One Voice One Vision 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 One Voice 4b One Vision One Voice One Vision 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 Olle Voice One Vision 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 One Voice + Research Agenda o 3 3 Health Professions o 36 Health Promotion and Disease Prevention o 40 Chapter 5: Fbesentation of National Workshop Recommendations+ 45 one Vision 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 One Voice One Vision 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. One Voice o One Vision Message from the Surgeon General o o o o + o + + + + + One Voice 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 One Voice Vision 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. One Vision 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 onr Voice B) . 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 onr Vision 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. One V&X One Vision 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- One VOiCt- 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 One Vision One Voice One Vision 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 One Voice One Vision 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. One Voice + One Vision 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 Vision 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 Vision 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. One Voice e- OIlC Vision 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 * . One Vision 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 . Vision 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 One Voice 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 One Voice Bb One -i Vision Work Group Presentations 4444+44+++44+ Research Agenda One 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 Vision 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 One Voice One Vision 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 One 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. One Voice One Q Vision 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. One 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 One Voice One 4 Vision One Voice One ViSiOIl 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 One Voice 9 One Vision Health Promotion and Disease Prevention One Voice 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. One Vision 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. One Voice One * Vision One Voice One Vision 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! One Voice One Vision Colegas, let us now get to the heart of why we have worked so earnestly in these past 3 days: Closing Remarks 4444444444444444 One Voice One Vision 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. One Voice Vision 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. one vision - 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 one Voice 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 one Viaion 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. Americansamoa Arizona California GUam H.?lWaii Id&O Nevada Oregon Trust Territory of the Padk Islands WWhillgtOZl one Voice One vision Amaicallsamoa Al-izam chlifomia Guam Hawaii Idaho NCVA TnutTemitmyof &Paci6clshdB WdliUgtOll one VOiOZ 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 Voice One 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 One Voice One Vision 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 One Voice One Vision + + + 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. One Voice One Vision 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 One Voice One Vision + + + + 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 One Voice One Vision 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 One Voice One Vision 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 One Voice One Vision 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 One Voice One Vision 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 One Voice Vision 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 Voice 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 One Voice One Vision One Voice 4b One Vision 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 One Vision 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. One Voice One Vision 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 Vision Appendix C 4444444444444444444 Regions V and VII Executive Planning Committee " Illinois Indiana Iowa KZUlSdS Michigan Minnesota Missouri Nebraska Ohio Wisconsin One Voice One Vision 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 Voice One Vision 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 Voice One Vision Alaska American Samoa Arizona California Guam Hawaii Idaho Nevada Oregon Trust Territorv of the Pacific islands Washington One Voice 4b One Vision 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 Vision 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 Voice 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 Vision 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 Voice One Vision 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 Vision 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 Voice One Vision 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 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 Voice Vision One Voice One Vision 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. One Voice 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 Vision One Voice One Vision 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 One voice One Vision ON Voice OX! Vision 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. One Voice One Vision One Voice One Vision 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. One Voice One Vision One Voice Otle Vision 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 One Voice 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 One Vision 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. One Vision 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. a One Vision One Voice One Vision 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 One Vision OIW Voice One Vision 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 One Vision One Voice One Vision 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 One Vision Ofle Voice One Vision 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 One Vision 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 One Vision 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 One Voice Oni Vision 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. One Vision 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 One Voice One Vision 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. One loice 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 One Vision 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 One Vision 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. One Voice 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. One Vision 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. One 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 Ok?. Vision 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. One Voice One Vision 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. One Voice One Vision