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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Charge to Partkipants   444444444444

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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Charge to Participants  44444444444444

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!

One

Voice

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o +44444444444444

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.

one

Voice

One

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Access to

Health

Care

OllC

Voice

One

Vision

  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.

One

Voice

  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

One

People 2000 objectives. We need to have better data

collection so States can track our health status and

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
*
  .





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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

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&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

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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.

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  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.

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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.

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