atinos within various regions, and to
target specific subpopulations within the Hispanic/

htino com.mmity-those of Cuban and South
American descent in Miami; multiple groups,
including migrants, in Chicago; Mexican-Americans
and those from Central America in San Antonio;
Puerto ~icans in New York/Newark; and Mexican-
Americans and migrant groups in Los Angeles. The
five meetings were held on the following dates:
* Miami: March3-4,1993 `-

. Chicago: March 11-12, 1993
D San Antonio: March 22-23, 1993
m New York/Newark: April 14-16,1993
D Los Angeles: April 19-20, 1993

In keeping with the goal of creating and
strengthening State and local partnerships for
addressing the health needs of Hispanics/Latinos,
Dr. Novello sought the assistance of the PHS
Regional Health Offices and numerous other groups
in planning and conducting the meetings.

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-
o Regional Ofkes
A Regional Meeting Sitn


Fist, from the national Executive Planning Com-
mittee, she selected regional Co-Chairpersons for
each meeting:

Ramon Rodriguez-Torres, M.D.,F.A.A.P.,
F.A.C.C.
Chief of StaR
Miami Children's Hospital
Sara Torres, R.N., Ph.D.
President

National Association of Hispanic Nurses
Aicla L. Giachello, Ph.D.
Assistant Professor
University of Illinois-Chicago
Steven Uranga McKane, D.M.D., M.P.H.
Program Director
W. K. Kellogg Foundation
cirov.suma~uD.
Associate Dean, Affiliated Programs and
Continuing Education
Director, South Texas Health Research Center

Paula S. Gomez
Executive Director
Brownsville (Texas) Community Health Center
Marilyn Aguirre-Moha,Ed.D.
Assistant Professor
Robert Wood Johnson Medical School
Carlos Perez, M.P.A.
Area Administrator
Office of Health Systems Management
New York State Department of Health
Castulo de la Rocha, J. D.
President and CEO
AltaMed Health Services, Inc.
Helen Rodriguez-Trias
President

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American Public He&b Association

  To support the regional Chairpersons,
Dr. Novello organized regional Executive Planning
Committees of approximately 25 members each,
with representation from the national sponsors and
co-sponsors and from leaders of local Hispanic/
Latin0 communities. The Executive Planning
Committee members recommended participants,
attended regional planning sessions, and provided
ongoing advice to the Chairpersons, their Vice
Chairs, and the Department of Health and Human
Services (DHHS) Regional Project Officer about

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the planning and development of the meetings.
The regional Executive Planning Committee
members are listed in Appendix C.
  In addition, more than 100 diverse public- and
private-sector organizations co-sponsored or provided
support at the local level to the five Regional Health
Meetings. These organizations represent departments
of health, academia, the media, the insurance industry,
reseamh institutions, community services providers,
and other business and indusu-y groups. These
organizations are listed in Appendix D.
  More than 975 participants-including health
care decisionmakers in Federal, State, and local
governments; religious leaders; experts in data
collection systems; leaders in the fields of education
and service; and advocacy groups-attended the
five meetings. As in the National Workshop,
participants were divided into Work Groups to
address the five areas crucial to HispanicLatino
health: improved access to health care, improved
data collection, development of a relevant and
comprehensive research agenda, increased repre-
sentation in the health professions, and health
promotion and disease prevention efforts. The
Work Groups were charged with (1) identifying
priority problems/issues for each area of concern
and (2) developing aims and accompanying imple-
mentation strategies to address each problem/issue.
At each meeting, a spokesperson for each Work
Group presented the Work Group's findings in a
closing plenary session. Key government officials
and experts in Hispanic/Latino health expressed
their support by speaking in plenary sessions.
  The Endings of the Work Groups in the
Regional Health Meetings reveal a similarity of
priorities and implementation strategies across
regions, The participants of all Regional Health
Meetings unanimously concluded that, despite many
innovative activities currently under way within
each region, much remains to be accomplished
within the five key areas of concern in promoting
Hispanic/ Latin0 health care.


Although Work Group priorities and sug-
gested implementation strategies were categorized
by the five key areas, many cross-cutting issues were
identified, including the need for funding; Hispanic/
~atino subgroup data, definitions, and culturally
sensitive identi&rs; an S-astructure for research on
Hispanic/I.&no health needs; tmining; and informa-
tion d&en&ration. These cross-cutting issues reflect
the interrelationships among the five areas. Like the
members of the national Executive Planning
Committee, the participants agreed that no one area
can he addressed in isolation; progress in one area
cannot be achieved without progress in the other areas.
  The identiRcation of number one priorities
in each area and the development of related implemen-
tation strategies resulted in oonsensus inmostareas.
Listed helow are the number one priorities iden&d at
the Regional Health Meetings.

m Access-Hispanics/Los across America
must have greater access to health care
coverage and services. Participants of all the
meetings identified the need for a universal
system of health care services and delivery as
the first priority strategy for improving access
to health care.

m Data-Data on Hispanics/J.atinos are now
either unavailable or inaccessible, but data are
in critical demand. AU five cities called for
Hispanic/L&no subgroup identifiers as a first
priority strategy for improving data collection.

. Research---Because research relevant to the
health of Hispanics/ Latinos is extremely
scarce, Hispanic/Latinos must be the subjects
of and the participants in more research.
There was no unanimity across cities for a
number one priority. Participanti in three of
the five cities identified the need for an
infrastructure for Hispanic/Latino research
and Hispanic/Latino leadership as the first
priority to advance the research agenda.
Other cities called for a Hispanic/Latino

infrastructure and power base; development
of appropriate Hispanic/Latino methodology,
theories, and models; and legislatively
earmarked funds as key strategies for intensi-
fying Hispanic/Latino research efforts.

. Representation-- Hispanics/ Latinos need
greater representation in the health profes-
sions. There are insufficient finances and
numbers of people and programs for the
entry, retention, and graduation of Hispanic/
Latin0 health professionals. There was no
unanimity across cities for a number one
priority. Participants suggested a variety of
activities, including educational financing and
preparation; Hispanic/Latin0 empowemqrt;
reduction of credentiahng obstacles for
foreign-educated professionals; and Hispanic/
Latin0 representation in certification and
accreditation policies as key strategies for
improving representation.

m Health Promotion and Disease Prevention-
Hispanics/ Latinos must become involved in
health promotion and disease prevention
efforts. There is a lack of a systematic
response to the full range of preventive
services for Hispanics/Latinos. There was no
unanimity across cities for a number one
priority. Participants recommended a variety
of activities, including Hispanic/L.&no data
collection and research; establishment of
more community programs and capacity-
building among existing programs; establish-
ment of advocacy networks; establishment of
public-private partnerships; and assessment of
available resources as key strategies for health
promotion and disease prevention.

one



Voice

  The remainder of this chapter provides summa-
ries of each of the five Regional Health Meetings.


one

Voice

The Miami Hispanic/ Latin0 Regional Health Meeting
                   I

The Brst Regional Heath Meeting was held at the
Hyatt Regency Miami Hotel in Miami, Florida, on

  March 3 and 4, 1993. Approximately
  225 participants attended.
    More than 2 million Hispanics/
Latinos live in Region IV, the largest percent-
age of whom are concentrated in Florida. Of
these 2 million people, more than 350,000

Mipmi live below the poverty level. Many
  Hispanics/Latinos in Florida are

typically unemployed, poor, and uninsured. In
addition, Hispanic/L&no migrant farmworkers in
the region are at risk for high infant mortality rates.

  Five Work Groups identified priority
Hispanic/Latino health issues and developed
implementation strategies for each issue. Following
is a discussion of top priority issues and strategies by
Work Group.

Access to Health Care
Priority Issue: Lack of an organized system of
health care access and delivery for all Hispanic/
Latinos at the local, State, and Federal levels.
Implementation %%ltegies:
o Implement a cost-effective universal health care
plan that includes undocumented persons.

o Implement a program producing public-private
partnerships to improve coordination and linkages
of health care services.

o Finance communi~-based health and social
services.

Data Collection

Priori9 he: No udorm Hispanic/Latino
identifier to capture ethnic heritage.
Implementation S-es:  ., -
o Involve community leaders to develop an
inclusive, global Hispanic/Latino definition for the
U.S. Census Bureau and other agencies; share this
definition to ensure standardized criteria, data
accessibility, and utilization.

o Establish linkages with government leaders to
ensure Hispanic/L&no participation in criteria
development and data collection.

o provide data collection form instructions that
ensure accuracy in the data collection process and
cultural sensitivity.

0

one



vii00

Antcmia CoeUo Novello, M.D.,
M.P.H.
Surgeon General
U.S. Public Health Service

Lydia E. SobTorrcs, M.D.,
lKP.EL
National Coordinator for the
Surgeon General's National
Hispanic/ Latin0 Health Initiative
Office of the Surgeon General

Olivia Carter-Pokrzs
Office of Minority Health

MatthewMurguia
Office of Minority Health
Betty Hawks
Office of Minority Health

Ramon Rodriguez-Tomes, M.D.
Co-Chairperson and Chief of Staff,
Miami Children's Hospital
Sara Torrez, R.N., Ph.D.
Co-Chairperson and President,
National Association of Hispanic
Nurses

Beaumont Hagebak
Vice Chairperson and Regional
Health Administrator for
Region IV
U.S. Public Health Service

Yvonne Johns
Minority Health Coordinator
for Region IV
Robert Rbera
Planning Liaison


/ + + + 4 4 4 4 4 4 4 4 4 4 4 4 Regional Health Meetings

Research Agenda

priority Issue: Lack of i&astructure relating to
educational institutions to promote relevant
research initiatives on Hispanic/Latino health issues.
Implementation StlategieS:
o Conduct research using priority funding to
support Hispanic/ Latin0 candidates from
elementary through post-graduate levels, thereby
ensuring a pool of potential Hispanic/Latino health
researchers and scientists.

o Establish a national clearinghouse network to
collect and disseminate Hispanic/Latino health
research and funding opportunities.
o Create a muItidisciplinary, national/regional task
force to institutionalize the process of establishing
Hispanic/Latino research priorities.

* Establish a Hispanic/ Latin0 professional
health journal.

Health Pmfessions

Priority Issue: Lack of Rnancing for education in
health and science professions.
Implementation Strategies:
o Finance HispanicLatino employee retraining
through private sector flexibility.
o Endow a chair for Hispanic/Latino faculty
members at colleges and universities.

o Establish service repayment programs, loans, and
scholarships at the Federal, State, and local level
specif&lly targeted for HispanicsLatinos.
o Establish an adopt-a-student program sponsored

by individual professionals.

o Develop HispanicLatino role models in
corporate-sponsored health and science professions.
o Examine the HispanicLatino-moded Minority
Access to Research Careers (MARC) model for
health careers.

o Reduce Hispanic/ Latin0 quahfying criteria for
workstudy programs.
o Financially support student expenses other than
tuition, including childcare, stipends, etc.
o Involve Hispanic/L.&no leaders at State and
local levels.

  Georgja

    FlOlidZl

  K=-b

-

NoebCaroIina

soudlcarolina


  T-

Health Promotion and Disease

Prevention

Priority Issue: Lack of health issues education
and awareness programs witbin the Hispanic
community.
Implementation Strategy:
o Request Federal and State funding for school
health education and prevention programs, health
care professionals' education for children, media
progmms, and Hispanic/Latino role model programs.

One

Voice

one



ViSiOO


Regional Health Meetings 4 4 4 4 4 4 4 4 4 4 4 4 4 4

The Chicago Hispanic/ Latin0 Regional Health Meeting

The second Surgeon General's HispanicLatino
Regional Health Meeting was held at the Westin

Hotel in Chicago, Illinois, on March 11 and
12, 1993. Approximately 24-O participants
  attended.

       More than 1.5 million Hispanics/
    Latinos live in Region V and nearly a
   quarter million live in Region VII. In both
regions, the past decade has wimessed the rapid
growth of the Hispanic/Latin0 populations. In
Minnesota, for example, the Hispanic/Latin0
population increased by 68 percent during the
1980s.

  Poverty stemming from low-paying jobs,
rather than unemployment, is the number one
reason that 23 percent of alI Hispanics/Latinos in
Illinois, as opposed to nine percent of the non-
Hispanic population, have no health insurance.
  AIDS, tuberculosis, neonatal infant deaths,
non-existent Hispanic/L&no data, and migrant
worker-related issues challenge both Region V and
Region VII. Despite the large numbers of migrant
farmworkers, migrant health issues continue to lack
any visibility.

one

Voice

  Seven Work Groups identified priority
Hispanic/L.&no health issues and developed
implementation strategies for each issue.  Follow-
ing is a discussion of tbe top priority issues and
strategies by the five major Work Groups.

Access to Health Care
Priority Issue: Lack of universal community
health system and health coverage.
Implementation Strategies:
o Ensure portability of services.
                    > -
o Develop a primary care infrastructure model.

o Ensure that the delivery system does not
discriminate based upon residency status.
o Develop a user-friendly system that includes
flexible hours of services and simplified, easy-to-
understand forms.

o Ensure that all programs receiving government
funding must demonstrate compliance with these
strategies.

Antonia Coello Novello, M.D.,
M9.E
Surgeon General
U.S. Public He&h Service

Lydia E. Soto-Ton-es, M.D.,
MP.E
National Coordinator for the
Surgeon General's National
Hispanic/Latino Health Initiative
Office of the Surgeon General
HazelFarrar
Office of Minority He&h

Aida L. Giachello, Ph.D.
Co-Chairperson and
Assistant Frofessor
Jane Addams College
of Social Work
University of Illinois at Chicago
Steven Uranga McKane, D.M.D.,
M.P.H.
Co-Chairperson and Program
Director
W. K. Kellogg Foundation
E. Frank Ellis, M.D., M.P.H.
Vice Mn and Regional
Health Adminisuator
for Region VII
U.S. Public Health Service

Julia C. Attwood, M.P.H.
Vice Chairperson and Acting
Regional HeaIth Administrator
for Region V
U.S. Public Health Service

Mildred Hunter, M.P.H.
Minority Health
Coordinator for Region V
Anita Satterly
Minority Health
Coordinator for Region VII


o Establish more uniform Federal forms and
?*????? Medicaid eligibility criteria across State
borders.

Data Collection

Priority Issue : Exclusion of Hispanics/Latinos in
data collection systems.
Implementation Strategies:
o Implement standardized data collection systems at
local and regional levels.
o Establish a data bank for the Midwest region.

Research Agenda
Priority Issue : Lack of cultural appropriateness
of research methodology.
Implementation Strategies:
o Validate research instruments and sampling methods
for the Midwest and for different s&populations.

o Take into consideration economic status of
Hispanics/Latinos in sampling.

Health Professions
priority Issue: Insufficient number and inad-
equate preparation of Hispanic/Latino students in
the educational system to pursue an education in
health and sciences.

Implementation Smgies:
o Encourage parental involvement by creating
models that are appropriate for individual locations.
o Control enviromnental factors that adversely
affect education such as violence, lack of safety,
gangs, and substance abuse.

o Identify high-risk students who are in danger of
dropping out of school at an early age.

o Establish appropriate intervention to keep
students in school and to encourage them to
graduate.

o Educate parents about and involve them in the
required academic preparation.

o Create partnerships between school, faculty,
health professionals, and health professions students
to provide role modeling, mentoring, teaching, and
health career exploration.

Health Promotion and Disease;
Prevention

Priority he: Inconsistent definition of
I-Iispanic/Latino ethnic groups and subgroups.

Implementation Str&egy:
Establish a health data collection system character-
ized by a urnform and consistent racial and ethnic
identifier. In particirlar:

o Develop I-Iispanic/Latino community actions to
request the establishment of procedures at the local,
State, and Federal levels.

o Advocate Federal legislation that mandates the
implementation of health promotion and disease
prevention (HPDP) in a standardized form.

o Establish advocacy groups that will make
community leaders and policymakers accountable
for implementing HPDP data collection.

o Train and educate providers as well as Hispanic/
Latin0 consumers on appropriate identification
procedures for data collection.

Mis.souri

Nebdu

  Ohio


Wisconsin

one

Voice


The San Antonio Hispanic/ L&no Regional Hedth Meeting

March 22 and 23, 1993. Approximately 160
participants attended.

   More than 5 million Hispani~/Latinos live in
Region Via million in Texas alone and one-half
million in New Mexico. Indeed, minorities constitute

  54 percent of the population in Region VI.
  Accesstohealthcarefortheunderservedisan
  ongoing problem in this region, especially along
     the Texas-Mexico border. Outbreaks of
    mberculosisandcholeraandahighrateof
anencephalic births are the most prominent health
risksafhecnngHispanics/Latinosofthisarea. In
addition, San Antonio ranks second in low educational
attainment of the 15 largest U.S. cities.
In Region VIII, there- are more than one-half
million Hispanics/Latinos-m ostofthemlivingin
Colorado. Approximately 43,000 migrant and
seasonal agriculd workers and their families live in
Colorado. These migrant farmworkers are among the
most deprived in the Nation, facing pervasive poverty,
unemployment, isolation, and alienation. Their
transience and inability to speak English severely

one



Voice

hampertheiraccesstohealthcare. Healthrisksfaced
in this region include diabetes, smoking, alcoholism,
andahighinfantmortahtyrate.

  Following is a discussion of top priority issues
and strategies identified by the Work Groups.

Access to Health Care

Priority Issue : Lack of universal health coverage.
Implementation Strategies:
o Conduct needs assessment of health coverage on
local level, where needed.

o Increase Hispanic/Latin0 participation in
decision-making processes regarding health care
service delivery.

o Standardize and streamline administrative forms to
decrease expenditures of human and fiscal resources
better allocated to service delivery.

Data Collection

prion'ty Issue: Need for Hispanic/Latino identifiers
at the national, State, and local levels for ethnic
subgroups, foreign-born, and migrant populations.
Implementation Strategies:
o Require all agencies authorized to collect health-
related data to include iden&m of ethnic subgroups.

o Require all agencies working with survey data to
draw adequate random sample sixes for statistical
accuracy*

o ??????????????????????? KEY PLANNER5  o ???????????????????????
Antoda Coello Novello, M.D.,     Ciro V. Sumaya, M.D., M.P.H.T.M.  En& Sloan, D.&W.
M.P.EL            Co-Chairperson and Associate Dean   Vice Chairperson and Acting
surgeon General          University of Texas HeaItb Science    Regional Health Administrator
U.S. Public He&b Service          Center at San Antonio        for Region VIII
Lydia E. Soto-Tones, M.D., M.P.H.   Paula S. Gomez              U.S. Public HeaItb Service
National Coordinator for the     Co-Chairperson and Executive     Sue Hammett, R.N., M.S., C.N.S.
Surgeon General's National          Director                HIV/AIDS Coordinator for
Hispanic/Latin0 Health Initiative   Brownsville Community Health      Region IV
Office of the Surgeon General         Center              Jane Win, M.S.
MatthewMurguia           James Dosz, M.B.A.        Minority Health Coordinator for
Office of Minority Health       Vice Chairperson and Acting       Region VIII
Donald Coleman           Regional Health Administxator
Office of Minority Health        for Region VI
                     U.S. Public HeaIth Service


o Earmark adequate funding for agencies to
incorporate identifiers of Hisptic/Latino groups
into data gathering procedures.

ResearchAgenda

Priority Issue: Lack of a Hispanic/L&no
research infrastructure.

Implementation Strategies:
o Develop specific PHS support programs for
Hispanic/Latino predoctoral and postdoctoral
training in behavioral and biomedical research to
eliminate underrepresentation.

o Develop programs directed to I-Iispti~/Latho
researchers to allow them to become better
equipped and to improve methodological expertise
in health-related research.

o Develop and fund PHS distinguished research
career programs to allow Hispanic/Latino
researchers to concentrate on research, writing, and
mentoring and to free them from the multiple
requirements and expectations commonly faced by
minority academicians.

o Assess the results of existing minority-focused
programs with respect to ~ispanic/L.atino students.
o Encourage professional associations to stimulate
Hispanic/Latino student involvement in research

careers.

Health Professions

Priority Issue: Lack of empowerment and
political influence in developing biomedical/health
education and delivery system.

Implementation Strategies:
o Increase Hispanic/Latino legislative and academic
representation and political system involvement
through Hispanic/Latino voter registntion and
political candidate evalmtions and recommendations.

o Increase academic involvement at the national
level through inclusion of Hispanics/Latmos in

national review boards of grant funding agencies
and in professional journal editorial boards.

o Increase involvement at the academic university
level by expanding the HispanicLatino presence
and involving Hispanic/ Latino faculty in decision-
making processes.

o Educate appointed and elected officials by
educating the Congressional Hiic Caucus and
the Boards of Regents members and by developing a
national lobby to promote the HispanWLatino
education agenda.

o Educate the public/community sector on issues
involving HispanWLatino education by ntilizing
mass media resources to market storytelling to
them, mobilizing community outreach, and
promoting inchssion by and use of institutional news
and information facilities.

Health Promotion and Disease
Prevention

Priority Issue: Lack of culturally sensitive and
population-specific comprehensive and systematic
approaches to clinical, community, and preventive
health programs, and lack of appropriate screening
and diagnostic procedures for HispanicsLatinos.
Implementation Strategies:
o Obtain interim strategy consensus from entire
Regional Health Meeting attendees.

o Request a Federal mandate for communi~
representation in regional health plans.

o Recommend immediate interim preventive
ambulatory care benefits package.

o Fund the creation of a national Hispanic/L.atino
multidisciplinary connnission to monitor policy,
create a sounding board, create a resource pool,
create a clearinghouse to disseminate information,
and conduct outreach using community resources.

  Arkansas

  coloIado


  LmCsiana


   Montana


New Mexico

NorthDakota

Oklahoma

South Dakota


    TIZXU

    Utah

Wyoming

one



voice

one



vision


The NewYork Hispanic/ Latino Regional Health Meeting

The fourth Regional Health Meeting was held at the
Radisson Hotel, Newark, New Jersey, April 14-16,
1993. Approximately 175 participants attended.
  ResidinginRegionsI,II,andIIIaremoxetban
7.5 million I-IiqmWLatinos who tend to be under-
employed, undereducated, and underimumd relative
to the rest of the population. Health risks endemic
   totbeHispauic/I.atinopopulationsintbese
   three regions include AIDS, espr&lly
   among women and children; a high infant
   mortality rate; andinadequate immuniza-
   tion. Unique to these regions, however, is
the Region I Puerto Rican and Cuban political
Dc reputation iu legislative and leader&p roles
  andintegmtedservicedeliveryprograms.
  Five Work Groups identiiled priority Hispanic/
Latin0 health issues and developed implementation
strategiesforeachissue. Followingisadisausionof
top priority issues and strategies by Work Group.

Access to Health Care
Priority Issue: Lackofa universal nonexchmonary
system e as a%ndable, accessible,
acceptable, and portable that offers integmted

comprehensive services, measures of cost containment,
easy enrolhnent and procedures, incentives, participa-
tion by recipients, and ouneach activities.

Implementation Strategies:
o Establish a health advocacy coalition involving
public and private providers and consumers in
Puerto Rico and each State with significant
HispanicLatino populations to review and develop
recommendations annually.

o Establish a methodology for accurately estimating
the cost of universal coverage.

o Create a national coalition to lobby on behalf of
Hispanic/Latino issues (e.g., National Hispanic/
Latino Coalition for a Healthy U.S.A.).

Data Collection

Priority Issue: Exclusion of HispanicsLatinos
from data systems.
Implematation strategies:
o Include ~-~ispanic/Latino subgroup identifiers in
all surveys and forms.

Anton& CoeIIo NoveIIo, M.D.,
MPWE.

SurgeonGeneral
U.S. public He&h Service

Lydia E. Sob-Ton-es, M.D., M.P.H.
National Coordiuator for the
Surgeon GeneraI's National
Hkpmic/Latino Health Initiative
Office of the Surgeon General
Olivia Carter-Pokras
Office of Minority Heahh

Pd JaCkSoIl

Office of Minority He&b
MarilynAgnhe-Molina,Ed.D.
Co-Chairperson and As&taut Professor
Robert Wood Johnson MedicsI school

Clubs Perez, M.P.A.
CO-chairpuaon and Ares
Admiu&rator of the Office of
He&b Systems Maqement in
the New York State Depsrtment
of Health

AndrewJohnson
Vice chairperson and Acting
Regional He&b Administrator
for Region I
U.S. Public Health Service

Raymond Portillo
Vice Chairperson and Acting
RegionsI Health Administrator
for Region II
U.S. Public Health Service

NormanDIttnum
Vice chairperson and Acting
RegionsI Health Admir%rator
for Region III
U.S. Public He&h Service

JanetLeeScott-Harris
Minority Heahb Coordinator
for Region I
Robert Davidson
Minority Health Coordinator
for Region II

Emory Johnson
Minority Heahh Coordinator
for Region III


o Tie FederaJ funding to data collection and reporting,
including undocumented Hispanic.s/Latinos.
o Encourage State Hispanic/Latino data collection
legislation.

o Share data collection, analysis, and dissemination
expmses between data users, including govemm~t.
o Define data collection purposes and establish
timelines.

o Include Hispanic/Latino data collection in
strategic plans such as Healthy People 2oo0, Minority
Health Activities, and Primary Care Access Plans.

o Expand the third National Health and Nutrition
Examination Survey sample to include Bndings from
the 1994 survey in New York.

o Enforce OMB Directive 15 and Public Law
94-3 11 among Federal agencies.

o Establish northeast regional Hispmic/Latio
health coalitions to monitor implementation of the
Surgeon General's National Hispanic/Latino Health
Initiative strategies.

ResearchAgenda

Priority Issue: Lack of a Hispanic/Latino
research infrastructure and lack of appropriate data
collection instruments, research Bndings dissemina-
tion, and Hispanic/Eatino-focused concepti
models and methodology.

Implementation Strategies:
o Provide Federal funding for practice-based
research networks and research capability at
community/migrant centers, mental health
facilities, and related facilities to generate
community- and patient-based health data.

.

o Expand programs and demonstration research
relevant to the Hispanic/L&no community in the
Northeast.

o Change Federal requirements to ensure more
inclusive definitions representative of the diverse
Hispanic/L&ho communities in the Northeast.

Health Pmfessions

Priority Issue: Ixuufkient numbers and inadequate
preparation of Hispanic/Lam~o students by the
educational system, kin- through undergradu-
ate, for pursuit of health professions education.
Implementation Strategies:
o Increase parental involvement through family
counseling, information dissemination, and en-
hancement of current programming.  ,
o Assist low-income families in their children's
educational planning.

o Ensure English language competency at early ages.
o Stimulate private-sector investment in educational
institutions with high mpanic/Latino populations, and
promote investment in scholarships and awards.
o Encourage Hisp anic/L.atino health professional
organizations to develop and provide mentor
programs.

o Increase student awareness of health career
opportunities.

Health Promotion and Disease

Prevention
Priority Issue: Increase and improve data
collection and research on Hispanic/L&no health
care issues.

Implementation Strategy:
o Develop effective and individualized marketing
strategies to promote health and prevent disease in
the Hispanic/L&no community.

o Increase the use of mass media and hotlines to
gather desired information on knowledge, attitudes,
and behaviors in the Hispanic / Latin0 community.

o ?*?????? ?????*? ? 1 vels for data collection.

   Delaware

      Maine

  Mvyland

Massdmetts

New Hampshire

  New J-Y

   New York

PUlUS$VaIlia

  Puerto Rico

  Mmdekland

    Vermont

   Virginia
viiginIdauds
Wachiqton, DC
West Virginia

One

voice

one



vision


The Los Angeles Hispanic/ Latino Regional Health Meeting

The f?fth Regional Health Meeting was held at the

L-  Westin Ronaventure Hotel in Los Angeles,

fJ%Jc&~~f;jg,~~~
                 `v' *          ,
     majority concentrated in Region Ix. In California
      (Region IX), for example, Hispanics/Latinos
       account for 25.6 percent of the total State
       population, and in Ariwna (also in Region IX),
      they represent the State's largest ethnic minority,

one



VOiCC

one



vii

with more than 32,000 migrant and seasonal
Hispanic/Latino farmworkers and their families.

  The Hispanic/Latino populations in Region IX
reflect a youthful community, with a median age of
26 to 28 ~WS. This CO~IUIXUC~ alsO has the highest
rate of poveq among any of the ethnic groups,
despite the fact that more than 78 percent of the
Hispanic/Latin0 population is working or actively
looking for work. One possible explanation might
be that most Hispanics/Latinos are employed in
low-wage manufactming, retailing, agriculture, and
service industries, with low wages and inadequate
benefits. In addition, Hispanics/Latinos face other
social/health problems, including poor nutrition,
heart disease and stroke, cancer, AIDS, high suicide

and alcoholism rates, diabetes, and high rates of
school dropout. Moreover, the number of minori~
clinicians has dropped sharply in recent years,
resulting in unmet health care service needs in many
communities.

  Hispanic/L&no-related issues of access to
care are among the most prominent concerns in
Region X, where the Hispanic/Latino population is
relatively small. These issues include problems
associated with the rural nature of some of the
States, including transportation and lack of health
care services. A striking pattern across Washing-
ton, for example, is the lack of timely prenatal care,
which can be directly atibuted to both problems.
Other social/he&h problems faced by the
Hispanics/Latinos of the region, who constitute a
large contingent of migrant workers, include a high
rate of births to school-age children, low rates of
childhood immunizations, poverty, high unemploy-
ment, and poor housing.

  Five Work Groups identified priority His-
panic/L&no health issues and developed imple-
mentation strategies for each issue. Following is a
discussion of top priority issues and strategies by
Work Group.

. . . . . . . . . . . . . . . . . . . . . . . . KEY PLANNER5  . . . . . . . . . . . . . . . . . . . . . . . .

Anton& CodI0 NoveIIo, M.D.,
MJJL
surgeon General
U.S. F'ublic Health Service

LydiaR!bto-Torres,M.D.,
lkP.FL
National Coordinator for the
Surgeon General's National
Hispanic/Latino Health Initiative
Office of the Surgeon General

BettyEtIWkS
Office of Minority Health
MarinScgrum,MB.
Office of Minority Health

C!astuIo de la Roeha, J.D.
Co-C&person and President and
Chief Executive Officer
AItaMed Health Services
Corporation
H&llRl&igU!Z-Trias
Co-chairperson and President
American Public Health Association

John D. Whitney
Vice Chairpemon and Regional
Health Administrator
for Region IX
U.S. Public Health Service

DOrothylMiUl&M.P.E.
Vice CL&person and Regional
Health Arhninkator
for Region X
U.S. Public Health Service

JoaeFnentes
Minority Health Coordinator
for Region IX
J. O'Neal Adams, M.P.A.
Minority Health Coordinator
for Region X


Access to Health Care
Priority Issue: Lack of universal, affordable
health insurance coverage and comprehensive
benefits for everyone.

Implementation Strategies:
o Ensure that special populations are covered under
Medicaid.

o Create new infrasnm3ures at various levels in
educational and governmental institutions that are
directed toward and sensitive to Hispanic/L.atin~
issues.

o Create a "seamless" health delivery system in
which all providers of primary care dealing with
special populations are included and supported.
o Encourage the incorporation of alternative health
care delivery systems that can effectively deal with
the needs of special populations.

o Recommend that service providers have con-
sumer representatives on their policymaking
boards.

o Ensure that traditional providers are placed on an
equal footing with other providers so they may
compete fairly in any new health care contracting
system.

o Give health purchasing governing boards the
flexibility to develop systems of care that reflect
local needs and priorities.

+ Ensure that quality of services is measured in
terms of bicultural, bihngual competency of
provider staff.

o Use different health settings as effective places of
health care and services.

Data Collection
Priority Issue: Lack of a universal ethnic
identifier.

Implementation Strategies:
o Develop community-based epidemiological data
that can complement and be compared with
hospital data.

o Improve collection of and access to current data,
and provide guidelines to users.
o Develop a centralized regional body that can
collect, analyze, and disseminate Hispanic/Latino
data.

o Include research data for health promotion and
disease prevention within the managed care system.
o Provide feedback to the Hispauic/Latino commu-
nities being analyzed.

Research Agenda
Priority Issue: Poor communication among
researchers and poor dissemination of findings.
Implementation Strategies:
+ Develop the capacity for HispanicLatino
research.

o Centralize and expand existing data banks.

o Develop a liaison with the Hispanic/L.atino caucus
to link research issues with immigration issues.

o Encourage bi-national collaboration.
o Promote collaboration among community-based
organizations, community clinics, and university
researchers in the design and execution of research
projects.
o Identify current data collection efforts and
demand that Hispanic/ Iatino ethnic identifiers be
incorporated.

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Health Pmfasions
Priority Issue: Lack of school counselors,
finding, programs, grants, and training to ensure
increased representation.
Implementation strategies:
o Increase the number of school counselors to help
decrease the dropout rate and ensure thorough
dissemination of financial aid to all Hispanic/Latino
students through identified counselors at each
institution.

o Hire elementary and secondary teachers who
better reflect the diverse ethnic population.
o Establish summer work program internships and
expand scholarship and loan programs.
o Provide awareness training on cultural diversity
issues to students, faculty, and staff at educational
facilities.

o Obtain data on trends and profiles of health
professionals to assist in health persome planning.

o Enhance the entry of foreign-trained Hispanic/
L&no health professionals into the health delivery
system.

o Ensure the availability of residencies and call for
national licensing standards with unrestricted
reciprocity.

Health Promotion and Disease
Prevention

Priori9 Issue: Need to build on the
nontraditional methods of access to care and need to
emphasize the importance of awareness, education,
early iden&cation, and intervention through health
promotion and disease prevention programs.
Implementation strategies:
o Provide home-based health education through
television and radio.

o Restrict negative promotional advertising.
o Create a Hispanic/Latino HPDP information
network and clearinghouse via a public-private
partnership.

o Increase the awareness of HPDP issues and
concepts among policymakers, community leaders,
and politicians.

o Enhance community capabilities in developing
targeted HPDP programs.

o Incorporate community workers into HPDP
models; recruit allied health professionals and
provide incentives to them.

o Use recent immigrants with skills in health
promotion in the workforce.


44444444444444  Priority Recommendations ,

Chapter 8 : Priority Recommendations

0 n April 22 and 23, 1993, the Executive Planning

Committee of the Surgeon General's National
Hispanic/Latin0 Health Initiative met at the
Madison Hotel in Washington, D.C., to review the
findings from the Surgeon General's National
Workshop on Hispanic/Latin0 Health and the five
Regional Health Meetings. During the past year,
the Committee had met three times to help guide
the activities of the Initiative and, thus, to help
create a unified Hispanic/Latin0 voice, TODOS, to
alert the Nation's leaders to the barriers that
Hispanics/Latinos face in receiving adequate health
cart. Members of the Executive Planning Committee
also served as Work Group chairpersons at the
National Workshop and as chairpersons to plan and
coordinate the Regional Health Meetings. At each
of the previous meetings, the Executive Planning
Committee members worked with hundreds of
other Hispanic/Latin0 leaders to identify, analyze,
and prioritize the issues and conccms with the
greatest implications for the health and welfare
of Hispanics/Latinos throughout the country.

  At this meeting, the Committee members
were charged with their final task-to determine
which of the recommended implementation
strategies will have the grcatcst impact for improv-
ing Hispanic/Latin0 health and to develop a
summary report of the critical rccommcndations
in each of the key areas:

= Access to health cat-c.

o Data collection stratcgics.

* Development of a rclcvant and comprchcn-
sive research agenda.

m Representation in the health professions,

  * Health promotion and disease prevention.
The Surgeon General, Dr. Antonia Novello,
challenged them to put their "collective reality" into
words that can be "bureaucratically understood."
She directed the Committee members to examine
the needs expressed in the recommended strategies,
looking for similarities across the board, and to
determine the strategies that are most feasible and
can best meet those broad-based needs. To guide
their deliberations, the Committee members were
asked to consider opportunities for action in
developing the report and to determine the strate-
gies that represent the best opportunities for action
in the following areas: representation of Hispanics/
Latinos and communication of their health needs,
development of policy to improve access to health
care, provision of resources to improve Hispanic/
Latin0 health status, public-private partnerships to
improve health care delivery, advocacy for Hispanic/
Latin0 health needs, and legislation that mandates
improved access and deliveT.

  During their deliberations, Committee
members from different regions related the special
health concerns that participants expressed at the
Regional Health Meetings. For example, a special
workshop on the health needs of migrant workers
was provided at the Chicago meeting. In San
Antonio, participants expressed concern about the
health implications of environmental conditions
along the U.S.-Mexican border. However, despite
these unique concerns, the issues raised contained
several recurring themes, for example-

, Universal access to health care for all persons
residing in the United States is imperative if this
Nation is to thrive. Without universal access,

One

Voice

One

Vision


Priority Recommendations  4444444444444'

many people delay getting proper care until
conditions become serious and costly to treat.
Adequate infrastructure for providing health
care must be developed in underserved areas
to ensure universal access.

Resources and mechanisms must be devel-
oped for enlarging the pool of Hispanic/
Latin0 health professionals to provide
culturally competent care, particularly in
underserved areas. Repeatedly, Committee
members echoed the urging of their col-
leagues in the regions that funding for
Hispanic Centers of Excellence and the
number of such centers be increased.

Working in small groups to address each area of
concern (access, data collection, research, representa-
tion in the health professions, and health promotion
and disease prevention efforts), the Committee
members selected specific strategies that address these
common themes and, when combined together, create
a feasible and achievable plan of action. The final step
in the preparation of the recommendations was to
choose approximately five strategies in each area that
the Committee members consider to be of highest
priority for implementation.

One



Voice









One



vision

In the development of the report, several issues
emerged that cut across the areas of concern that the
lnitiative addresses. Because a number of the recom-
mended strategies have implications for all the areas of
concern, the group categorized them separately as
`cross-cutting issues.n These cross-cutting issues
indicate that no one area of concern can be addressed in
isolation; rather, progress in one area is dependent
upon progress in the other areas. For example,
health promotion and disease prevention cannot be
adequately addressed in the Hispanic/Latino popula-
tion without culturally sensitive research and data
collection. Similarly, access to appropriate health care
services cannot be achieved without Hispanic/ Latin0
representation in the science and health professions and
in decision-making positions.

The remaining sections of this chapter contain
the recommendations developed at the Executive
Committee Meeting. Presented first are the cross-
cutting issues. Next are the implementation
strategies for each of the five critical areas of
concern. These sections begin with a statement of
the problems related to the area, then present the
implementation strategies deemed of highest
priority (listed as the summary of key strategies),
and conclude with specific implementation strate-
gies grouped by areas of opportunities for action.

This report is intended to guide the Hispanic/
Latin0 national health agenda for years to come.
Progress will not occur overnight. However,
Hispanic/Latino leaders will continue to work
together to tailor these strategies to solve key
problems within their communities and to ensure
that this plan of action for HispanicsILatinos
becomes a vital part of a national universal system of
health coverage for all Americans.

Cross-Cutting Issues

o Establish an advisory body to monitor the
implementation of the National Hispanic/ Latin0
Health Initiative and to ensure accountability within
all offtces of DHHS.

o Ensure that all racial/ethnic minority populations
be given equal access to all relevant resources of the
Office of Minority Health of the Office of the
Assistant Secretary for Health.

o Establish o&es of minority health in all public
health agencies, and, for those already established,
provide adequate resources and stafftng to ensure
access to health care for all Americans.

o Develop national, uniform standards for
quality of care.

o Provide appropriate resources to strengthen
public health assessment, policy development, and
surveillance activities pertaining to HispanicILatino
health issues.


o ?????????????  Priority Recommendations

o Ensure that organizations serving Hispanics/
Latinos are culturally competent and represent
their needs.

o Increase resources to maintain adequate data on
Hispanic/Latin0 health issues.

o Disseminate Hispanic/Latin0 research, data, and
health information via centralized clearinghouses to
researchers, health care providers, and others who
require such data.

o Appoint Hispanics/Latinos to review panels,
study sections, PHS advisory councils, and working
groups at the Federal, State and local levels.

o Ensure that at least 50 percent of the boards of
organizations serving Hispanics/Latinos are
Hispanics/Latinos, with Hispanics/Latinos in key
administrative and program staff positions.

o Develop regulations that require private and
nonprofit institutions (including universities) that serve
Hispanics/Latinos to include adequate Hispanic/Latino
representation at decision-making levels.

o Secure scholarships for training Hispanic/Latin0
leaders in all health professions (clinical and
nonclinical).

o Enforce existing Federal and State mandates to
ensure opportunities for Hispanics/Latinos in higher
education (faculty and boards), decision-making
positions, and the workplace.

o Base health promotion and disease prevention
efforts on the needs of the community being served.
o Promote the participation of health care providers
and the community in health promotion and disease
prevention outreach activities.

o Coordinate the administration of intervention to
ensure effective and efficient management.

Access to Health Care

The Hispanic/Latin0 population is composed of
individuals and families of multiple national origins,
some of which date back to the 1600's. The vast
majority of Hispanics/Latinos live in large urban
centers; however, included in this population are
rural residents and migrant and seasonal workers,
as well as those who are undocumented. Despite
having the highest rate of labor force participation of
all U . S . population groups, Hispanics/ Latinos are
the poorest minority group living in the United
States today, and more than one-third of the
population is uninsured. Not only do they lack
accessible, affordable, available, affable, and
portable health care, but they also are severely
underrepresented in ownership of health-related
enterprises.

  Because of the great diversity of Hispanic/Latin0
populations, to address the needs of this group,
national health reform must allow States to meet
the national goals and standards of universal coverage
and quality health care in creative and different ways.
The Federal Government should facilitate any
processes that allow States to select and craft their own
administrative and insurance entities.

On!?

Voice

1. Lack of comprehensive and portable health care
coverage for Hispanics/Latinos.

2. Underrepresentation of Hispanics/Latinos in
leadership positions during critical phases of            One
local, State, and national budgetary and pro-            Vision
grammatic planning activities.

3. Lack of adequate and available health care service
delivery systems and infrastructure to address
primary, secondary, and tertiary health care needs
of the diverse Hispanic/Latin0 population groups.


Priority Recommendations  44444444444444

4. Lack of accessible and adequate health care
facilities because of financial and nonfinancial
barriers in Hispanic/Latin0 communities.

1. Provide for Hispanic/ Latin0 participation in the
development and implementation of a national
health care system that ensures universal access
to all persons living in the United States, the
Commonwealth of Puerto Rico, and U.S.

  territories.

2. Increase Hispanic/Latino representation at ah
levels of the public health and health policy
leadership pool and workforce.

3. Ensure Hispanic/Latin0 participation in the
planning, design, staffing, evaluation, and
ownership of public health and health care
infrastructure to ensure that it serves commu-
nity needs.

4. Eliminate all financial, cultural, language, age,
belief, or gender barriers to health care.

One



Voice

Key audiences: Local, State, and Federal adminis-
trators and officials; Hispanic/Latin0 communities;
and the media.

A. Provide Universal Health Care for AU Americans

o Develop a universal health care system that-
, IS affordable, accessible, available, acceptable,

affable, and portable.

One            * Offers a basic package of services that includes

Vision

health promotion and disease prevention.

* Gives a choice of providers.

o Allows for a regular source of such care and
facilitates continuitv of care.
                ,

* Integrates systems of care: combines public
health, community health, and private
providers .

.







.







.





.







.







.





.





.







.





.





.









.





.









.

Strives for innovative health care financing
that spreads the burden across all sectors of
society.

Ensures coverage eligibility regardless of U.S.
residency and employment status (does not
exclude undocumented persons).
Offers easy enrollment and service
procedures that facilitate participation.
Provides measures of cost containment,
quality assurance, improved efficiency, and
accountability to service recipients.
Allows service recipients and all providers,
including "safety net providers," to participate
in the governance of plans.
Offers rewards for providing services to
underserved and unserved populations.
Provides incentives for coverage of preventive
services.

Enforces uniform procedures for reimburse-
ment while recognizing differences by region
and geography.

Provides outreach activities to increase
awareness and use of available programs.
Is culturally competent and linguistically
appropriate.

Addresses other needs specific to the
Hispanic/Latino population (e.g., respite
care, long-term care, transportation, child
care, and other support services).
Does not exclude persons with preexisting
illness and conditions.

Establishes health advocacy coalitions of public
and private providers and consumers in Puerto
Rico and in each State with significant Hispanic/
Latin0 populations to review programs and
develop recommendations annually.
Establishes a methodology for accurately
estimating the cost of universal coverage.


44 4444444444 + + Priority Recommendations

Representation and Communication
o Develop a mass media marketing plan that
informs the public about how to gain access to and
prop+ utilize health and related services. This
plan should target Spanish-speaking and bilingual
Hispanics, especially in areas where little or no
information is available. (State and local)

o Include Hispanic/ Latin0 representation in the
development of outreach and public information
campaigns, including television, radio, and the
print media.

Policy

+ Allow for cultural and regional differences in
clinical and administrative measurements. What
may be appropriate for one ethnic communitv or
region may not be appropriate for others.

o Make client surveys, chart pulls, and nonmedical
content of care components of quality measurement.

o Measure quality of care in terms of the bicultural
and bilingual competency of staff. Capacity to serve
in a culturallv competent manner must be demon-
strated. This competency should be addressed as
part of any contracting process.

o Emphasize preventive and primary services in
quality measurement. Standardization of tracking
and data systems is needed and should be oriented
toward periodic and preventive care that is
age-appropriate.

o Include a cultural index of accessibility to cam as
part of qualitv measurcmcnts and requirements.
         ,
Financial resources must be made available to those
entities that need infrastructure development to
meet this requirement.

o Strengthen the public health capacitv for sur-
veillance, assurance, and policy and planning.

o Develop plan coverage information in the
language of the population and adapt it culturallv as
    c
ncccssarv. Mcmbcr services should also have

language-proficient representatives to serve
individuals. Representatives should bc required to
provide outreach to job sites, social service centers,
and other locations where these populations
congregate.

o Require health care plans to provide physicians
and other providers who have a minimum of
24 hours of training in cultural competency.

o Require States to develop certification compo-
nents for interpreters to serve underserved
populations.

o Provide a health benefit package that includes
the following:

m

*

?

*

*

?

?

*

Primary care and preventive services,
including mental health services, immuniza-
tions, periodic screening, health education, a
full range of reproductive health services,
comprehensive perinatal care, and outpatient
medical care. (Local)
In-patient hospital care and alternatives to
hospitalization, including skilled home health
services. (State and local)
Emergency services, including emergency
transportation. (Local)

Social services.

Dental services. (Local)
In-patient and out-patient drug and alcohol
abuse prevention, treatment, and rehabilita-
tion. (State and local)
In-patient and out-patient rehabilitation
services (physical, occupational, and voca-
tional therapy).

In-patient and out-patient mental health
services.

Case management, including psychosocial
support services.
Nutrition counseling.
Prescription drugs.

One

Voice

OnI-

Vision


Priority Recommendations  44444444444444

* Vision and hearing services.

* Long-term care and alternatives to long-term
care, including case management, in-home
support services, hospice, and adult day
health care.

* Transportation for health care visits.
Structure a financing package that distributes cost
quitably according to ability to pay, stressing
rogressive financing schemes, cost-effective
elivery systems, and infrastructure development
3r special populations:

o

.

.

              m
One

Voice

*

*

One

.

Shared payment responsibility between
employers and employees.
Government subsidies for small businesses.

Information safeguards for undocumented
workers in an employment-based system.
Simultaneous reform of medical malpractice,
the tort system, and workers' compensation.
Incorporation of Medicaid, CHAMPUS, and
private and public employer-based health care
payment systems, as needed.
Focus on progressive taxes with strong consider-
ation of alcohol and tobacco taxes and with
recognition that additional funds will be needed.
Consideration of equalization of reimburse-
ment regardless of the individual.
Maintenance and equalization of efforts in terms
of State government financial commitments.
Recognition of special financing needs of
special populations.

Systemic incentives for cost-effective health
care system approaches.

Vision

o Conduct needs assessment of health coverage at
the local level, where needed.

o Enact Federal legislation to include coverage for
the uninsured and the undocumented as part of
health care reform.

o Increase the participation of representatives of     o Provide a benefits package that is universal,
diverse segments of the HispanicLatino population,    whether the recipient gains access to care through
including grassroots leaders, in decision-making      employer-based coverage or is unemployed,
processes regarding health care service delivery.      undocumented, or a Medicaid recipient.

o Standardize and streamline administrative forms
required to be completed by patients and providers.
Reallocate the saved human and fiscal resources to
service delivery.

o Enhance the health care infrastructure that services
Hispanic/Latino populations. Funds should be
earmarked speciRcally to develop local community-
based primary care facilities and service network
associations. The financial authority should fund
community-based infrastructure development projects
operated and managed by minority-owned and/or
managed corporations and organizations.

o Include "safety net" providers-primary care
clinics, traditional providers, and public health
providers-in the health care system. The system
must have representative governance and commu-
nity involvement.

Public-Private Partnerships
o Direct the agencies within PHS to implement
programs to foster establishment of public-private
partnerships that improve and increase delivery of
health care services for Hispanics/Latinos in all regions.

Advocacy

o Support the development of community advisory
boards to evaluate community grievances, provide
feedback, address quality issues, and influence
community empowerment.

o Secure funding to provide health leadership
training at the grassroots level to ensure community
empowerment.

Legislation


o ?????????????  Priority Recommendations

o Enhance the health care infrastructure and
provide funds for the construction of health facilities
in Hispanic/Latin0 communities.

o Reformulate the criteria for appointing physicians
and other health providers to health professional
shortage areas (HPSAs) .

o Create community-based health training centers
that provide both training and job opportunities.

o Reformulate the criteria for Federal designation
of medically underserved areas to accurately reflect
the ethnic, demographic, and cultural characteristics
of the communities served.

o Fund pilot projects that explore alternative
primary health care financing and delivery systems
(analogous to Health Care Financing
Administration's SHMO demonstrations).

B. Provide Accessible Health Care and Workmen's
Compensafion for the Farmworker Population
Farmworkers are the most underserved of all

groups. Because 3 to 5 million of them are
Hispanic/Latino, a special emphasis is required to
address their health needs.

Policy

o Foster and reward networking through technical
assistance and remove bureaucratic barriers, such as
categorical funding that limits care for patients with
multiple needs because of separate tracking of
services by fund source. All existing efforts to
integrate and coordinate health, education, and
social services should be mandated. (Federal)

o Guarantee the participation of Medicaid-eligible
farmworkers in the PHS329 program and identifv
alternate funding resources for others not eligible.
Include case management as a mandatory reimburs-
able service for farmworkers. (State)

o Require companies that hire migrant workers to
provide access to health cart facilities. (Federal)

o Recognize that environmental factors-such as
nonexistent or inadequate housing, lack of alcohol and
drug abuse programs and mental health services, and
the failure of implementation of occupational and
environmental regulations-play a significant role in
the health of the migrant farmworker, the family, and
the community as a whole.

Resources

o Provide funding for standardized data collection
procedures and continuous analysis and reporting to
provide a base for advocacy for future funding.

Advocacy

o Provide funding for standardized data collection
procedures and continuous analysis and reporting to
provide a base for advocacy for future funding.

Legislation

o Federalize the Medicaid Program, eliminating the
conflicting State eligibility criteria and varying
reimbursement rates. Establish a national set-aside
of funds to cover farmworkers. (Federal)

o Under the PHS329 services, expand farmworker
eligibility for Medicaid to all farmworkers. (State)
o Establish national guidelines for farmworkers'
coverage under the States' worker's compensation
laws, thereby guaranteeing full and unrestricted
access to rehabilitating and financial compensating
services by those suffering accidents and diseases
contracted in the performance of their jobs.

o Include the following features in the demonstra-
tion projects:

. Simplification of all farmworker eligibility
processes.

*  Recertification of farmworkers on the basis of
annual or semiannual income, not month-to-
month earnings.

* Recognition of all farmworkers' eligibility.

OIle

Voice

OllC

Vision


Priority Recommendations  ++44444+4+++44

Clarification of payor reimbursement rates
and eligibility standards, regardless of the
origin of eligibility or site of service delivery.
Assurance of access to all primary care
services on a timely basis.
Provision of funding for primary care re-
search, including psychosocial and mental
health services.

Data Collection

It was not until 1989 that Hispanic/Latin0 identi-
fiers were included on the standard registration
certificates for vital events recommended for use by
the States. Although the ability to assess mortality
among Hispanics/Latinos has greatly improved,
significant gaps in knowledge still exist regarding
morbidity, quality of life, and disability in Hispanic/
Latin0 communities. This lack of data has pre-
vented the establishment of adequate baselines and
subobjectives for the Healthy People 2000 objectives
that target Hispanics/Latinos. Because funding
decisions at the Federal, State, and local levels have
often been based on the Healthy People 2000

One

objectives, this lack of data has hindered progress to
improving health status of Hispanics/Latinos.

1.

         2.
One

Vision       3.




          4.

Inadequate inclusion of HispanicsILatinos in
data systems.

Lack of data on specific Hispanic/Latino health
issues.

Limited awareness of and access to local, State,
and Federal Hispanic/Latin0 health databases.
Lack of quality, accurate, timely, and culturally
sensitive data system design, data collection, and
analvsis.

5. Duplication and lack of coordination of
efforts in health data collection by State and
Federal agencies.

1.









2.









3.

4.









5.

Include Hispanic/ Latin0 and Hispanic/ Latin0
subgroup identifiers in all surveys and forms,
and provide for adequate sample sizes for
detailed analysis to establish new baselines and
subobjectives for Healthy People 2000.

Increase Hispanic/Latin0 representation in the
design, implementation, analysis, and dissemina-
tion of health assessment and health monitoring
data systems, and in funding decisions affecting
these systems, including the identification of health
indicators specific for Hispanics/Latinos.

During current Federal and State budget
appropriations hearings, request additional funds
to take advantage of the resources already
developed for the third National Health and
Nutrition Examination Survey. These funds
should be used to (1) update the data collected
on Puerto Ricans and Cubans during the
Hispanic Health and Nutrition Examination
Survey and (2) collect, for the first time,
detailed health data on other Caribbean and
Central and South American subgroups in areas
where they are geographically focused.

Establish Federal, State, and local laws to ensure
confidentiality of respondents and to provide
absolute protection of respondents from use of
the identifying information by law enforcement
and immigration authorities.

Ensure that sociocultural data be collected, so
that analysis and interpretation of Hispanic/
Latino health data can be placed in the context
of larger social issues.


Key Audiences: Local, State, and Federal adminis-
trators and officials.

Representation and Communication
o Develop methodologies and programs for educating
public and private entities regarding the need for
scientifically valid Hispanic/Latino health data.

o Increase Hispanic/Latin0 representation in the
design, implementation, analysis, and dissemination
of health assessment and health monitoring data
systems and in funding decisions affecting these
systems. This increased representation is needed in
Federal, State, and local departments and agencies,
community-based organizations, colleges and
universities, and other private research entities.

o Increase Hispanic/Latin0 membership in com-
mittees, councils, and commissions appointed by
county, State, and Federal health departments;
agency administrators; State and Federal legislators;
and Governors to monitor data collection, analysis,
interpretation, and dissemination.

o Provide regular Hispanic/Latin0 health data
updates in publicly funded electronic newsletters,
bulletin boards, and other communication activities.

o Increase the use of Hispanic/Latin0 newsletters,
radio, and other effective media mechanisms as
tools for disseminating data information.

o Facilitate public access to Hispanic/Latin0 health
data reports and systems. Federal, State, and local
health departments should identify existing data sets
that can be used to assess the health status of
Hispanics/ Latinos and should determine the
accessibility of these data sets to researchers.

o Identify a Person in each agency or organization that
collects and disseminates data to serve as the principal
point of contact for Hispanic/Latin0 data analysis.

o Encourage researchers to report back to Hispanic/
Latin0 communities regarding their research fmdings

before public dissemination of results, including
publication and presentation at scientific meetings.

Policy

o Include Hispanic/Latin0 and Hispanic/Latino
subgroup identiiicrs in all surveys and forms (e.g.,
birth and death certificates, patient discharge forms,
and forms from primarv and ambulatorv cart
                             I
clinics). Analvsis and dissemination should be
subgroup specific for State and local communities
  c
with a significant (5 pcrccnt or grcatcr) Hispanic/
Latin0 population.

o Tie the release of Federal funds to States to the
collection and reporting of Hispanic/Latin0
ethnicity. Data collection and reporting should
include both documented and undocumented
Hispanics/Latinos.

o Allocate funds in Federal, State, and local health
programs to pay for data collection, analysis, and
dissemination of Hispanic/Latino health data so that
progress in improving Hispanic/Latino health status,
and ultimately the health status of the Nation, can be
tracked. Government agencies that use these data, but
do not produce data, should share in the expenses of
data collection, analysis, and dissemination.

o Set timelines for improving data collection for
Hispanics / Latinos.

o Include the improvement of Hispanic/Latin0 data
collection, analysis, and dissemination in Federal,
State, and local strategic plans, such as Healthy
People 2000, Minority Health Activities, and
Primary Care Access Plans.

o Include consideration of the heterogeneity of the
Hispanic/Latin0 population in all county, State, and
Federal health department data collection and
research designs. Oversampling has been identified
as a feasible method for highly concentrated
Hispanic/Latin0 subgroups; develop other survey
methodologies to collect data for geographically
dispersed Hispanic/Latin0 subgroups.

One

Voice

One

Vision


Priority Recommendations  44444444444444

o Employ culturallv and linguisticallv appropriate
interviewing techniques at all times when conduct-
ing surveys on Hispanic/Latin0 health issues. For
example, dependence on telephone interviews is
not appropriate for Hispanic/Latin0 communities
with high rates of telephone noncoverage.

o Develop incentives to increase the quality and
quantity of Hispanic/Latin0 health databases.
Review data sets continuously for inconsistencies;
errors in reporting, coding, and keying; and other
issues that affect quality. Development plans for
databases should include financial, technical, and
training resources for establishment and mainte-
nance of quality control programs.

o Create a Hispanic/Latin0 advisory board to the
Secretary of Health and Human Services, State
departments of health, and philanthropic founda-
tions to oversee the implementation of the recom-
mendations from the National Workshop and
Regional Health Meetings of the Surgeon General's
Hispanic/Latin0 Health Initiative.

o Establish local, State, regional, and national
Hispanic/Latin0 health data clearinghouses.

One



Voice

o Starting immediately, review existing Healthy
People 2ooO objectives and establish subobjectives to
target Hispanics/ Latinos. Provide baseline data for
Hispanics/Latinos for those subobjectires at the
Federal, State, and local levels.

o Develop publicly accessible computerized systems
for retrieval of Hispanic/Latin0 health data.

One



Vision

o Promote needs assessment at the local level to
empower communities to prioritize their health
needs and seek funding accordingly.

o Identifv and develop funding mechanisms for
      ,
survey methodologies to study Hispanic/Latin0
subgroups. Additional funds should be allocated to
the National Center for Health Statistics' Minority
Health Statistics Grant program and Census survey
research programs to support targeted research to

develop appropriate, culturally competent, and
linguistically sensitive survey methodology to study
subgroups of HispanicsILatinos. Consideration
should be given to the undocumented and recent
immigrants.

o Enforce OMB Directive 15 and Public Law 94-3 1 I
among Federal agencies. Educate Federal agencies
about the use of OMB Directive 15 for inclusion of
Hispanics/Latinos (and Hispanic/Latin0 subgroups) in
data systems and in federally funded intramural and
extramural research programs.

o Develop a clear definition of the term "Hispanic/
Latino," incorporating the concept of subgroup
populations, to be uniformly implemented in
county, State, and Federal health department and
agcncv data collection and analysis activities.
    ,

o Ensure that sociocultural data are collected and
that appropriate statistical methodologies and
interpretation of these data are used. Analysis and
interpretation of Hispanic/Latin0 health data should
be placed in the context of larger social issues to
ensure that "blaming the victim" is avoided and to
allow identification of social factors that contribute
directly and indirectly to the production and
treatment of disease.

o Develop and disseminate written guidelines for
confidentiality. Such guidelines should include a
requirement for a detailed rationale for collecting
and using data items. In addition, the guidelines
should include a procedure for true informed
consent in obtaining data from Hispanics/Latinos.

o Use existing data systems (e.g., Census Bureau
and the National Center for Health Statistics
(NCHS)) to establish cooperative agreements with
States to develop standard State and local health
status profiles for Hispanic/Latin0 communities.

o Conduct a national conference--cosponsored by
the NCHS, other parts of the Centers for Disease
Control and Prevention, the Commerce


Department, the Department of Education, the
Department of Justice, the Environmental Protec-
tion Agency, and other Federal agencies-to
improve the coordination of data collection,
analysis, and dissemination, with the goal being to
reduce the burden of voluntary and mandatory
reporting by the States and to improve the consis-
tency of reporting of race/ethnic origin. Recom-
mendations based on the fmdings from the 1993
PHS Task Force on State and Community Data
should be used to help develop the agenda for the
conference. Among the products of this conference
should be guidelines for comparability and plans for
providing, on a continuous basis, technical assis-
tance and resources to State and local agencies
responsible for data collection. This conference
should take place by 1995 at the latest to ensure that
tracking of Healthy People 2000 objectives can be
based on consistent and accurate data.

Resources

o Increase funding by county, State, and Federal
health departments and agencies to provide techni-
cal assistance and training for data collection and
analysis of Hispanic/Latin0 health data.

o Fund county, State, and Federal Hispanic/Latin0
health research and data analysis training centers.

o Provide support for local, State, regional, and
national Hispanic/Latin0 health data forums,
conferences, and workshops.

o Develop standardized forms for data collection on
Hispanics/Latinos.

o Increase quantitative skills of HispanicILatino
undergraduates to expand the pool of Latin0
researchers with the skills necessary to conduct
research on Hispanic/Latin0 health issues.

o Require statistical agencies of the Federal Govem-
ment to provide technical assistance to State and local
agencies for development of data collection instru-
ments and completion of instruments according to high

standards of quality. Additionally, software to assist in
this process should be developed and provided.

o Develop programs for Hispanic/Latin0
community-based organizations to enhance their
skills in Hispanic/Latin0 health data collection,
analysis, and interpretation.

Public-Private Partnerships
o Establish cooperative agreement mechanisms to
develop easily accessible Hispanic/Latin0 health
data retrieval computer programs.

o Develop funding incentives to increase the use of
Hispanic/Latin0 health databases by public and
private entities.

o Include Hispanics/Latinos in interdisciplinary work
groups, which should plan for research and data
collection, evaluate data collection instruments, ensure
that collected data are inclusive and usable, and assist in
the interpretation and dissemination of these data.
These work groups should include multiethnic
individuals from the community to be studied,
community-based organizations, health care profes-
sionals, advocates, and researchers.

o Establish a balance between the data needs for
research and policy-making and the burden on the
health care provider to collect information in
addition to providing services.

o Establish regional Hispanic/ Latin0 health coali-
tions to monitor implementation of the strategies
developed during the national and regional work-
shops of the Surgeon General's Hispanic/Latin0
Health Initiative.

Advocacy

o Prepare user-friendly summary reports regarding
Hispanic/ Latin0 health on a regular basis and
distribute them to local elected officials and
community leaders.

o Collaborate with church groups, media sources,
public figures, and leaders of multidisciplinary

Otle

Voice

One

Vision


professional associations to inform the American
public regarding Hispanic/Latin0 health data issues.

o Develop summarv reports on Hispanic/Latin0
              ,
health for dissemination to policy analysts, program
planners, elected officials, and community and
political leaders.

Legislation

o Pass State laws requiring the collection of data on
Hispanics/Latinos, especially in States with large
Hispanic/Latin0 populations. The California
legislation can be used as a model.

One

o During Federal and State budget appropriations
hearings, request additional funds to take advantage of
the resources already developed for the third National
Health and Nutrition Examination survey. These funds
should be used to ( 1) update the data collected on the
Puerto Rican community in the New York City
metropolitan area during 1984, and (2) collect, for the
first time, detailed health data on Caribbean and
Central and South American subgroups. Appropria-
tion of funds should not wait for the fourth National
Health and Nutrition Examination Survey. Taking
advantage of already trained staff and existing
questionnaire and other survey materials from the
current survey (to be completed in 1994) should
result in an economy of scale.

Voice









One



Vision

o Establish Federal, State, and local laws to ensure
confidentiality of respondents and to provide absolute
protection of respondents from use of the identifying
information by law enforcement and immigration
authorities. Such laws should not restrict the linkage of
data sets for the purposes of aggregate epidemiologic
analyses and program development.

Research Agenda

Health research provides the foundation for
understanding health. However, Hispanics/Latinos

are disproportionately underrepresented in research
activities. Without adequate and targeted research,
HispanicsILatinos are disadvantaged in policy-
making, resource allocation, program planning, and
program implementation activities.

  Currently, our body of knowledge about
Hispanic/ Latin0 health is limited at best. There are
few culturally appropriate theoretical frameworks,
and many research methodologies (instruments,
data collection, and data analysis) are inadequate for
addressing the unique health services research and
delivery needs of the diverse Hispanic/Latin0
population groups.

Underfunding of Hispanic/Latin0 health
research initiatives and agendas.

Lack of culturally appropriate theories, models,
and methodologies.

Underrepresentation of Hispanics/Latinos at all
levels of research activities, including students,
research faculty, and administrators of research

programs.

Lack of U.S. and international multidisciplinary
Hispanic/Latino health research and lack of
coordination of efforts among diverse areas of
investigation.

I . Increase funding to ( 1) determine high-priority
health problems that affect morbidity and mortality
of Hispanic/L&no groups (such as cardiovascular
disease, cancer, diabetes, HIV/AIDS, substance
abuse, violence, accidents, environmental and
occupational hazards, and tuberculosis); (2) assess
the impact of gender, ethnicity, and physical ability
on the health status of urban and rural Hispanics/
hinos across their lifespan; and (3) assess the role
of factors such as assimilation, country of origin.
and migratory status.


2. Increase Hispanic/ Latin0 representation on
multidisciplinary grant review bodies, advisorv
groups, and task forces to identify and implc-
ment Hispanic/Latin0 research priorities at
local, State, and Federal levels.

3. Create and update directories of multidisciplinary
Hispanic/L&no researchers for use by publicly or
privately funded health departments, agencies,
organizations, and/or institutions.

4. Reform the curricula of multidisciplinary health
professional institutions and continuing educa-
tion programs to include Hispanic/Latin0 health
research theories, methodologies, and models.

5. Ensure the recruitment, training, and retention of
Hispanic/Latino investigators and administrators.

Key Audiences: Local, State, and Federal adminis-
trators and officials.

Policy
Local and State

o Create Hispanic/Latin0 representation on
multidisciplinary grant review bodies, advisory
groups, and task forces to identify and implement
Hispanic/Latin0 research priorities at local, county,
and State levels.

o Create linkages to local educational, philan-
thropic, corporate, and research organizations.

o Utilize community-based organizations and
neighborhood opinion leaders as distribution
channels for information and service delivery.
These groups and opinion leaders should also be
used as a way of providing feedback to the scientific
communitv on the effectiveness of research in
       i
addressing the needs of the communities and
population groups.

o Create registries and update directories of
muhidisciplinan Hispanic/Latino s&mists and

researchers for USC by publicly or privately funded
health departments, agencies, organizations and/or
institutions.

o Reform curricula of multidisciplinary health
professional institutions and continuing education
programs to include Hispanic/Latin0 health
research theories, methodologies, and models.

o Assess the results of programs such as the Minority
Behavioral Research Supplement, Minority Access to
Research Careers, and Health Careers and Opportu-
nity Programs with respect to recruitment and
retention of Hispanic/Latino students and rcscarchcrs.

o Develop innovative research internship and
fellowship programs for Hispanic/Latin0 students
and scientists at the Federal and State Icvcls.

o At the local levels, develop and enhance publicly
and privately funded training and mentorship
programs at various sites, such as the Minority High
School Mentorship Program.

o Develop programs and initiatives to fund research on
the role of assimilation, acculturation, country of origin
or background, and socioeconomic status and migra-
tory history on the health status of Hispanics/Latinos.

o Develop programs and initiatives to fund research
on the impact of age, gender, geographic location,
and functional ability on the health status of
Hispanics/Latinos.

Federal

o Enhance Hispanic / Latin0 representation on
multidisciplinary grant review bodies, advisory
groups, and task forces to identify and implement
Hispanic/Latino research priorities at Federal health
departments and agencies.

o Enhance opportunities for and appointment of
Hispanics/L.atinos in key administrative and policy-
making jobs in Federal agencies.

o Create and/or enhance Hispanic/Latin0 research
agendas and health training in PHS and other

One

Voice

Ofi

Vision


Priority Recommendations  44444444444444

agencies of DHHS. These programs should
incorporate and emphasize the cultural, linguistic,
and socioeconomic aspects and needs of the
subpopulations.

o Create and/or enhance linkages within and across
Federal agencies to replicate "best practices" and
augment research and training resources.

o Establish county, State, and national clearing-
houses to collect and disseminate information on
Hispanic/Latin0 health research and funding
opportunities.

Resources

o Increase funding to determine high-priority health
problems (such as cardiovascukr disease, cancer,
diabetes, HIV/AIDS, tuberculosis, and substance
abuse) that affect morbidity and mortality of
Hispanic / Latin0 groups.

o Increase funding for enhanced recruitment,
training, retention, and promotion of Hispanics/
Latinos into health research leadership positions.

o Allocate funding for increased recruitment,
training, retention, and promotion of Hispanic/
Latin0 researchers employed by county, State, and
Federal health departments and agencies.

One



Voice
+

One



Vision

o Examine and reapportion institutional funding,
with special emphasis on discretionary funds, spent
on Hispanic/Latin0 health research, particularly in
the inner cities and rural areas.
o Develop and fund Distinguished Scholars pro-
grams to enhance career development for Hispanic/
Latin0 researchers at the undergraduate, graduate,
and postgraduate levels.

o Allocate funds, including set-aside funds, to
ensure that research on Hispanics/Latinos is
responsive to their subgroup needs and priorities.

* Fund a repository of Hispanic/Latino survey
instruments, research methodologies, and data
within PHS, with special emphasis on making the

information accessible and affordable to Hispanic/
Latin0 institutions or researchers.

o Establish a directory of Hispanic/ Latin0 research-
ers to disseminate for use by county, State, and
Federal health departments and agencies.

o Fund activities and programs that will promote
linkages between community-based health delivery
systems serving Hispanics/Latinos and academic
institutions.

Public-Private Partnerships
o Establish collaborative partnerships between
academic and health institutions.

o Collaborate with public officials, corporate
leaders, and foundation administrators in establish-
ing multidisciplinary mechanisms for determining
Hispanic/Latino research priorities and funding

sources.

o Establish and support ongoing U.S.-Latin American
health conferences and research cotiaborations .

Advocacy

o Collaborate with editorial boards of established
professional journals to focus on Hispanic/ Latin0
health issues.

o Establish new information dissemination strate-
gies to meet the needs of Hispanic/Latino research-
ers and health service providers. (For example,
include specific columns in the Journal ofthe
American Medical Association and local newsletters of

professional organizations.)

o Establish new health information dissemination
strategies to meet the needs of the general Hispanic/
Latin0 community.

o Continue and expand interaction with legislative
bodies (city council members, mayors, county
commissioners, State and Federal legislators, Hispanic
Congressional Caucuses, and committee staff).


Legislation

o Consider alternatives that could allow U. 5 -
trained, foreign medical gaduates to maximallv
participate in research activities, particularlv those
related to Hispanic/Latin0 issues.

o Ensure reauthorization of the Disadvantaged
Minority Health Act and appropriations of related
Federal agencies.

o Amend the Disadvantaged Minority Health Act to
specifically address the health needs of the Hispanic/
Latin0 populations.

o Enhance tax incentives and programs for busi-
nesses that provide funding for Hispanic/Latin0
research and training.

Representation in
He&h Professions

Hispanics/Latinos are severely underrepresented in
the health professions. Accordingly the delivery of
health care services to the Hispanic/Latin0 commu-
nity suffers. In addition, communities need.
culturally competent, and culturally sensitive
professionals in all disciplines to address their needs
with appropriate programs and services.

1. Underrepresentation of Hispanics/Latinos at all
levels of the health professions, including
practitioner, faculty, advanced career positions,
and decision-making bodies.

2. Underrepresentation of Hispanics/ Latinos in the
educational pipehne of the health professions.

3. Lack of adequate mechanisms for identifying,
recruiting, retaining, and promoting Hispanics/
Latinos in health and science professions.

1

2

3,

4.

5.

6.

Promote the recruitment, rctcntion, and
advanccmcnt of Hispanic/Latin0 health profcs-
sions faculty, including an incrcasc of tenurctl
and tcnurcd track faculty. (Local)

Ensure the rntrv and retention of Hispanics/
Latinos through funding incentives (such as
institutional dcvclopmcnt) in undcrgra~luatc and
graduate programs at Hispanic/Latino-scr~ing
institutions and Hispanic Ccntcrs of Ilsccllcncc.

Establish guidelines for thr rccruitmcnt and
retention of Hispanic/ Latino students in all
health professions and make univcrsitics
accountable by tying the rcquircmcnts to Icvcls
of funding.

Ensure the broad dissemination of information on

fmancial assistance and educational initiativcs-
such as college work-study programs, grants,
scholarships, fellowships, and national service.

Develop and support awareness, educational
enrichment, and student guidance and
mentoring programs to encourage Hispanic/
Latin0 students to pursue careers in the health
professions.

Develop licensure preparation courses, alternate
competency examinations, and tracking
mechanisms to increase retraining opportunities
and promote the greatest use of Hispanic 1 Latin0
foreign-trained health professionals.

4. Underfunding for Hispanics/Latinos in health
and scicncc education programs.

5. Underutilization of linguistically and culturally
competent foreign-educated Hispanic/Latin0
health professionals to provide care in Hispanic/
  Latin0 communities.

OllC

Voice

Olle

Vision


Key Audiences: Local, State, and Federal adminis-
trators and officials.

Communication and Representation
o Increase the use of media resources to promote
positive images and advancements of Hispanics/
Latinos of both genders in health and science
careers. (Local, State, and Federal)

o Increase the participation of Hispanics/ Latinos in
commissions, task forces, advisory committees,
boards, and conferences sponsored by county,
State, and Federal health departments or agencies.
(Local, State, and Federal)

Policy

o Develop information programs on Hispanic/Latmo
education data for members of school boards,
university regents, foundation boards of trustees, and
county, State, and Federal education and health
administrators. (Local, State, and Federal)

One



Voice

o Develop electronic and computer-accessible
Hispanic/Latin0 bulletin boards to provide access to
Hispanic/Latin0 databases via 800 lines for "net-
working" information regarding available resources
and career development programs. (State, Federal)
o Require the NIH Office of Minority Health Research
to establish a Hispanic/Latino health division. (Federal)

o Increase access for Hispanics/Latinos in bio-
medical research and health professional educational
systems. (Local, State, and Federal)

One



Vision

o Increase the involvement of Hispanic/ Latin0
families, teachers, principals, and faculty in decision-
making processes regarding all levels of Hispanic/
Latin0 education issues.

o Increase the involvement of Hispanic/Latin0
faculty in planning, funding, admission, and
curriculum activities. (Local)

o Encourage education administrators to provide
Hispanic/Latin0 bilingual tutors for students in
primary and secondary levels and to increase the
number of Hispanic/Latin0 faculty to be consistent
with the Hispanic/Latin0 population.

o Promote the retention, advancement, and increase
of tenured and tenured track faculty. (Local)

o Develop leadership training programs, such as the
Cuban-American National Council Leadership
Board Training Model, that enhance the career
development of Hispanic/Latin0 health profes-
sionals. (Local, State, and Federal)

o Support and expand program s targeting Hispanic/
Latino student participation (such as Minority Bio-
medical Research Support Programs and Minority
Access to Research Careers (MBRSMARC)) at
biomedical research and health professional schools and
Hispanic Centers of Excellence. (Federal)

o Establish funding incentives targeting the entry
and retention of Hispanics/Latinos in undergraduate
and graduate institutions serving Hispanic/Latin0
populations to reverse the extremely low rates of
Hispanics/Latinos with a college education.

o Expand support for culturally competent educa-
tion and science enrichment programs and models
that promote the success of Hispanic/Latin0 health
and science students, clinicians, and academicians.
(State, Federal)

o Provide funding to health professional schools
that recruit Hispanic/Latin0 clinicians from low
income areas. (State, Federal)

o Develop additional loan forgiveness, college
work-study, and scholarship/fellowship programs
specifically targeted for Hispanic/Latin0 students
and practitioners, particularly in extremely rural
and urban communities.

o Establish mechanisms to disseminate information
on how to obtain student financial assistance,
grants, scholarships, and fellowships.


44444444444444  Priority Recommendations

o Promote the use of nonbiased cultural measures
and assessments for admission and licensing exams
and accountability and performance standards.
(State, Federal)

o Develop tracking mechanisms for foreign medical
graduates to determine sites where retraining opportu-
nities are available, health care positions and vacancies
are posted, and license requirements are disseminated.

o Develop licensure preparation courses and alternate
competency examinations for Hispanic/Latin0 fore@-
trained health professionals. (State, Federal)

Resources

o Develop and fund adopt-a-student programs to
encourage recruitment and retention of Hispanics/
Latinos into health and science professions.
(State, Federal)

o Increase the number of HispanicILatino health
professionals by eliminating barriers that prevent,
deter, or delay licensure. (Local, State, and Federal)

o Develop and increase support for programs that
employ foreign-trained Hispanic/Latin0 health
professionals. (State, Federal)

Public-Private Partnership
o Develop and support early awareness, dropout
prevention, and other education enrichment programs
such as "Padres A la Escuela" (Washington, D. C.) and
the Hispanic Mother-Daughter Program at Arizona
State University. (Local, State, Federal)

o Support Hispanic/Latin0 corporate-sponsored
mentoring programs in the health science profes-
sions. (Local, State, and Federal)

o Develop cooperative agreements behveen private
and public institutions for support of research by
Hispanickatino scientists. (Local, State, and Federal)

o Solicit funding for endowed Chairs for Hispanic/
Latin0 faculty members at educational institutions.

(Local, State, and Federal)

o Collaborate with State licensing boards, univer-
sity prcsidcnts, State legislators, and professional
associations to expand career opportunities for
Hispanic/Latin0 educators and health professionals.
(Local, State)

Advocacy

o Develop and support education enrichment and
student guidance programs that address special
needs of Hispanic/Latin0 students contemplating
health or science careers. (Local, State, and Frdcral)

o Promote awarcncss among clccted officials (tit!
council members, mayors, county commissioners,
etc.) of health education issues affecting Hispanics/
Latinos. (Local, State, and Federal)

o Support the development of liccnsurc cxamina-
tions for foreign-trained Hispanic/Latin0 health
professionals. (State)

o Collaborate with leaders of educational and health
professional associations to increase Hispanic/
Latin0 involvement and leadership. (Local, State,
and Federal)

o Promote inclusion and participation of Hispanic/
Latinos in editorial boards of professional health and
science journals and publications. (Local, State,
and Federal)

?*?

Health Promotion and
Disease Prevention

Voice
a

The overall health profile of Hispanics/Latinos
presents a striking socioeconomic disparity when
compared with the health status of the rest of the
American population. Nevertheless, much can be
done to improve the health of this population by
implementing health promotion and disease
prevention (HPDP) interventions. The challenge is
to develop and implement efficacious HPDP

One



Vision


Priority Recommendations  44444+4444444*

strategies for improving the health of Hispanics/
Latinos across the country. HPDP interventions
targeted to Hispanics/Latinos are essential for
achieving the Hispanic/Latino-specific health care
objectives for the Nation by the year 2000.

1. Weak infrastructure for training in HPDP:


  * Lack of multidisciplinary approaches to HPDP
  curricuhun development.

  * Lack of HPDP curriculum in schools.


  * Lack of formal HPDP training for Hispanic/
  Latin0 leaders.

  * Institutionalized and individual racism as a
  barrier to service delivery and professional
  development.

2. Lack of proven models for comprehensive,
culturally competent, and community-specific
primary prevention programs.

One



Voice

3. Lack of public-private partnerships in support of
HPDP goals for Hispanics/Latinos.

4. Lack of diffusion of culturally appropriate HPDP
models and lack of community resources for
the replication of successful Hispanic/Latin0
HPDP models.


5. Lack of media awareness of Hispanic/Latin0
  HPDP issues.

One



Vision

6. Lack of cooperation in addressing environmental
hazards and HPDP issues among countries in the
Americas (the U.S.-Mexican border, Central
and South America, and the Caribbean).

1. Encourage and endorse authorizing legislation at
the Federal level to direct Federal funds for the
development and evaluation of HPDP programs
directed toward Hispanic/ Latin0 groups.

2.

3.

4.

5.

6.

Integrate paraprofessionals, informal communit!
leaders, ethnic/folk healers, "Promotores de
Salud," and other community health workers in
HPDP programming for the Hispanic/Latin0
community, and provide appropriate recogni-
tion and incentives for their participation.

Use appropriate media resources and commu-
nity networks at local, State, and Federal levels
to educate Hispanic/Latin0 communities
regarding HPDP issues.

Establish guidelines for Hispanic/ Latin0 national
and community-based organizations for acccpt-
ing corporate contributions; corporations'
products and services must hr compatihlc with
HPDP goals.

Make HPDP issues (including cnvironmcntaf
issues) critical elements in the regulations and
implementation of the North American Free
Trade Agreement (NAFTA).

Develop a mass media marketing plan that
informs the public on how to gain access to and
properly utilize health and related services. This
plan should target Spanish-speaking and bi-
lingual Hispanics, especially in areas where little
or no information is available. (State and local)

Representation and Communication
o In&de culturally sensitive and competent Spanish-
language components in all public health education
campaigns currently being funded by DHHS.

o Include Hispanic/Latin0 representation in the
development of outreach and public information
campaigns, including television, radio, and the
print media.

o Integrate par a p rofessionals, informal community
leaders, ethnic/folk healers, "Promotores de Salud,"
and other community health workers in HPDP


4444444444 o o Priority Recommendations

programming for the Hispanic/Latin0 community,
and provide appropriate recognition/incentives for
their participation.

o Establish a comprehensive HispanicILatino-
specific HPDP mentorship program for research,
teaching, and community interventions.

o Develop agendas, workshops, and training for
media representatives to promote Hispanic/Latin0
HPDP programs.

o Develop a mass media marketing plan that
informs the public on how to gain access to and
properly utilize health and related services. This
plan should target Spanish-speaking and bilingual
Hispanics, especially in areas where little or no
information is available. (State and local)

o Develop multilingual, multimedia public health
education campaigns that address lifespan, gender-
based, and cultural needs of the diverse Hispanic/
Latin0 population groups.

o Use appropriate media resources and community
networks at local, State, and Federal levels to educate
Hispanic/Latino communities regarding HPDP issues.

o Increase the media's awareness of Hispanic/
Latin0 health and HPDP issues and clarify their role
in HPDP information dissemination.

o Develop training programs in media advocacy for
community residents and organizations.
. Use paid media to complement other HPDP
efforts targeting Hispanics/ Latinos.

Public-Private Partnerships
o Establish linkages for HPDP programs and
services among community-based organizations,
universities, the private sector, and lay people in
the community.

Policy

o Establish policies and procedures by which ail
requests for proposals (RFPs) for prevention
activities at the Federal and State levels have
Hispanic/Latin0 community input.

o Develop partnerships among training institutions,
community-based organizations, and national
Hispanic/L&no agencies to collaborate in the
design of more appropriate HPDP programs.
o Create a Hispanic/L&no HPDP information
network and clearinghouse via a public-private
partnership.

o Make HPDP issues (including environmental      o Foster close collaboration between Latin
issues) critical elements in the regulations and      American countries and the United States regarding
implementation of the NAFTA.                 HPDP issues.

Resources

o Provide incentives, such as tuition, loan forgive-
ness programs, and financial benefits, to HPDP
program providers for serving Hispanics/Latinos in
underserved communities.

o Increase funding for and the number of Centers of
Excellence for Hispanic/ Latin0 health professions
with emphasis in HPDP.

o Recommend that all levels of government (Federal,
State, and local) increase the use of toll-free hot lines in
a culturally appropriate fashion and that they be
properly advertised in the communities they serve.

o Foster initiatives that will target and fund
Hispanic/Latino-specific HPDP activities (nc\r
funding and reallocation of existing funds).

o Expand, establish, and fund HispanicILatino
health education information clcaringhouscs at the
Federal, State, and county levels.

o Establish guidelines for Hispanic/ Latin0 national
and community-based organizations for accepting
corporate contributions; corporations' products and
services must be compatible with HPDP goals.

Ofle



Voice

+



One



Vision


Priority Recommendations   4444444444444

Advocacy

o Promote the importance of wcllness, education,
early identification of health problems, and appropriate
intervention in HPDP via community coalitions.

o Develop national and local Hispanic/ Latin0
constituencies to counter disease=promoting industries.

Legislation

o Encourage and endorse authorizing legislation at
the Federal level to direct Federal funds for the
development and evaluation of HPDP programs
directed toward Hispanic/Latin0 groups.

Voice

One

Vision


Amendix A: National

Workshop Participants

Executive Planning Committee

Lydia E. Soto-Torres, M.D., M.P.H.
National Coordinator
Surgeon General's National Hispanic/ Latin0 Health
Initiative
0%~ of the Surgeon General
200 Independence Avenue, SW
Room 71 SE
Washington, DC 20201

Marilyn Aguh-re-Molina, Ed.D.
Assistant Professor
Robert Wood Johnson Medical School
Department of Environmental and

Jane L. Delgado, Ph.D.
President and Chief Executive Officer
National Coalition of Hispanic Health and Human
Services Organizations
1501 16th Street, NW
Washington, DC 20036

Eunice Diaz, Ph.D., M.P.H.
Commissioner
National AIDS Commission/Infant Mortality
Commission
770 Kristen Court
Santa Barbara, CA 9 3 111

Community Medicine
Division of Consumer Health Education
675 Hoes Lane CB35
Piscataway, NJ 08854-5635

Mari Carmen Aponte, J.D.
Attorney

Gartrell, Alexander, Gebhardt and Aponte
1314 19th Street, NW
Washington, DC 20036

Castulo de la Rocha, J.D.
President and Chief Executive Officer
AltaMed Health Services Corporation
500 Citadel Drive, Suite 490
Los Angeles, CA 90040

John W. Diggs, Ph.D.
Deputy Director for Extramural Research
National Institutes of Health
Building I, Room 144
Bethesda, MD 20892

Robert G. Eaton, J.D., M.B.A.
Associate Administrator for Program Development
Health Care Financing Administration
200 Independence Avenue, SW
Suite 325-H
Washington, DC 20201

Carola Eiienberg, M.D.
Consultant
9 Clement Circle
Cambridge, MA 02 138

Anna Escobedo Cabral, M.S.
Executive Staff Director
U.S. Senate Republican Task Force
on Hispanic Affairs

Special Assistant to Senator Orrin G. Hatch
135 Russell Senate Of&e Building
Washington, DC 205 10

Vision

Rosamelia de la Rocha, B.A.
Director
O&e of Equal Employment and Civil Rights
Food and Drug Administration
5600 Fishers Lane, HF 15, Room 892
Rockville, MD 20857
.


0

George R. Flores, M.D., M.P.H.
Public Health Officer
Sonoma County Public Health Department
33 13 Chanate Road
Santa Rosa, CA 95404

John Flares
Past Director

White House Initiative on Education Excellence

for Hispanic Americans
U.S. Department of Education
400 Maryland Avenue, SW, Room 2 135
Washington, DC 20202

Aida L. Giachello, Ph.D.
Assistant Professor
University of Illinois-Chicago
Jane Addams College of Social Work
P.O. Box 4348 M/C 309
ECSW Building, 4th Floor
1040 West Harrison
Chicago, IL 60680

Paula S. Gomez
Executive Director
Brownsville Community Health Center
2 137 East 22nd
Brownsville, TX 78 5 2 1

Robert Gomez, B.A.
President
National Association of Community
Health Centers

ihe

839 West Congress
Tucson, AZ 85745

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Vision

lkana C. Herrell, Ph.D.
Associate Administrator for Minority Health
Ofice of Minority Health
Health Resources and Services Administration
5600 Fishers Lane, Room 14-48
Rockville, MD 20857

Peter Hurley
Associate Director for Vital & Health
Care Statistics Systems

National Center For Health Statistics
Centers for Disease Control and Prevention
6525 Belcrest Road
Hyattsville, MD 20782

Sharon Katz, M.P.A.
Special Assistant
Centers for Disease Control and Prevention
200 Independence Avenue, SW, Room 714B
Washington, DC 20201

Leonard R. Klein
Associate Director for Career Entry
U.S. Offtce of Personnel Management
1900 E Street, NW, Room 6F-08
Washington, DC 20415

Laudelina Martinez, M.A.
President

Hispanic Association of Colleges and Universities
4204 Gardendale Street, Suite 2 16
San Antonio, TX 78229

VidaI Martinez, O.S.M.
Pastor
La Asuncion Catholic Church
P.O. Box 1335
777 Cortlandt Street
Perth Amboy, NJ 08862

Janie Menchaca Wilson, Ph.D., R.N., FAAN
Immediate Past President
National Association of Hispanic Nurses
4 126 Longvale

San Antonio, TX 78217

Enrique Mendez, Jr., M.D.
Assistant Secretary for Health Affairs
U.S. Department of Defense
OASD (HA), Room 3E346
The Pentagon

Washington, DC 20301- 1200

Hermann N. Mendez, M.D.
Associate Professor of Pediatrics
State University of New York
Health Science Center at Brooklyn
450 Clarkson Avenue, Box 49
Brooklyn, NY 11203


c:u-Ios Perez, M.P.A.              Helen Rodriguez-Trias, M.D.
\r-(,.t .~tlministrator                     President
, )II'~` c` c,t' 1Hcalth STstcms Management            American Public Health Association
\,.\\ `I'ork State Department of Health            11565 Alta Via Road
1 I(, \\`cl>t 32nd Street, 13th Floor               P.O. Box 418
Kc~\\ l'ork, NY 10001                 Brookdale, CA 95007

12uisa de1 Carmen Pollard, M.A.

l)ircctor
K.\D.\K Network
C`cntcr for Substance Abuse Prevention
t'uhlic Health Service
substance Abuse and Mental Health Services

.-\dministration
iiockwall Building II, Room 9CO3
5600 Fishers Lane
Rockville. MD 20857

Michael E. Ramirez, M.P.A., B.S.W.
Personnel Officer
D. C. Office of Personnel
613 G Street, NW
Washington, DC 20001

Mario E. Ramirez, M.D.
Vice Chairman

University of Texas System Board of Regents
Route 3, Box 10
Rio Grande City, TX 78582

Jaime Rivera-Dueno, M.D.
Executive Director
San Juan AIDS Institute
1250 Ponce de Leon Avenue
Banco de Ponce Building, Suite 71 1
Santurce, PR 00907

Rene F. Rodriguez, M.D.
President
The InterAmerican College of Physicians
and Surgeons
915 Broadway, Suite 1610
New York, NY 10017

Ramon Rodriguez-Torres, M.D.
Chief of Staff
The Mary Ann Knight International Institute

of Pediatrics

Miami Children's Hospital
6 125 South West 3 1 st Street
Miami, FL 33155-3098

Raul Romaguera, D.M.D., M.P.H.
International Health Officer
Office of International Health
Public Health Service
Parklawn Building, Room 18-74
5600 Fishers Lane
Rockville, MD 20857

Margarita Roque
Executive Director
Congressional Hispanic Caucus
557 Ford House Office Building
Washington, DC 205 15

Jose M. Saldana, D.M.D., M.P.H.
President

University of Puerto Rico
P.O. Box 364984
San Juan, PR 00936-4984

Shiree Sanchez
Assistant Director
O&e of Public Liaison
White House, Room 95 OEOB
Washington, DC 20500

Ruth Sanchez-Way, Ph.D.
Director

Division of Community Prevention and Training
Center for Substance Abuse Prevention
Substance Abuse and Mental Health Services

Administration
Public Health Service
Rockwall Building II, Room 9D 18
5600 Fishers Lane
Rockville, MD 20857

Maria D. Segarra, M.D.
Associate Director for Policy and Internal Affairs
Of&e of Minority Health
Public Health Service
Rockwall Building II, Suite 800
5600 Fishers Lane
Rockville, MD 20857

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Appendix A 4444444444444444444

Belinda Seto, Ph.D.
Deputy Director
Ofice of Minority Programs
National Institutes of Health
9000 Rochille Pike, Building 1, Room 255
Bethesda, MD 20892

Ciro V. Sumaya, M.D.
Associate Dean for Affiliated Programs and
Continuing Medical Education
University of Texas Health Science Center at

San Antonio

7703 Floyd Curl Drive
San Antonio, TX 78284-7790

Fernando M. Trevino, Ph.D., M.P.H.
Dean

Southwest Texas State University
School of Health Professions
60 1 University Drive
San Marcos, TX 78666-46 16

Steve Urunga McKane, D.M.D., M.P.H.
Program Director
W. K. Kellogg Foundation
One Michigan Avenue East
Battle Creek, MI 49017-4058

Frank Vasquez, Jr., M.B.A.
Executive Director
Hidalgo County Health Care Corporation
1203 E. Ferguson
Pharr, TX 78577

Richard A. Veloz, J.D., M.P.H.
Staff Director
Select Committee on Aging
U.S. House of Representatives
712 O'Neill Building
Washington, DC 205 15

Marcelle M. Willock, M.D., M.B.A.
Professor and Chairman
Boston University Medical Center
Department of Anesthesiology
88 East Newton Street
Boston, MA 02 118

Raul Yzaguirre, B.S.
President

National Council of La Raza
8 10 First Street, NE, Suite 300
Washington, DC 20002

In Memoriam

Rodolfo B. Sanchez
Sanchez and Associates
1003 North Daniel Street, Suite A
Arlington, VA 22201

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+ + + 4 + + + 4 4 4 4 4 4 4 4 4 4 4 4 Appendix A

Office of the Surgeon General

.Intonia Coello Novello, M.D., M.P.H.
Surgeon General

Lydia E. Soto-Tomes, M.D., M.P.H.
Special Assistant for Minority and Women's Health
National Coordinator for the Surgeon General's

National Hispanic/Latin0 Health Initiative

M. AM Drum, D.DS., M.P.H.
Director of Program Activities

Shellie Abramson
Program Analyst

Florence Dwek
Program Analyst

Mary Jane Fingland
Special Assistant for Public Affairs

Margaret Garikes
Executive Assistant

Gloria U. Gonzalez
Special Assistant

Gwen Mayes, M.M.Sc.
Project Officer
Division of Organ Transplantation
Health Resources and Services Administration

Elizabeth Schmidt
Special Assistant for Communications

Interns
Marlowe Dazley
Aymee Gaston
Maria Jimenez
Michael Johnson
Stephanie Lott
Angeli Maun
Gladys Melendez-Bohler, M.S.

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Appendix A 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Office of Minority Health

Office of International
Health

Claudia R. Baquet, M.D., M.P.H.
Deputy Assistant Secretary for Minority Health

Samuel Lin, M.D., Ph.D.
Special Assistant to the Deputy Assistant Secretary
for International Health

Olivia Carter-Pokras
Public Health Analyst

Donald Coleman
Senior Audio-Visual Information Specialist

Tuei J. Doong, M.H.A.
Acting Associate Director

Hazel Farm
Program Analyst

Betty Lee Hawks, M.A.
Acting Associate Director

Matthew Murguia, M.P.A.
Supervisory Public Health Analyst

Maria D. Segarra, M.D.
Associate Director

DonaJd L. Sepulvado, Ph.D.
Acting Associate Director

John Walker III, M.A.
Service Fellow

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+ + + + 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Appendix A

Speakers

Barbara Everitt Bryant, M.D., Ph.D.       Samuel Lin, M.D., Ph.D.

I lircctor                   Acting Deputy Assistant Secretary for

I~LIITJU of the Census
11. S. Department of Commerce
\Yashington, DC 20233

Eleanor Chelimsky
.\ssistant Comptroller General
Program Evaluation and Methodology Division
II .S. General Accounting Off%ze
-441 G Street, NW
Washington, DC 20548

Minority Health
Office of Minority Health
Public Health Service
U.S. Department of Health and Human Services
55 15 Security Lane, Suite 1102
Rockville, MD 20852

Louis D. Enoff

John T. MacDonald
Assistant Secretary for Elementary
and Secondary Education
U.S. Department of Education
Washington, DC 20202

,%zting Commissioner
Social Security Administration
U.S. Department of Health and Human Services
6401 Security Blvd., ALT. Bldg., Room 960
Baltimore. MD 21235

Rafael J. Magallan
Director
Washington Office
Hispanic Association of Colleges and Universities
1 DuPont Circle, NW, Suite 230
Washington, DC 20036

The Honorable Nancy Landon Kassebaum
Senator
State of Kansas
U.S. Senate
302 Russell Senate Office Building
Washington, DC 205 10

Karen R Keesling, Esq.
Acting Administrator
Wage and Hour Division
U.S. Department of Labor
200 Constitution Avenue, NW
Washington, DC 202 10

Thomas Komarek, M.B.A.
Assistant Secretary for Administration
and Management
U.S. Department of Labor
200 Constitution Avenue, NW
Washington, DC 202 10

The Honorable Lynn Martin
Secretary
U.S. Department of Labor
200 Constitution Ave., NW
Washington, DC 20210

James 0. Mason, M.D., Dr.P.H.
Assistant Secretary for Health
Public Health Service
U.S. Department of Health and Human Services
Washington, DC 20201

J. Michael McGinnis, M.D.
Director

Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
Washington, DC 20201

Robert S. Murphy, M.S.P.H.
Director
Health Examination Statistics
National Center for Health Statistics
6525 Belcrest Road
Hyattsvillc, MD 20782

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AppendixA 4444444444444444444

Antonia Coello Novello, M.D., M.P.H.
Surgeon General
U.S. Public Health Service
200 Independence Avenue,
SW, Room 710G
Washington, DC 20201

The Honorable Solomon P. Ortiz
Representative, State of Texas
Chairman, Congressional Hispanic Caucus
U.S. House of Representatives
2445 Raybum HOB
Washington, DC 205 15

Kenneth Shine, M.D.
President
Institute of Medicine
2 101 Constitution Ave., NW
Washington, DC 20418

The Honorable Louis W. Sullivan, M.D.
Secretary
U.S. Department of Health and Human Services
200 Independence Ave., SW, Room 615-F
Washington, DC 20201

William Toby, M.S.W.
Acting Administrator
Health Care Financing Administration
U.S. Department of Health and Human Services
Washington, DC 20201

Gail R Wilensky, Ph.D.
Deputy Assistant to the President for Policy
Development
The White House
Washington, DC 20500       

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b ++44444444**4444444 AppendixA

Resource Attendees

J. Jarrett Clinton, Jr., M.D.
.~dministrator

.\gcncy for Health Care Policy and Research
10 I East Jefferson Street, Suite 600
Rockville, MD 20852

Alicia Coro

Director
School Improvement Programs
U.S. Department of Education
400 Maryland Avenue, SW
Washington, DC 20202

Lily 0. Engstrom, M.S.
Assistant Director
Office of Extramural Research
National Institutes of Health
Shannon Building, Room 252
9000 Rockville Pike
Bethesda, MD 20892

Marilyn Gaston, M.D.
Director

Bureau of Primary Health Care
Health Resources and Services Administration
5600 Fishers Lane, Room 705
Rockville, MD 20857

Robert G. Harmon, M.D.
Administrator

Health Resources and Services Administration
5600 Fishers Lane, Room 14-05
Rockville, MD 20857

James A. Herrell
Deputy Director
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
Switzer Building, Room 2 132
330 C Street, SW

Washington, DC 20201

Elaine M. Johnson, Ph.D.
Acting Administrator
Substance Abuse and Mental Health Services

Administration
5600 Fishers Lane, Room 12- 105
Rockville, MD 20857

Marguerite M. Johnson
Program Officer
Robert Wood Johnson Foundation
Route 1 at College Road East
P.O. Box 2316
Princeton, NJ 08543-2316

J. Henry Monks
Assistant Director for Minority Health
National Center for Prevention Services
Centers for Disease Control and Prevention
1600 Clifton Road, NE, Mail E-07
Atlanta, GA 30333

Paul M. Schwab
Deputy Director
Bureau of Health Professions
Health Resources and Services Administration
5600 Fishers Lane, Room 8-05
Rockville, MD 20857

Henry L. Solano, J.D.
Lecturer in Public Policy
Kennedy School of Government
T-360 Harvard University
79 JFK Street
Cambridge, MA 02 138

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Participants

Myrna Alvear-Pinto, R.N., M.S.
Nursing Special Project Coordinator/Hispanic

Employment Coordinator
James A. Haley Veterans' Hospital
13000 Bruce B. Downs Blvd.
Tampa, FL 33612-4798

Hortensia Amaro, Ph.D.
Senior Visiting Research Scientist
COSSMHO
1501 16th Street, NW
Washington, DC 20036

Gabriel Arce
Chief Executive Officer
San Ysidro Health Ccntcr/Communitv
                            I
Health Group
4380 Otay Valley Road, Suite 207
Chula Vista, CA 919 11

Irma E. Arispe, Ph.D.
Evaluation Officer
Agency for Health Cart Policy and Research
2 10 1 East Jefferson Street, Suite 603
Rockville, MD 208 5 2

One



Voice

Joseph Baldi, M.A.
Deputy Chief
Urban Health Branch
Bureau of Primary Health Care/HRS.\
5600 Fishers Lane, Room 7A55
Rockville, MD 20857

Ledia Esther Bernal, M.B.P.A.
Equal Employment Manager
OfBcc of the Assistant Secretary for Personnel
Administration
Center for Human Resource Strategic Planning
and Policv

Vision

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 500 E

Washington, DC 2020 I

Kenneth Block, Col., M.C. U.S.A.
Deputy Director
Quality Assurance (representing Enrique Mendez)
Department of Defense
ASD-HA-Room 3E-346
The Pentagon

Washington, DC 20301

Diana M. Bonta, Dr.P.H.
Director
Department of Health and Human Services
City of Long Beach               \-
2655 Pine Avenue
Long Beach, CA 90806

John P. Brown, D.D.S., Ph.D.
Professor and Chairman
Department of Community Dentistry
The University of Texas Health Science Center
7703 Floyd Curl Drive
San Antonio, TX 78284-7917

Nilda Candelario, M.D.
Dean
University of Puerto Rico School of Medicine
P.O. Box 365067
San Juan, PR 00936-5067

Olivia Carter-Pokras, M.H.S.
Public Health Analyst
OfBce of Minority Health
Rockwall II Building
55 15 Security Lane, Suite 1102
Rockville, MD 20852

Carmela Castellano, J.D.
Attorney
Public Advocates
1535 Mission Street
San Francisco, CA 94103

Francisco L. Castillon, M.P.A.
Executive Director
California Health Federation, Inc.
2260 Park Towne Circle, Suite 103
Sacramento. CA 95825


Nelvis C. Castro
Coordinator
Hispanic Education Program
National Cancer Institute
Office of Cancer Communications
9000 Rockville Pike
Building 3 1 Room 4B-43
Bethesda, MD 20892

Laura F. Cavazos, Ph.D., M.A.
Adjunct Professor of Community Health
Tufts University School of Medicine
1000 Station Street
P.O. Box 1628

Port Aransas. TX 78373

Martha Corks, D.D.S.
Acting Regional Representative
Hispanic Dental Association
745 5th Avenue, Suite 1802
New York, NY 10151

Victor De La Cancela, Ph.D.
Senior Assistant Vice President
Grants Research and Development
New York City Health and Hospitals Corporation
346 Broadway, Room 5 15
New York, NY 10013

Antonio L. Estrada, Ph.D.
Assistant Professor and Research Coordinator
Southwest Border Rural Health Research Center
Department of Family and Community Medicine
College of Medicine
University of Arizona
Tucson, AZ 857 16

Leo Estrada, Ph.D.
School of Architecture and Urban Planning
UCLA

Ana Lopez Fontana, M.S.
President

13 17 Perloff Hall                    National Conference of Puerto Rican Women, Inc.
405 Hilgard Avenue                   5 Thomas Circle, NW
Los Angeles, CA 90024- 1467            Washington, DC 20005

Adolph P. Falcon, M.P.P.
Senior Policy Advisor
COSSMHO
1501 16th Street, NW
Washington, DC 20036

Alicia G. Fernandez-Mott
National Monitor Advocate
U.S. Department of Labor/ETA
Frances Perkins Building, Room N4470
200 Constitution Avenue, NW
Washington, DC 202 10

Hazel Ferrar
Program Analyst
Division of Policy and Coordination
Office of Minority Health
Rockwall Building II, Suite 1102
Rockville, MD 20857

Candida Flow, B.A.
Executive Director
Hispanic Health Council
96 Cedar Street
Hartford, CT 06106

Hector Flores, M.D.
Co-Director
White Memorial Medical Center
1720 Brooklyn Avenue
Los Angeles, CA 90033

Juan H. Flares, MS.
Executive Director
Center for Health Policy Development, Inc.
6905 Alamo Downs Parkway
San Antonio, TX 78238-45 19

Loiita Fonnegra, M.D.
Assistant Director
New York State Governor's Office for Hispanic
Affairs

New York, NY 10047

Antonio Furino, Ph.D.
Professor of Economics and Director
Center for Health Economics and Policy
The University of Texas Health Science Center
7703 Floyd Curl Drive
San Antonio, TX 78284-7907

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Jesus Garcia, MS.
Statistician Demographer
Bureau of the Census, Population Division
Hispanic Branch
Building 3, Room 2324
Washington, DC 20233-3400

Roland Garcia, Ph.D.
Section Chief
Centers of Excellence
HRSA - BHPR - DDA
Parklawn Building, Room 8A08
5600 Fishers Lane
Rockville, MD 20832

Elsa M. Garcia, R.N., M.H.A.
Manager of Benefits Interpretation and Vendor
Quality Assurance
Humana Health Plan
255 5 S. Martin Luther King Drive
Chicago, IL 606 16

Catalina E. Garcia, M.D.
Member
Texas State Board of Medical Examiners
National Council of La Raza
6902 Chevy Chase Avenue
Dallas, TX 75225

Jane C. Garcia, M.P.H.
Executive Director
La Clinica de la Raza-Fruitvale Health Project, Inc.
15 15 Fruitvale Avenue

One

Oakland, CA 94601

Voice

Rosa Maria Gil, D.S.W.
Chief Executive Officer and Education Director
Phase, Inc. and Hire, Inc.
599 Broadway, 11 th Floor
New York, NY 10012

One



Vision

Jorge A. Girotti, Ph.D.
Assistant Dean and Director
Hispanic Center of Excellence
University of Illinois at Chicago College of Medicine
CMW (M/C 786)
185 3 West Polk Street, Room 15 1
Chicago, IL 606 12

Priscilla Gonzalez-Leiva, R.N.
Chief

Health Professions Career Opportunity Program
Office of Statewide Health Planning and

Development
1600 Ninth Street, Room 441
Sacramento, CA 958 14

E. Liza Greenberg, R.N., M.P.H.
Project Director
Primary Care
Association of State and Territorial Health Offtcials
415 Second Street, NE, Suite 200
Washington, DC 20002

Amelie Gutierrez Ramirez, Dr.P.H.
Assistant Director for Administration and
Community Health Promotion
The University of Texas Health Science Center
South Texas Health Research Center
Bluff Creek Tower, Suite 280
7703 Floyd Curl Drive
San Antonio, TX 78284-779

Linda Gutierrez, M.A.
Intergovernmental Coordinator
AHCCCS Administration-State of Arizona
Arizona Health Care Cost Containment System
Hermosillo Building, Suite 1360
110 South Church Street, Box 70
Tucson, AZ 85701

Betty Lee Hawks, M.A.
Associate Director
Division of Information
Dissemination and External Liaison
Ofice of Minority Health
Rockwall Building II, Suite 1102
Rockville, MD 20857

David Hayes-Bautista, Ph.D.
Director
Center for the Study of Latin0 Health (CESLA)
UCLA School of Medicine
10911 Weybum Avenue, Suite 333
Los Angeles, CA 90024


+ ++++444444444444444 Appendix,4

Alaria V. Jimenez, M.HS.A.
I {calth Policy Analyst
COSSMHO
I 501 16th Street, NW
\Vashington, DC 20036

Mim A. Kelly, Ph.D.
Health Science Administrator
.iqcncv for Health Care Policy and Research
Cintc; for Medical Effectiveness Research
2 10 1 East Jefferson Street, Room 605
Rockville, MD 20852

Pedro Lecca, Ph.D., RPh., C.S.W.
Professor

School of Social Work
University of Texas
2 11 South Copper
P.O. Box 19129
Arlington, TX 76019-0129

Cristina Lopez, M&d.
Director

Health and Elderly Component
National Council of La Raza
810 First Street, NE, Suite 300
Washington, DC 20002

Gloriana M. Lopez, D.D.S., M.P.H.
Epidemic Intelligence Officer
Epidemiology Program Office
Centers for Disease Control and Prevention
Mail Stop C-08
1600 Clifton Road, NE
Atlanta, GA 30333

Rosalio Lopez, M.D.
General Practioner
Mulliren Medical Clinics
1783 1 South Pioneer Boulevard
Artesia, CA 90701

Jean W. MacCluer, Ph.D.
Scientist
Southwest Foundation for BioMedical Research
7620 Northwest, Loop 410
San Antonio, TX 78227

Caroline A. Macera, Ph.D.
Associate Professor of Epidemiology
School of Public Health
University of South Carolina
Columbia, SC 29208

Saul Malozowski, M.D., Ph.D.
President
Hispanic Employment Organization
Visiting Scientist
Endocrine and Metabolism Division
Food and Drug Administration
Parklawn Building, Room 14B-04
5600 Fishers Lane
Rockville, MD 20857

Gerard0 Marin, Ph.D.
Associate Dean of Arts and Sciences   '
University of San Francisco
2 130 Fulton Street, Room 243
San Francisco, CA 94 117- 1080

Alberta G. Mata, Jr., Ph.D.
Associate Professor of Human Relations
Department of Human Relations
University of Oklahoma
601 Elm Avenue, Room 728
Norman, OK 7301 P-03 15

Fernando Mendoza, M.D.
Associate Professor of Pediatrics and Director
Chicano Research Center
Cyress Hall, E. Wing
Stanford University School of Medicine
Stanford, CA 94305

Magdalena Miranda, M.S.
Director
Program Planning and Development
Educational Commission for Foreign Medical
Graduates
2000 Pennsylvania Avenue, NW
Suite 3600
Washington, DC 20006

Manuel R. Modiano, M.D.
Director
Minority Cancer Control
Arizona Cancer Center
15 15 N. Campbell Avenue, Suite 1995
Tucson, AZ 85724

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On.5

Voice

One

Vision

Roberto Montoya, M.D., M.P.H.
Director

California Shortage Area Minority Medical
Matching Program
California Offrice of Statewide Health Planning
and Development
1130 K Street, Suite 150
Sacramento, CA 958 14

Emma Moreno
Deputy Director
Congressional Affairs Office
Bldg. 3, Room 2077-3
Bureau of the Census
Washington, DC 20233

M. Eugene Moyer, Ph.D.
Economist

Office of the Assistant Secretary for Planning

and Evaluation

U. S. Department of Health and Human Services
200 Independence Avenue, SW,
Room 442 E

Washington, DC 20201

Eric Munoz, M.D., M.B.A.
Medical Director and Associate Dean for

Clinical Affairs

University of Medicine and Dentistry of New Jersey
University Hospital
150 Bergen Street
Newark, NJ 07103

Felicia Nault, RD., M.B.A.
Public Health Nutritionist
Orange County Health Cart Agent!
960 South Barton Court
Anaheim, CA 92808

Gilbert M. Ojeda
President
Latin0 Health Affairs Council
P.O. Box 238
300 Lakeside Drive
Berkeley, CA 94701

Susan Opava-Stitzer, Ph.D.
Chairperson
Department of Physiolog!
University of Puerto Rico School of Medicine
P.O. Box 365067
San Juan, PR 00936-5067

Robert Otto Valdez, Ph.D., M.H.S.A.
Associate Professor
Health Policy and Management, UCLA
Health Policy Analyst, RAND
IO833 La Conte Avenue
Los Angeles, CA 90024- 1772

Mara Patermaster, M.P.A.
Manager
HIV/AIDS Prevention Grants Program
The United States Conference of Mayors
U.S. Conference of Local Health Officials
1620 Eye Street, NW
Washington, DC 20006

Janice Petrovich, Ph.D.
National Executive Director
ASPIRA Association, Inc.        .

1112 16th Street, NW, Suite 340
Washington, DC 20009

F. Xavier Pi-Sunyer, M.D., M.P.H.
President

American Diabetes Association
National Center
1660 Duke Street
Alexandria, VA 2 2 3 14

Carmen J. Portillo, Ph.D., RN.
Assistant Professor
UCSF School of Nursing
3rd and Pamassus
P.O. Box 0608
San Francisco, CA 94114

Annette B. Ramirez de Arellano, Dr.P.H.
Associate Dean

School of Health Finances
Hunter College
600 W. 115th Street, #92
New York, NY 10025

Juan Ramos, Ph.D.
Deputy Director for Prevention and Special Projects
National Institute of Mental Health
Parklawn Building, Room 18-95
5600 Fishers Lane
Rockville, MD 20857


.JW~ G. Rigau, M.D., M.P.H.
c`i&d

1 l~itl~miology Section, Dengue Branch DVBlD,
SLID

C`cntcrs for Disease Control and Prevention
11. 5. Public Health Service
.<~n Juan Laboratories
1 C`allc Casia

.ian Juan, PR 00921-3200

Elena V. Rios, M.D., M.S.P.H.
t'rcsident
C'hicano/Latino Medical Association of California
4 1 -C N _ Boyle Avenue
Los ;\ngeles, CA 90033

Ralph Rivera, Ph.D.
Associate Director
Mauricio Gaston Institute for Latin0 Community
Development and Public Policy
Hcaley Library, 10th Floor
University of Massachusetts
100 Morrissey Boulevard
Boston, MA 02125-3393

Gloria M. Rodriguez, MAW.
Project Director
Division of Alcoholism, Drug Abuse and

Addiction Services
New Jersey State Department of Health
2 Veteran's Place
Paterson, NJ 07505

Evelyn M. Rodriquez, M.D., M.P.H.
Medical Officer

National Institutes of Health
6003 Executive Blvd., Room 240P
Bethesda, MD 20892

Socorro M. Roman, M.S.N., R.N.
Assistant Professor of Nursing
Indiana University School of Nursing
Division of Nursing, Northwest Campus
3400 Broadway Street
Gary, IN 46408

Josephine Rosa, R.D.H., M.S.
President
Hispanic Dental Association
One South Wacker Drive, Suite 1800
Chicago, IL 60606

Elva Ruiz, B.S.
Director
Hispanic Cancer Control Program
National Cancer Institute
National Institutes of Health
Executive Plaza North, Room 240
9000 Rockville Pike
Bethesda, MD 20892

Sally E. Ruybal, Ph.D.
Professor

College of Nursing
University of New Mexico
Albuquerque, NM 87131

Linda &inches
Program Analyst
Director of Public Health Policy      ,
Of&e of the Assistant Secretary for Planning

and Evaluation

U. S. Department of Health and Human Services
200 Independence Avenue, SW
Room 432-E

Washington, DC 20201

Chris Sandoval

Section Manager and Director of AIDS Services
Men's and Women's Health Section
Santa Clara County Health Department
976 Lenzen Avenue, 2nd Floor
San Jose, CA 95128

Sarah Santana

Director of Epidemiology and Vital Statistics
Maricopa County Department of Public Health
1825 East Roosevelt
Phoenix, AZ 85006

Wayne E. Sauseda
Director
Office of AIDS/SIDA
California Department of Health Services
830 S. Street
P.O. Box 942732
Sacramento. CA 94234-7320

Esther Sciammarella, M.S.
Special Assistant for the Commissioner

of Hispanic Affairs
Chicago Department of Health
50 W. Washington Street, Room 2 15
Chicago, IL 60602

One

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One

Vision


Donald L. Sepulvado, Ph.D.
Acting Director

Program Evaluation and Data Analysis Branch
Office of Minority Health
Rockwall Building II, Suite 1 102
55 15 Security Lane
Rockville, MD 20852

Marta Sotomayor, Ph.D.
President

National Hispanic Council on Aging
2713 Ontario Road, NW
Washington, DC 20009

Mary Thorngren, M.S.
Director

Maternal and Child Health Division
COSSMHO

1501 16th Street, NW
Washington, DC 20036

Kathleen A. Torres, M.P.H.
Deputy Chief of Staff
California State Senator Charles Calderon
6 17 West Beverly Boulevard
Montebello, CA 90640

Rosemary Torres, J.D., B.S.N.           Adela de la Torre, Ph.D.
Special Assistant to the Director               Chair
Of&e of Research on Women's Health           Chicano and Latin0 Studies
National Institutes of Health             California State University
Building 1, Room 201                    1250 Bellflower Blvd.
9000 Rockville Pike               Long Beach, CA 90840

OIM!

Bethesda, MD 20910

Voice

One

Sara Torres, Ph.D., R.N.
Associate Professor
College of Nursing
University of South Florida
MDC Box 22
12901 Bruce B. Downs Boulevard
Tampa, FL 33612

Vision

Henrietta Villaescusa, R.N.
National Association of Hispanic Nurses
20 18 Johnston Street
Los Angeles, C.\ 9003 1

Antonia M. Villarruel, M.S.N., R.N.
Clinical Nurse Specialist
Children's Hospital of Michigan
390 1 Beaubien

Detroit, MI 48201

Robert M. Wilson
Deputy Assistant Secretary
Office of Policy External Affairs
Administration for Children and Families
370 L'Enfant Promenade, SW, Suite 700
Washington, DC 20447

Christina Wypijewski, M.P.H.
Prevention Policy Advisor
Office of Health Promotion and Disease Prevention
Switzer Building, Room 2 J 32
330 C Street, SW           5 -

Washington, DC 20201

Frank Beadle de Palomo, M.A.
Director
Center for Health Promotion
National Council of La Raza
8 10 First Street, NE, Suite 300
Washington, DC 20002


Appendix B: National Workshop Agenda
SurEeon General's National Workshop on Hispanic/ I&no

He&h, Washington, DC

12:00 pm-l:00 pm
Registration

.ANA Westin Hotel Main Lobby

1:OO pm-2:00 pm
Opening of Plenary Session
Welcome

Antonia Coello Novello, M.D., M.P.H.
Surgeon General
Public Health Service
U.S. Department of Health and Human Services
Keynote Speaker
The Honorable Louis W. Sullivan, M.D.
Secretary
U.S. Department of Health and Human Services
Charge to Workshop Participants
Antonia Coello Novello, M.D., M.P.H.

2:00 pm-290 pm
Break

2:30 pm4:OO pm
Hispanic/Latin0 Health
Issues Panel-Background
Summary Papers
Chair

Antonia Coello Novello, M.D., M.P.H.

Panelists

Improving Access to Health Care in Hispanic/
Latin0 Communities
Robert Valdez, Ph.D., M.H.S.A.

Improving Data Collection Strategies
Jane Delgado, Ph.D.
Increasing the Representation of Hispanics/Latinos
in the Health Professions            i

Fernando Trevino, Ph.D., M.P.H.

The Development of a Relevant and
Comprehensive Research Agenda To Improve
Hispanic/Latin0 Health
Gerard0 Marin. Ph.D.

Health Promotion and Disease Prevention
Marilyn Aguirre-Molina, Ed.D.

4:00 pm-530 pm
Work Group Session I

Identification and Prioritization of the Key
Problems/Issues

6:OO pm400 pm
Reception

Organization of American States Building
Welcome

Antonia Coello Novello, M.D., M.P.H.
Introduction of Speakers

Samuel Lin, M.D., M.P.H.
Acting Deputy Assistant Secretary for
Minority Health
Office of Minority Health
Public Health Service
U.S. Department of Health and Human Services

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One

Voice

4b

One

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Appendix I3 4444444444444444444

Speakers
The Honorable Solomon P. Ortiz
Representative
State of Texas
Chairman, Congressional Hispanic Caucus
U . S . House of Representatives
The Honorable Nancy L. Kassebaum
Senator

12:00 pm-l:30 pm
Lunch (free time)

1:30 pm-2:00 pm
Keynote Speaker

The Honorable Lynn Martin
Secretary
U.S. Department of Labor

State of Kansas
U.S. Senate

2:00 pm-3:30 pm
Work Group Session IV
Implementation Strategies (cont'd)

7:00 am-8:30 am
Buffet Breakfast

3:30 pm-4:00 pm
Break

\ .

ANA Westin Hotel Colonnade Restaurant

Speakers
Gail R. Wilensky, Ph.D.
Deputy Assistant to the President for

Policy Development
The White House

Barbara Everitt Bryant, Ph.D.
Director
Census Bureau
U . S . Department of Commerce
Robert S. Murphy, MS. P. H.
Director

Division of Health Examination Statistics
National Center for Health Statistics
Centers for Disease Control and Prevention

8:30 am-10:OO am

Work Group Session II
Implementation Strategies

10:00 am-lo:30 am
Break

4:00 pm-6:OO pm
Work Group Session V
Finalize Implementation Strategies

6:00 pm-7:00 pm
Chairpersons, Vice Chairpersons,
and Staff Meeting

7:00 pm-8:OO pm
Work Group Session VI

Finalize Presentation
(Chairpersons3 Vice-chairpersons. Rapporteurs, and
Presenters only)

7:00 am-8:00 am
Continental Breakfast

ANA Westin Hotel Court

8:OO am-9:OO am
Remarks

lo:30 am-12:00 pm
Work Group Session III
Implementation Strategic3 (cont'd)

Rafael J. Magallan
Director, Washington Office
Hispanic Association of Colleges and Universities
Hispanic Access to Health Care/GAO Report


Elwnor Chelims&
\>Gtant Comptroller General
Ll.\;. ticncral Accounting Offke

Y:OO am-10:lS am
Work Group Reports to Workshop
Participants
Chair

Antonia Coello Novello, M.D., M.P.H.
Panel Presentations

10: 15 am-lo:30 am
Break

lo:30 am-11:00 am
Work Group Reports to Workshop
Participants (cont'd)

11:00 am-1250 pm
Responder Panel
Chair

Antonia Coello Novello, M.D., M.P.H.
Guest Panelists

James 0. Mason, M.D., Dr.P.H.
Assistant Secretary for Health
U.S. Department of Health and Human Services

John T. MacDonald, Ph.D.
Assistant Secretary for Elementary and
Secondary Education
U.S. Department of Education

Thomas Komarek, M.B.A.
Assistant Secretary for Administration
and Management
U.S. Department of Labor

Karen R. Keesling, J.D.
Acting Administrator
Wage and Hour Division
U.S. Department of Labor

Louis D. Enoff

Acting Commissioner
Social Security Administration
U.S. Department of Health and Human Services

William Toby, M.S. W.
Acting Administrator
Health Care Financing Administration
U.S. Department of Health and Human Services

Michael McGinnis, M.D.
Director

Of&e of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services

Robert S. Murphy, M.S. P.H.
Director, Health Examination Statistics
National Center for Health Statistics    .
Centers for Disease Control and Prevention
Public Health Service
U.S. Department of Health and Human Services

Rafael J. Magallan
Director
Hispanic Association of Colleges and Universities

Kenneth Shine, M.D.
President
Institute of Medicine

12:30 pm-12:45 pm
Charge for the Future: Where Do
We Go from Here?

Antonia Coello Novello, M.D., M.P.H.

0I-X

Voice

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e + 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Appendix C

Appendix C: Regional Health

Meetings-Executive Planning
Committees and Agendas

Antonia C. Novella, M.D., M.P.H.
Surgeon General U.S.P.H.S.
200 Independence Avenue, S.W.
Washington, D.C. 20201

Dear Dr. Novello:

Please convey my best wishes for a successful meeting to the participants
in the New York Regional Meting on Hispanic/Latino Health.

As an integral part of the National Iiispanic/Latino Realth Initiative, the
Regional Meetings are an historic milestone in our public health
activities.  The Regional Heetings are the firat, regionally focused
effort to address the special health needs of the Hispanic and Latin0
community.

The findings of the Regional Meetings will be used to inform Department
and key regional and national health policy leaders of the health needs of
the Hispanic/Latino people in five critical areas:  access to health care,
representation of Hispanic/Latinos in science and health professions;
tiproved data collection atrategies; a relevant and comprehensive research
agenda; and health promotion and disease prevention irsues.   I am
confident that the Regional Meetings will result in strong and lasting
partnerships committed to implementing effective health care and access
strategies.

I applaud your efforts and I commend your dedication to improving the
health of the Hispanic and Latin0 member8 of our American family.

Sincerely,

Donna E. Shalala

This letter is a sample of the letters setIt bx Secretac Shalala for all the Regional Health Meetings.

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Alabama

Florida

Georgia

Kentucky

Mississippi

North Carolina

South Carolina


Tennessee

One

voice

One

Vision

Appendix C 4444444444444444444

Region IV Executive Planning Committee

Co-Chairpersons
Ramon Rodriguez-Torres, M.D.
Chief of Staff
Miami Children's Hospital
Sara Torres, Ph.D., R.N.
Associate Professor, College of Nursing
University of South Florida
Vice-Chairperson
Beaumont R. Hagebak, Ed.D.
Health Administrator, Region IV

Coordinators

Robert C. Ribera
Special Projects Office
Miami Children's Hospital
Peggy Smith Maddox
Special Projects Offrice
Miami Children's Hospital

Members
Myriam B. Ares, M.D., M.P.H.
Chief, Office of Disease Prevention
Dade County Public Health Unit
Salvador Bou, M.D.
OfIke of Clinical Management
Public Health Service, Region IV
Jean Malecki, M.D., M.P.H.
Medical Director
Palm County Health Unit

Pedro Castillo

Minority Health Advisory Council
North Carolina Department of Health
and Natural Resources

Orlando Dominguez, M.D., F.A.A.P.
President
Cuban Pediatric Society

Jose Szapocnic, Ph.D.
Professor of Psychiatry and Deputy Director
Center for Biopsychosocial Studies and AIDS

Caroline A. Macera, Ph.D.
Assoc. Prof. of Epidemiology
University of South Carolina School of Public
Health                    I-

Josefina Carbonnell
President

Little Havana Activities and Nutrition Centers

Estela Niella-Brown
Public Affairs Specialist
Food and Drug Administration

Linda S. Quick

Executive Director
Health Council of South Florida, Inc.

Ariela Rodriguez, M.D.
Director of Health and Social Services
Little Havana Activities and Nutrition Centers

Eleni D. Sfiianaki, M.D.
Medical Executive Director
Dade County Public Health Unit

Yvonne Jons

Associate Regional Health Administrator for
Minority Health

Public Health Service, Region IV


Region IV Regional Health Meeting Agenda
Miami, Florida

8:OO am-9:00 am
Registration

9:00 am-lo:30 am
Opening Plenary Session
Welcome

Ramon Rodriquez-Torres, M.D.
Co-Chairperson
Miami Children's Hospital
Sara Torres, Ph.D., R.N.
Co-Chairperson
University of South Florida
Beaumont Hugebuk, Ed. D.
Vice-Chairperson
Acting Regional Health Administrator
U.S. Public Health Service, Region IV

Donna E. Shalulu (invited)
Secretary of Health and Human Services

Claudia R. Buquet, M.D., M.P.H. (invited)
Deputy Assistant Secretary for Minority Health
U .S. Public Health Service

Lydia E. Soto- Torres, M.D., M.P.H.
National Coordinator
Surgeon General's National Hispanic/Latin0

Health Initiative

Office of the Surgeon General
U.S. Public Health Service

Keynote Address and Charge to
Participants
Antoniu Coello Novello, M.D., M.P.H.
Surgeon General
U.S. Public Health Service

lo:30 am-1l:OO am

Break

11:00 am-12:30 pm
Work Group Session I
Access to Health Care

Co-Facilitators:

Rosebud L. Foster, Ed.D.
Professor of Health Services Administration
Florida International University
Arielu C. Rodriguez, Ph.D., A.C.S. W.
Director of Health and Social Services
Little Havana Activities and Nutrition Centers of

Dade County, Inc.
Data Collection

Co-Facilitators:

Linda Jacobs

Project Administrator
OfIke of Vital Records and Public Health Statistics
South Carolina Department of Health and

Environmental Control

Teresa Femandez, R.N., M.H.M.
Ambulatory Care Director
University of Florida Medical Center
Research

Co-Facilitators:

Donna Richter, Ed. D.
Assistant Dean
University of South Carolina
Susannah Young, R.D., M.P.H.
Director
North Carolina Migrant Health Program

   Alabama

    Florida

   Georgia

  Kentucky

Mississippi

North Carolina

South Carolina


  Tennessee

One

Voice

One

Vision


Alabama

Florida

Georgia

Kentucky

Mississippi

North Carolina

south Carolina

Tennessee

One

voice

One

Vision

Appendix C 444444

Health Professions
Co-Facilitators:

Robert Femandez, D.O., M.P.H.
Deputy Dean
Southeastern College of Osteopathic Medicine
Hilda Brito, R.N., B.S.N.
Career Counselor
Jackson Memorial Hospital
Health Promotion and Disease
Prevention

Co-Facilitators:

Pedro Castillo

Director, Casa Guadalupe
Member, North Carolina Mental Health Advisory

Council

Gustav0 Saldias, M.P.H.
Director for Safety and Health
Farmworkers Legal Services of North Carolina

1250 pm-2:OO pm
Luncheon
Speaker

A. Frederick Schild, M.D., F.A.C.S.
President
Florida Medical Association

2:00 pm-3% pm
Work Group Session II

3:30 pm-4:OO pm
Break

4:00 pm-530 pm
Work Group Session III

530 pm-6:OO pm
Facilitators Meeting

6:00 pm-7:30 pm
Reception

Sponsored by CAC-Ramsay Health Plans

9:00 am-lo:oo am
Work Group Session IV

10:00 am-lo:30 am

Break

lo:30 am-12:00 pm
Plenary Session
Work Group Reports
Access to Health Care
Rosebud Foster, Ph.D.
Data Collection Strategies
Linda Jacobs
Science and Health Professions
Robert A. J. Femandez, D.O.M., M.P.H.,
F.A.C.G.P.
Comprehensive Research Agenda
Donna Richter, Ed.D.
Health Promotion and Disease
Prevention
Gustav0 Saldias, M.P.H.
Responder Panel
Moderator
Marisa Azaret, Psy. D.
Faculty Member
Miami Children's Hospital
Jose Szapocznic, Ph.D.
Professor of Psychiatry
University of Miami
Burton Dunlop, Ph.D.
Director of Research
Southeast Florida Center on Aging
North Miami, Florida
Sister Barbara Harrington, G. N.S. H.
St. Joseph's Hospital
Atlanta, Georgia


Gmrr Hernandes D. P.A.
.Aw)ciatc Professor
%()\`.A Universitv
Ft. Lauderdale, Fiorida

,Mcrdelin Escagedo Menacho, M.S.
licgional Coordinator for the National Hispanic
Education and Communication Project
kIiami, Florida

12:00 pm-l:30 pm
Luncheon
Speaker
The Honorable Lincoln Diaz-Balart
U . S. Congressman
Closing Remarks
Antonia Coello Novello, M.D., M.P.H.
Surgeon General

   Alabama

    Florida

  Georgia

  Kentucky

Mississippi

North Carolina

South Carolina


  Tennessee

One

Voice

One

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Appendix C 4444444444444444444

Regions V and VII Executive Planning Committee
                                                "

Illinois


Indiana


Iowa


KZUlSdS

Michigan

Minnesota


Missouri


Nebraska


Ohio


Wisconsin

One

Voice

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Co-Chairpersons
Aida L. Giachello, Ph.D.
Assistant Professor
Jane Addams College of Social Work
University of Illinois at Chicago
Steven Uranga McKane, D.M.D., M.P.H.
Program Coordinator
Kellogg Foundation

Members

Connie Alfaro
Public Health Consultant
Office of Minority Health
Michigan Department of Public Health
Nohema Astaburuaga
Program Specialist
Ohio Commission on Minority Health

Jose Avila, R.N.

Lisa Bartra
Case Manager
Good Samaritan

Ira Bey

District Manager
Marion-Merrell Dow Pharmaceuticals, Inc.

Tony E. Caceres, M.D., M.P.H.
Medical Director
Sinai Samaritan Medical Center

Gerard0 Colon
Hispanic Liaison
Community Relations Board
Citv of Cleveland

Elsa Garcia, R.N., M.H.A.
Manager, Medical Benefits and Vendor
Quality Assurance
Humana Health Plan

Jorge Girotti, Ph.D.
Assistant Dean, Urban Health
Director, Hispanic Ccntcr of Exccllcncc
Univ-ersity of Illinois at Chicago

Romeo Guerra
Administrator
Offrce of Minority Health
Nebraska Department of Health
Monica Medina
Executive Director
Centro Hispano
Theitypanic Center
Augustine Paz
Effort for AIDS

Ila Plascencia
L.U.L.A.C. Midwest Education

Betsy Reyes
Assistant Director for Community Affairs and

Minority Business
At-two Robles

Office of Local and Rural Health
Kansas Department of Health and Environment
Socorro Roman, R.N.
Indiana University Northwest
Adriana Ruiz
AIDS Coordinator
C.L.U.E.S.

Esther Sciammarella
Special Assistant to the Health Commissioner
Director, Chicago Hispanic Health Coalition
Chicago Department of Health

Sylvia Tijerina
Administrator
Commission on Latin0 Affairs

Kathy Wederspahn
Health Program Representative
Minnesota Department of Health


Federal Representatives
s.itionaI Coordinator

/-!.dja Soto-Torres, M.D., M.P.H.
sdtional Coordinator
,iurpcon General's National

IIispanic/Latino Health Initiative
()fficc of the Surgeon General
5600 Fishers Lane, Rm 18-67
Rockville, Maryland 20857
(30 I ) 443-4000/3574 fax

Vice Chairpersons
Julia Attwood

Acting Regional Public Health

Administrator, Region V
U.S. Public Health Service
105 W. Adams St./l7th Floor
Chicago, Illinois 60603
(312) 353-1385/353-0718 fax

E. Frank Ellis, M.D.
Regional Health Administrator, Region VII
U.S. Public Health Service
601 E. 12th St., 5th Fl
Kansas City, MO 64106
(816) 426-3291/2178 fax

Other Representatives
Mildred Hunter
Regional Minority Health Coordinator
U.S. Public Health Service, Region V
105 W. Adams Street, 17th Floor
Chicago, Illinois 60603
(312) 353-1385/0718 fax

William Mayfeld
U.S. Public Health Service, Region VII
Reg. AIDS/Minority Health Coordinator
601 E. 12thSt., 5thFl.
Kansas City, MO 64106
(816) 426-3291/2178 fax

Hazel Farrar
Offke of Minority Health
U.S. Public Health Service
Rockwall 2 Building
55 15 Security Lane/Suite 1102
Rockville, MD 20852
(301) 443-9923/8280 fax

Illinois

Indiana

   Iowa


  Kansas

Michigan

Minnesota


Missouri

Nebraska


  Ohio


Wisconsin

One

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One

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Appendix C 4444444444444444444

Regions V and VII Regional Health Meeting Agenda

Illinois

Indiana


lOW.3


KSWd.3

Michigan

Minnesota


Missouri

Nebraska

Ohio


Wisconsin

One    Sponsored by the Chicago Department of Health

Voice

and the Chicago Hispanic Health Coalition
Welcome Remarks
Antonia Coello Novello, M.D., M.P.H.
Surgeon General

One

Vision

Chicago, Illinois

1O:OO am-l:00 pm
Work Group Chair and Co-Chair
Orientation

1:OO pm-2:00 pm
Lunch

2:00 pm-3:30 pm
Midwest Regional Executive
Planning Committee Meeting

350 pm-4:00 pm
Break

4:OO pm-8:OO pm
Regional Meeting Registration

6:00 pm-8:OO pm
Reception

7:30 am-9:00 am
Continental Breakfast

Wcstin Hotel

8:30 am-9~00 am

Opening Plenary Session
Welcome Remarks
Aida L. Giachello, Ph.D.
University of Illinois at Chicago
Regional Health Meeting Co-Chairperson

Julia Attwood

i -

Acting Regional Public Health Administrator
U.S. Public Health Service, Region V
Regional Health Meeting Vice-Chairperson
Steven Uranga McKane, D. M.D., M.P.H.
Program Coordinator, Kellogg Foundation
Regional Health Meeting Co-Chairperson
Donna E. Shalala (invited)
Secretary of Health and Human Services
Claudia R. Baquet, M.D., M.P.H. (invited)
Deputy Assistant Secretary for Minority Health
Of&e of Minority Health
Mayor Richard M. Daley (invited)
City of Chicago

9:00 am-9:20 am
Public Health Issues

E. Frank Ellis, M.D., M,P,H.
Regional Public Health Administrator
U.S. Public Health Service, Region VII
Regional Health Meeting Vice-Chairperson

9:20 am-9:35 am

The SurgeonGeneral's National
Hispanic/Latin0 Health Initiative
Overview

7:30 am-3:00 Dm

Registration


e 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 AppendixC

L!& E. Soto-Torres, M.D., M.P.H.
~,lticd Coordinator
surgeon General's National Hispanic/Latin0

Health Initiative
(>t'ficc of the Surgeon General
U.S. Public Health Service

9:35 am-1O:lS am

Overview of Hispanics/Latinos
in the Midwest
Sylvia Puerte, M.A.
Director of Research and Documentation
Latin0 Institute, Chicago, IL

lo:15 am-lo:30 am
Break

(Sponsored by Blue Cross and Blue Shield of Illinois)

lo:30 am-12:00 pm
Hispanic/Latin0 Health Issues
in the Midwest
Summary of Background Papers
Moderator

Steve Uranga McKane, D.M. D.. M.P.H.
Regional Co-Chairperson
Access to Health Care
Aida L. Giachello, Ph.D.
Jane Addams College of Social Work
University of Illinois at Chicago
Data and Research
Jose 0. Arrom, M.A.
Midwest Hispanic AIDS Coalition
Health Professions
Jorge Girotti, Ph.D.
Hispanic Center of Excellence
College of Medicine
University of Illinois at Chicago
Health Promotion and Disease
Prevention
Cristina Jose-Kampfier, Ph.D.
Eastern Michigan University

Migrant and Rural Health Issues
Manny Gonzalez

12:00 pm-2:00 pm
Working Luncheon

Luncheon Moderator

E. Frank Ellis, M.D., Ph.D.
Regional Meeting Co-Chairperson
Invocation

The Reverend Thomas A. Baima
Director, Office of Ecumenical and

Interreligious Affairs
Archdiocese of Chicago
Partners in Health

Karen Timmons

Chief Operating Officer
Joint Commission on Accreditation of

Health Care Organizations
Beau Stubblefield, M.B.A.
Program Director, Division of Medical Affairs
American Medical Association

Linda Bresolin, Ph.D.
Director of Women's and Minority Health
American Medical Association

2:00 pm-2:30 pm
Break/Networking

Sponsored by the Norwegian American Hospital

290 pm-3:30 pm
Keynote Address/Charge to
Workshop Participants
Antonia Coello Novello, M.D., M.P.H.
Surgeon Genera1

3:30 pm400 pm
Concurrrent Workshops
Workshop A-Access to Health Care
Chairperson
Elsa Garcia, R.N.
Humana Health Plan
Chicago, Illinois

Illinois

Indiana


   Iowa


  Kansas

Michigan

Minnesota


Missouri

Nebraska

  Ohio


Wisconsin

One

Voice

ds

Vision


Appendix C 4444444444444444444

Illinois

Indiana


Iowa


Kansas

Michigan

Minnesota


Missouri

Nebraska

Ohio '

Hispanic Center
Intlianapolis, Indiana

RcPorter
lvun de la Rosa
University of Michigan
Workshop B-Data and Research
Chairperson
Flavio Marsiglia, Ph.D.
1% Bat-d of Education
Chveland, Ohio

Wisconsin

(:c,-Chairperson
Victoria Amaris
St. Paul, Minnesota

Rkporter
Mm-cedes Rubio
University of Michigan
Workshop C-Health Professions
(`hairperson
Socorro Roman, R.N., Ph.D.
lntliana University Northwest
<`o-Chairperson
Jorge Girotti, Ph.D.
~Iniversity of Illinois at Chicago

One



Voice

Reporter
~`mnen Abriego
~iniversity of Illinois at Chicago
Workshop D (l)-Health Promotion
and Disease Prevention

(`hairperson
hligdalia Rivera
I:sccutive Director, Latin0 Institute

One



Vision

~`0Chairperson
( `mnie Alfaro
h\ichigan Department of Public Health

Reporter
\ `it-ginia Lopez
c'linica Sta. Maria
(; rand Rapids, Michigan

Workshop D (2)-Health Promotion
and Disease Prevention

Chairperson
Steve Guerra
Illinois Prevention Resource Center
Chicago
Co-Chairperson
Cristina Jose, Ph.D.
Eastern Michigan University

Reporter
Jose Avila
Cudahy, Wisconsin

6:OO p-7:00 pm
Chairs/Co-ChairsLRepbrters Meeting

6:30 pm-7:30 pm
Reception
Mariachis Band
Sponsored by Marion-Merrell Dow
Pharmaceuticals, Inc.
Hacienda Los Gutierrex Mexican Restaurant

7:30 pm-1O:OO pm
Regional Award/Recognition Dinner
Sponsored by Marion-Merrell Dow
Pharmaceuticals, Inc.
Entertainment by "Las Cuerdas Clasica"
Master of Ceremonies

Rod Sierra
WGN Radio
Chicago, Illinois
Invocation

The Reverend Ruben Cruz
Welcome Remarks
Steve Uranga McKane, M. D.M., M.P.H.
Regional Co-Chairperson
Aida L. Giachello, Ph.D.
Regional Co-Chairperson
Ira Bey
District Manager
Marion-Merrell Dow Pharmaceuticals, Inc.


Remarks

.+uonia Coello Novello, M.D., M.P.H.
hqcon General

Awards Recognition Ceremony
Regional Awards

Main Awards

Special Awards

lllinois

Indiana


Jowa

Michigan

Minnesota

Missouri

Nebraska

Ohio

Wisconsin

One

Voice

One

Vision


Appendix C 4444444444444444444

Regions VI and VIII Executive Planning Committee

Arkansas

Colorado


Louisiana


Montana


New Mexico

North Dakota

Oklahoma

south Dakota


T.3.3S


Utah

Wyoming

One

Voice

One

Vision

Chairpersons
Ciro V. Sumaya, M.D., M.P.H.T.M.
Associate Dean for Affiliated Programs and
Continuing Medical Education
University of Texas Health Science Center at
San Antonio

Paula S. Gomez
Executive Director
Brownsville Communit: Health Center

Associate Chairpersons
Amelie G. Ramirez, Dr. P.H.
Assistant Director for Administration

and Health Promotion
South Texas Health Research Center
University of Texas Health Science Center

at San Antonio

Antonio Furino, Ph.D.
Professor of Economics and Director
Center for Health Economics and Policy
University of Texas Health Science Center

at San Antonio

Conference Coordinators
Virginia Seguin
Social Science Research Associate
South Texas Health Research Center
University of Texas Health Science Center
San Antonio, Texas

Ileana Fonseca
Research Assistant
Center for Health Economics and Policy
University of Texas Health Science Center
San Antonio, Texas

Members

Mary Bowers
Program Liaison Specialist (Minorit? Health)
U.S. Public Health Service, Region VI
Dallas, Texas

James A. Doss
Acting Regional Health Administrator
U.S. Public Health Service, Region VI
Dallas, Texas

Estevan Flares, Ph.D.
Coordinator of Research
Center for Studies in Ethnicity and

Race in America
University of Colorado at Boulder
Adela Gonzalez
Director

Department of Health and Human Resources
Dallas, Texas

Sue Hammett

Program Liaison Specialist (AIDS)
U.S. Public Health Service, Region VI
Dallas, Texas

Albert0 Mata, Ph.D.
Associate Professor
Department of Human Relations
University of Oklahoma
Norman, Oklahoma

Oscar L. Medrano
Chief of Environmental Health
New Orleans Health Department
New Orleans, Louisiana

Hector Mena, M.D.
Representative for Nuevo Mexicanos for Health
Instructor, University of New Mexico at

Albuquerque

Virginia Ramirez
Co-Chair

Communities Organized for Public Service
San Antonio, Texas

Revmundo Rodriguez
Executive Associate
Hogg Foundation
University of Texas at Austin


Hugh Sloan, D.S. W.
.\c.ting Regional Health Administrator
11.5. Public Health Service, Region VIII
I )c*n\-cr, Colorado

Frmando M. Trevino, Ph.D., M.P.H.

IX-an

Southwest Texas School of Health Professions
San Marcos, Texas

Chris Urbina, M.D.
Department of Family and Community Medicine
University of New Mexico

Pauline Valdez
Director, Hispanic Affairs
Salt Lake City, Utah

Jane Wilson

AIDS/Minority Health Coordinator
U.S. Public Health Service, Region VIII
Denver, Colorado

Arkansas

Colorado

  Louisiana


   Montana


New Mexico


North Dakota

Oklahoma


South Dakota


    Texas


    Utah

One

Voice

One


Appendix C 444444444444444444(

Regions VI and VIII Regional Health Meeting Agenda
San Antonio, Texas

Arkansas

Colorado


Louisiana


Montana


New Mexico

North Dakota


Oklahoma

South Dakota


Texas

Utah

Wyoming

One

Voice

One

Vision

3:00 pm-S:00 pm
`Ikaining Session for Chairs,
Co-Chairs, and Recorders

5:30 pm-7:30 pm
Registration

6:00 pm-&O0 pm
Reception

Introduction of Executive Planning Committee
Guest Speaker

John P. Howe III, M.D.
President

University of Texas Health Science Center
at San Antonio

7:30 am-S:30 am

Registration and Continental
Breakfast

8:30 am-9:00 am
Invocation

Monsignor Balthesar Janacek
Christ the King Parish
San Antonio, Texas

Welcome

Ciro V. Sumaya, M.D., M.P.H.T.M.
Associate Dean for Affiliated Programs and
Continuing Medical Education
University of Texas Health Science Center
at San Antonio

Paula S. Gomez
Executive Director

Brownsville Community Health Center
Claudia R. Baquet, M.D., M.P.H.
Deputy Assistant Secretary for Minority Health
U.S. Public Health Service

Overview of the Surgeon General's
National Hispanitiatino Health
Initiative

Lydia E. Soto-Torres, M.D., M.P.H.
National Coordinator
Surgeon General's National Hispanic/Latin0

Health Initiative
Of&e of the Surgeon General

9:00 am-9:15 am

Keynote Address
The Honorable Donna E. Shalala, Ph.D.

(invited)
Secretary

U.S. Department of Health and Human Services

9:15 am-9:45 am
Charge to the Participants
Antonia Coello Novello, M.D., M.P.H.
Surgeon General

9:45 am-9:55 am

Regions VI and VIII Health

Perspective

Amelie G. Ramirez, Dr. P. H.
Assistant Director for Administration and
Community Health Promotion
South Texas Health Research Center


!I:55 am-10:OO am
Introduction and Guidelines for the
Work Groups
.-\nronio, Furino, Ph.D.

Dirrctor
Ccntcr for Health Economics and Policy
University of Texas Health Science
Center at San Antonio

1030 am-lo:15 am
Break

lo:15 am-12:00 pm
Work Group Session I

(Review National and Regional Issues)
Access to Health Care

Chairperson
Estevan Flares, Ph.D.
Coordinator of Research
Center for Studies in Ethnicity and Race in America
University of Colorado at Boulder

Vice Chairperson
Oscar Medrano, M.P.H.
Chief of Environmental Health
New Orleans Health Department

Data

Chairperson
Adela Gonzales, M. P.A.
Director
Department of Health and Human Services
Dallas, Texas

Vice Chairperson
Renato Espinoze, Ph.D.

Research Agenda

Chairperson
Christopher Urbina, M.D., M.P.H.
Department of Family and Community Medicine
University of New Mexico

Vice Chairperson
Robert Trevino, M.D.

Health Professions
Chairperson
Hector Mena, M.D.
Instructor
University of New Mexico at Albuquerque
Vice Chairpersons
Janie Menchaca- Wilson, Ph.D., R.N.
John Alderete, M.A.

Health Promotion and Disease
Prevention
Chairperson
Pauline Voldez
Director of Hispanic Affairs
Salt Lake City, Utah
Vice Chairperson
Louise Villejo, M.P.H., C.H.E.S.

12:00 pm-l:30 pm
Lunch

Guest Speaker
Patricia Montoya
Executive Director
New Mexico Health Resources
Albuquerque, NM

1:30 pm-3:30 pm
Work Group Session II
(Prioritize and Develop Issues)

3:30 pm-3:45 pm
Break

3:45 pm-6:OO pm
Work Group Session III
(Define Implementation Strategies and
Funding Sources)

6:30 pm-&O0 pm
Dinner

Sponsored by Marion-Merrell Dow
Pharmaceuticals, Inc., Levi Strauss, Inc., and
Abbott Laboratories

Arkansas

Colorado


Louisiana

Montana

New Mexico


North Dakota


Oklahoma

South Dakota


    Texas


     Utah

Wyoming

One

Voice

One

Vision


Appendix C 4444444444444444444

Arkansas

Colorado


Louisiana


Montana

Speakers
James Doss, M.B.A.
Acting Regional Health Administrator
U.S. Public Health Service, Region VI
Hugh Sloan, D.S. W.
Acting Regional Health Administrator

Representation
Hector Mena, M.D.

Health Promotion and Disease Prevention
Pauline Valdez

lo:30 am-lo:45 am
Break

New Mexico

North Dakota

Oklahoma

South Dakota


Texas

Utah

Wyoming

U.S. Public Health Service, Region VIII

8:00 pm-9:00 pm

Work Group Leaders and
Recorders Meeting






7:30 am-MO am
Continental Breakfast

lo:45 am-12:00 pm
Responder Panel

8:OO am430 am
Guest Speakers

Moderator
Ciro V. Sumaya, M.D., M.P.H.T.M.
Ledy Garcia-Eckstein
Policy Advisor
Offtce of the Governor        
Denver, CO
Reymundo Rodriguez, M.Ed., M.P.A.
Executive Associate
Hogg Foundation
University of Texas at Austin

Maria Guajardo              Austin, TX
                      Mario Gri@n
                     Manager of Contributions
                             Levi Strauss Foundation
                           El Paso, TX

Executive Director
Latin American Research and Service Agency
Denver, CO

Christopher E. Urbina, M.D., M.P.H.
University of New Mexico
Department of Family and Community Medicine
Albuquerque, NM

One

Joseph D. Diaz, M.D.
President

voice

Mexican American Physician's Association

8:30 am-lo:30 am
Work Group Reports
Moderator
Paula S. Gomez

Bryan Sperry

Deputy Commissioner
Health and Human Services Commission
Austin, TX

Charles B. Mullins, M.D.
Executive Vice Chancellor for Health Affairs
The Office of University of Texas System
Austin. TX

12:00 pm-l:30 pm
Luncheon

One



Vision

Access to Health Care
Estevan Flores, Ph.D.

Research
Christopher Urbina, M.D., M.P.H.

Data
Adela Gonzalez, M. P.A.

Featured Speaker
Senator Don Mares
Denver, CO
Closing Remarks
Antonia Coello Novello, M.D., M.P.H.
Surgeon General


Regions I, II, and III Executive Planning Committee

Chairperson
Dr. Marilyn Aguirre-Molina
Robert Wood Johnson Medical School
University of Medicine and Dentistry of New Jersey
Piscataway , NJ
Co-Chairpersons
Carlos Perez
Department of Health
New York State
New York, NY

Raymond PotjZio
U.S. Public Health Service
Region II
New York, NY

Members
Hortensia Amaro, Ph.D.
Boston University School of Public Health
Boston, MA

Mercedes Bamet
Office of Minority Health
Commonwealth of Massachusetts
Boston, MA

Aixa Beauchamp
New York Community Trust
New York, NY

Mercedes Benitez-McCrady
University of Medicine and Dentistry of New Jersey
Newark, NJ

Leslie Boden
Office of Bronx Borough President
Bronx, NY

Oscar Camacho, Jr.
Governor's Offtce of Hispanic Affairs
New York State
New York, NY

Emilio Carrillo, M.D., M.P.H.
William Ryan Community Health Center
New York, NY

Gilbert0 Cardonas, M.D.
U.S. Public Health Service
New York, NY

Lorraine Cortes-Vazquez
Aspira of New York, Inc.
New York, NY

Christina Cuevas
The Ford Foundation
New York, NY

Carola Eisenberg, M.D.
Harvard University
Cambridge, MA
Sandra Estepa
Latin0 Commission on AIDS
New York, NY

Rafael Lantigua, M.D.
College of Physicians and Surgeons
Columbia University
New York, NY

Ana M. Lopez Fontana, MS.
National Conference of Puerto Rican Women
New York, NY

Father Vidal Martinez
La Asuncion Church
Perth Amboy, NJ
Hermann Mendez, M.D.
Brooklyn Pediatric AIDS Network
Brooklyn, NY
Carlos Molina, Ed. D.
York College
City University of New York
Jamaica, NY

Hildamar Ortiz, Esq.
New York City Health and Hospital Corp.
New York, NY

Carmen I. Paris
Philadelphia Department of Health
Philadelphia, PA

  Connecticut

    Delaware


      Maine

  Maryland

Massachusetts

New Hampshire

  New Jersey

   New York

Pennsylvania

  Puerto Rico

  Rhode island


    Vermont

   Virginia
Virgin Islands
Washington, DC

West Virginia

One

Voice

One

Vision


Appendix C 4444444444444444444

Connecticut

Delaware


Maine

Maryland

Massachusetts

New Hampshire

New Jersey

New York

Pennwlvania

Puerto Rico

Rhode Island

Vemont

Virginia
Virgin Islands
Washington, DC

West Virginia

Piscataway, NJ
Annette Ramirez de Arellano
National Hispanic Council on Aging
New York, NY
Nancy Reyes-Svarcbergs, R.N., M.S.N
New Jersey State Department of Health
Trenton, NJ
Jenny Romero
Boricua Health Organization
Piscataway , NJ
John Sepulveda
Connecticut State Department of Health
Hartford, CT
Stephanie Siefken
New York City Department of Health
New York, NY
Hector Velazquez
National Puerto Rican Forum
New York. NY

Technical Advisory Group

Regional Health Administrators
Andrew G. Johnston
U.S. Public Health Service, Region I
Boston, MA

Norman C. Dittman
U.S. Public Health Service, Region II
Philadelphia, PA
Regional Program Liaison to the Executive
Planning Committee
Sunchita F. Tyson
Public Health Service, Region II
New York, NY

Regional Representation on the Executive
Planning Committee
Janet Scott-Harris
U.S. Public Health Service, Region I
Boston, MA

Emory Johnson
U.S. Public Health Service, Region III
Philadelphia, PA

One

Voice

One

Vision


Host Committee

Moises Perez
Executive Director
.\lianw Dominicana

Lorraine Cortes-Vaquez
Executive Director
.-\spira of New York, Inc.
Belkis Pimental-Mateo
National President
Boricua Health Organization
Jane Delgado, Ph.D.
President
COSSMHO

Christina Cuevas
Program Officer
Ford Foundation

Aixa Beauchamp
Program Officer
Hispanics in Philanthropy
Walter Alicea
President

Hispanic Society - N.Y .C. Police Department
Isaura Santiago, Ph.D.
President
Eugenio Maria de Hostos Community College
City University of New York
Angelo Falcon
President and Founder
Institute for Puerto Rican Policy, Inc.
Ricardo Femandez, Ph.D.
President

Lehman College
City University of New York
Dennis Rivera
President
Local 1199

Union of Health Workers

Margaret Hamburg, M.D.
Commissioner

New York City Department of Health

The Honorable Fernando Ferrer
President
Office of the Bronx Borough President
Congressman Jose Serrano
The Bronx, New York
Congresswoman Nydia Velazquez
Brooklyn-Queens-New York, New York
Felix Cruz
Director, Office of Minority Affairs
Office of the Governor
State of New Jersey            

Marlene Cintron de Frias
Director, Office of Hispanic Affairs
Office of the Mayor
City of New York
Raymond Porjilio
Office of the Regional Administrator
U.S. Public Health Service, Region 11
Jaime Rivera-Dueno, M.D.
Executive Director
San Juan AIDS Institute, Puerto Rico
Susan S. Addiss, M.P.H., Mu.R.S.
Commissioner, Administration
Department of Health Services
State of Connecticut

Bruce Siegel, M.D., M.P.H.
Offrice of Minority Health
Department of Health
State of New Jersey
Mark Chassin, M.D., M.P.H.
Commissioner
Department of Health
State of New York

Ana Lopez Fontana
President
National Conference
of Puerto Rican Women

  Connecticut

    Delaware


      Maine

  Maryland

Massachusetts

New Hampshire

  New Jersey

   New York

Pennsylvania

   Puerto Rico

  Rhode Island


    Vermont

   Virginia
Virgin Islands

Washington, DC

West Virginia

One

Voice

One

Vision


Raul Yzaguirre
President

Connecticut

Delaware


Maine

Marvland

.Massachusetts

New Hampshire

New Jersey

New York

Pennsylvania

Puerto Rico

Rhode Island

Vermont

Virginia

Virgin Islands

Washington, DC

West Virginia

National Council of La Raza

Hector Velazquez
President
National Puerto Rican Forum

StanZey H. Bergen, M.D.
University of Medicine and
Dentistry of New Jersey

Onf!

Voice

Norman Edelmann, M.D.
Dean
University of Medicine and
Dentistry of New Jersey
Robert Wood Johnson
School of Medicine

Jose M. Saldana, D.M.D., M.P.H.
President

University of Puerto Rico

One

Vision


Regions I, II, and III Regional Health Meeting Agenda
Newark, New Jersey/NewYork, NewYork

4:00 pm-5:30 pm
Executive Planning Committee Meeting with the
Surgeon General

4:00 pm-t?:00 pm
Registration

6:00 pm-7:30 pm
Reception

Hosted by the University of Medicine and
Dentistry of New Jersey

8:OO pm-9:30 pm
Meeting of Speakers, Facilitators,
and Recorders

7:30 am-3:00 pm

Registration

7:30 am-S:30 am
Continental Breakfast

8:30 am-lo:oo am
Plenary Session I
Call to Order and Welcome
Marilyn Aguirre-Molina. D. Ed.
Chair, Regional Executive Planning Committee
Greetings
Representative

Office of Minority Health
U.S. Public Health Service

Raymond Porfiiio
Acting Regional Health Administrator
U.S. Public Health Service, Region II, and on

behalf of Regions I and III
The Honorable Enrique Vazquez

Quintana, M.D.

Secretary of Health
Commonwealth of Puerto Rico
On behalf of the Governor of Puerto Rico

Bruce Siegel, M.D., M.P.H.
Commissioner

New Jersey State Department of Health
Oscar Carnacho, Jr.
Deputy Director
New York State Governor's Office of

Hispanic Affairs

Yvette Melendez Thiesfieid
Deputy Commissioner
Connecticut State Department of Health Services
Overview of the Surgeon General's
National Hispanic/Latin0 Health
Initiative

Lydia E. Soto-Torres, M.D., M.P.H.
National Coordinator
Surgeon General's National Hispanic/Latino
Health Initiative

Introduction of Keynote Speaker
Hector Velazquez
President
National Puerto Rican Forum

Keynote Address
Antonia Coello Novello, M.D., M.P.H.
Surgeon General
U.S. Public Health Service

Connecticut

Dela1vare

      Maine

   Maryland

Massachusetts

New Hampshire

  New Jerse!

   New York

Pennsylvania

  Puerto Rico

  Rhode Island

    Vermont

   Virginia
Virgin Islands
Washington, DC

West Virginia

One

Voice

One

Vision


Connecticut

Dclawarc

!blainc

.\lar\-land

iMassachusetts

New Hampshire

Ye\\- Jet-se\

New 1'ork

Prnns\-lvania


Puerto Rico

Rhode island


\~ermont

\`irginia
I'irgin Islands
\\`ashington, DC

West \-irginia

One

Voice

*
  1






One


Vision

Appendix C  444444

10:00 am-11:15 am
Regional Health Issues
Access to Health Care
J. Emilio Carillo, M.D., M.P.H.
Medical Director
William F. Ryan Community Health Center
New York, NY

Data Collection
Olivia Carter-Pokras, M.S.
Public Health Analyst
Offke of Minority Health
U.S. Public Health Service

Representation in the Health
Professions

Stanley S. Bergen, Jr., M.D.
President and Professor of Medicine
University of Medicine and Dentistry of New Jersey
Research Agenda
Ruth E. Ziunbrana, Ph.D.
Center for Medical Effectiveness Research
National Institutes of Health
U.S. Public Health Service

Health Promotion and Disease
Prevention
Annette Ramirez de Arellano, Dr. P. H.
Chairperson
National Hispanic Council on Aging
New York Chapter

11:15 am-1190 am
Break

11:30 am-1290 pm
Work Group Session A
Problem Identification

Access to Health Care

Facilitator
Edwin Mendez-Santiago
Executive Director
Raices, Inc.
New York, New York

Recorder
Nancy Reyes-Svarcbergs, R.N., M. S. W.
Outreach Coordinator
O&e of Minority Health
New Jersey State Department of Health
Data Collection

Facilitator
Olivia Carter-Pokras, M. S.
Public Health Analyst
Office of Minority Health
U.S. Public Health Service

Recorder

John Sepulveda
Manager Analyst
Ofice of Health Policy Development
Connecticut Department of Health Services
Health Professions

Facilitator
Rene Rodriguez, M.D.
President
Inter-American College of Physicians and Surgeons

Recorder
Maria Soto-Green, M.D.
Physician
University of Medicine and
Dentistry of New Jersey

Research Agenda

Facilitator

Barbara S. Menendez, Ph.D.
Assistant Professor
Lehman College
City University of New York

Recorder

To Be Announced

Health Promotion and Disease
Prevention

Facilitator

Carlos Molina. Ed. D.
Vice President for Academic Affairs
York College

City University of New York


I;`%? ,n <*I-
    I
/sc*.x/ic BO~CII, kf.s.
\..,rL.iatc Director of Health and
1 Iunun Services
I;~,WS Borough President's Office

1 X0 pm-2:00 pm
Luncheon

invocation
Fclther Vidai Martinez, O.S.M.
Introduction of Guest Speaker
R&e1 Lmtigua, M.D.
,\ssociate Clinical Professor of Medicine
College of Physicians and Surgeons
Columbia University

Guest Speaker
The Honorable Enrique Vazquez
Quintana, M.D.
Secretary of Health
Commonwealth of Puerto Rico

2:00 pm-MO pm
Work Group Session B

Development of Recommendations
and Strategic Action Plans

6:30 pm-8:30 pm
Awards Dinner and Cultural Event
Performance by Grupo Folklorico de la Alianza
Dominicana

8:45 pm-g:45 pm
Meeting of Facilitators and
Recorders

8:30 am-10:OO am

Work Group Session C
Final Review of Recommended Strategies and
Preparation for Presentation

1O:OO am-lo:15 am

Nutrition Break

lo:15 am-12:00 Drn

Plenary Session II
Work Group Presentations
Presiding
Marilyn Aguirre-Moiina, D.Ed.
Chairperson, Regional Executive Planning
Committee                    

Carlos Perez, M.P.A.
Co-Chairperson, Regional Executive Phmning
Committee

12:30 pm-l:30 pm
Luncheon
Invocation
Father Vidal Martinez, O.S.M.
Introduction of Guest Speaker
Lorraine Cortes- Vazquez, M. P.A.
Executive Director
Aspira of New York
Guest Speaker
The Honorable Nydia Velazquez
U.S. Congresswoman

1:30 pm-2:00 pm
Closing Remarks
Where Do We Go From Here?
Antonia Coello Novello, M.D., M.P.H.
Surgeon General

  Connecticut

    Dela1vare-


      Maine

  Maryland

Massachusetts-

New Hampshire

  New Jersey

   New York

Pennsylvania

  Puerto Rico

  Rhode Island


    Vermont

   Virginia
Virgin Islands
Washington, DC-

West Virginia

One

Voice

One

Vision

7:30 am-k30 am
Continental Breakfast


Appendix C 4444444444444444444

Regions IX and X Executive Planning Committee

Alaska

American Samoa


Arizona

California

Guam


Hawaii


Idaho

Nevada

Oregon
Trust Territory of
the Pacific Islands

Washington

One

Voice

One

Vision

Co-Chairpersons
Cast&o de la Rocha, J.D.
President and Chief Executive Officer
AltaMed Health Services Corporation
Los Angeles, California
Helen Rodriguez-Trias, M.D.
President
American Public Health Association
Brookdale, California

Vice-Chairpersons
John Whitney
Regional Health Administrator
U.S. Public Health Service, Region IX
San Francisco, California

Dorothy Mann, M.P.H.
Regional Health Administrator
U.S. Public Health Service, Region X
Seattle, Washington

Coordinators
Jose Fuentes
Department of Health Services
San Francisco, California

J. O'Neal-Adams
Minority Health Coordinator
U.S. Public Health Service, Region X
Seattle, Washington

Members

Gabriel Arce
Chief Executive Officer
San Ysidro Health Center/Community
Health Group
Chula Vista, California

Maria Becerra-Cruz, M.P.H.
Program Assistant
California Area Health Education Center
Fresno, California

Diana M. Bonta, Dr.P.H.
Director
Department of Health and Human Services
City of Long Beach        .-
Long Beach, California
Luis Caraballo
Attorney at Law
O&e of Immigration Coordination Chair
Governor's Immigration Coordination Committee
Portland, Oregon
Tina Castanares, M.D.
La Clinica de1 Carino
Hood River, Oregon
Francisco Castillon, J. D.
Executive Director
California Health Federation, Inc.
Sacramento, California

Adela de la Torre, Ph.D.
Chair, Chicano and Latin0 Studies
California State University
Long Beach, California
Eunice Diaz, Ph.D., M.P.H.
Commissioner
National Aids Commission
Infant Mortality Commission
Santa Barbara, California

Steven Escoboza
Director
Santa Barbara County Health Care Services
Santa Barbara, California


.I, I.\(' f-tv7lallde~
i )il'l,< tar, Medical Services
,t.,tts l)cpartment of Health Services
~.l~~l~dn~wto, California

~;cf(lqy R. Flares. M.D., M.P.H.
I'&lic. Health Officer
5c,nonla County Public Health Department
Santa Rosa, California

Robert Gomez
I'rcsidcnt
National Associations of Community Health Centers
Tucwn, Arizona

Priscilla Gonzalez. R.N.
C'hicf
I 14th Careers Opportunity Program
Sacramento, California

Dalfd Hayes-Bautista, Ph.D.
Director
UCLA Center for the Study of Latin0 Health
Los Angeles, California

Dan R. Jimenez, Ph.D.
Director of Urban Affairs
Kaiser Permanente Health Plan
Pasadena, California

Rosalio Lopez, M.D.
Genera1 Practitioner
Artesia, California

Lia Margolis
Director, Planning Division
Public Health Program and Ser\-ices
County Health Services
Los Angeles, California

Makota Nakayama
President and Chief Executive Officer
San Gabriel Valley Medical Center
San Gabriel, California

Gilbert M. Ojeda
Latin0 Health Affairs Council
Berkeley, California
J. Carlos Olivares
Executive Director
Yakima Valley Farmworker Clinic
Toppenish, Washington
Stan Pallida
Medical Director
Qual-Med Health Plan
San Francisco, California

Roberto Reyes Colon
SLIAG Program Coordinator
Governor's Immigration Coordinating Committee
Salem, Oregon
Rogelio Riojas
Executive Director
Sea Mar Community Health
Seattle, Washington
Elena V. Rios, M.D., M.S.P.H.
President
Chicano/Latin0 Medical Association
of California
Sacramento, California

Roberta Salazar
Monterey Park, California

Chris Sandoval

Section Manager and Director of AIDS Services
Men's and Women's Health Department
San Jose, California
Wayne Sausada
Director, OfFice of AIDSISIDA
California Department of Health Services
Sacremento. California

American Samoa


      Arizona

    California


       Guam


      Hawaii

      Idaho

     Nevada

    Oregon
Trust Territory of
the Pacific Islands

  Washington

One

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One

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Alaska


American Samoa


Arizona


California


Guam


Hawaii


Idaho


Nevada

Oregon

Trust Territorv of
the Pacific islands

Washington

One

Voice

4b

One

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Appendix C  444444444444444444

Regions IX and X Regional Health Meeting Agenda
Los Angeles, California

8:OO am-&30 am

Registration

8:30 am-10:OO am

Opening/Welcoming Session
Moderator
Castulo de la Rocha, J.D.

Lydia E. Soto-Torres, M.D., M.P.H.
National Coordinator
Surgeon General's National Hispanic/Latin0

Health Initiative

Donna E, Shalala (invited)
Secretary of Health and Human Services
Claudia R. Baquet, M.D., M.P.H. (invited)
Deputy Assistant
Secretary for Minority Health
U.S. Public Health Service

Charge to Conference Participants
Antonia Coello Novello, M.D., M.P.H.
Surgeon General

10:00 am-lo:15 am
Break

10: 15 am-12:15 pm
Plenary Session: Regional Health
Issues

Moderators
Diana Bonta, R.N., Dr.P.H.
Carlos Olivares

Panelists

Access to Health Care I and II
Camela Castellano, Esq.
Richard Figueroa
Carlos Olivarez
Gladys Sandlin

Data Collection
David Hayes-Bautista, PhlD.
Jane Delgado, Ph.D.

Health Professions
Robert Montoya, M.D., M.P.H.
Priscilla Gonzalez-Leiva, R.N.

Research Agenda
Adela de la Torre, Ph.D.
Miguel Tirado, Ph.D.

Health Promotion and Disease Prevention I and II
Diana Bonta, Dr.Ph.
George Flores, M.D., M.P.H.
Chris Sandoval
Lia Margolis

12:X pm-l:45 pm
Luncheon

Master of Ceremonies
George Flores, M.D., M.P.H.
Welcome

Robert Gates
Director
Los Angeles County Health Services Agency
Empowering State and Local Actions
Art Torres
California State Senator
Chairman, Committee on Insurance


1~45 pm-3% pm
\vork Group Sessions (5 areas,
7 sub-groups)
Esperti in Issue Areas
&Access I-Impact of Health Reform
Proposals on Latinos
Carrneia Castellano, Esq.
Richard Figueroa
Bob Valdez, Ph.D.
Richard Valdez, Ph.D.
Richard Veloz, J.D., M.P.H.
Jose Femandez
Helen Rodriguez-Trias, M.D.
r\ntonio Sanchez
Access H-Health Care for Latinos
in Underserved Areas: Emphasis on
Needs of Special Populations
Carlos Olivares
Gladys Sandlin
Francisco Castillon, M.P.A.
Barbara Garcia
Jane Garcia, M.P.H.
Sylvia Villarreal, M.D.
Hector Flares, M.D.
Data Collection--State and Local
Actions: Promoting Federal Linkages
David Hayes-Bautista, Ph.D.
Jane Delgado, Ph.D.
Ed Mendoza, M.P.H.
Fernando Mendoza, M.D., M.P.H.
Leo Estrada, Ph.D.
Adorfo Falcon, Ph.D.
Health Professions-Reforms in
Health Professional Development
Robert Montoya, M.D., M.P.H.
Priscilla Gonzalez-Leiva, R.N.
Elena V. Rios, M.D., M.P.H.
Margie Beltran
Ed Martinez, M. H.A.
Carmen Vasquez

Research Agenda-Creating Public,
Private, and Community
Partnerships
Adela De La Torre, Ph.D.
Miguel Tirado, Ph.D.
Carmen Portillo, Ph.D.
Eliseo Perez Stable, M.D.
Health Promotion and Disease
Prevention I-Latin0 Public Health
Issues and Policies

Diana Bonta, Dr.Ph.
George Flores, M.D.
Carrnen Navarez, M.D.
Eunice Diaz, Ph.D.
Steve Escoboza
Guadalupe Olivas, M.D.      '
Health Promotion and Disease
Prevention II-Healthy Latinos:
Successful Programs and Strategies
Chris Sandoval
Lia Margolis
Henry Montes
Sylvia De Trinidad
Tony Najera
Maria Becerra-Cruz
Wayne Sauseda
Note: Emphasis on prioritizing national findings
and interpreting their relevance in various States
and regions; invitees will receive outlines and
questions that will facilitate their participation.

3:15 pm-3:30 pm
Break

3:30 pm-5:OO pm
Work Group Sessions II

Note: During this second set of sessions, the groups
will focus on specifying doable actions at the local
and State level to implement priority findings.

5:OO pm430 pm
Work Group Session Followup:
Meetings of Issue Coordinators and
Facilitators

State Breakout Sessions

Alaska

American Samoa

Arizona

California

Guam

Hawaii

Idaho

Nevada

OIYgCXl

Trust Territorv 01
the Pacific &ds

Washington

One

Voice

One

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6:00 pm-7:00 pm
Reception

Alaska

American Samoa

Arizona

California

Guam


Hawaii

Idaho


Nevada

Oregon
Trust Territory of
the Pacific Islands

Washington

One

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7:OO pm-9:30 pm
Reception and Dinner
Speakers

Richard Veloz, J. D., M.P.H.
National Health Care Reform Task Force
Liaison to the Congressional Hispanic Caucus
Bob Valdez, Ph.D.
Professor
UCLA School of Public Health
National Health Care Reform Task Force Member

9:00 am-10:15 am

Work Group Sessions III
Note: During this third set of sessions, the groups
will focus on how to forge effective coalitions
among Latinos and with other communities of
color, the private sector, and government.

lo:15 am-lo:30 am

Break

lo:30 am-11:45 am
Closing Plenary Session
Moderators
Gilbert M. Ojeda
Sandra Hendricks

Work Group Reports
State-by-State Summary Statements
Reaction Panel
Note: Persons would be designated by State to
prepare statements on the expected impact in
their State for actions and policies endorsed by
Work Groups.

12:45 pm-2:00 pm
Luncheon

Master of Ceremonies
Castulo de la Rochu, J.D.
Keynote Speaker
Jose Femandez

. . -

Director of Medical Services

California Department of Health Services
Closing Remarks
Where Do We Go From Here:
Latin0 Health Initiative Projected
Outcomes
Antonia Coello Novello, M.D., M.P.H.
Surgeon General

0oC

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Appendix D: Regional Sponsors
and Co-Sponsors

Miami:

C-o-Sponsors:

I'ublic Health Service, Region IV
()l\icc of Minority Health, Region IV
I:(& and Drug Administration, Southeast Region
hliarni Children's Hospital
Lit& Havana Activities and Nutrition Centers

of Dade County

Additional Co- Sponsors:
C.+C-Ramsay Health Plans
D&a Business Systems
IBM

U.S. Printers & Lithographers, Inc.

Chicago:

Co-Sponsors:

Health Resources & Services Administration

Bureau of Maternal and Child Health
Public Health Service Ofice, Region V
Public Health Service Office, Region VII

Sponsoring Corporations:
Marion-Merrell Dow Pharmaceuticals, Inc.
W. K . Kellogg Foundation
Ewing Marion Karffman Foundation
Blue Cross & Blue Shield of Illinois
Chicago HMO
Additional Co- Sponsors:
American Medical Association
Chartwell Midwest
Chicago Department of Health
Chicago Hispanic Health Coalition
Chicanos/Latinos Unidos En Servicio (CLUES)
City of Cleveland

Commission on Latin0 Affairs
Eastern Michigan University
Effort for AIDS, St. Louis
El Centro Hispano, Indianapolis
Good Samaritan, Kansas City
Health & Medicine Policy Research Group
Home Visits Plus

Humana Health Care Plans
Illinois Department of Children & Family.Services
Illinois Department of Public Health
Indiana University Northwest, Gary
Iowa Health Department, Des Moines
Kansas Department of Health and Environment,

Kansas City

La Hacienda de Los Gutierrez Restaurant

La Raza Newspaper

L.U.L.A.C. Midwest Education
Michigan Department of Public Health
Midwest Farmworker Employment and

Training, St. Paul

Midwest Hispanic AIDS Coalition
Minnesota Department of Health, Minneapolis
Missouri Department of Health
Nebraska Department of Health, Lincoln
Norwegian American Hospital
Ohio Commission on Minority Health, Columbus
Ohio Department of Health, Columbus
Presbyterian St. Luke's Hospital
Sinai Samaritan Medical Center, Milwaukee
Smith Barney, Harris Upham & Co., Inc.
Staff Builders

University of Illinois at Chicago, Jane Addams
College of Social Work
University of Illinois at Chicago,
Chancellor's Office

University of Illinois at Chicago, College of
Medicine's Hispanic Center for Excellence

One

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One

Voice

Valet Parking Services
Walgreens Corporation
West Side Health Center, St. Paul
Wisconsin Department of Health, Madison
Witchita State University
WSNS, Telemundo Channel 4-4

San Antonio:

sponsors:

U.S. Department of Health and Human Services
The University of Texas Health Science Center
at San Antonio

Co-Sponsors:

The Bureau of Health Professions, Health
Resources and Services Administration
Brownsville Community Health Center
Center for Health Economics and Policy
National Hispanic Leadership Initiative on Cancer
Public Health Service Office, Region VI
Public Health Service Office, Region VIII

Supporters:
American Heart Association
W.K. Kellogg Foundation
Abbott Laboratories
Area Health Education Center of South Texas
Levi Strauss, Inc.
Mexican American Physicians' Association
Mesilla Valley Psychiatric Hospital
Southwestern Bell Telephone Company
The University of Texas Health Science Center
Austin Minor Emergency Clinic

New York:

Co-Sponsors:

Public Health Service, Regions I, II, and III

Contributors:

Josiah I. Macy, Jr. Foundation
Robert Wood Johnson Foundation
Prudential Foundation
W . K . Kellogg Foundation
Brooklyn Union Gas
Marion-Met-t-e11 Dow Pharmaceuticals, Inc.

Los Angeles:

Sponsors and Co-Sponsors: . .
AltaMed Health Services Corporation
Arco Foundation
Arizona Physicians IPA
California State Ofice of AIDS
CareAmerica

FPH
Intergroup Health Corporation
James Irvine Foundations
Kaiser Permanente Southern California
Marion-Merrell Dow Pharmaceuticals, Inc.
National Council of La Raza
National Health Service Corps
PacifiCare Health System
Sisters of Providence
Southern California Edison

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Appendix E : National
VKrkshop Speakers

Keynote Speakers

Louis W. Sdlivan, M.D.

U.S. Department of Health and Human Services

Dr. Novello has been an outstanding Surgeon
Gcncral, and I want to thank her here in front of all
of you for the very outstanding job that she is doing
and continues to do, not only for the Hispanic/
Latin0 community, but really for all of our citizens.
I'm very pleased and honored to have her as a
member of the President's team in PHS.
   This is an historic conference that is under
way today. It's historic because it marks the first
time that health professionals from the Federal
Government have joined with Hispanic/Latino health
experts and community leaders to address the health
concerns of the Hispanic/I&no community.
  America is justly noted for its culturally and
ethnically diverse populations. Our Nation's
strength comes, I believe, from the very national
and ethnic ties that make up the rich American
mosaic. As our national motto so aptly puts it,
e pluribus unum, out of many, one. The Hispanic
contribution to this Nation's history from the very
b eginning has been enormous. One might say that
Hispanics laid some of the cornerstones of the
American mosaic. Of course, as we all know, there
is a great deal of diversity within the Hispanic
community itself, and this Workshop recognizes
and takes into account that diversitv.
                         ,
  History has shown us time and time again that
with diversity sometimes comes inequitv. This
inequity frequently gives rise to economic and social
disparities. We are here todav to address the health

care disparities that affect the Hispanic/Latino
population. America is a culturally diverse Nation,
but one thing all Americans have in common is the
need and the desire for good health and good health
care. This Department and this administration will
not rest until we have raised the level of health care
for all Americans. We can, and we will, close the
gap in health disparities. I do not have to remind
you here today that the situation is indeed critical.
Recent reports indicate that, from a health perspec-
tive, the Hispanic population is significantly more at
risk than the non-Hispanic white population.

  Hispanics face many barriers to decent,
equitable health care. They also suffer dispropor-
tionately from such diseases as cancer, diabetes,
HIV and AIDS, and other conditions. Additionally,
Hispanics have a high incidence of substance abuse,
homicide, and accidents. To address these prob-
lems, we have identified five areas that we need to
focus on if we are going to improve the health care
and the health status of the Hispanic/Latin0

community.
  First, we need to enhance access to health

Voice

care. Second, we need to improve data collection
on the Hispanic/Latin0 population. Third, it is
imperative that we increase Hispanic representation
in the sciences and the health professions. The
fourth area of emphasis calls for a comprehensive
and relevant research agenda for the Hispanic/
Latin0 populations. Finally, we need to focus
greater attention and resources on health promotion
and disease prevention.

One



Vision

  Hispanics encounter numerous barriers to
health care, but one of the major barriers is lack of
health insurance. In fact, of the approximatclv 35


Appendix E  4444444444444444444

to 37 million Americans without health insurance,
approximately 7 million are Hispanics. This means
that, while only 8 percent of the general popula-
tion, Hispanics constitute about 20 percent of the
uninsured.

  The Administration's health care reform
agenda would go a long way toward remedying this
situation, but there are also financial, structural, and
institutional barriers that impede Hispanic/Latin0
communities from safeguarding their health. Many
Hispanics reside in areas where clean water is not a
given, where transportation is inadequate, where
violence is depressingly routine, and where working
conditions are unhealthy. Before we can begin to
address health care reform in these communities,
we must first ensure that the Hispanic/Latin0
community can expect a basic level of health care
access that all Americans deserve.

One



Voice

One

  Since 1970, the Federal Government has been
engaged in a continuing effort to upgrade data
collection on Hispanic/ Latin0 communities. As a
result of a DHHS task force established in 1984, we
now base Hispanic/Latin0 birth and mortality data
available for 44 States and the District of Columbia.
This represents coverage of 97 percent of our
Nation's Hispanic/Latin0 population. Also in 1984,
the National Center for Health Statistics conducted
the first comprehensive Hispanic/Latin0 health
survey ever to be carried out in the United States.
These and other positive measures that we have
undertaken are encouraging, but they are not
enough. In response to the need for more
Hispanic/ Latin0 health data, Congress called on the
sational Center for Health Statistics to "collect and

analyze adequate health data that is specific to
particular ethnic and racial populations, including
data collected under national surveys."
  It is often said that knowledge is power. The
knowledge that wc gain from improving our data
collection will be a powerful tool in our efforts
to improve the health of the Hispanic/Latin0
communitr.

Vision

  One arca, I believe, that is especially crucial
to achieving this goal is increasing the representa-
tion of Hispanics in the health professions. The
paucity of minorities across the spectrum studying
for and working in these fields is of crisis propor-
tions. We simply have to have more minorities
involved in the health professions if we are to
provide our underserved communities with
adequate health care.

  Why is this so essential to improving health
care in Hispanic communities! Well, first, minority
health professionals typically show greater than
average interest in and willingness to serve and
establish their practices in medically underserved
areas. Additionally, they are able to bridge cultural
differences that often create obstacles to effective

patient care. In recognition of the critical need for
more minority participation in the health care
professions, I've developed a five-point plan to
reduce minority health disparities. A major
component of the plan is a 20 percent increase in
funding for the National Health Service Corps. This
includes training, recruitment, placement, and
retention of providers, with a particular emphasis
on minority providers.

  We are taking steps to improve our data
collection on Hispanic/Latin0 communities. To
make maximum use of that data, we will need to
design a relevant and comprehensive research
agenda to improve Hispanic/Latin0 health. This
will require action in three areas: First, the
development of an appropriate research infrastruc-
ture; second, increasing the availability of needed
research instrumentation; and third, identifying and
assigning priorities. In conjunction with my
previous point, this research agenda must identify
mechanisms for increasing the number of trained
Hispanic/Latino researchers and health professionals.
The data we collect will tell us what we need to
know. This research agenda will tell us what we
need to do.


  `l`hc I'inal priority to be addressed at this
ii., ,,.k5hoIJ is health promotion and disease preven-

, ,, ,,, `[`hc Hispanic/ Latin0 population is growing
I..lI,itIl\-, It \\-iI1 soon constitute the largest ethnic
I'.lL i.11 group in America. It will also be the youngest
,,lj,l,,ritv population in the Nation. This poses a
,I,l><,iaI challenge for those of us charged with
promoting the health and well-being of the popula-
t ion. The challenge is to develop and maintain
[Il(,roughgoing strategies for improving the health of
lllc various and diverse Hispanic/Latin0 populations
,1<`ross the Nation. Implementing health promotion
.lnd disease prevention is critical. Health promotion/
discasc prevention interventions targeted to Hispanic/
I .atinos are essential if we are to achieve Hispanic-
sI,rcific health care objectives for the year 2000.
  It is almost impossible to overstate the
importance of the task ahead of us. The Nation as a
whole has a tremendous stake in improving the
health of the Hispanic/Latin0 population. The
national costs of bearing the burden of untreated
health problems-frequently, the uninsured who
csentually become more and more expensive, who
eventually require more and more expensive
hospital and specialtv care-arc prohibitive. Our
society incurs additional costs when people are
unable to work or unable to contribute to societv
                                   I
because of illness. The tragedy is compounded
when one considers that these illnesses arc often
preventable, or with early, primary medical
intervention or treatment, thev are frequently
controllable.

  As you can see, there is much work ahead and
manv things to be done.
b '       This Workshop is only the
eginnin g. We'll be following up with five regional
meetings, in New York, Chicago, San Antonio, Los
Angeles, and Miami. This takes into account the fact
that the Hispanic/Latin0 community is itself a diverse,
multiracial, muhicthnic qoup. The culmination of this
program will be a national conference on Hispanic/
Latin0 health to bc held in 1993.

  Achieving our goal, which is improved health
for the Hispanic/Latin0 community, is a daunting
task. This requires a broad range of approaches and
strategies, but I'm reminded once again of our
national motto, e pluribus unlcm. From the many
bright, committed, and talented minds assembled
here today will come a single comprehensive
strategy to advance the worthy cause of improved
Hispanic/Latin0 health. The diverse gifts that you
bring to this mission convince me that we will
succeed. So I look forward to working with all of
you toward achieving these goals in the months and
years to come. Thank you.

The t-lonorable Lynn Martin

Secretary
U.S. Department of Labor

We are only 8 years away from the 2 1 st century.
Those who say that tomorrow never comes are
wrong. It does, and it seems to come even faster
than it ever did before. We're also living in a world
that's not just different from 100 years ago. It's
different than it was a decade ago. That means the
people of this great Nation-the people who work
or who want to work, the American workforce-
are at a crossroads, and we have to make sure that
we go in the right direction. To do so, we really
just have to start asking ourselves questions. What
do we need? To answer that from the position of
the Department of Labor, we can figure out pretty
easily the two major challenges that we face.

  One is to recognize that the jobs of tomorrow
are more complex. They will require higher skills
and more education. I don't have to tell you that
many of the young people in America, therefore,
are headed in exactly the wrong direction. One
million students drop out of high school each year,
and 50 percent of those who do graduate from high
school never go to college or have any additional
education. Only 24 percent of our young people
who go to college get a degree, and that means,

One

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One

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Appendix E 444444444444444444.

One

Voice

Vision

bluntly and nonpolitically, that too many young
people arc entering the workforce absolutely
unprepared to meet the future. Twenty million
16- to 24year-olds are in that category, and these
kids are being left behind. You can talk all you
avant. I can talk all I want. Without change, those
young people will be left behind. Although
minorities do constitute a disproportionate share of
that number, these aren't just poor inner city youth.
They're from all over. Too many of our young
people aren't motivated.

  Before, in a less globally dominated economy,
there was less required of an employee. Our
grandfathers could work at a low-skill job, raise a
family, save, perhaps get a house. That is not true
now, and it will not change.

  Young people are still in demand in the labor
market. There are jobs for them, but they have to
have more skills and specialized skills. Today young
people have to hit the ground running. They need
updated skills. They need a path that will connect
their schooling with careers, and that's where you
and I come in.

  We've got to get businessmen and women to
increase their presence in schools. In the schools,
we have to increase the desire to have business
there. We have to show. students what skills are
required to succeed, and schools have to be held
more accountable. They've got to make sure that
their students are able to perform. There's
something very wrong with a system that can allow
our young people to graduate from high school
when thev still don't have the basic skills needed to

      I
perform on a job.

  I'm not placing blame. Blame is easy enough.
Job demands are changing so rapidly that I'd have a
tough time right now telling a child what career to
choose that would be absolutclv relevant in
tomorrow's workplace. I'd have a tough time
knowing as a parent if mv school was training my own
children corrcctlv for future cmplovmcnt. But, that
doesn't mean that wc shouldn't address the problem.

  To deal with this, we've moved toward
something called America 2000. It's a bold,
comprehensive, long-range plan-not a 1 -year
solution but a 20-year plan-that offers a very
different vision for schools. We must restructure
and revitalize the educational system. That goal
means making every school in America free of the
drugs and violence that a small minority use but a
large majority are ftnding now an impossibly
difficult part of their lives. We should be increasing
our high school graduate rate to at least 90 percent,
and we've got to make sure that every adult in
America is literate and exercises the rights and
responsibilities of citizenship..

  We also saw in my own Department that
Federal job training programs were too difficult to
find and that many overlapped. Therefore, the
President gave me a mandate to make these
programs more accessible, more efficient, and more
responsible to real jobs and job training. Not too
originally, we called it Job Training 2000. We
think it is the right way to go. It will help young
people who haven't completed their education. It
will help adults with minimal skills to get better
training, and it will help discipline workers to
expand their skills.

  We had, within the Department, a commis-
sion with outstanding people from unions, from
business, from education. It's called SCANS, the
Secretary's Commission on Achieving Necessary
Skills. It has, for the first time, provided concrete
guidelines on what particular skills young people
will need to succeed in the workplace. We went to
business and said, "Hey, enough telling me what's
wrong; be part of the solution. Tell us what you
need today and tomorrow." The commission's
guidelines are now being, little by little, worked
into the curricula of schools all through this
country. In conjunction with that workforce
strategy, we've initiated a youth apprenticeship
program to dcvclop a bcttcr school-to-work system
for the 50 percent of our voung pcoplc \vho don't

.


,.,, ,,, ,.ojjcgr. It combines academic training with
.-
( ,,, ~bc.-jOb training. Students who complete the

I I IliI'W get a diploma and a job. We cannot have
;o j,`.rcent of our young people, the ones who
<IO11 t . gc) on to school, ignored. We can't keep
,..rjjing them "the forgotten half." Someone has to
rc.mL.mbcr them, and that's what we're trying to do.

  Last month, the President announced the
xl.,\- Century Workforce, a S3 billion per year
training proposal to help working men and women
\,bo set their jobs changing or who see job loss.
.jbis program would give adult workers up to
s 3,000 in vouchers for a training program of their
choice. It triples the money currently now allowed.
  In addition to this commitment to worker

adjustment, we're talking about a youth program
that has four major parts: a youth training corps for
those disadvantaged youth; a comprehensive drug
treatment plan that provides job training as well as
rehabilitation so that, while you're going through
rehabilitation, you can also be looking to a future
with a job; an expanded apprenticeship program;
and an ROTC [Reserve Offtcers' Training Corps]
program that is double the current size, because, in
many schools, this is one of the avenues out for
voung people who desperately need it.

  I said there were two big challenges. One is
to have the state-of-the-art workforce. The second
is to make sure that all Americans have a chance to
get and then to use these skills. We must continue
to remove all obstacles that might prevent qualified
minorities, qualified women, anyone, from achicv-
ing the benefits that they earn. In the United States,
we've always held that democracy is not complete
until the rights and opportunities are extended to
all. Democracv means freedom, but it also means
fairness. We cannot say one thing and do another.
Our actions must match the message. We must
confront the new ccnturv and this new cconom\
                                   <
with the same spirit we've had over the last ,200
vears, but renew it so it includes more Americans.

   Who better than all of us understand what a
free society is? That, if 1 may state the obvious, is
what drew many Hispanics to America, the same
need that drew Coronado to Mexico when he risked
everything on a new venture. The first ship brought
Columbus from Spain-some wanted that ship to
turn back, you know, but the ship came-and the
world was given a new land and, eventually
together, our fathers and grandfathers and great-
grandmothers and grandmothers all will come
together as we look for a better place for our
children and grandchildren.

   The waters of this brand new sea have often
been turbulent, but then again nothing good ever
comes easy. The challenge now is to expand the
good. The President and I have committed to
shattering, for instance, the glass ceiling. It may
seem a daunting task. After all, it is still too easy to
find reasons why one shouldn't be promoted, why
one shouldn't be given the advancement; but it will
be done. Those who have been outside looking in,
those who have been at the end of the line, the
minorities, disadvantaged, disabled, women, will
have new opportunities for success.

  Those are our challenges. The work is
difficult. It is not over, but we can and we will
make a difference. We must open the doors of
opportunity, and we must help all Americans walk
through these doors with their heads held high. We
can see the American dream endure. We can see
the dream become a reality, because after all, what
is America but the chance to reach for a better life
and a better future, and part of that life and future
includes the chance for a job, for a career, to grow,
and to prosper.
  Thank you for letting me be with you. I'11 be
happy to answer any of your questions.

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Vision

Q. Dr. Martin, as you stated, a disproportionate
nufnber of people W/JO are Latin0 or Hispanic participale
in the lower paying workforce. I would like to know
from you. what is your perspective on the issue of these


workers who provide rhe person powerfor the agricul-
ture industq and the service industries if our technology
tomorrow and the education required for tomorrow's
jobs are actually increased? Who will take the place
of rhose workers in the future, and whar assurances
are there that people who continue to take those jobs
will have adequate insurance for health needs and
adequate incomes to provide for theirfamilies, and this
is in spite of whether they're legal or not? They're
participating as taxpayers in our laborforce to drive
the American economy.

A. First of all, do not mix reality with the idea that
somehow, someday a migrant worker is going to
make S 50,000 a year. It's not going to happen.
There can be a minimum wage, but ~4.75 an hour
isn't what you want your kids to grow up to do.
Most migrant workers don't want that for their
children, and we shouldn't confuse the two issues.
It is the job and appropriate role of the Department
of Labor to make sure that migrants are safe, that
there's not peonage, that there is responsible pay,
that there is the minimum wage, that there are ways
to live. But, don't ever let anybody kid you that,
boy, are those great jobs. They're hard, and they're
tough, and their very nature is they're never going
to pay a lot of money.

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  Don't worry, then, about who the planter is
going to hire 10 years down the line. Worry about
what our kids are going to do. Worry about how,
in city after city, we have growing numbers of kids
dropping out of high school. They're not going to
be migrant workers; it isn't even part of their camp.
But, they're not going to be able to be part of this
society. No matter how many speeches or pro-
grams are given, it is now so directly tied to
education.
  I'm going to tell you something from the
Secretary of Labor. If our young people, a young
girl, drops out of high school, is unmarried, has a
child, and doesn't complete her education, she's
going to be poor all of her life-period. Take the
voung man, the I S-vcar-old, the cool guy, and he

drops out of school. Guess what? If you're talking
about anything legal, he's poor all his life.

  My grandfather could work a job in the steel
mills. The job in the steel mills today is so com-
plex, it requires skills and ability and education. It's
not that there aren't going to be some low pay jobs.
There always are, but not as many, and they're not
going to be good.

  So I am absolutely convinced, the reason
we're talking about job apprenticeship training, the
reason we're talking about the fact that jobs and
careers are important is we've diminished labor
over the last 20 or 30 years.

  We're trying to get that connection again in
high school. I have been blessed in my life with
children and step-children. Therefore, 1 see them
all of the time. Now I'm just going to tell you,
I S-year-olds don't have judgment. The idea that
we have these systems where we let them make up
their minds strikes me as so silly it takes your breath
away. We owe them more than that. You can't tell
a 1 S-year-old, "Listen, stay at this boring thing that
has no relevance in your life, and you'll see some-
day." I mean, an hour ahead is forward thinking for
them. So we have to have stuff for the connector.
  For that 50 percent who aren't going to go

right on to college, there has to be something that
keeps them there. But, we have a responsibility not
to lie to them and not to tell them that somehow
the rest of the world is going to be wonderful for
them, if they choose to make some of these other
choices and get off the line. The fact is, it won't
and it can't happen. We spend in Job Corps about
s 2 3,000 a year for kids who need a second or third
chance. It's one of our good programs that the
President wants to make bigger, but it won't hit
everybody. We've got to do better in schools.
Every company, every union tells me the kids aren't
ready. We've got to do it.

  Just for a moment, I'm going to speak about
Hispanic Americans. I'm not Hispanic American. I
can't think of anything more aggravating than


someone telling you what it would be like to be
Hispanic American who's not. I'm a woman. I
look at the numbers of young girls who aren't going
on in math and science when there are now open-
ings in every engineering firm and when, with the
glass ceiling on the push, there's a chance to work.
I want to find out why the same young girl, the
same young minority boy, the same Hispanic boy or
girl who was doing just fine, thank you, to fifth
grade suddenly start going down the tubes. You
and I know what part of it is; but then let's start
looking at why sixth and seventh and eighth grade
just aren't working. Let's not lose our children.

  Compared to 50 years ago, there's finally
opportunity for people, and what a waste if our
youngsters aren't ready to just grab that opportu-
nitv and push it forward. So I just think we've got a
ton to do here. I think we can do it, but I think we
have to be very clear that, if we accept lesser
standards, if we try to homogenize the world for
our children and say, "Oh, it will be fine, whatever
vou do is going to be fine," that isn't going to work
either. We have to be ver)- clear what's going to be
needed. It's going to be tougher. The jobs are
going to be safer, cleaner, pay more. They'll have
more satisfaction. That's the good part. You must
get the skills to get there.

  1 really went around on that, but I feel so
strongly about it. Between migrant workers and
what we have to do for our vounger workers-
especially, I think, Hispanic, African American, and
voung women-to lose some of that talent is just
outrageous. We cannot afford to do it.

Q. At the Depaftment of Labor in 1985, they had the
Youth X00 program invoh~irrg 50 major corporations
and the Departments of Education, Health and Human
Set-vices. and Labor. It bcas concluded by the major
corporations and the few Federal agencies that miuori~
youth i~ould be the major bvorkforce in fhis count? l?\
the years 2000 to 2010. Unff~rfunatel~. that was 7 years
ago. and I hrn*e vef nof seen fhis. Whaf happened in
7 years:' It is in the best interest ofour Nation to not be

so guarded in saying we `re going to put mone.v into the
Hispanic youth and the black. Unfortunately, both
Democrat and Republican chose not to look at that issue
and let America become a second power.
A. Through the 198Os, the same time you're talking
about, there were about 20 million new jobs. A
majority of them were filled by African Americans,
Hispanic Americans, new immigrants, and women.
And just so you are quite clear on this, there are job
programs. I just went through some of them     c

briefly. I haven't been here for 7 years, but I would
hope that most people would agree that in the last
year and a half, we've made some enormous
progress at the Department. But; the most compel-
ling jobs are going to come from the private sector.
Government jobs in the long run are paid for by
people, by taxpayers. There's no advantage there.
So you can have some for a short period of time.

  In my view, every single thing should be
judged in the light of how many new jobs it creates.
Then we can move people to fill them, but unless we
get that, I think we have real additional problems for
minorities and for women and for immigrants.
  Last year, immigration was three times what
it was 5 years ago. So part of the growth of the
Hispanic American community is certainly coming
from recent immigrants. That's going to make
America even better.

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Gail R. Wilensky, Ph.D.

Deputy Assistant to the President for Policy
Development

Good morning. It's a pleasure to join you here. I'm
delighted to have a chance to begin this morning's
session with a discussion of access to health care for the

uninsured. Let me just try to give you some brief
background. These are numbers concerning access to
health care that now are recognized as features of the
debate on access to health care. You probably have
heard them on a number of occasions. Let me try to
put our problems of access in perspective.

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  We have approximately 34 million people
without insurance coverage in the United States.
One-third of these people are poor officially-that
is, their income level is below the poverty line. The
other two-thirds are low and middle income
families. There are some upper middle income
families among the 34 million as well.

  We really have two groups of populations that
are without health insurance coverage and a very
small third group. The first of the two groups
includes those who are without health insurance
coverage primarily because they're poor. This
group consists of poor people who don't have the
financial resources to buy insurance, yet fall through
the cracks of Medicaid. They don't meet the
Medicaid rules of eligibility. Medicaid primarily
follows the receipt of welfare cash assistance.
Pre_gnant women and young children also are
eligible by virtue of being pregnant women and
young children.

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  The other substantial group is formed
primarily by those who work for small employers or
are dependents of people who work for small
employers and are not provided with health
insurance benefits. They work and are not poor, but
some have very low incomes and large families. The
smaller the firm, the more likely it is that they will be
without health insurance coverage. In general, we
really have these two groups of people without health
insurance coverage in the United States.

  Another very small group is made up of
people who are medically uninsurable. Tbev
                                ,
present a problem because their profile indicates
that they will incur significant medical expenses.
  We know that lack of insurance is not the

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onlv problem we have with regard to access.
However, the absence of insurance coverage makes
health care more difficult to obtain and more
expensive. People without health insurance
coverage typicallv USC about half of the health care
that people with health insurance coverage do.

  WC also know that the problem is not only an
issue of financial access. We know that many
people on Medicaid, for example, still have enor-
mous difficulty getting full access to health care
because of the way their Medicaid program may be
constructed. Similarly, there may be people who,
although well insured, have difficulty getting health
care because of where they live. There may be too
few doctors, too few nurses, and/or a lack of health
clinics and facilities. In the United States, however,
we have rather an abundance in the aggregate of
these human and professional resources.
  I say that only because, as an economist, I
typically focus on the problems of not having
financial access-that is, health insurance. How-
ever, we do need to remember that, even for those
with health insurance coverage, there may still be
some problems in gaining access. This group is an
easier group to deal with, but we can't assume that
the problem has been solved once we have financial
wherewithal.

   Now we come to an issue that for many
                                 ,
people who are activists in health may not seem like
such a big deal. For me, however, this is a central
issue. Both political parties and their official
candidates have said that the poor are the
Government's problem. The President's health
care plan covers all people below the poverty line
by a voucher of credit, with the notion being that
such coverage will enable the economically disad-
vantaged to purchase health insurance. The
Democrats have expanded on this approach and
have proposed a public sector plan that would also
cover people up to the poverty line. So our
arguments these days are really not about the poor
per se. We haven't done it, but we have at least
proposed that poor people be covered by Govcrn-
ment programs. There are some diffcrenccs in
terms of hovv they're constructed, but both assign a
key role to the Government.

  The big fight right now is Govcmmcnt
obligation and rcsponsibilitv and the best wav of


resolving the problem for the nonpoor. There arc
basically three different approaches you can take
and, in terms of presidential politics, two different
strategies that are being proposed. It's important
that we understand this, and it's particularly
important that those of YOU who are interested in
Latin0 health understand this, because you may be
differentially affected in terms of how these choices
work out.

  One proposal requires employers to provide
health insurance to their employees. Usually, that
comes in the form of what's called "play or pay."
"Play" means that an employer provides the health
insurance coverage that the Government or some
group appointed by the Government says he or she
must provide. If not, the employer "pays" into a
fund and somebody else provides the health
insurance.

  That has been the Democratic leadership plan.
It is being adopted by Governor Clinton. He's
saying that the "pay" part is not a payroll tax, which
is what Senators Mitchell, Rockefeller, Reigel, and
Kennedy have said. He's said, if you don't provide
it, vou have to pay a mandators premium. In ml
view, that's a little sill!; a mandatory premium is a
tax for anTbody who is trying to run a business. So,
one idea is to say the way you get to the emploved
population-those two-thirds that are not poor but
that may have low income-is to require employers
to provide that coverage or to pav and then base it
provided directly.

  That may sound appealing, because it does get
at a large part of the group that is uninsured. The
difficulty is that, once YOU cnforcc this mandate on
     ,           I
emplovers, vou effectivclv make workers more
    I ,
expensive. This is particularlv a problem for
lvorkers who are at or near the minimum wage.
YOU have effectively raised the cost of hiring
somrbodv. Somebodv said to mc that WC real11
don't have anv minimum \vaqc lvorkcrs in this
                     L
countrv. Being a curious numcricallv oriented
economist, I didn't quite bclic\-c that. So I talked to

my colleagues at the Labor Department and asked
about people that get a rate within fifty cents of the
new minimum wage limit. The answer is not zero;
it happens to be that 8 million people are within
fifty cents of the minimum wage. Five million of
them are women. The reason this is a worry to
somebody like me is that, while I want to make sure
that people have health insurance coverage, I also
really want to make sure that, in the name of
providing health insurance coverage for these
people, we don't put them out of a job and kill off
small businesses.

  My reasons for being so concerned about this
problem are twofold. First, small business has been
the road to success in the United States. ' Second,
small businesses happen to be the source of almost
all economic growth in the United States.

  The question is: How do we provide health
insurance for people who are working in small
firms? One option is to just say "thou must" or
"thou shall or otherwise pay directly." That isn't
the strategy that this administration has been taking,
and our logic is the following.

  Without the Government telling employers
what they have to provide or how much money they
have to put into the premium, almost all employers
provide health insurance as a fringe benefit. This is
not a mystery. The Tax Code strongly encourages
people to take part of their compensation as a fringe
benefit because you don't pay taxes on the part that
your employer contributes. The problem has been
that, while some small firms offer health insurance
coverage, others do not. It's almost never a case
where a firm offers health insurance coverage and an
employee says, "No thanks." Therefore, our
strategy has been to try to break down the barriers
that have kept some small firms from offering health
insurance coverage.

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  The problem is that health insurance for small
firms has been too expensive and too unreliable. If
somebody in vour small firm of 10 or 20 employees
bccomcs ill-l mean really ill, has cancer, has a


serious heart condition, has a serious case of
tliabctcs-that makes health insurance tither impos-
siblc for your firm or extraordinarily expensive

  What we have proposed is basically a restruc-
turing of the rules that the insurance firms use when
marketing to small firms. Under our proposal,
insurance companies could vary their premiums
only by a certain amount. They could increase
premiums only by a certain amount over time.

  We try to encourage small firms to band
together by exempting them from some State
mandates and taxes. That is, if you go into the
marketplace representing 20 or 40 insured lives,
with 15 employees, nobody is going to pay much
attention when you ask for a good price. But, if you
come in representing fifty thousand insured lives,
you will command the same kind of attention that
vcrv large corporations do. Small firms coming
together will represent a big block of business. Our
approach, rather than mandating that employers
provide insurance coverage, has been to trv to break
down the barriers that have kept some small firms out.

ON



Voice

  Now these are very different strategies to
solve a commonly agreed upon problem. We all
want to see people in this country protected by
health insurance. It's a part of a larger fight because
it involves different views of the classic role of
Government in terms of solving problems. One
involves using the force of Government to directly
intervene and make the fix. The other requires the

use of the force of Government to set up rules and      Let me stop here and see whether there are
enforce these rules to allow a fix to occur on its     questions that I can answer before I turn you over to
own. The problem with the direct alternative is     the rest of your program.

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that in attempting to provide health insurance, you
kill off small firms and risk uncmplovment for many
low-wage employees. This is central to the debate.
  I think the positive news is that there is a clear
and strong recognition of the problem that those of
us \vho have been involvrd in health have felt
plagued by for the last IS vears.
  That is, a pcrsistcnt number of people
without health insurancr covcragc arc at financial

and medical risk to themselves and impose some
real difIiculties in their communities. The good
news in the United States is that, for the most part,
people who have a real need for health care will get
health care, even when they don't have health
insurance coverage. Nevertheless, we understand
that they don't often get the right health care at the
most appropriate time or from the best set of health
care providers.

The issue is one that has been around for a

long time. It's been one that we have now seen the
Government focus on for the last couple of years,
but we have yet to really solve this battle as to how
to take care of the problem for;the nonpoor. It is a
question that we will have to deal with in acute care

coverage. It is even going to be more difficult when
we try to answer the same question for long-term
care. That is, by the way, the question we're going
to have to deal with, not who's going to take care of
the poor. We know who's going to take care of the
poor-the Government. Who else is going to take
care of the poor? The real battle is going to be what
obligation, if any, does the Government have to
people who are not poor.

  That question becomes even more compli-
cated for us as a countrv as we move to combina-
                 ,
tions of medical and social service away from pure
medical care, because we have a much less clear
definition of what we think the proper role for
Government is.

Q. In earlier discussions it was said that 7 million of
the uninsured are Hispanics and that many fall below the
poverty line. My question is: How are we going to
ensure access for these projected 7 million Hispanics?
Also. can we help ourfamilies stay together rcherl this
effort may make many persons ineligible for Medicaid
benefits.7


A. h strength of the Hispanic community is that     might not pq for nix family. Do I lose my inswance if I
families hart tended to stay together. This is a real    change jobs? That's number one. The second olle: (f 1
positive, but it does cause a problem with Medicaid    have n small business, do I have a deduction bigger than

coverage. This is a problem only because of our
past of reliance on Melfare as the main entrance into
Medicaid coverage. The President is now proposing
that anyone, b> virtue of being below the povert)
line, should be covered by a public program. This
will address the problem Lou raise.

25 percent?

  I think also the issue of what happens to small
firms is of no small interest and consequence to the
Hispanic community. Hispanics as a group have
long been associated with small business and with
the integrity and stability of family life. The
challenge is to solve both problems while ensuring
that \ve don't put small business at risk. These are
concerns that hare traditionally resonated in the
Hispanic community.

A. The second question is the easiest. We arc
proposing a 100 percent deduction for all
self-employed and unincorporated busincsscs. It is
totally unreasonable to take our smallest, most
vulnerable businesses and put them at the least tax
advantaged position, that is, being able to deduct
onl>- 25 percent of the premium. We actually have
legislation that has been up on Capitol Hill since
May 8, with financing attached to it to increase the
deductibility to 100 percent for self-employed. It
has been enormously frustrating. Even with strong
policy agreement, the bitterness of the political year
has just kept things from being enacted.

  Let mc mention one other thing. WC knon
that financial access is not the onlv problem.
Physical availability is sometimes a problem. In
Medicaid, we have had many programs that really
have not been constructed in a way that enhances
the ability of people to access phvsicians and nurses
and obtain care outside of the emcrgcncv room. I
know there is someone here from the .\rizona
Access Program. That's usually one of the pro-
grams I cite as an example of how wc can, even
spending at Icwls that wc have traditionallv
associated with Medicaid, arrange health cart in
such a way that people arc not pushed off to the
emergency rooms to reccivc their health cart. The
.-\rizona ACCCSS Proqam enables pcoplc to rcccivc care
             c
from health professionals outside of institutions and to
USC institutions only when and where nccdcd.

  With regard to the first issue, family coverage
and changing jobs, we again are not proposing to
people to provide coverage through their place of
work. Our proposal seeks to ensure that, if you
change jobs, vou cannot be kept out of insurance
coverage because of a preexisting condition. This
would be true for large companies as well as small
companics. No one, according to the insurance
restructuring legislation that WC have up on the Hill,
lvould be able to be kept out of insurance because of
a preexisting condition once they go through an
initial 9-month lvaiting period, pregnancy not
counting, as long as they are generally going
through insurance coverage.

  We need to remind oursclws that financial
access is the first step. WC also have to bc more
creative in providing financial XCCSS, or \vc \vill
spend a lot of moncv and end up not providing
health cart to wmc pcoplc \\-ho vcrv much need it.

  We have to make sure that insurance compa-
nits lvho cover man! sick people don't go out of
business. States will have to put up high risk pools
to help insurance companies that happen to face an
unusual number of sick people. This is the quid pro
quo: Insurance companies must take all comers,
but we will give a couple of diffcrcnt stratcgics that
States can folio\\- to make sure that those companics
\vith disproportionate numbers of sick pcoplc have a
\vav to get compensating pavmcnts. Without such
  d c               ,
support at the State level, insurance cornpanics

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would be put out of business or have a strong
incentive to find a way to skirt whatever rule you
put up, which is usually what happens.

Q. Are taxes going to be raised to pay for this
insurance?

A. There are some substantial ways that we can
fund health care without increasing taxes. Probably
every one of us in this room at one time or another
has said ~800 billion really is enough-we're just
not spending smartly. The first place that we would
look is something that we call "disproportionate
share spending." These are monies, mainly under
Medicaid but a little under Medicare, that go to
hospitals to cover payments for uninsured people.
They are Medicaid and Medicare monies that don't
go for Medicare and Medicaid people; rather, they
are being used under these programs to finance care
for the uninsured. But, vve're doing it in the worst
manner. That is, we're paving hospitals that treat
people without health insurance in their emergency
rooms and in the hospitals. We would like to divert
a substantial amount of this money so that we can
get people in the front door, not the back door, and
keep them out of the emergency room.

  Additional!\-, we know that some things use a lot
of money in our svstem, such as malpractice, which
            ,
causes institutions and physicians to do things not for
their medical benefit but to protect thems&es.

  We know we can do some things to make the
system more administratively efftcient: using
common billing forms, electronic billing, and
common data elements for medical review, and
getting some information out so that purchasers of
health care know \\-hat it is they are purchasing, who
charges what, and what thev get for their money.

  The base that we would start from is the
S85 billion that we are going to be spending over
the next 5 \-cars for hospitals to provide health care
to people without insurance coverage. Dispropor-
tionate share spending has got to bc one of the
worst \\.avs to spend such a large block of money.

Frankly, it reflects the financial maneuvering that
States were doing in the last couple of years. The
fact is, until 1990, disproportionate share spending
under Medicaid was about ~3 billion a year. It is
now close to S 16 billion a year.

Q. Many of us who are adequately insured have seen
really rip-roaring increasing costs with minimum benejit.
That one issue has been of great concern to the middle
class of the United States. Coverage for preventive
service has been shrinking over time. How do you plan
to address the issue of increasing costs in what is a
highfy unregulated society, a highZy unregulated
industv, including pharmaceuticals, possible billing
equipment, etc.? How do you expect to deal with the
costs that have to be paidfor Medicaid or Medicare in
this largely unregulated industry?
A. Basically, you have two choices, and you have
only two choices. One is to regulate the entire
industry by price controls. The other is to treat the
factors that contribute to rising expenses.

  We have tried price controls in this country
from time to time. We have not liked them. Thcv
haven't worked very well. They have typically led
to very rigid systems. European countries that have
tried to limit spending by directly controlling prices
and setting global budgets have enjoyed some
success in limiting spending. However, this control
has typically been associated with rather long lines
and with the unavailability of services during certain
parts of the year.

  Instead, we are trying to go after all of the
forces that keep spending so high. Our approach
features malpractice reform, coordinated care,
managed care systems, repeal of anti-managed care
laws that exist in a lot of the States, restructuring of
the insurance market, assumption of managed risk,
and requirements for States to put out consumer
information (who charges what, what hospitals
charge, which hospitals arc good, what networks of
phvsicians arc doing, what YOU get for your money,
what insurance companies arc doing, how much of

.


the bills they pay in benefits versus how much
premiums they collect). We are basically trying to
attack the problems that have kept health care from
responding to normal kinds of economic forces and
incentives.

  These really are your only two choices. You
can try to control the industry by Government
intervention across the board-hospitals, physi-
cians, pharmaceuticals, medical supplies, wages,
etc.-r you can try to make this area work the
wav other parts of the economy work.

  I actually tried to set 7,000 prices under
Medicare as part of the relative value scale. Having
Government take over the function of setting the
"right price"-not just in 1 year but over time-
and making sure that prices really reflect both what
the costs are of producing them and what people
feel about them (so you don't end up with long lines
because you miscalculate where it was people
wanted to go) is a very daunting job.

  I think the general concern that we feel in this
country about having the Government try to
regulate 13 percent of the GNP [gross national
product] by direct Government regulation ought to
make us pause. The worst thing we can probabl!
do is go toward the middle in this choice. Either
we're going to have to be serious about trying to
unleash the forces that will allow for incentives and
market forces to work or lve're going to have to
regulate like crazy; but you can't do a sloppy job in
either approach. It's what we've been doing, and it
doesn't work. We have found ourselves in the
worst of both worlds.

Q. I think the key word is prel-ention. Any farnil! who
is on the borderline in terms of affording medical
coverage can be destroyed by acute care. Yet insurance
companies have a notorious repumtion of not providing
adequate coverage for preventive medicine. I'm
wondering if in any of these programs involving
insurance companies, the! hare been agreeable to
increased co\.erage for preventive medicine.

A. It depends on the setting in which it occurs.
Preventive care, as part of a coordinated care/
managed care setting, makes a lot of sense. In fact,
when you look at who provides the most preventive
care coverage, it's HMOs [Health Maintenance
Organizations] and other groups that are financially
responsible for all of the individual's health care.

  Under our program, we have insisted that
States must make a coordinated care plan available
for everybody who is under the voucher. Although
we're not going to force people to go into it, we
would like to have coordinated care as the rule
rather than the exception, because we think it offers
the best amount of benefits for your money and
encourages preventive health care. We &so
recognize that not everybody wants to be part of a
group. Some people have rather strong feelings
about not being part of a group, and we don't want
to force them. The question of whether or not
insurance either can or should insure a low-cost
event, if it's outside of a managed care setting, is a
much different question.

  For people who are on the border of being
poor and low income, you want to make sure that,
if thev are out of an HMO or a managed care
setting, they have preventive health care available to
them. That is why we have such a big push on
community health centers, migrant health centers,
and rural health centers. We have had an almost
50 percent increase in PHS funding over the last
3 or 4 years. But it's not always the right role for
insurance coverage unless it's done within the
coordinated care setting.

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Q.  With the increase in access that the administration          One

is working on and the plan to increase insurance
availability in what direction is the administration
heading regarding health professionals ' capacie to
handle the increased health service deliveries that can

come about from this?

A.  We have been worried about the numbers of
pcoplc who arc in specialtv care in mcdicinc versus

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primary cart and the number of pcoplc in urban
arcas versus rural areas. One of the reasons for
making the relative value scale changes was to tip
the balance of Medicare pavments in favor of
primarv care medicine and away from specialt?
care. The 10 percent bonus payment for physicians
that serve in underserved areas and the more liberal
USC of physician assistance reimbursement rules in
rural and undcrserved areas were similar. Our
proposal for several vears, to reimburse hospitals'
undergraduate medical education programs more
for primarT care residencies than secondarT and
tertiary care residencies and more for first residen-
tics than secondary residencies, indicates a whole
series of politics to tip this balance awa! from
spccialtv care and into primary care.

  There is also some real potential for more
selective, targeted loan forgiveness programs to
target individuals, minorities, and others who are
underrepresentcd in providing access to special
populations, and to get people out to areas that
othcrwisc don't get enough health care profes-
sionals. We tried this approach during the late 1960s
and earl\ 197Os, and it was pretty much a failure. But
tuition at the time, at least for medical school, was ve?
low by comparison, sav S2 ,ooO or S 2,500 in terms of
the cost that most of the loan forgiveness programs
\vcrc targeting. Medical school tuition is up to
S22,ooO a year. That gives you leverage on students,
particularly \\,hcn Lou add in living expenses; that
rcallv does allow vou a lot of levcraec if YOU cart to use
                        c ~

it. I think we're going to need to recoLgnize it's going
to take not one or n\-o policies but a scrics of policies
all moving in the same direction.

.A concern has hccn that thr minority physi-
cian is treating a disproportionate number of
patients in those arcas in need. Yet, I don't know if
a IO pcrccnt incrrasc per patient is enough to
motivate my collcagucs to take thrsc patients when
the\- arc alrcadv carrying a huge patient load. I
           ~ .
don't see how wc could continue to cncouragc
nictlical pcrsonn<~l dc\-clopmcnt in the minorit\

arcas for minorit? groups if this trend continues.
WC end up treating our own, but we don't get
compcnsatcd for our own.

  Pcoplc have to understand that there's no
single one police that's going to do it. If all people
who are poor have health insurance coverage, that
will substantiallv change the whole dimension,
particularly in urban areas, of who's been treating
what, since large numbers of people who are in the
urban areas don't have any fmancial wherewithal
when they're coming in. The second thing is the
change in the relative value scales tipping toward
higher reimbursements for primary care and lower
relative reimburseme& fo; secondary care. In
addition is the 10 percent bonus for people in
underserved areas. If, in addition to that, there is
greater use of selective loan forgi\-cness or other
kind of targeting programs in working with medical
schools, that's how you begin to change things. I
know that the University of Minnesota at Duluth has
reported a verv successful venture in terms of
recruiting people for rural areas and keeping them
in rural areas. Dartmouth has a very intensified
effort to produce primary care physicians. If we can
get medical schools around the country to have a
more aggressive role in recruiting minority students
and other people who are likely to go into primary
or rural practice, then you can begin to change this.
Now there are some Federal possibilities for
intervention, but these are largely outside of PHS:
the military related program or public or private
institutions with some Federal monies. Frankly,
getting the medical schools to alter their attitudes
and behaviors is really what's needed and not
particularly amenable to legislation.

Barbara Everitt Bryant, Ph.D.
Director, Census Bureau
U.S. Department of Commcrcc
Buenos dias. Thank you for inviting mc to share
some of the information that the Cc*nsus Bureau


produces that has relevance for the Hispanic/Latin0
Health Initiative. I'm going to present the census data
on charts, because we always give you too man\
numbers to absorb, particularly after breakfast.

  As you well know, the Hispanic/ Latin0
population has been growing at a vey rapid pace.
Hispanic health, therefore, is of growing impor-
tance to the well-being of this Nation. Between
1980 and 1990, the Hispanic population grew by
53 percent or about 7 times as fast as non-Hispanics.
This was one of the most dramatic findings of the
1990 Census. Numerically, this was an enormous
growth, and it's showing up in all of our survey
now that we can do more detailed profiling of the
Hispanic community.

  The Mexican-American nationality, origin, or
population grew at about the same rate, 54 percent,
as the Hispanics overall. The slower growth of the
Puerto Rican and Cuban populations-I'm talking
about those in the 50 States and D.C.-of 35 and
30 percent rcHcct a slower level of immigration,
but it's, nevertheless, very impressive compared to
the white, non-Hispanic growth, vvhich was onlv
4 percent. Now those we call "other Hispanics" are
primarily of Central and South American origin.
                                 c
There are so many countries involved, vve can't just
disaggregate them bv their nationalitv. But, you'll
see that the 1980s was a time of enormous immigra-
tion and a grovvth of 67 percent. Not all of that
growth was from immigration, but a great deal of it
was immigration among what \vc call the "other
Hispanics," which arc those from the south of us.
Our most recent projections which vvill be rclcased
later this year, perhaps even within the coming
month, show that vve expect this rapid growth to
continue well into the next ccnturv.

  Now here are some of the findings. First of
all, in 1970 there were 9 million Hispanics in the
United States. 1 point out that. though the Census
has been around since 1790. we did not have a
specific question on whcthcr or not vou wcrc of
Hispanic origin until the 1970 Census. You'll see
        c

that, between 1970 and 1990, you went from
9 to 22 million, and this dots not include a
separate count of Puerto Rico. There are 3.5
million persons there, most of whom would be
called Hispanic.

  In 1992, \ve already are estimating about
24 million Hispanics. According to our latest
projections-and we do a sort of high, low, and
middle series-the middle series shows that
Hispanics may range from 29 to 3 1 million by the
year 2000 and 37 to 54 million by 2020. Of
course, as we get out further, there's more wobble
in our projection; so we show a wider range of 74
to 96 million. At around 2010, we expect the
Hispanic population to pass the African American
population in this country.

  In 1970, Hispanics in this country-and again
I'm excluding Puerto Rico, though they are
American citizens-were about 4.5 percent of our
population; by 1990, this had doubled to 9 percent.
We already know this growth is continuing, and by
the >-ear 2000, it's going to 10 to 11 percent. Then
our numbers go on out again with a wider range
when we get to 2050.

  One advantage for you in doing a Hispanic/
Latin0 initiative is that you can conccntratc on a
smaller number of States than SO in terms of your
numbers. Five States in the Southwest-California,
Texas, Arizona, Colorado, and New Mexico-
contain over 60 percent of the Nation's Hispanics.
California has over one-third. Incidentally, Cali-
fornia grew by about 6 million betvvecn 1980 and
I 990; one-half of that grovvth, 3 million, was
Hispanic, and about one-fourth of it was Asian.
Thus, your Hispanic health initiative must focus
disproportionatelv on these five southwestern
States, plus Florida and the New York City area.
You can include most Hispanics by concentrating on
seven States; howcvcr, then the rest of the Hispanic
population is very dispersed over the remaining
45 States and, thcrcfore, much harder to focus that
initiative on. In a number of States, the proportion

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Appendix E  444444444444444444

of Hispanics is higher than the national 9 percent

avcragc, and most notably, both California and
Texas arc now 26 percent Hispanic. So one out of
everv four citizens of those two States is Latino.

  The Hispanic population is young and will
continue to be comparatively young when you
compare that to the non-Hispanic population.
However, as time goes by, naturally, it will age.
The median age of the Hispanic population is now
26 years, compared to 35 years for non-Hispanic
whites. That is an enormous difference because, as
all of you know, median means half are older and
half are younger. It takes large numbers to move
the median around, and that 9 percent difference
there is really quite enormous.

  Currently, this means that you've got a lot of
children. About 35 percent of Hispanics are below
age 18, and only 5 percent are age 65 and older.
Thus, in the health field and in this initiative, you're
going to need to concentrate more on pediatrics
than gerontology. The 35 percent who are children
or minors, i.e., below eighteen-teenagers would
never let you call them children, of course--compares
to 26 percent in the total U.S. population. The
5 percent of Hispanics who are senior citizens
compares to 13 percent in the total United States.

  This age mix will shift a few percent each
decade. By 2020. between 31 to 34 percent, about
one-third, will be below age 18, compared to the
35 percent today, and about 8 percent, compared
to the 5 percent today, will be senior citizens. So
you will still have, though with some change, a
smaller perccntagc of elderly and a higher percent
of children than in the population as a whole.

  One of the real challenges for the Hispanic
community is going to be to keep those children in
school. Hispanics now have a lower educational
attainment than other U.S. residents. Onlv about
                               I
one-half or 5 3 percent of Hispanics who arc age
25 or older-we start measuring education after
age 25 to give most of us a chance to get it-have
complctcd high school, compared to 82 percent of

non-Hispanics. That is an enormous difference.
Only 9 percent have graduated from college,
compared to 22 percent of non-Hispanics. How-
ever, the good news is that there is progress. But,
we need to be sure that progress continues
because, obviously, deficits in education affect
economic ability, and that in turn affects health
care and access.

  Hispanics are more likely to be unemployed
than non-Hispanics. In March 1992 when we
measured it, just a few months ago, 11.3 percent of
Hispanics were unemployed, compared to 6.5 per-
cent of non-Hispanic whites. There are clear
variations among the Hispanic nationality groups,
ranging from 9.5 percent among Cuban Americans
to 12 percent among the Puerto Ricans in the
50 States. When employed, Hispanics are more
likely to be employed in lower paying, less stable-
and, as our previous speaker points out, less stable
means less health insurance-and more hazardous
occupations than non-Hispanics. Among males,
Hispanics are more likely to be employed in
services, farming, forestry, and precision produc-
tion, and as operators in factories and other places.
Non-Hispanics are more likely to be employed in
managerial, professional, technical, and sales
occupations. Interestingly, Hispanic women closely
match non-Hispanics in the proportion of technical
and sales jobs among women.

  Hispanics tend to have lower incomes than do
non-Hispanics, which has some correlation with the
education levels that I showed you earlier. It also
reflects the fact that proportionately more Hispanics
are newcomers to the Nation. The median farnib
income of Hispanics, at s 2 3,400, was about
s 14,000 less than non-Hispanic white families.
These are families with related people. There is
variation among Hispanic groups, and thcrc would
be more variation if we had time this morning to go
into details and look at groups according to whether
thev'rc first, second, or third generation within the
                      c
country, whether thev arc recent immigrants. and


vvhcthcr they've completed college or high school.
Averages alvvays, you know, mask diversity.

  Based on cash income only, and that is the
official definition by which Office of Management
and Budget requires that we measure poverty,
Hispanic families are more likely to be poor than
non-Hispanic families. About one-fourth of
Hispanic families, 26 percent, were below the
poverty level for last year, 1991 (we measured it in
March 1992, covering the previous year), compared
to 10 percent of non-Hispanic white families.
Again, there are some rather dramatic differences
among groups by national origin. The Cubans
reflect the fact that most of them have been in the
country longer, having a much smaller proportion
in poverty than other Hispanic groups. The Puerto
Ricans have the highest levels there.

  Poverty disproportionately affects children,
and this is true whether vou're white, non-
                 ,
Hispanic, African American, or Hispanic. But, it's
rather dramatic among Hispanic children because
proportionatelv the Hispanic population has more
children. About 41 percent of Hispanic children
live in poverty, compared with 13 percent of non-
Hispanic children. This is why I am just so pleased
about this Hispanic health initiative; because it is the
children who are the future for us all. About
2 1 percent of Hispanic adults, including the elderly,
also live in fovcrty.

  How do these demographics affect health?
Here, I reallv feel as though I am picking upon the
subject of our earlier speaker, only showing it to
                        ,
you in a somevvhat diffcrcnt wav. We have a
survev called "The Survev of income and Program
   i
participation" in which we interview families
periodically over a period of 28 months, a littlc
more than 2 vears. Thcrcforc, wc can track things
         I
like health insurance, instead of doing what most
burveys do, which is ask vvhat vvcrc vou doing
Festerdav or todav when I intcrvicvv vou. This
            ,
sho\\-s the pattern.

  First of all, Hispanics are less likely than non-
Hispanics to be covered by either private or
governmental health insurance. Even among
Hispanics with health coverage, they're less likely to
be continuously covered than are non-Hispanics.
Over this 28-month period that we measured,
11 percent of Hispanics had no health insurance
during the entire 28 months. Thirty-six percent
had coverage during some part of that time. These
may be people who went in and out of the labor
force; they may be children who became adults and
lost family coverage-many reasons, some of them
related to what our earlier speaker talked about.
Only a little more than one-half or 54 percent had
coverage the whole 28 months, the total health
safety net.

  So let me just summarize what I've covered
this morning and take a few questions, if there's
time. The Latin0 or Hispanic population has been
growing at a very rapid rate. We fully expect the
rapid growth to continue well into the next
century, which is as far as we can see. Our crvstal
                                  I
balls get very cloudy after that. immigration has
played, and will probably continue to play, an
important role in this rapid growth. The Hispanic
population is young, with a high proportion of
children. Of course, the Hispanic population will
age, but it will not have the proportions of clderly
that exist in the total population until well after
2020. Compared to non-Hispanics, Hispanics have
less education on average; are more likely to be
unemployed; are more likely to be employed in
lower paying, less stable, and more hazardous
occupations; have lower income; are more likely to
be poor, and this is particularly so for children; and
have lower proportions covered or continuoush
covered by health insurance. These demographic
differences are important to consider as vou
                             ,
continue vour planning of this Hispanic/Latin0
Health Initiative.

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Q. W/EW discussing the issue of being accounted for.
one must mention the undercounting ofkztinos. What do
you see being done by the year .?OOO?

A. I see a lot of change coming for the year 2000.
First of all, 1 lvould not say that 1990 was worse
than 1980, even though the media said so. We nor\
know that we have much better research on
undercount in 1990 than Eve did in 1980. The t\vo
kinds of research we've done since the census do
suggest an undercount of about 1.6 percent and
about a 5 percent undercount among Hispanic. So,
vou know, there's possiblv a million more than the
24 million we're saving there are in 1992.
  What the undercount research has done has
su_eested some different ways of counting in 1990,
plus probably incorporating some statistical
estimation right into the counting process as we go
along. For example, there's a much higher
undcrcount among renters than among owners.
Well this suggests that in the year 2000 we ma? do a
\-cry different, a more massive targeting of areas
\vith a large number of rental homes, even perhaps
bcforc the major mail-out of questionnaires. I think
\vc jvill also have more wa?s of being counted. WC
have, in the past, had to be ver> careful with hoI\
many questionnaires wcrc out thcrc so that nobody
could vote early and often, as the old joke goes.
  WC certainly arc going to bc able to handle
tnultiplc languages much bcttcr in the Tear 2000.
.A lot of this will bc computer-assisted telephone
intcrvictving in which, if you want to be inter-
viewed in Spanish rather than rccciving a ques-
tionnaire in English in the mail, there will be an
SO0 number that you call. WC actually used
cnumcrators who spoke 52 languages finishing up
the Census in Ne\v York City.

Q. I norice in your data that you had "other His-
pmics. " How do JYM determiue \therl JWI disaggregate
the wrious groups 1' When do .wf disaggregate that
pcrrticulor desiSqrrtrtior~ to people~~our El Strlvcrdor or
cUlicr pluccs?

A. It is disaggregatcd. When I say we can't
disaggregate in detail, what I mean is that we can't
keep disaggrcgating in too great a detail. What
happens, when you get to different groups, you
then can't start looking at things like, their health
insurance by age or by poverty status.
  We do know that the "other Hispanics" are
mostly Central and South American. But, even a
few from Spain itself come under Hispanic, and
then we have a Philippine population that has
come in as sort of Asian Hispanic. We get lots
of variations.

Q. A fairly significant proport of titinos along the
border in California and Texas, in particular, migrate
from Mexico legally and illegally at different times of the

year. Did the Census account for people who are here
temporarily on green cards. people who are here as
laborers. both legal and not? And, where does it appear
in the data? They do impact our services, and it is a
significant burden to provide care for these.
A. Everybody who is in the United States on April
1, 1990, is to be counted, and it doesn't matter
whcthcr he or she is documented, undocumented,
citizen, or noncitizen. The exception would be if
you were on a tourist visa. Even students that arc
here for the year are counted. Those \vho come
across the border and just work for a week are
counted. So the effort is to get everybody who's
resident whether citizen or noncitizen, and that's
the way our Constitution has been interpreted.

Q. How do we encourage people to corne,fonvard to be
counted without the traditional fears? How do we show
that numbers will not be used against thorn. but for their
benefit and the benefit of others? How is the census
going to have a friendly face?

A. We count on people like you to communicate
that. The census does have the clcancst record in
the world of ncser hasing revcalcd clata on an
individual-that is, not for 72 scars. It is a
particular problem to communicate that fact to an
undocumrntecl person. WC do kno\v from the


r~.~~~arch on 1980 that we did count at least
7 million undocumented persons.

  The census has a tremendous outreach
program, working with community and national
c~rganizations. Some of these organizations put a
,Trcat deal of their resources into trying to get
>
their communities counted. Still, communication
is a problem.

Robert 5. Murphy, M.5.FTH.
t)ircctor, Division of Health Examination Statistics
National Center for Health Statistics
Center for Disease Control and Prevention

Buenos dias. I'm very pleased to be here on the 10th
anniversary of the beginning of the Hispanic HANES
[Health and Nutrition Examination Survey] Survey.
Together, we made that work, and many Hispanic
and Latin0 researchers that were involved in the
definition and support for that study are here at this
leadership conference. The tasks you have cm-
barked upon involve very difficult issues, because
what you are doing is trying to take the progress
that has been made, sustain that progress, and go
further. But, bureaucracies are feeling rather
complacent after having made such progress.

  We are now entering a time when resources
are going to be rather scarce. There are going to be
difficult decisions every day on what kind of
programs can be supported. I think information is
going to be crucial in allocating resources, both in
the health field and all other fields. You are going
to need to determine priority areas and push for
them very hard. As a bureaucrat, at times I am
going to be rather uncomfortable with the pushing,
but it's necessary, and it's important because it will
show what the priorities are in your communities.

  I'm going to speak very briefly about the
availability of data and somehow try to deal a little
bit with what I see as the gaps. Some of the very
important things that you're dealing with here in
this conference involve how we position for the

future, because clearly the way we're doing things
now in trying to develop health studies that will
satisfy the needs for data will need to change.

  They will need to have different dimensions.
It will no longer require oversampling of Hispanics
when there are 50 million in the population or
60 million or even more. It will require having
many different kinds of issues covered and
different kinds of dimensions that researchers will
find very difficult to deal with. And, we need to
b ,
egin now. so one of the major purposes for my
talk this morning is to try to define where we go
from here and what I see as some of the issues that

are involved.

In looking at the data availability over the
decade, it's really impressive the progress that has
been made, in vital statistics. Forty percent of the
registration areas in 1980 reported Hispanic
identifiers. In 1992, that percentage is up to
95 percent. We have a long way to go on the
quality of the data. There are aspects of it that need
to be improved dramatically, but it's no longer
selling the need for the information in that area.

  In the National Health Interview Survey we
have made dramatic progress. It's very clear.
Blacks will have been or have been oversampled in
1986 through 1994; Hispanics or Latinos in 1987,
1992, and 1993; and Asiangroups in 1992. This
basically means that we are going to be able to
produce an awful lot of morbidity statistics, an
awful lot of information about health characteristics
and health actions and perceptions of health.

  The redesign of the Health Interview Survey,
begun a long time ago and instituted for 1995, will
have, as part of its objective, the oversampling and
the provision of information for Latinos, for blacks,
for Asian and Pacific Islanders, and for special
population studies. There's a big question, though,
and I think it's important this group be aware. The
design of the study calls for a huge increase in
sample size of that study. Along with that, a lot of
costs will be incurred, and the costs are going up.

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What happens if the resources aren't available?
How will that sample be allocated? Will you have
the data that was basically built into the original
proposal? It's an important question. I don't have

an answer.

  In the Health Examination Survey, in the
1960s up through the end of the 197Os, we pro-
duced information for the total population for
blacks and for whites, and then we had the Hispanic
Health and Nutrition Examination Survey, which
was a landmark in its time. In HANES III, the
current study being conducted from 1988 through
1994, we are oversampling some Hispanic people.
In the Hispanic study we sampled Mexican Ameri-
cans, Puerto Ricans, and Cuban Americans. In
HANES III, we are oversampling only Mexican
Americans.

  What happened? We've made a lot of
progress, but not enough. What we tried to do in
planning for the HANES III study was to incorpo-
rate the gains of the previous study for the most
important arcas. The HANES study is a very
expensive study, and the way we've approached it,
it is very difficult to expand to small groups.

  The original proposal for HANES III included
a sample for the Puerto Rican population. The
resources simply weren't available. Now I'm going
to come back to this point a little bit later and try to
say something about what this means, but it's the
reason I raised the question about the Health
Interview Survey. With the HANES study we are
able to produce a lot of information on physiological
variables, on physical characteristics, and on
attaching this information to information about
health care utilization, about perceptions, about
assessing if our messages are getting through to
pcoplc. We can ask both perceptions and get
objective measures of certain types of characteris-
tics. The important thing, I think, in looking at the
HANES study is that one can sav we made some
progress, but we're not vvhcrc wc need to bc.

  The methodological and conceptual issues
abound in trying to expand these national studies to
cover more population groups. It's really an
awesome task to try to see how to position the
national studies to deal effectively with many
different kinds of issues. I'd like to just raise a few,
because I think we have to systematically address
these kinds of issues, and having a group like this
available and thinking about them and working with
us to deal with them, I think, is vital. There are
difficult issues, even for detailed research studies,
no less the national population studies.

  How does one separate out race and ethnicity
issues from socioeconomic and demographic
measures? We need efficient ways to sample
minority populations. We need information,
detailed information, for denominators in sampling
frames if we are to reach minority populations in a
cost-effective way. These denominators are very
difficult to interpret, even when you gather
information on ethnic and racial categories. There's
a lot of disagreement on how to ask these questions,
how they'll be interpreted. How do you define
how the people feel their national origin should be
reported, and what does it mean? Problems and
limitations exist with current questionnaire design.
Issues arise with cross-cultural validity and sensitiv-
ity. Interviewing techniques and conceptually
equivalent approaches need to be developed if
responses are to be standardized in their interpreta-
tion. This is a huge issue. This is not the kind of
issue that is going to go away as your population
gets bigger. This issue is going to remain constant.
So this is an area in which we have to do research,
and we have to do it now.

  Numerous operational issues also exist.
Methods and modes of operation need to be
carefully examined. This is clear from what I think
happened in HANES III. WC tried to expand
coverage to just one more population group, and
the expense was too high. What's the implication?
Something needs to change with thr mechanism. I


,,,~.~,,,. it needs to be examined again. Research will
I,~. n~.~.c*ssary to develop simpler methods, and
,,,<,th& that can be employed under different, less
L.Kl,c*nsivc type of circumstances. It's not an easy
thing to deal with, because you can't compromise
the concept that you're trying to measure. You
ncctl to do it better and more efficiently. It's not
ooing to be easv.
>           ,
  In addition, we need to look at issues of

L.,>n,parability over time and timeliness of the
production of information. To address these issues
\vith national samples and national studies is going
to bc very difEcult. It could mean the need for
major rethinking about how we go about our studies
and design them. This is not good news to
bureaucrats. This is uncomfortable, because it
means change. It means reevaluation, and it means
real thinking.

  These are complex and multidimensional
issues, and they arc fundamental in trying to get Lou
the kind of information you need about your
communities. In the past, in designing statistical
studies, in designing any kind of study, you set the
objectives on what you wanted to be able to control
for and how much precision you wanted your
estimates to have. Typically, in the past this has
been done by saying, for the total population, b!
age and sex group, we want this kind of informa-
tion. Now if we are going to design studies that
produce information for subgroups of the popula-
tion with good precision and have the ability to do
analysis in some detail to try to effect change or
look at underlying relationships, this concept needs
to change. The total is the sum of the parts rather
than the other way around; i.e., find the total and
then we'll get the parts that we can. The totals arc
vet-v important for this country, and we are a
  ,
country. On the other hand, we have to balance that
with the need for detailed information on health cat-c,
health utilization and access, and the health charactcris-
tics of the population. Arc the diffcrcntials disappcar-
ing? Are our actions or the money wc'rc spending on

health education and nutrition programs being
effcctire? We need the information, and the onlv wav
                                  I 2
we're going to get it is bv looking at more detail in the
subpopulation groups.

  What mechanisms arc available to support and
promote this kind of effort? Well, I think there are
several, and 1'11 only speak for NCHS and CDC a
little bit. I think there is a recognized need that this
is an important area and that we have to make
progress in it. I think that's number one. I think
you have to know that there's a problem before you
can start dealing with it, and I think that is in place.

  I think it's important that the issues and the
urgency of the need for information be raised to the
highest level people you can find. In thi$ case,
you've got a workshop here in which you have the
Surgeon General of the United States, and I think
that this is a vital way of approaching this problem.
When the top recognizes the problem, it's amazing
how the bottom follows along and does something
about it. But, I think there's another important
thing; it can't be a one-time occurrence. I think it
needs to have periodic progress reviews, and I think
they need to be visible. There are programs in
place for doing intramural and extramural research.
These kinds of mechanisms need to be employed to
help change the systems that are currently in place
for gathering health information.
  We need to be able to develop cross-cultural

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questionnaires and sampling strategies that permit
complementary and supplementary studies to the
targeted populations, studies closely related to the
national studies or incorporated into them. Other-

wise, the analysis of the data is confounded by
differences in time, comparability of methods, and
a number of other issues that can be raised.
Perhaps even the grant mechanism that NCHS has
could be used to do some kind of special studies.
I think it's also important in these grant mechanisms
that the minority communities, researchers, and
others involved be strengthened so that we can
continue to have those that arc informed, that

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know the issues, and that can raise them effectively
in agenda setting meetings.

  I think it's important that we support the
research of the Census Bureau. It's basically the
Census Bureau that gives us the population denomi-
nators and the information on how to go about
sampling strategies and to effectively and efficiently
deal with changing our mechanisms for getting
minority populations.

  I think there is also a need for better analysis
of the data that is available. This is difficult, because
there is a shortage of money, and lots of times the
research dollars go to basic research that is looking
at new data collection. I would like to see more
analysis of the data that is available. I think that this
would help us in a number of ways in my program.
It would help me get into the data in such a way that
I could see what we have addressed adequately, and
people that are doing the analysis could raise what
we couldn't address adequately. Then we can
change to address those most important issues.

  I commend you for your support of the efforts
of this workshop, and I look forward to your
recommendations and any questions you have.

One

Q. One of the major problems, we know, is the
availability of Hispanic researchers in putting national
data to good use. What mechanisms do you think need to

Voice

be developed that could expand training and promotion
of Hispanic researchers in working on those national

data sets?

A. With the institution of the minority health
program in NCHS and the subsequent grants for the
program, the recognition for the need for technical
workshops and support, as part of the grant
mechanisms for the development of Hispanic
researchers is recognized and, to the extent
possible, will be pursued. I can't tell you how
much, other than that. I think, as the center
bccomcs more knowlcdgcable and obtains more
funds for the minority grant program, that it's

ncccssarv.

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Q. Why is there so little baseline information in the
year 2000 objectives? There are 300 objectives; 25 of
them are Hispanic spec@c. The reasoning is that there's
not enough baseline. So for 275 objectives, they're
saying that we don `t have information on Hispanics. I
thoqht that Hispanic HANES was going to be a good
resource to get at that issue. What happened? What
happened to the baseline on those 275?

A. I guess you know that HANES addresses maybe
25 or 30 research areas, and of those, only a subset
are in the year 2000 objectives. On the other hand,
I think the information from the health interview
surveys will begin providing baseline information
for a wide variety of those objt-ctives.

  I really think that this group should discuss
this issue surrounding Puerto Ricans, because it has
lots of implications. One option is, obviously, to
continue to pit one group against the other. I think
it's important that, several years ago when the
analysis of Hispanic HANES data occurred, it was
really the action of lots of concerned individuals,
many of you sitting in this room right now, that
moved the appropriate political forces to suddenly
get money to get the analysis done. So my sense
of it, based on history, is that we can do this again. In
order not to lose the opportunity to collect data,
we must really mobilize and address the appropriate
forces. We need to do something about HANES IV.

  I am a witness that the Hispanic community
basically mobilized the resources not only for the
data analysis but also to conduct the study, the
definition of the study and, further, the analysis of
the data. It was mobilized at a time of very tough
competition for resources. It was mobilized
because the Hispanic leadership at that time went to
the White House and said, "This is most important
to us." Can it be done again? I would think so, but
I think the point of my remarks was that what WC
know now and what we knew then is somewhat
different. We know that we can't really expand
HANES the way it's run or some of the other
studies the way they're run to cover thcsc groups


and lots of other groups, too, adequately. Can you
mobilize? Yes. I think that this type of initiative
that the Surgeon General has sponsored here is a
first step in future development.

  I'm just wondering what we can do to help
you, and I'd like to make three points. I'm still not
delighted to be part of the oversampling group,
because this oversampling means I'm still not part of
the big picture. So I'm not comfortable with that,
and as part of a larger Hispanic group I think that
doesn't serve me among my peers. Second, I think
that it affects majority health care when we produce
numbers that pertain to one group, and several
things can happen. One, they can try to spread that
knowledge among other Hispanic groups where it
doesn't fit or, worse, they can say, this knowledge,
we know, is only pertinent to this group. There-
fore, we're just going to throw it all out and not use
it at all. So that does not serve us. Third, I don't
think the responsibility of leaning on people to get
us funds for our group should be our responsibility.
The majority of the country is included in this
study, just as a fait accompli, as a natural course of
events. I don't know what we can do, but I'm
asking you to help us. How do we become part of
this national course of events?

  I agree with all your comments. What we
have tried to do in the past in terms of looking at
minority health populations, regardless of which
minorities, has been to somehow add them to the
national sample and keep everything else constant.
That has to change, if we are going to do a better
job on these areas. It has to change the way we
sample, or it has to change the depth to which we
can go in different types of studies, or it has to
change in terms of accommodating special concur-
rent studies so that the data is comparable and of as
high quality as the national studies are. It's very
difficult for a national survey mechanism to address
local types of population groups and issues.
We've got to adapt those mechanisms differently
and better.

  We tried to build in, at a reasonable cost, two
of the major Hispanic populations and to institution-
alize the approach to understanding the health of
these groups better, and it didn't work. What it
means is that we now have to do something else.
There's going to be a lot of competition for how we
cover different population groups trying to gather
information. It's going to be: Do you want this
information or do you want more funds for Medi-
care? Do you want more funds for WIC [Supple-
mental Food Program for Women, Infants, and
Children]? There's going to be a lot of competition
for Federal funds. So it's going to be necessary for
people who want information to make sure that the
importance of that information is recognized by the
people making the policy decisions, by the people
that have the resources to allocate. By the time it
comes down to me as a program manager, I may
have so few options that I may not be able to do
things in different kinds of ways.

  I think that's crucial to this group to under-
stand that the competition for funds is going to be at
times very ugly. Do you want more services or do
you want to study the problem? That's a hard
question to deal with when you see how important
those services are to people, to individuals. Infor-
mation is important to make things happen, not just
for the individual. So we'll try to be responsive.

OIK!

Voice

Rafael J. Magallan

Director, Washington Office

Hispanic Association of Colleges and Universities
Buenos dias. I plan to touch on three topics in my
brief presentation: first, to share some information
regarding the Hispanic Association of Colleges and
Universities, HACU; second, to make a few
observations regarding the condition of Latinos in
higher education; and third, to explore with you
some possible opportunities for action and
collaboration.

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  First, I think you should know a little bit
about HACU. It's a very young organization. It's
been around for only 6 years. But as young as it is,
it has grown very rapidly. It comprises a network
of I I8 colleges and universities, all of which have
at least 25 percent Hispanic/Latin0 enrollments.
A good number of these schools have Latin0
majorities. It was felt that 25 percent represented
a significant measure not so much of distribution,
but of a sufficient enrollment to constitute a

critical mass.

When we look at HACU member institutions

designated as Hispanic-serving institutions (HSIs),
those 1 18 colleges and universities represent one-
half of all Latin0 students enrolled in U.S. higher
education; that includes all our institutions in
Puerto Rico as well. It's not insignificant. Our
kids, our students are extraordinarily concentrated
in a handful of those colleges and universities here in
the countrr , . WC have 3,400 colleges and universi-
tics, and half of all Latin0 students are concentrated
in I I 8. Such a concentration obviously portends
well when we want to target serving those students
bcttcr, taking opportunities to those students,
providing intcrvcntions that might make the
diffcrencc in terms of getting them into particular
careers, particular academic tracks.

  In addition to those I 18 institutions, there are
another 44 collcgcs and universities that belong to
HACU as associate members. Associate member-
ship status does not require a 25 percent Hispanic
enrollment. Such a school says, "We have Latin0
students. We might have 2,000 of them (or 5,000),
but not 25 percent. Yet, we feel committed to do
something above and beyond the norm with our
institution's efforts to better serve these students."

  HACU is growing rapidly. It is helpful to
understand that the definition of an HSI is not a
static definition. The best parallcl is with the
historically black collcgcs and universities, crcatcd
by Icgislativc fiat after the Civil War in 1862 and in
1898. Those arc schools that wcrc clccmcd then to

bc historically black colleges. A few were added a
little bit later on. But in essence, there has been no
change. Those are HBCUs by definition, and those
will always be HBCUs.

  In contrast, HACU institutions, or HSIs,
become HSIs because their populations change.
Some might be schools that were not initially
founded to serve Latinos. We have only two
accredited institutions in the country in existence
today that were founded with a charter to serve
Latinos. One is St. Augustine College, a small
2-year college in Chicago. Another one is Boricua
College, which is a small 4-year institution in New
York. HOSTOS Community College, which is part
of the CUNY [City University of New York] system
in New York, also came aboard later primarily to
serve Latinos. I mean, that's what their constitu-
ency is. HOSTOS is a 2-year college. WC have
another institution-the National Hispanic
University-in the Bay area in California that is
going through accreditation. It's not yet a member
of HACU because to be a member of HACU you
have to be a fully accredited institution.

  By and large, all those 118 colleges have been
working hard to train Hispanic students, as part of
their mission of being Latin0 serving institutions.
That dynamic--one that's driven by demo-
graphics-means that there will be more HSIs
tomorrow. There will be more members of HACU
next year because, as our population continues to
grow, we are going to have more Latinos in higher
education. This is a demographic reality, even if WC
did nothing to improve the very sorry state of
precollege education. These institutions do share
another important pattern, and it's a historical
pattern of being seriously undersupported and
underfunded. Our schools, by and large, arc low-
wealth institutions. Of these 1 18 HSIs, 59 of them
are 2-year colleges, and the other 59 today arc 4-
year colleges. Eighty-four of these institutions arc
found on the mainland, and 34 of them arc found in
Puerto Rico. The nice thing about our schools in


i~tl~.rto Rico is that they have never had any problem
.,l,,,ut their mission of serving Latin0 students.

  I l.XCU has three main goals: to strengthen
I l,c `..~pacitv of our colleges and universities to
i,r'nitJe a quality education for their students; to
r,use the educational attainment of our students in
these institutions; and to be of service to the
~.~,mmunity and our schools by providing linkages
\\ ith the corporate and Federal sectors, and with
anvone else who wants to work in improving the
I%ducation of HSIs' institutions and our students.

  It is significant to point out that the HACU
nctw.ork stretches across the country more than
3,000 miles from Puerto Rico to California. It's
even more significant to note that, like a bridge, the
netvvork rests, figuratively at least, on strong
vertical pillars. These pillars are its member
institutions. We draw from all sectors of higher
education. HACU schools arc a microcosm of the
div.ersity of American higher education. WC have
some schools with research capabilities, we have a
lot of comprehensive colleges and universities, and
then we have a lot of junior colleges. Likewise,
about two-thirds of our schools arc public and the
other one-third are private institutions.

  HACU also has a rather innovative precollege
program, known as the Hispanic Student Success
Program (HSSP). The program involves a set of
interventions that were put in place to help
precollege students-starting with junior high and
working through high school-better prepare
themselves to move into postsecondary education,
with an eye to moving them into academic careers
such as research, which might lead hopefully to
positions in the professorate.

  The importance of these early outreach and
intervention efforts becomes clear for all families
with educational attainment rates. Hispanics arc
being undcrscrvcd by the educational systems.
Latin0 students at all levels lag behind their Anglo
and other minority peers. Hispanic students,
including virtuallv cvcrv subgroup, do poorly in
                 ,

grade school, middle school, and high school,
particularly in the transition from one level to
the next.

  The kc! indicator of high school completion
has worsened. High school graduation rates for
Latinos have dropped from 62.9 percent in I985 to
54.5 percent in 1990. Comparable white rates
were 83 percent in 1985 and 82 percent in 1990,
and black rates were 75 percent and 77 percent
during the same period. Only 44 percent of
Mexican-Americans, 56 percent of Puerto Ricans,
and 64 percent of Cubans have completed 4 years
of high school, while the figures for whites showed
80 percent with at least 4 years of high school. The
corollary data are bleak.

  Now, the bleakness of this precollege data
takes a predictable toll on the Latin0 college-going
population. In 1990, 29. I percent of Latin0 high
school graduates went to college. This was an
increase over the 1985 level of 26 percent. How-
ever, 39.4 percent of the white graduates attended
college, up from 34 percent in 1985, and black high
school graduate figures showed a similar increase.
Although Latin0 college enrollments in the 50
States and Washington, D.C., increased from
472,000 to 758,000 in the years between 1980 and
1990, their percentile of the total only went from
3.7 to 5.5. In addition, Hispanics are dispropor-
tionately enrolled in 2-year colleges, with 56 per-
cent of all enrollments in this sector versus 38 per-
cent for all other students. Those students are
concentrated in just a handful of colleges.
  In terms of undergraduate outcomes, His-

OtlC

Voice

panics received 22,000 associate degrees in 1989-
1990 for 4.9 percent of all such degrees awarded
that year. Also, in the same year, Hispanics earned
32,686 bachelor degrees for 3.1 percent of the total
conferred in the 50 States and D.C. In terms of
graduate education, in 1990, 56,000 Hispanics were
enrolled in postbaccalaureate programs, with
46,000 found in graduate school and another
10,000 in professional programs. Hispanics

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OIW

Voice

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comprise only 3. s percent of all master's students
in the U.S. in 1990, and Hispanic-Americans
received 7,905 master's degrees in 1989, which was
2. s percent of all such degrees.
  Now, it's important for us to rid ourselves of
the belief that Hispanic students go on to profes-
sional schools. Hispanic first professional school
enrollments increased only from 2 percent in I 980,
to 3.5 percent in 1990. Now, in actual enroll-
ments, the number went from 7,000 to 10,000
students. Hispanic students are not being diverted
from graduate school by professional school
enticements; they are not necessarily going into
professional degree programs. GMAT data show
that onlv 1.1 percent of all the GMAT test-takers in
I989 were Chicanos, and only 0.7 percent were
Puerto Ricans. And in terms of law school, to
quote a colleague of mine, Law Professor Michael
Olivas, "Hispanics are not flocking to law school."
There were approximately 5,000 Hispanics enrolled
in law schools in 1990 for only 3.8 percent of the
total, and the situation is equally dismal in other
professional fields.

  I suspect you've had an opportunity to talk
about what the Hispanic representation is in the
schools of medicine and allied health fields. In
1989, the number of Hispanic college graduates
with science degrees was 1,682. Of those, a good
part of them-l ,338-applied to medical school.
In 1990, Hispanic Americans constituted only
5.6 percent of all first year students enrolled in
U.S. medical schools. The total enrollment, or the
enrollment of Hispanic-American students in
medical schools in 1990, was also 5.4 percent, and I
suspect that Hispanic-American representation in
the other health professions-nursing, dentistry,
pharmacy, physical therapy, research in bioscience
areas, public health, health administration, health
policy-is equally low as it has been documented
for these others.

  One particular conccm is the alarmingly small
number of Hispanic U.S. citizens that are earning

doctorate degrees. We argue strenuously that those
small numbers are a critical stumbling block in our
ability to change the face of U.S. higher education.
In 1989-l 990, the total number of doctorates
awarded in the United States was 37,980. Of that
number, only 783 doctorates, or 2.1 percent, were
awarded to Hispanics. These degrees represent
2.6 percent of the doctorates awarded to U.S.
citizens that year. Hispanic Ph. D . s represent
approximately 1.7 percent of all doctorate degree
recipients in the sciences and mathematics. Now,
while there have been fluctuations in the number of
doctoral degrees awarded to Hispanics over the last
10 years, the overall share has not increased
substantially, with the actual numbers remaining
minuscule. Clearly, the dearth of Hispanic Ph.D.
recipients has reached a critical level in terms of
participation in academia and in research and
development. One obvious outcome of such poor
postbaccalaureate attainment rates is that Hispanics
constitute approximately 2 percent of university
faculty and about 2.3 percent of full-time
postsecondary education administrators.
  Your conference provides a golden opportu-
nity to address the national resource needs for
Hispanic representation in the medical profession
and allied health fields. Given the already noted
dismal participation levels of Hispanics in graduate
education and in the postsecondary education
teaching and administrative ranks overall, much
remains to be done.

   HACU shares the belief that the soundest
method for increasing the number of Hispanics with
doctorates and professional degrees is to enhance
the awareness of college research and teaching
careers among Hispanic students at earlier stages in
the collegiate experience. We just cannot continue
to cream the cream. We have to work strenuously
to expand that pool. Hispanics need to bc informed
of opportunities for doctoral study and the career
advantages that can be afforded to them from
pursuit of a career in medicine and health. Only bv


,uch targeted interventions can we create a larger
Pt,ot at the undergraduate level of potential medical
,,,,d rclatcd health professionals.

  In addition, HACU strongly believes that
increased Federal support for such study is an
c>sscntial element for correcting the current shortfall
of Latin0 health professionals. It is critical that
these considerations be addressed. HACU seeks to
bring attention to the particular human resource
needs of HSIs. Increasing the number of Latin0
faculty will have a broad-reaching and sustained
Jfcct of providing appropriate role models for
undergraduate students moving through the
educational stream. At every level from grade
school to graduate school, Latinos lag in academic
achievement.

  There is progress, and I don't mean to paint
such a dismal picture. As I noted earlier, our
numbers have increased. We just don't think that
they have increased significantly enough to make a
difference because, if every student that you have in
vour medical programs now graduated tomorrow,
it would still be a drop in the bucket.

  Although the gap between Hispanics and
other groups has widened in terms of education,
there are some preliminary data from both pro-
grams that HACU runs at the precollege level as
well as work done by colleagues of ours working
with Hispanic community-based education efforts
that suggest that community-based programs can
lead to significant measurable improvements in
student performance as well as significant increases
in parent and community involvement in the
educational process. I underscore the latter because
it's only by working at those early levels that we can
ensure ourselves of a better stream, a fuller stream,
more representative of the numbers involved,
subsequently coming through programs later on.
I will encourage us not to look for just piecemeal,
quick fixes. I think those would not be sufficient for
our country's needs.

  It's my sense that many of us have come to
the conclusion that we arc all interdependent and
that our strategies will succeed if we have viable
partnerships and lots of friends. We all recognize
that Hispanic students face monumental challenges.
If they are to achieve and attain beyond the isolated
and piecemeal types of successes we find here and
there, institutions such as the Department of Health
and Human Services, PHS, and community-based
organizations must enter into new and even more
creative collaborative relationships.

  HACU is in the position to serve as a conduit
in this respect. You have out in the field some of
the best programs targeted at providing the early
career awareness and support for students within
the pipeline. We just don't have enough of them.
A case in point is the Health Careers Opportunities
Program: I counted about seven such programs
funded in our 118 HSIs. That tells you that there's
not enough connection to Hispanics. The Minority
Biomedical Research Support Program (MBRS
Program), the MART programs, the minority high
school student research apprenticeships, the Health
Service Corps-how much are these entities really
targeting our students? We must do a better job of
somehow bringing them into a better focus with our
institutions, both our community-based institutions
and our institutions at the postsecondary level. I
suggest that you consider how you can expand and
maybe even consider other reauthorizations and

One

Voice

legislative vehicles to bring attention to the Latin0
dimension of our minority equation.
   There are 38 HSIs that offer health science

degrees at the 2-year college level. At the 4-year
college level, among our HSIs, we have 3 1 schools
that offer a variety of baccalaureate and master's
degrees, etc., in health science. In terms of allied
health, at the community college level, 38 HSIs
offer degree programs. Twenty-three 4-year HSIs
offer bachelor's or higher degree programs in allied
health. In terms of life sciences, 21 2-year HSIs
offer clegree programs and 39 4-year HSIs offer a

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varictv of baccalaurcatc degrees or higher. Twentv-
one L-\-ear HSIs and 3 1 4-vear HSIs offer degrees in
mathematics. Seventeen undergraduate HSIs,
17 community college HSIs, and 33 4-year HSls
offer a variety of degrees in psychology. What we
don't have is a lot of medical schools. We do have
our programs in Puerto Rico, and I think a lot of us
on the mainland often give short shrift to the
benefits of our institutional systems on the island. It
behooves us to consider how we can better tie both
the programs and the flow of students, faculty, and
resources of our schools on the island to the needs
here on the mainland.

  One of the things that I learned about this past
vear is the development of the new Hispanic
Centers of Excellence in the United States. The
numbers of the Latin0 students in the Centers of
Excellence are not what they should be, so I would
encourage that those Centers of Excellence receive
a lot more funding. The funding that was divided
among those institutions was paltry. Such a
situation is intolerable. There are more than
400,000 students in those institutions. It's a fact
that has been taken up with some notice bv our
                               <
friends in the Federal bureaucracies. As bad as
things are for us obviouslv in health, thcv're not
                              ,
much better in the other professional fields, and so
we have had other agencies who have had that light
bulb come on and say, "Ah, can we work \vith you
guys to get these students thinking about careers in
agricultural science and various other technology
and math fields?"

  HACU is not a panacea to the larger issue of
gross underrepresentation of Hispanics. We have to
work at building strong partnerships. That's why I
emphasize strengthening the precollege as well as
the postsecondary linkages so that the students that
come in don't fall out, so that you can be guaran-
teed that you're going to have students being
tracked through thcsc institutional linkages, and so
that JVJ'I-~ going to havr students prepared to go
into your advanced programs.

  Approximately 138,000 students are enrolled
in Puerto Rican institutions. You have another
222,000 in California alone. The California system
of higher education is structured in such a way that
68 percent of those students are in community
colleges. If we want to have a significant impact on
pulling many of these students into health profes-
sions, we have to be creative at finding ways to
bring health career opportunities to community
colleges. Not that we start there; I'm suggesting we
start much earlier. We have to find ways to engage
all the segments in implementing additional ways to
bring Hispanic students into health professions, hold
them, and carry them through the process.

Eleanor Chelimsky

Assistant Comptroller General
U.S. General Accounting Of&e

It's a great pleasure to be here. Today what I
thought I'd do is talk about the GAO report that I
see most of you have received and our work
generally on Hispanic Americans and especially
their access to health care. Let me begin by
presenting a short profile of the Latin0 population
living in the United States and then move on to a
discussion of five specific barriers to health care that
they currently face.

  Latinos make up the second largest and also
the fastest growing minority group in the United
States. We tend to have only a one-sided picture of
the issues. We hear a lot more about machismo, for
example, than about the strength and cohesiveness
of Latin0 families, more about high rates of diabetes
than about low rates of infant mortality, more about
school dropouts than about the achievements of
Latinos in all areas of American life. Is this because
we're a problem-oriented society with a strong
belief in the idea "if it ain't broke, don't fix it"? Is it
because we get our information mostly from whatever
data the media may choose to report? Or is it bccausc
we simplv haven't come around yet to a very balanced
      i


understanding of the diverse Hispanic population
rooted and _qrcuwing in our midst?

  The fact is that, since 1980, the Hispanic
population has experienced phenomenal growth, up
from 9 million people in 1970 to 2 1 million people
today. This is largely a result of two factors-a high
birth rate and massive immigration-both of which
Icad, in turn, to a relatively youthful Latin0
population having a median age of 26, compared
with 34 for non-Hispanics. In a nutshell, about 1 of
cvcry 12 persons in the United States today is
Hispanic, and by the turn of the century Latinos
will be our largest single ethnic group. So we've
seen dramatic increases in size for the Hispanic
population but much slower progress in socio-
economic &riding.

  About one in four Latinos lived in poverty
in 1989. That's about the same as it was in 1980.
.\nd that compares to only one in nine for
non-Hispanics. Two of every five Latin0 children
arc born into poor families, and this includes the
children growing up in single, female-headed
households, about half of which fall below the
povertv Icvel. Now, the importance of sizeable
numbers of poor, single, female-headed households
in any population subgroup is that, for the single
mother and her children, the pathways for breaking
out of poverty, and especially the pathways of
education and economic opportunity, are severely
limited. In 1991, Latin0 families maintained by a
female householder with no husband present
amounted to 24 percent of all Latin0 families
compared to 16 percent for non-Hispanic families.
Of course, the diversity that I mentioned earlier is
reflected here. You find only I9 percent of
Mexican American households headed by single
mothers, compared to 43 percent of Puerto Ricans.
Still, the 24 percent average rate for Hispanic
families as a vvholc is nearly twice the 13 percent
avcragc rate for white families. Suffice it to say that
poverty and c&cation arc intimatclv linked.

  Now, let mc turn to health status. Here
again, the Hispanic protile differs notably from that
of non-Hispanics. Data on mortality indicate that,
while Hispanics live about as long as non-Hispanic
whites on average, they tend to die from different
causes: accidents, diabetes, and cirrhosis of the liver
kill proportionately more Latinos than non-Latinos,
and the top 10 killers include homicide and AIDS,
whereas neither of these is among the major killers
for the white population. On the other hand,
Mexican American infant mortality rates have been
at or below white rates and much below black rates
since data have been collected on this group. With
regard to morbidity, Hispanics are more likely than
non-Hispanics to suffer from hypertension, cardio-
pulmonary problems, strokes, cirrhosis of the liver,
and cancer of the cervix. AIDS also represents a
serious increasing concern, not only for those
Latinos who are addicted to intravenous drug use
but also for larger numbers of people, especiall)
teenagers, who may not have received sufficient
health education to understand the risks of AIDS
and especially how it is transmitted. Hispanics are
two to three times more likely than non-Hispanics
to have both diabetes and its complications, like
blindness or amputation, which often occur without

treatment. A studv of Texas border counties that

we looked at, for example, showed that, among all
the cases followed in the study, 60 percent of
diabetes-caused blindness, 5 1 percent of kidney
failures, and 67 percent of diabetes-related amputa-
tions of feet and legs could have been prevented
with timely and proper treatment.
  Given these data on the high rates of Hispanic

  One



Voice






   . a

mortality and morbidity with respect to so many
diseases that are preventable, or at least treatable,
access to the health care system emerges as a critical
issue for Latinos. Unfortunately, I would say that
the situation here is far from encouraging. In 1989,
as all of you know, more than 14 percent of the
American population as a whole had no health
insurance, public or private. But for Hispanics, that

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Ofle

Voice

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f ~gurc was more than twice as high-33 percent
had no health insurance versus about 19 percent for
blacks, 12 percent for whites. Yet in the United
States, the lack of health insurance erects a prima?
barrier to the receipt of adequate and timely health
care. People who are uninsured are less likely to
have a re gular source of health care or to have an
ambulatory visit during the year. They are more
likely to use an emergency room as their usual
source of care, and they are less likely to use
preventive service, such as pap smears, blood
pressure checks, and breast examinations. Even
if they have a chronic and serious illness, they'll
make fewer visits to the physician than if they were
insured. And when they finally do receive care,
their physical complications are likely to be more
advanced and, hence, also more difftcult and
costlv to treat.

  But why are Hispanics so disadvantaged with
respect to health insurance? We uncovered in our
work a number of reasons, some applying to private
health insurance, some to public programs. Begin-
ning with a lack of private coverage, we found that
two factors are principal contributors to the
problem: jobs that fail to provide health insurance
and incomes that don't reach the poverty level.

  The fact that Hispanic families are more likely
to be uninsured than either white or black families
is, of course, well-known. What is less well-known
is that this holds true regardless of whether there is
an adult worker in the family. Whites are likely to
be uninsured mostly when there's no adult worker
in the family. But having a job is no guarantee for
Latinos. In families with adult workers, only
57 percent of Hispanics, compared with 84 percent
of whites, have private insurance coverage. Said
another way, this means that if Hispanic families
with adult workers had the same rate of insurance
coverage that whites have, the overall rate of non-
insurance for Hispanic families would have been
18 percent, not 33 percent. The issue here is that
some jobs in some industries don't provide health

insurance benefits to employees. The problem for
Hispanics is that, in comparison with both whites
and blacks, they are more likely to work in indus-
tries that don't provide health insurance coverage-
for example, personal services or agriculture-
and less likely to work in industries that routinely
provide such coverage-for example, manu-
facturing, professional services, and public adminis-
tration.

  With regard to income as a contributor to
non-insurance, this relates to the potential for
buying health insurance when a job doesn't offer it.
We found that employed Hispanic men with
incomes above the poverty level had much higher
rates of private insurance than those with incomes
below that level, with 67 percent versus 3 1 per-
cent. Higher income meant not only a greater
likelihood of insurance coverage through employers
but also the ability to afford private health insurance
when coverage through a job was not available.
Higher incomes are also relevant when workers
receive job-related health benefits for themselves
but not for their families. Low incomes simply
preclude the additional coverage needed, and the
problem gets worse because, on average, Hispanics
have larger families than non-Hispanics and,
therefore, more persons for whom to purchase
extended coverage. So the outlook for Hispanic
health insurance, at least in the private sector, is not
currently very encouraging.

  But what about public insurance? Are
Hispanics better off with Medicare and Medicaid
than they are with private insurance? Well,
certainly with Medicare they are. The Medicare
program covers only the elderly, but it has the rare
virtue in the United States of being nearly universal
with 96 percent of people 65 or over having
coverage. Ninety-six percent of whites, 95 percent
of blacks, and 9 1 percent of Hispanics are covered
by Medicare, and the reason coverage is so wide-
spread is that M d'
     e mare eligibility is relatively
straightforward. Anyone over the age of 65 who is


eligible to receive Social Security is automaticalb
eligible to receive Medicare. But even though
coverage is nearly universal, I would still point out
to you that 4 percent of elderly Hispanics, about
42,000 people, are covered neither by Medicare
nor by any other health insurance at all.

  The situation is very different with Medicaid,
whcrc stringent eligibility criteria greatly restrict
access to the program in a number of States with
high concentrations of Hispanics. Because each
State determines its own eligibility criteria for
Medicaid, even though the criteria must fall within
Federal guidelines, the criteria obviously vary
dramatically across the States. Two of the most
restrictive States are Texas and Florida, in which
about 3 of every 10 Hispanics reside. In California
to qualify for Medicaid a family of three must earn
less than 79 percent of the Federal poverty line
income. But to qualify in Texas, a family of three
must cam less than 22 percent of the poverty line
income. So in 1989, when the poverty level was
about S 12,000, a family of three earning S6,500 a
year would have qualified for Medicaid in California
but not in Texas.

  Now, there are major differences in Medicaid
coverage across Hispanic subgroups, which are
largely explained by these differences in cligibilitv
criteria. For instance, Mexican Americans and
Puerto Ricans both have high rates of poverty and
low median incomes. But Puerto Ricans, who are
concentrated in New York and New Jersey, are
much more likely than Mexican Americans, with a
substantial population in Texas, to meet Medicaid
eligibility criteria. As a result, a higher proportion
of Puerto Ricans than Mexican Americans receives
Medicaid. It's true that the greatest numbers of
Mexican Americans, about 42 percent, do reside in
California, and California has the least stringent
eligibilitv criteria for Medicaid in the Nation. Still,
with more than 30 percent of Mexican Americans
residing in Texas, Texas Medicaid policies do plav a
     c
role in restricting health cart coverage for the

group. Further, and let-y important, despite
California's less restrictive criteria, 23 pcrccnt of
California's non-elderly population-that's
6 million people-were uninsured in 1989. This
reflects once again the effect of cmplovmcnt in Ion
wage jobs that don't provide health insurance.
  c
  The situation in California illustrates very well

the complexitv of the policy difficulties that are
involved here. Just raising the Medicaid thresholds
closer to the poverty line would still leave
uninsured manv working people who earn more
than poverty level income but not enough to afford
health insurance.

  Now, let me turn to three other kinds of
barriers that I wanted to talk about with-you today
that also affect Hispanic access to health care. The
first of these is the extraordinary complexity of the
Medicaid program. Let me just point out that, in
addition to the problem of variable and sometimes
restrictive income eligibility criteria that I noted
earlier, the Medicaid program is itself a barrier to
access because of the impenetrable maze it presents
to potential applicants.

  In Texas, for example, there are nearly
10 different programs for Medicaid enrollment,
each with its own criteria for eligibility. For
example, pregnant women with incomes up to
133 percent of the poverty line; children born
before January 2, 1982, who are eligible for AFDC
[Aid to Families with Dependent Children]; children

One



Voice

born before October 1, 1983, with incomes
between the AFDC and medically needed criteria;
and so on. Medicaid case workers in Texas engage
in 4 weeks of training just to learn the eligibility
criteria and how to communicate them to potential
recipients. Medicaid officials are well aware of the
formidable barrier the program's complexity
represents. They note that it's difficult to explain
to people that they mav not be eligible for Medicaid
now but could be so in the future and that the
process of enrolling people is excruciatingly
burdensome, and they realize that standing in line

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for a full dav at the Medicaid of&c does not
        ,
compete favorably with the practical alternative of
receiving free care in an emergencv room or a
                         ,
communitv health center. But recognition is not
resolution. Medicaid needs either to find a cord
with which to lead applicants through its maze or
destroy the maze.

One



Voice

  On the other hand, making health insurance
available and simplifying bureaucratic procedures,
no matter how important those actions might be,
are still not enough to resolve the problem of
Hispanic access to health care. The second
noninsurance barrier I wanted to mention is the
fundamental impediment constituted by the
shortage of physicians serving Hispanic communi-
ties. This is a truly critical problem, but it's more
severe in some places than it is in others. It's acute
in El Paso. Only 30 of the city's 800 phvsicians,
4 percent, maintain practices in the poorest part of
the city that houses 32 percent of the El Paso
population. Twenty years ago, some of vou mav
                                   ,
remember, the American Medical Association used
to estimate that a ratio of 1 general practitioner for
a population of 750 was reasonable. Today, we
have fewer general practitioners, and ratios of
1 physician to 5.000 or 6,000 people are not
uncommon in the center cities where manv Latinos
reside. Now, this shortage of physicians is naturally
accompanied by a dearth of primarv care facilities
                          ,
available to the Hispanic community. It's hard to
overestimate the importance of this problem.
Taken together, these two supply problems
involving phvsicians and facilities are at least as
         i

One

important as noninsurance in impeding effective

access of Latinos to health care.

Vision

  Finally, let me turn to a third barrier that
needs to be mentioned, and that's patient health
education. Two factors arc particularlv salient in
                            I
the demographic health profiles of Latin0 popula-
tions that I spoke to you about carlier-compara-
tively lower Icvcls of educational achievement and
comparativelv higher Icvcls of preventable or

treatable disease. There is a need for special efforts
to educate Latinos about effective health practices
and generally the special health problems they face
and to educate them in their language, taking
account of the cultural factors particular to the
different Hispanic communities. It's probably
unnecessary to make the case to this audience of the
importance of early detection in the outcomes of
diseases like cancer or diabetes. Yet, early detec-
tion depends largely on the patient's knowledge,
which triggers a visit to the doctor in the first place.
  It seems clear that all of these five prob-
lems-noninsurance, bureaucratic complexity, a
shortage of physicians, a shortage of primary care
facilities, and very uncertain patient awareness of
important health issues-are major barriers to
health care facing Latinos today. I think these
problems are at the heart of improving not only
access but also health status, and especially the
preventable or treatable diseases aMicting this
population. I think the shortage of physicians,
facilities, and health information contribute heavily
to a situation in which patients go to community
health centers or hospital emergency rooms in
advanced stages of illness.

  This situation makes prevention academic. It
causes treatment to be more difficult and more
expensive, and it renders outcomes much more
uncertain. This is especially the case for diabetes
among Hispanics where severe complications arise
because of delayed treatment and lack of patient

awareness. But of greatest concern are the failures
of prevention, the inadequacy of prenatal care that
could reduce high rates of pregnancy or childbirth
complications for women and children, the
unavailability of pap smears that allow early
detection of cervical cancer, the lack of health
counseling to deter obesity or alcoholism, or the
transmission of HIV.

  In conclusion, the five barriers I've discussed
are not the only ones facing Hispanics in their quest
for bcttcr health care. But it certainlv seems clear


that improvement is not going to occur if we don't
address them. Initial steps should include more
adequate health insurance coverage, both private
and public; simplification of eligibility deterrnina-
tion in the Medicaid program; stronger community
provision of primary care; and greater Federal and
State efforts to educate Latin0 populations with
regard to both the prevention and the treatment of
those diseases most likely to affect them.

  Finally, I would also make a plea for better
data. Our current information is plagued by lack of
Hispanic identifiers in 20 States, by uncertain
reporting in the other 30 States, by Hispanic
samples too small to use for analysis or estimation,
and by I O-year gaps between data collections for a
population that is growing with this speed. The
truth is that no existing database currently provides
accurate, complete, and timely data on the entire
Hispanic population, including the often very
different subgroups. Perhaps this conference might
also consider data improvement. I realize vou have
a difficult and a complex task in front of vou, and
                              .
some of you may be thinking right now of Alfonso
the Learned's remark as he considered Spain's
problems in the 13th century: "If God, in His
wisdom, had thought to consult me before embark-
ing on the creation of the world, I lvould have
suggested something simpler."

Responder Panel

James 0. Mason, M.D., DtfH.

Assistant Secretary for Health
U.S. Department of Health and Human Services

The first step in solving a problem is to identify and
to define it. You've done a masterful job of that
during this Workshop. I want you to know that
those of us who arc responding arc hcrc not just to
learn and to listen, but we've come to act as a result
of the work that you've done. Rcprrsentcd here
arc men and women who report directly to Secrc-

tat-y Sullivan, to Secretary Alexander, and to
Secretary Martin. These three individuals report
directly to President Bush. So your recommenda-
tions, your identification of issues and problems,
have the President's car.

   You should also know that the President
already has a comprehensive health care reform
initiative on the table. His plan will provide access,
security, choice, and affordability for all Americans.
It is a plan that can work.

  You've discussed community and migrant
health centers. HRSA has just awarded 71 new
sites, either through expansion or new grants. In
addition, we are putting more money into commu-
nit>- and migrant health centers in high-risk areas
with the "weed-and-seed" program. For years,
there haven't been new programs in community
health centers. Through this administration's
support of these programs, we're moving ahead
again. And if we can get Congress to act on the
President's budget for fiscal year 1993, there will
be more expansions and more increases during the
next fiscal year.

  We're also revitalizing the National Health
Service Corps. It almost disappeared. Now it's on
its way up. We promise you in accordance with the
recommendations that you've made that we will target
minorities. Among those minorities, our Hispanic/
L&no community will be specifically targeted.

One



Voice

In the area of research, we've had funding

increases over the last few years. However, we're
afraid that Congress is not going to give us the
President's budget for NIH or for SAMHSA. At
NIH, we've recently created an Offtce of Minority
Health Research. And SAMHSA is our nevv
organization that will come into being tomorrow
morning. Its mission is to ensure knowledge is used
effectively and comprehensively for the prevention
and trcatmcnt of addictive and mental disorders.

OIW



Vision

  So the structure is there to begin to address
the issues that you have identified. We will work
with you.


Appendix E 444444444444444444

Michael McGinnis, M.D.

Director

Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services

I'd like to begin today by emphasizing that the
process of setting and implementing national health
promotion and disease prevention objectives
highlights that serious and intolerable gaps exist in
our national effort to improve the health of the
Hispanic/Latino community, but it also demon-
strates that we can and will close those gaps.

One

  I'd like to applaud the focus that the Surgeon
General has given here to the issues in disease
prevention and health promotion and commend
each of the members of the work group for identify-
ing some of the key issues in succinct fashion. Let
me take a few minutes to revisit some of the issues
by looking at three categories of targets in Healthy
People 2&&e Nation's health promotion and
disease prevention objectives: (1) the first category
includes those objectives that have specific Hispanic
targets, (2) the second category includes those
objectives that do not have specific Hispanic
targets and for which Hispanics are actually doing
better than the general population, and (3) the
third category includes those objectives that do not
have specific Hispanic targets and for which the
Hispanic population is at higher risk than the

Voice

general population.

In the first category, targets were set for those

issues that I know are viewed as of greatest impor-
tance to each of you, as they are to me. These
include increasing the regular source of primary
care specifically for Hispanics, increasing receipt of
clinical preventive services by Hispanics, reducing
tuberculosis among Hispanics, confining the
incidence of AIDS among Hispanics, reducing
diabetes among Hispanics, reducing adolescent
pregnancy among Hispanics, reducing growth
retardation, increasing access to prenatal care,
reducing infant mortality, increasing access to
mammography and Pap tests, reducing untreated

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dental caries, increasing the years of healthy life
among Hispanics, reducing homicides among
Hispanics, reducing cigarette smoking and over-
weight among Hispanics, reducing infertility among
Hispanic couples, increasing Hispanic representa-
tion in the health professions, and reducing data
gaps by specifically improving the availability of
Hispanic data. Those are the key targets among the
25 that were set specifically for the Hispanic
population.

  Let's take a look at the second category, the
area in which available data tell us that the Hispanic
population is doing better than the general popula-
tion. From this COSSHMO publication, The State of
Hispanic Health, we know that the Hispanic popula-
tion is doing better with respect to coronary heart
disease, stroke, cholesterol levels, high blood
pressure, cigarette smoking among adolescents, and
suicide. Because the Healthy People 2000 special
population targets were set only for those areas in
which the population was at higher risk than the
general population, there are no targets specific to
the Hispanic population in these particular areas.
However, as a Nation, we clearly must be vigilant
in preserving that relative advantage in these areas.

  Let me now focus on the third category-in
which there are several priority areas with no
Hispanic-specific objectives but in which we know
that Hispanics may be at higher risk than the general
population. These priority areas include alcohol
and other drugs, unintentional injuries, occupa-
tional safety and health, environmental health, food
and drug safety, and sexually transmitted diseases.
It is quite clear that the reason that there are no
Hispanic-specific objectives is not because the
Hispanics are doing better, but because we just
don't have adequate data in these critical areas.
This was pointed out time and time again by the
presenters. We could have arbitrarily set targets
without data, but that would have obscured the fact
that we don't have the data that we need. We riced
to find the data and use it as we establish objectives


for the future. But, most importantly, we cannot
let the absence of data get in the way of progress.
The issue should not onlv be the presence or
absence of Hispanic or Latin0 objectives. We also
need to ensure that we close the gaps and that we have
a plan in hand for reaching the Hispanic/ Latin0
community with implementation efforts. The priority
must be improving Hispanic health, and I can pledge
that this issue will be an ongoing commitment of
Heal+ People Zoo0 and all PHS efforts.

Louis D. Enoff

Acting Commissioner
Social Security Administration

U.S. Department of Health and Human Services

I would like to address the issue of access. Although
we're alreadv doing a good job, we know that we
need to do better in terms of access to services that
we provide at the Social Security Administration.
Among our 1,300 offices, more than 65 percent
have Spanish-speaking employees. About 3,300, or
one-tenth, of our employees in the field offtces
speak Spanish. However, in a survey of all of the
offices that we did earlier this year, we found that
300 of those offices have a need for additional
services, and that may include additional technical
personnel.

  You can't always rely solely on a translator
to provide access. You have to have someone who
understands the program and who understands
some of the cultural issues that may be involved in
revealing some v-e? personal data that help determine
eligibility for Supplemental Security Income (SSl).

  Now, in addition to our field offices, we have
the busiest 800-number in the world. Last year we
had some 76 million calls. In that 800.number
service, which is available nationwide 12 hours a
da!, we have more than 300 Spanish-speaking
teleservicc representatives. Now, I understand that
some folks do not like to use the telephone to take
cart of that business. WC arc not saying you must
use the telephone. Wc'rc saving you have access

either through the telephone or through the
personal visit to our of&e, but we want to provide
that availabilits to evex-vone.
                ,
  Our notices are well-known throughout the

newspaper world as being some of the most
technical notices that go to anyone, not only in
Spanish-we have a problem communicating in
English some of these technical kinds of decisions
that are made. But all of our pamphlets and forms
are in Spanish as well as English. Thanks to new
computer innovations, we now send Spanish
language notices automatically to people who
request them and to residents of Puerto Rico. We
are constantly improving our capabilities in this
area, and I believe we will have our computers
geared to offer all of our communications in Spanish
in about a year and a half.

  We now provide our very popular personal-
ized earnings and benefits estimate in Spanish. This
service provides your wage record and your benefit
estimate upon request and regardless of your age, it
tells what you can expect to receive in Social
Security benefits. It's very good for retirement
planning. It's also good in the area of wage report-
ing, a particular area of interest in some of your
communities, particularly for migrant workers.
Next month we will be distributing some 75,000
publications to migrant farm workers in four States,
California, Arizona, Florida, and Texas, to remind
them of the need to check their wage records. And,
working with our colleagues in the Labor Depart-
ment and IRS, we will be reminding the employers
of their need to report wages.' We are working
toward better compliance in that area.
  Two other areas may be of interest. We
know that there are areas of the community where
we have not been able to reach all of the people
who may be eligible for SSI. Estimates run from
two-thirds to three-quarters of eligible persons who
may be receiving SSI benefits. Along that line,
Commissioner King launched an aggressive outreach
program about 3 years ago. We've awarded more

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Appendix E  444444444444444444

than 83 grants, working with private-sector
organizations as well as some State and local entities
to reach out into the community to find persons
who may be eligible for SSI but who have not come
in contact with our o&e or may not be aware of it.
And, I would tell you that one-fourth to one-third
of those grants have been given to organizations that
are Hispanic or that are reaching out into Hispanic
communities.

  Finally, as the Commissioner of Social
Security, I do have the Hispanic Affairs Advisory
Council. I meet with them on a regular basis.
These are employees from throughout our organiza-
tion who bring to our attention particular needs of
the Hispanic community, and I can tell you that they
are very aggressive, very open, and forthright about
some of the things that we need to continue to do.
So we'll take your report, we'll look at it, and we'll
get back to you and we promise that we will
improve, too.

John T. MacDonald, Ph.D.

Assistant Secretary for Elementary and Secondary
Education
U.S. Department of Education

One

Voice

Your work is so important to the work that we're
trying to accomplish, particularly when one views
that, by the year 2000, 34 percent of our school
population will be Hispanic/ Latino. And in terms
of that population right now, as Dr. Novello has
said, we're not doing so well, as indicated by a
headline like "Schools Still Fail Hispanics" in The
Miami Herald.

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  We're losing about 35 percent of the young-
sters who attend school. About 63 percent of those
youngsters are immigrants. I believe that through
the multitude of services that we have in the Office
of Elementary and Secondary Education-Compen-
satory and Chapter 1 programs, programs for the
homeless, follow-through programs, the Even Start
program, the dropout prevention program, magnet
programs, and Chapter 2 programs--coupled with

services provided by the Office of Migrant Educa-
tion and the Office of Indian Education--\ve must
be able to affect what is happening to our Hispanic/
Latin0 youngsters. In my opinion, and in the
opinion of my colleagues, we have to take an
entirely different direction with public education
and the way we operate schools.

  We have been working with folks, including
Jim Mason and others from DHHS, on some of
these concepts. I am going to touch on something
that 1 think needs to be addressed in this country:
schools that operate on extended-day or extended-
year schedules, schools that address the multitude
of diverse issues related to children and families and
the need for services. This concept is formally
called "integrated services" or "school-linked
services." What I heard in the five forums con-
ducted by Secretary Cavazos around the country
2 years ago was that people were not aware of
what services they could access and how to access
them. They were not aware of how they could be
represented and how they could seek representa-
tion. The conclusion was that our schools had to
be redesigned and reconfigured so that they served
the population that needed those particular kinds
of services.

  We are proposing to develop, through our
Even Start model, the first Federal integrated family
service literacy program for children ages zero
through seven and their parents. This program will
be a partnership with DHHS as a formula program
that ties in with more than Even Start grantees that
we have today and provides an ability to have these
youngsters served by Medicaid. The Department of
Agriculture is presently working with us to have
these youngsters served by the Women, Infants, and
Children's Supplemental Food Program. What we
are saying is that we have to have varieties of
services that reach each and every child in a way
that is appropriate not just to their schooling and
language acquisition needs but also to their allied
health and nutrition needs. This effort is


currently under way and it is being prepared for
secretarial review.

  In the meantime, there is nothing to stop us
from encouraging local grantees today to pursue
these ends and develop these kinds of programs.
For example, Jim Mason and I cochair an
interagency program on school-related health
issues. You might want to think of it as an ad hoc
committee to that agency to advise and consult on
allied health issues, because schools are the common
thing in our communities that people go to. Schools
are not only the largest real property investment we
have but also the one with which people are
familiar. It is possible to use them as a location to
coordinate the services that children and families
need through the establishment of family service
centers. Between the programs in Jim Mason's
office and in mine, there are ways of pulling public
health and education programs together to facilitate
this, and it is time that we did it. We are running
out of time with these youngsters and we are
making no inroads in terms of the dropout rate for
the Hispanic children.

  One program that we are going to be watch-
ing carefully is through our heavy involvement with
Hurricane Andrew, particularly in Dade County.
(Tomorrow I will be in Louisiana working with
parish superintendents there that have been affected
by the hurricane.) In Dade County, they have pro-
posed to start a new Phoenix Project, which will be
operating in 26 schools. The Department will be
funding that. It will cost us about $12 million to
establish a new model like the one I described. It
will provide not only for the educational needs of
children but also for their multidiverse needs in terms
of allied health, nutrition, acculturation, and recre-
ation. Both children and families will be served on an
extended-day and extended-vear schedule.

  We should operate our schools to accommo-
date the diverse needs of today's society. Our
society is not the same societv that our schools were
originally designed to serve. -Schools have to change

to meet today's needs and meet them wherever
they are located, if we are to succeed, interagency
collaboration at the Federal, State, and local levels.

  In terms of representation, we should be
working together with our Eisenhower program,
directed by Alicia Coro, among the school improve-
ment programs to identify the 5 percent set-aside
that serves specifically under-represented groups in
the science areas. We should be working with
DHHS and the National Science Foundation to see if
we can design new programs to reach out and serve
more people than we are serving now in the areas
that are being neglected. This is going to take
interagency collaboration.

  In terms of the free trade agreement, for the
past 2% years, we have had under way a Memoran-
dum of Understanding with the Mexican govem-
ment and the Mexican Secretary for Education. (I
visited with Mexican education officials last month
to discuss the changes that have taken place with
their change of administration.) We are very
hopeful to complete our Credit Accrual Project,
which can give youngsters moving back and forth
across the border some hope of finishing high
school. Hopefully, this can be phased into our
College Assistance Migrant Program (CAMP), so
that we can increase the numbers of attendance in
higher education. We are getting excellent
cooperation from States like California, Arizona,
and New Mexico, but we have a long way to go in
terms of this population.

  There are 3X$00 youngsters who need these
kinds of services. With your effort and your support,
and with your recommendations in terms of issues
related to access and representation, we'll get there.

Thomas Komarek, M.B.A.
Assistant Secretary for Administration and Management
U .S . Department of Labor

The primary policy issue at the Department of
Labor is jobs for American people, and, as we all

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kno\\-, one of the primary way to provide health
cart to pcoplc is associated with employer-
provided health care. UnfortunateIT, at this point
in time, we do not have enough jobs. The unem-
ployment rate for all Americans and for Hispanics/
Latinos, which make up about 9 percent of the
overall labor force, is unacceptably high. The
President, Sccrctarv Martin, and everybody at the
Dcpartmcnt of Labor is working today on that very
serious problem.

  I learned something during this visit that I sort
of intuitively knc\v; I \vas reading the GAO report
on Hispanic health cart and noted the numbers in
there that indicated that rvcn when Hispanics and
Latinos had jobs, oftrn those jobs did not provide
employer-assist4 health cat-c to the same dcgrcc
that others in our socictv rcccivcd, and that's a
problem. One of the problems as we move forward
toward the year 2000 is the need for education and
skills to get the good jobs, the jobs that do provide
the health care assistance from employers.

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  The most important impression I take away
from this conference is the overwhelming complex-
ity of all these issues that you have raised. When
you think about it, education leads to jobs, which
lead to health care. Each of those areas requires
much work, many resources, and devoted atten-
tion. There is one thought, however, that I heard in
many of the presentations this morning that is also
very dear to the heart of my boss, the Secretary of
Labor. Lvnn Martin. At least half of the presenters

' i

spoke about the importance of Hispanic/Latin0
representation in the policymaking levels of the
Federal Government and in other decision-making
areas. Secretary Martin has been pushing very hard
with her glass ceiling effort in the Department of
Labor and throughout the Federal Government. I
think we all need to realize that, in the years ahead,
we're going to have some very difficult budget
times, and we will not be able to do all the things
we would like to do. One of the keys to making
sure that thr best decisions arc made in these very

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difficult times is to have a diverse group of ke?
policymakcrs in the Federal Government who will
make decisions on grants and on job and health
policies, Key to that is getting Hispanics/Latinos
and a diverse corps of policymakers.

  You can have the assurance of the Department
of Labor that we will continue to push this effort as
hard as we can. As long as the people at the top in
our decision-making processes do not appreciate
diversity, then we will have some problems. Once
we get a diverse group-women, minorities,
Hispanics/Latinos-in those top jobs, I think the
problems will go away gradually. The best program
that we have to work on to achieve this objective is
the glass ceiling program.

Karen R. Kees[ing, J.P.
Acting Administrator, Wage and Hour Division
U.S. Department of Labor

I'm hcrc as a rcprcscntativc of a la\v cnforccment

agency. You might ask: What is the Acting Aclmin-
istrator of the Wage and Hour Division doing hcrc?
But as you have heard, we've been working with the
Social Security Administration, and wc'vc been
working with the Department of Education.

We enforce two very important statutes that
should be of major concern to you. One is the Fair
Labor Standards Act, which is what we were
created for, minimum wage and overtime, and child
labor provisions. In the child labor area, as Assis-
tant Secretary MacDonald mentioned, we have also
been very active in an MOU between our Depart-
ment of Labor and the Mexican Department of
Labor, and I have also been down to Mexico

working on a joint report with my colleagues there
on child labor. So there's a lot of activity going on,
and I know that was a recommendation, and I
would encourage you to continue to work in the
health field with our Mexican counterparts.

The other most important statute is the
Migrant and Seasonal Agricultural Worker Protec-


tion Act, or MSPA, which we enforce. Although
we don't enforce health standards ourselves, one of
the things we do enforce is the housing for migrant
workers. We're there to make sure that health
hazards are eliminated, working with the State
agencies. A lot of times when we go into these
areas we're there with the State departments of
labor and health to look at these conditions. We
also work with our sister agency, the Occupational
Health and Safety Administration, as far as field
sanitation is concerned. So when we find violations,
we work with the State agencies to try to correct
the health and safety areas.

  We also have an annual meeting with the farm
employers, with the farm and migrant workers, and
with the State and local agencies. I happened to
attend a meeting last month in Portland, and I was
very impressed with the representation from all of
the local agencies. One of the things we talked
about was access to health care, and I think it's
something that the representatives were continuing
to try to address and to get the right parties
together to continue to work on those areas. So
those are the things that we're doing on the
enforcement side, working with the various
agencies and trying to assist in getting the migrant
workers the adequate health care that they need.

William Toby, M.5.W.

Acting Administrator,

Health Care Financing Administration
U.S. Department of Health and Human Services

The first thing I want to say is that as I looked at
your paper, it reminded me of the mistakes that
were made in 1965 when Medicare and Medicaid
were first envisioned and implemented. If we were
implementing the Medicaid and Medicare programs
today, I can assure you that issues such as access and
need for prevention would not even be discussed.
We'd probably be talking about something else
because one of the main mistakes I think we made in
the beginning of this program was to focus almost

primarily on the fee-for-service system at the
expense of other modalities of delivering services.
and we've been paving for that ever since. So one
             I
of the things that I have inherited is to try to
straddle the structural problems that create some of
the issues vou have mentioned.

  You talked about the need to improve data,
the need to have trained personnel, the need to have
targeted research programs, and I must tell you that
HCFA really can make significant improvements in
all of these areas because HCFA is perhaps the
largest financing agency in this Nation and has the
12th largest budget in the entire world. But there
are some things we can't fix.

   Let me talk about data for a minute. When I
was getting ready for this conference, I asked for
Hispanic data in terms of Medicaid, and they gave
me the numbers-5.6 million. I asked for the data
in terms of Medicare. There are no data. Medicare
does collect data by race but not by ethnicity.
Consequently, I don't have any data. So yesterday I
fired off a very nasty memorandum to my staff
suggesting that we look at that issue because the
next time I have this kind of meeting, I'd like to
have some information on Hispanics on Medicare.

  The second thing you mentioned is the need
for trained personnel. I walked into HCFA
6 months ago, and I have some sense and some              One
sensitivity. So the first thing I noticed was that             Voice
there was nobody really of my color at the senior

level in HCFA, and I raised that question about
improving it. The next thing I noticed, and I've
known for a long time, is that you can forget about
Hispanics in HCFA. So I have a few opportunities.
I was given an opportunity when I was there about a
month. The Director of Personnel came in to see
me and said, "Look, Bill, we're getting ready to hire
12 scholars. We have a program which allows us to
get around all the bureaucracy. If you are smart,
truly smart, if you're at the top of your class, then
we can basically hire you almost on the spot." SO
they gave me a list of I2 individuals to be hired.  I

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looked at the list. There was not one minority on
the list. I asked them to try again. I asked them to
come back with seven minorities and five others.
We had more than 100 people who had been
interviewed, but not one minority on the list. We
have the final list, and Dr. Sullivan entertained the
I2 scholars I presented to him just 1 month ago.
We have 12 scholars, 7 of whom were minority-
4 are black and 3 are Hispanic. And I got Iucky-
the three Hispanics are all beautiful women. One
graduated from Smith, and the other two went to
incredible colleges, and I just learned that we have
another Hispanic in the agency I didn't know about,
a daughter of one of the participants here today. So
I'll find out about her tomorrow, and I'll make sure
that my staff understands that we're going to target
Hispanics, going to target minorities to be on the
fast track for promotions in my agency.

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  The third thing on personnel-I am the only
head of an agency in DHHS who is not a physician.
You all know about Dr. Mason, who has been a dear
friend to me, seriously, since I've been on board.
Dr. Novello, Dr. Bob Harmon, everybody is a
doctor. I am not a doctor. I have a master's degree
in social work and a master's degree in public
management. So I'm in discussions with a brilliant
physician who happens to be Hispanic and who has
agreed to become my physician advisor. So I hope
in the near future, at the next meeting of this type,
to be accompanied by a physician who is of

Hispanic background.

  The other thing I want to mention is that we
as an agency have enormous clout in terms of
reimbursement policies to try to do something
about primary care. That's something else you care
about deeply. And we have been trying to do
something under current law. We have basically
been working with States to increase reimburse-
ment for obstetrical services. We are also trying to
make other changes in primary care by using the
leverage of HCFA.

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We pay for about 60 percent of graduate

medical education, and we have decided to see how
we can take the Ievcrage of Medicare, in particular,
to change the minds of the medical schools, which are
putting out so many specialists. We will use the clout
of the Medicare reimbursement and use the clout of
PHS as a team to send a message to medical schools
that if they don't produce more primary care physi-
cians, they are not going to get our money.

  Dr. Mason and I are going on the road. We
are working with the National Governor's Association
and with private foundations to send a message to
increase the supply of primary care providers, and
we're going to have the first symposium, I believe,
in Burlington, Vermont, next March. Basically, WC
are going to have a public affairs strategy to get the
words out that this administration cares deeply about
the need for primary care doctors. And because
most minorities live in urban areas, we are going to
particularly focus on the need in those areas.
We are also working very hard to expand eligibility
for pregnant women, infants, and children, and
adolescents under Medicaid, and we are closely in
touch with States to make sure that they do what
they are supposed to do. And my hope is that that's
going to help.

  One of the things I did when I came in was to
ask the question of our public affairs people,,how are
we communicating with the Hispanic population?
I was not happy with the answers. We have hired
more consultants to translate our documents into
Spanish throughout. We have also decided that we
are going to talk to our Medicare contractors about
the need to have more Hispanics around the country.
We have 28,000 people who work for Medicare
through our contractors. We want to have Hispanic
people working in those Medicare contractors,
to be able to talk to Hispanic providers, to talk to
Hispanic beneficiaries.

  Two years ago when I was living in New York, I
found out that even though we had a Spanish transla-
tor in Washington working on the Medicare hand-
book, the people in Puerto Rico did not understand


the handbook. So wc made sure this Tear that we
sent that handbook to our Puerto Rico office, and
my staff in Puerto Rico has done a herculean task of
reviewing that document, translating it to make
sure that local idioms in Puerto Rico are undcr-
stood, and that it will be understood in Texas,
Colorado, Kansas, and everywhere in this country
where there are Hispanics.

  I also would like to say that as we talk about
the fact that most Hispanics lack access to the health
care system, the best hope for the Hispanic popula-
tion, the best hope for all minorities, will be health
care reform, and the President's health care reform
plan is the major strategy that we have. I know
Dr. Wilensky met with all of you. I know you
understand probably the various strategies we have,
the concepts in that plan, and I won't bore you with
that. But I will tell you that if you're interested in
access, and most Hispanics are working for small
employers, the President's health care plan at least
provides tax credits, tax certificates, tax deductions,
and will allow them to buy insurance. So it's one
way, not the only way, but it's one way to gain

access. It is the best hope for the future.
  I had been asked a question by Tony about

"whenever we are united as a family, some of the
benefits?" It is true that the Medicaid program is
not devoted to paying for services based on needs.
The Medicaid program is a medical program that is
a component of the cash assistance program, SO it's
an entitlement program. So you can't just get
Medicaid services because you have a need. YOU
have to have some linkage to the cash assistance
program or you have to be pregnant or a child and
meet a certain income test. My sense is that you
have to work with Congress if you want to change
the program in terms of meetin g needs and break
the linkage to the cash program. We're already
doing that. Congress has made the reforms that it
has because you have been active. You must have
been complaining about Medicaid and how it
operates, otherwise Congress would not have been

moving under the current trend that it is. And the
current trend is to try to break the linkage to the
cash programs, and thr low-income pregnant
women and poor children benefit is one example
because before we got that, changing it would have
been impossible. So basicall!, until we change the
entitlement aspects of the Medicaid program, there
will continue to be a great deal of tension and lack
of access because it is a means-tested program based
on income resources and category of relationship.

  Six weeks ago, I testified bcforc the Senate
Finance Committee, the Committee on Long-Term
Care and Medicare, and one of the things I talked
about was the fact that in the future, in terms of the
new direction of Medicarc reimburscmcnt for
graduate medical education, we will bc tying our
reimbursement to medical schools that go beyond
the hospital setting to other kinds of settings.  In
other words, we are thinking about community
health centers as being a site for training. WC are
thinking about increasing the reimbursement for
those kinds of settings. We want to weigh the
reimbursement to the medical schools that look for
alternate settings, such as community centers, and
that is basically the direction we will be going. And
we are preparing a legislative package to go before
Congress to do just that.

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Kenneth Shine, M.D.

President
Institute of Medicine

I'm sort of the odd person out in this. For one

Voice

a-
  "

thing, I'm the only one on the podium who doesn't
work for the Government. The Institute of
Medicine, the National Academy of Sciences, is an
independent, not-for-profit corporation chartered
by Congress to advise Government with regard to
health, health policy, and other aspects of science.
But we're not a governmental institution. In that
regard, we have the capacity to do a number of
things that can be helpful in confronting the issues

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Appendix E  444444444444444444

that 1.0~ dcscribc and with which you are concerned,
including the capacitv to convene around issues of
health and health polic!.

  I'm an odd person on the podium also in that,
until the end of June, I served as dean of an American
medical school-UCLA in Los Angeles. And there's
both good news and bad news. The good news is
that I had the privilege not long ago of conferring the
medical degrees on 3 1 Hispanic physicians in a class
of 150, the largest number of Hispanic physicians
ever awarded medical degrees in a single medical
school at a single time. I'm also pleased that, this
November, a member of the UCLA graduating class
of 1993 will receive the McLean Award as the
outstanding minority medical student in the United
States. A UCLA student has won that award in 9 of
the last 14 years, and 7 of them have been Hispanics.
So, the good news is that we're making some
significant progress with regard to at least one
medical school in Los Angeles in educating Hispanics
as physicians, that they are doing extremely well.

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  The bad news, of course, is that 1 also played a
role in creating a task force on access in the county
of Los Angeles and had the opportunity to address
that task force on the morning of its first meeting
and to remind them that two out of three preschool
Hispanic youngsters in Los Angeles were not
immunized. I have had the personal experience in
our teaching hospitals of attending to several cases of
measles occurring in youngsters who had seizures
associated with that illness, cases which should never
have happened, and I've had the experience of taking
care of tetanus in a migrant Hispanic farm worker
because of lack of immunization. So in coming to
this meeting, I have a personal sense of the intensity
of the concerns and the issues that are confronting
the Hispanic/ Latin0 community in terms of dealing
with health and health care.

  The Institute of Medicine in the Academy does
several kinds of things. It is best known perhaps for
the reports that it issues based on analysis of data that
arc used to influcncc public policy, and we've issued

reports on access, on primarv care. In 1978, we
issued a report strongly urging that 50 percent of
American medical school graduates be in primary
cart specialties. We're still fighting that battle.
  We have issued reports on nutrition, child
care, maternal and child health, and I can also tell
you that I have had the personal experience of
tending to two of the first six AIDS cases that were
reported. They were also at UCLA, and I watched
AIDS develop in our community and also recog-
nized that until the Institute of Medicine published
its famous report on AIDS in 1986, the response
was not very outstanding in terms of either research
or patient care.

So we will continue to work on those kinds of

reports. There are several that will be of great
interest to you. The first is a report on recruiting
minorities to the health professions, an activity that
will go on over the next year, which will include a
series of workshops in which we will invite public
comment to the committee responsible for making
those recommendations. The second is a report on
employer-based health insurance, which is likely to
be directly responsive to some of the issues that
you've raised with regard to health in small compa-
nies and in segments of the workforce in which
many of the Hispanic and Latin0 workers work.

   I think that the other main function that we
serve is a convening function. We run a variety of
forums to guide public policy and private activity
from this point of view. And we intend to continue
to focus on the importance of AIDS in minority
communities as part of that forum activity.  We
have just initiated a forum on health statistics, and
we remain concerned about many of the issues that
you've addressed. Part of our goal in creating this
forum is not so much to issue a report as to bring
together Federal and local Governments to under-
stand how to better collect health statistics and

health data.

  We have a major and abiding interest in the
issue of the pipeline for health professionals,


particularly as it relates to minorities in both
research and education, and I want to point out a
couple ofaspccts that I think are important to you.
First, math and science education is a major issue.
We believe that there is a major role in the United
States for academic health centers and scientists to
become involved in education, particularly in
minority communities in math and science in
kindergarten through grade 12. You ought to be
aware of those activities, and you ought to try to
participate in those activities wherever they take
place because for them to succeed there has to be a
community linkage. Second, we will continue to
evaluate ways in which we can encourage more
Hispanics to choose health careers, particularly in
medicine. And, as you know, we are working
closely with the Association of American Medical
Colleges on the 3,000 by 2000 project, which tries
to get proportionality with the population.

  In terms of public and private activities, it's
very clear that we need more faculty members in
medical schools and in other health professional
schools who are of minoritv backgrounds. We need
role models. And in that regard, I would point out

to 1.0~ that I continue to bc disappointed that the
Robert Wood Johnson minority faculty program has
relativclv few applicants from Hispanic faculty
members. You need to cncouragc voung Hispanics
to apply for that program because it is a preeminent
program for facultv tlevclopment.

  I'm very much involved with another pro-
gram in identifying gcncralist physicians and facult\
development in collaboration with Robert Wood
Johnson. And again, w-c need to be sure that there
are adequate nominccs for those kinds of activities.

  Finally, I would point out to you that we have
recently established a formal relationship with the
Mexican National Academy of Medicine. We have
established a foundation that will be funded by both
the American and Mexican Governments. The
amount of money is not great in the initial stages,
but it will allow funding of research activities,
particularly in the areas of border health. And I
anticipate that we will again use our capacity to
bring together governments, academies, and the
public and private sectors in a way that will try to
address a number of the issues that you've raised.

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