The Health of Mexican-American in South Texas 


Lyndon B. Johnson School of Public Affairs Policy Research Project Report 
Number 32 

The Health of Mexican-Americans 
in South Texas 

A report by the Mexican-American Po/i(·y Research Project The LBJ School of Public Affairs The University of Texas at Austin 
Library of Congress Card Number: 79-88345 
© 1979 The Board of Regents The University of Texas 
Cover design hr .\'ancr Whittington H'ith photo by Amy l\ii·alwasser 


Foreword 

The Lyndon B. Johnson School of Public Affairs has established interdisciplinary research on policy problems as the core of its educational program. A major part of this program is the nine-month policy research project, in the course of which two or three faculty members from different disciplines direct the research of ten to twenty graduate students of diverse backgrounds on a policy issue of concern to an agency of government. This "client orientation" brings the students face to face with admin­istrators, legislators, and other officials active in the policy process, and demonstrates that research in a policy environment demands special talents. It also illuminates the occasional difficulties of relating research findings to the world ofpolitical realities: 
This report on Mexican-American health care in South Texas is the product of a Policy Research Project con­ducted in 1976-77 at the LBJ School. Funded by the Lyndon Baines Johnson Foundation and the Hogg Foun­dation for Mental Health, the project researched a broad range of health issues in forty counties in South Texas in order to consolidate the scattered information on the health status, programs, and needs of the Mexican­American population in that area. 
It is the intention of the LBJ School both to develop men and women with the capacity to perform effectively in public service and to produce research which will enlighten and inform those already engaged in the policy process. The project which resulted in this report has helped to accomplish the former; it is our hope and expectation, that the report, itself will contribute, to the latter. 
Elspeth Rostow Dean 



Preface 

This report on the health and mental health of Mexican­Americans in South Texas has taken two and a half years to complete. It was initiated, and the greater part of the work on it was done, as a Policy Research Project conducted during the 1976"-77 academic year. Because of loose ends, other commitments, and the increasing scope of the project, it took much longer than a single year to complete. Initially this project was funded with a grant from the Lyndon Baines Johnson Foundation, which was quite generous in the amount allocated to the project. Subsequently, in the summer of 1977 and the spring of 1978, the Hogg Foundation for Mental Health contribu­ted sums of $3,500 and. $1,000 to. the. project. Finally, the_ publication costs of this report were subsidized in part by the LBJ Foundation. 
That this report was completed at all is due to the enormous amount of work devoted to it by a number of the students and faculty in the project. Specifically, Stephen Clyburn wrote substantial sections of the first, second, and fourth chapters; Roy McCandless wrote chapter three and helped edit most of the rest as a research associate over the summer of 1977; Bonnie Young worked out most of the details in chapters eight and nine; Lilas Kinch wrote the chapter on nutrition; Norm Linsky wrote the chapter on mental health; and Joe Morin wrote part of the chapter on migrant health. Stan Kaplan and Tom Martin were responsible for build­ing the data base from which much of the analysis came and for putting the data obtained from the Robert B. Green Hospital in San Antonio in usable form. Bryan Hamon prepared the EPSDT analysis, much of the morbidity and mapping analyses, and some of the finan­cial data. John Rooney and Herb Rubenstein assembled a great deal of information concerning the U.S./ Mexico border and did everything possible to improve interna­tional relations. Finally, Emil Pena pulled together data relating to San Antonio in particular. 
Of the supporting faculty, Albert Blum and Robert MacDonald assisted in the overall direction and day-to­day management of the project. Reymundo Rodriguez provided help at every stage in addition to taking the lead in the mental health chapter. He helped us to see a number of problems more clearly and continued to take an active part in the research and writing after the end of the project. 
In the first semester, Ray Marshall provided a number of insights into the health needs of rural areas. Richard Ellis helped us extensively at the Robert 8. Green Hospi­tal and in preparing the final draft. 
In addition to the work and direction provided by the supporting faculty a number of other experts and special­ists from relevant fields shared data, infonnation, and ideas with us over the two-year period. Reuel Waldrop visited the class, met with the students and me a number of times and had a significant impact on our approach to demographic and health data. Juan Chavira and Robert Trotter of Pan American University provided us with the unpublished manuscript of their work on curanderismo. Dan Cardenas visited the class and made a presentation on the migrant health program in general and the Nation­al Migrant Referral Program in particular; he also was kind enough to comment on drafts of that chapter. Manual Solis, of the Rio Grande Federation of Health Oinics, has provided valuable suggestions, as has Dr. William Schottsteadt of the Area Health Education Cen­ter at the University of Texas Medical Branch at Galves­ton. Dr. Paul Friedman and Dr. Herschel Douglass pro­vided us with valuable information concerning the Family Practice Training Program which is administered at the Robert B. Green Hospital by the University of Texas Health Science Center at San Antonio. Many persons at the Texas Department of Health provided us with infor­mation, including the data on Texas mortality arid mor­bidity. Troy Lowry and Alan Hamilton of TOH were helpful in describing the migrant camp inspection pro­gram. 
This list is not exhaustive and in particular does not mention many persons who provided time and informa­tion to individual members of the class in this endeavor. Literally dozens of people were consulted and were extremely helpful in providing information for the mental health, nutrition, border conditions, and financing chap­ters. Because the course is long over and the students are now in locations ranging from Washington to Dallas and from Austin to Plainview, New Jersey, it is certain that I have not adequately thanked a number of persons who made a significant contribution to this study. 
During the final editing and research for publication, Tessa Wardlaw served as a research associate for two months during the summer of 1978. Elizabeth Day drew 
the maps in the text, while Nancy Whittington designed 
the cover. Marilyn Smiland and Toni Nelson ha\IC been 
responsible for typing innumerable drafts. The Office of 
Publications at the LBJ School produced the final docu­
ment. 
We hope this work will serve as a reference point and 
beginning for more study of the issues which we have 
examined. Further, we hope that our analysis will en­
courage formulation of policies designed to alleviate the 
problems documented here. 
David Warner 
Project Director 

List of Participants 
Students 

Steven A. Clyburn, B.A. (Sociology), The University of Texas at Austin Bryan L. Hamon, B.A. (Government), The University of Texas at Austin Stan M. Kaplan, A.B. (History), Rutgers University Lilas J. Kinch, B.A. (Government), The University of Texas at Austin Norman M. Linsky, A.B. (English), Boston University; M.A. (English), Northwestern University 
· Thomas A. Martin III, B.A. (Zoology), The University of Texas at Austin Roy McCandless, B.A. (Psychology), M.A. (Communication), The University of Texas at Austin Joe Morin, B.A. (Political Science), Southwest Texas State University Emilio T. Pena, B.A.. (Political. Science), Texas Agriculturaland. .lndustriaLUni:versity; 
M.A. (Environmental Management), The University of Texas at San Antonio 
John Rooney, B.A. (History), The University of New Orleans 
Herbert R. Rubenstein, B.A. (Politics), Washington and Lee University 
Bonnie M. Young, B.S. (Political Science), Southwest Texas State University 

Faculty 

Albert Blum, Professor, LBJ School of Public Affairs 
Richard Ellis, M.D., Associate Professor of Family Practice, The University of Texas 

Health Science Center at San Antonio 
Ray Marshall, Professor of Economics, The University of Texas at Austin* 
Robert J . Macdonald, Deputy Director, Office of Conferences and Training, 

LBJ School of Public Affairs 
Reymundo Rodriguez, Executive Associate, Hogg Foundation, The University of Texas 
David Warner, Project Director, Associate Professor, LBJ School of Public Affairs 

*Ray Marshall was an active participant only in the fall semester of 1977. 


Table of Contents 

Foreword ..................................................................................................................................................................... i 

Preface ....................................................................................................................................................................... iii 

List of Participants ......................... ,. .............. , ............................................................................................................ v 

List of Tables ............................................................................................................................................................ ix 

List of Maps ........................................................................ ; ................................................................................... xiii 

List of Figures ......................................................................................................................................................... xiii 
lntroduction .•.................................... , ..........................•. ; ............................................................................................ l . 

Section I: Socioeconomic and Health Conditions .................................................................... : ................................. 5 

Chapter 1: Socioeconomic Conditions Among Mexican· Americans in South Texas ............................................. 7 
Chapter 2: Mortality and Morbidity in South Texas ........................................................................................... 17 
Chapter 3: Conditions in Urban Low-Income Areas in South Texas ................................................................... 33 
Chapter 4: Conditions in South Texas Border Counties and Neighboring Northern Mexico .............................. 61 
Section II: Selected Health Topics ........................................................................................................................... 77 

Chapter 5: Nutrition and Mexican-Americans ............................................................................ : ......................... 79 
Chapter 6: Mental Health Services and Mexican-Americans ............................................................................... 93 
Chapter 7: Health Care for Migrant Workers ........ : ........................................................................................... 109 
Section III: Health Program Resources ................................................................................................................. 121 

Chapter 8: Health Care Resources in South Texas ............................................................................................ 123 
Chapter 9: Government Financing of Health Programs in South Texas ............................................................ 147 
Appendices: ............................................................................................................................................................ 179 

Appendix A: Folk Medicine in South Texas ...................................................................................................... 181 
Appendix B: Cause of Death Categories and Corresponding Three-Digit ICDA Classifications 
Used in 1975 South Texas Research ............................................................................................................... 185 
Appendix C: Fonner's Classification System ...................................................................................................... 187 


List of Tables 

Table I: Population and Ethnic Distribution of 40 South Texas Counties ...................................2 
Table 2: Population of South Texas Standard Metropolitan Statistical Areas, 1979 ...................... . ....2 

Table 3: Fertility Rates Among the Anglos and Mexican-Americans in South Texas, 1970 .................... IO 
Table 4: Sex and Age Characteristics of Ethnic Groups in South Texas, 1970 .... . .......................... IO 

Table 5: Income and Poverty Characteristics in South Texas, 1970 ........................................ 13 
Table 6: Percent of Labor Force Unemployed in South Texas SMSAs, 1976 ................................ 13 

Table 7: Education of Persons 25 and Older in South Texas, 1970 ......................................... 14 
Table 8: Housing Characteristics in South Texas, 1970 ........................... ........................ 14 

Table 9: Ten Leading Causes of Deaths to Texas Residents by Sex and Ethnicity, 1969-71 .................... 19 

Table JO: Cause Specific Death Rates for Mexican-Americans 
Standardized to Those for Anglos, Texas, 1969-71 . ............................................20 

Table 11: Ten Leading Causes of Deaths to South Texas Residents by Sex and Ethnicity, 1975 ... . ...... . ....21 

Table 12: Infant and Neonatal Mortality Rates Per 1000 Live Births 
by Ethnicity in South Texas, 1970-1975 ................................. . ....................22 

Table 13: Cause of Specific Infant Mortality Rates Per 10,000 Live Births 
by Ethnicity in South Texas, 1975 ........... . ................................................23 

Table 14: Five Leading Causes of Death to South Texas Residents 
by Age Group, Sex and Ethnicity, 1975 .. . .. . ................................................24 

Table 15: Reportable Communicable Disease Rate per 100,000 Population, 
Texas and South Texas, 1974-76 . . ............ .. ..... . ............................... . ......25 

Table 16: Morbidity Rates per 100,000 Population for Hepatitis, Tuberculosis, 
Meningitis and Amebiasis in South Texas Counties, 1975 .................................... . . 26 

Table 17: Population of Urban Areas in South Texas, 1970 ...............................................33 

Table 18 : Population Changes in Urban Counties in South Texas, 1960-1975 .................... . ..........35 

Table 19: Population Increases in Brownsville, McAllen and Laredo, 1910-1970 .............................36 

Table 20: Population of Selected Low-Income Areas, 1970 .............................. .................48 
Table 21 : Ethnic Composition of Selected Low-Income Areas, 1970 . ............... . .. . ................ . ..48 

Table 22: Median Ages of Mexican-Americans in Low-Income Areas, 1970 .................................49 
Table 23: Percent of Persons Under Age 20 by Ethnicity, 1970 . .......................... . ............... .49 
Table 24: Percent of Persons Age 45 and Older, by Ethnicity, 1970 ....................................... .49 

Table 25: Percent of Persons 25 Years and Older with Less Than Ninth Grade Education, 1970 ...............50 
Table 26: Median Family Income in Dollars, 1970 ................ ~ ......................................50 
Table 27: Average Persons per Household, 1970 ......... . . . ......................... . ..................50 

Table 28: Percent of Families Below Poverty Level, 1970 .................................................51 
Table 29: Percent of Civilian Labor Force Unemployed, 1970 .............................................51 

Table 30: Percent of Occupied Housing Units with More Than One Person Per Room, 1970 .................. 52 
Table 31 : Percent of Occupied Housing Units Which Lack Some or All Plumbing Facilities, 1970 .............52 

Table 32: Live Births in Specified Years Per 1,000 Women Ages 15 Through 44 in 1970 ......................53 
Table 33: Fertility in Three Border Counties, 1970 ....................................................... 53 

Table 34: Infant Deaths Per 1,000 Live Births in Specified Years ....................... . ..................54 
Table 35: Fetal Deaths Per 1,000 Live Births in Specified Years ...........................................54 

Table 36: Neonatal Deaths Per 1,000 Live Births in Specified Years ................. ......... .............55 
Table 37: Infant, Fetal and Neonatal Deaths Per 1,000 Live Births 
in 1975 for Selected Border Cities .......................................................... . 55 

Table 38: New Active Tuberculosis Cases in Specified Years Per 100,000 Persons in 1970 .. . ..................56 

Table 39: Hepatitis Cases in Specified Years Per 100,000 Persons in 1970.......•...........•••••......•..• •56 
Table 40: Amebiasis, Shigella and Salmonella Cases in Specified Years Per 100,000 Persona in 1970 ......•....57 
Table 41: Syphilis Cases in Specified Years Per 100,000 Persons in 1970 ...•.......................•..••.. . 51 

Table 42: Gonorrhea Cases in Specified Years Per 100,000 Persons in 1970 .......................•......••.58 

Table 43: Populations of South Texas Border Counties 
and Neighboring Mexican Municipios; 1950, 1960, 1970 ................................•....•.61 

Table 44: Population Under 15 and Over 64 Years of Age for Selected 
Municipios and Counties Along the U.S.-Mexico Border, 1970 .................................64 

Table 45: Percent of All Wages Earned in the United States by Workers 
Residing in Four Border Municipios, 1968 .................•........................••.......66 
Table 46: Unemployment and Subemployment in Selected Areas of Northern Mexico, 1970 ........•.•.•••.••66 

Table 47: U.S. to Mexico Border Crossings in 1973 ................................••••.....•......•....67 
Table 48: Age-Specific Mortality Rates for Selected Border Municipios in 1973 and Texas in t97Q..•..........67 

Table 49: Five Leading Causes of Death for Selected Texas Border Counties 
and Neighboring Municipios, 1973 ...................................................•..•..•68 

Table 50: Cause-Specific Infant Mortality for Selected Municipios in Mexico 1973, 
and for Mexican-Americans in South Texas 1975 . .......................•....••..............69 

Table 51: Reportable Communicable Diseases in Selected Municipios and Counties, 1975 ....................70 

Table 52: Rates of Tuberculosis Per 100,000 Persons in Selected Border Counties 
and Neighboring Municipios, 1972-74 A verges .............................•.. : .•........•••..71 

Table 53: Reported Communicable Disease Rates Per 100,000 Persons in the Municipios 
of Matamoros, Reynosa and Nuevo Laredo; 1972-74 Averges .............••.. ; ......•.••..••.•.72 

Table 54: Hospital Beds, Doctors and Nurses Per Thousand Population for Selected Municipios 
in 1977; and Counties-Along the· U.S.-Mexico-Border:. .••••..•.....•..•.....••.•.•••....• ~· ....72 
Table 55a: Expenditures for Major Nutrition Programs in Texas .........................••....•..•••••..•82 
Table 55b: Participation in Major Nutrition Programs in Texas .................................•.•.••.•..82 

Table 56: ...............................................................................•.•.••...••85 

Table 57: Comparison of Nutrition Status of A Sample of the Population of Duval County 
With Nine Other Counties in South Texas ...................................................86 

Table 58: Ethnic Comparison of Mortality Data for Diabetes Mellitus ..............................•.•.••.87 
Table 59: Prevalence of Diabetes Mellitus by Family Income Level, 1975 .......................•...•.......87 

Table 60: Percent of Patients Ever Diagnosed as Diabetic by Ethnicity, Sex, and Age Groups; 
Robert B. Green Family Practice Clinic .................................•....................89 
Table 61: Age Adjusted Rates of Diabetes Among Clinic Patients ............................•..•.........89 

Table 62: State of Texas Appropriations for TDMHMR, 1974-77 .....................•...................98 
Table 63: Sources of Funds for Community Mental Health Centers, FY 1975-77 ............. . ..............98 

Table 64: TDMHMR Personnel Statewide on June 30, 1976 ...................................•......... 100 

Table 65: TDMHMR New Hires FY 1976-Mexican Americans ......................................... IOI 

Table 66: Clients Receiving Mental Health Services of All Texas CMHCs in 1976 .....................•.... 102 
Table 67: Clients Receiving Mental Health Services of South Texas CMHCs in 1976 ....................... 102 
Table 68: State Hospital Population and the Texas Population .....................................•.... 102 

Table 69: County of Residence of State Hospital Inpatients, 8/31/76 .........................•........... 103 

Table 70: Texas Needs Assessment, Mental Health Clients, and Population .........................•...... 104 
Table 71: Bexar County CMHC Clients and Populations ............................•..................• 104 

Table 72: Bexar County CMHC Clients by Age Groups ..........~....................................... 105 

Table 73: SASH Personnel as of 3/ 23/77 ............................................................. 106 
Table 74: South Texas Population and Professional Mental Health Personnel. ............................. 106 

Table 75: Texas: Work Injury Survey; 1970 Summary .. .......................................•.•...... 110 

Table 76: Health Problems in Hidalgo School Children ................................................. 111 

Table 77: Federally Funded Migrant Health Projects ..................................................• 116 

Table 78: Non-Federal South Texas Physicians Engaged in Direct Care 
as Major Professional Activity: December 31, 1973 ........................................... 124 

Table 79: Population and Physician Distribution in SMSA and Non-SMSA South Texas Counties ........... 125 
Table 80: Distribution of Physicians Between Bexar, Nueces, and the 38 Other South Texas Counties ......... 125 
Table 81: Distribution of Physicians in Texas by Size of County Population .................•............. 125 

Table 82: Primary Care Physicians Engaged in Direct Patient Care 
as Major Professional Activity: December 31, 1973 ......... · · .. · · · · · · · · · · · · · · · · · · · · • · · · · · • · · .126 


Table 83: Population Per Primary Care Physician: December 31. 1973 .................................... 127 
Table 84: List of Medically Underserved Areas in South Texas ............ ..................... ......... 127 
Table 85: Total Number of Family Practice Residencies in Texas . . ....................................... 127 

Table 86: Obstetricians,' Gynecologists in South Texas: December 31, 1973 ................................ 128 

Table 87: Jn-and Out-Migration for Births in South Texas: 1975 ................... ..................... 129 

Table 88: South Texas Counties Recording 1,000 or More Nonresident Births in 1975 . ..................... 130 
Table 89: Out of State Residents Giving Birth in 5 South Texas Counties ................................. 130 

Table 90: South Texas Pediatricians by County and by Number of Children Aged 0-14 ... .................. 132 

Table 91 : Leading Causes of Death to South Texas Residents Age 0-14: 
1975 Percentage of All Causes . ....... . . . ..... . .......... . .... . .......................... . . 133 
Table 92: Dentists in South Texas: 1973 ...... . ....... .. ... .. ........ . ................................ 133 

Table 93: Dentists in South Texas . . ....... . ... .. . . .... .. ...... . .. . .................. . ..... . . . ........ 134 

Table 94: Dental Visits Per Person Per Year by Age. Family Income. and Residence . . .. . ................... 135 
Table 95: Registered Nurses in South Texas ............... ...................... ...................... 135 

Table 96: Local Health Departments ...... ................ ........................................... 136 

Table 97: Outpatient Facilities in South Texas ........ . ............. ... ........ . ............ . .. . .... .. . 137 

Table 98: Ambulance Services in South Texas Metropolitan Counties .. . ..... .. ........... . .... . .......... 138 

Table 99: GSTCB Counties: General. Short-Term Stay Hospital Statistics: 1975 .......... .. .. .. .......... . . 139 

Table 100: Greater South Texas Cultural Basin Counties 
In-Migration and Out-Migration for Hospitalization .. .. . . ... .... . ................ . ........... 140 

Table IOI: Locally Owned Public Hospitals in South Texas: May 15. 1975 ... . ........ . ... . ..... . .. . ..... . 141 

Table 102: Medicare Certified Skilled Nursing Facilities in South Texas ...... ......................... .... 142 

Table 103: Greater South Texas Cultural Basin Counties: Nursing Homes, 1975 .............. . .... . ....... . 143 

Table 104: Federal Obligations and Expenditures for Direct Health Care Services in South Texas ............ 148 

Table 105: Per Capita Medicare Expenditure: Fiscal Year 1976 .......................................... 149 

Table 106: Distribution of Federal Medicaid Funds in South Texas: FY 1975 .............................. 150 

Table 107: The Poverty Population and Medicaid Recipients in South Texas ....... ..... ....... . . . ........ 152 

Table 108: Medicaid Expenditures by County. Fiscal Year 1975 .. . .. .. .... . ... . ............... . .. . ....... 153 
Table 109: DHEW Grants in South Texas as of September 1976 ............ .................. .......... . 153 

Table 110: Direct DHEW Project Grants to South Texas as of September 1976 ............................ 154 

Table 111: Federal Health Care Expenditures Per Poverty-Le\<el Person. 
South Texas Metropolitan Counties ...................... . ...... . .......... . ....... . ....... 156 
Table 112: Percentage of Persons 65 Years or Older by County .................. .............. ..... ..... 156 

Table 113: Relationship Between AFDC. Medically Needy. and Federal Poverty Criteria .. ............ ...... 157 

Table 114: Cost Estimates for Optional Program Expansions ... . .. . ............... . ............. . ....... 158 
Table 115: Cost of Using Financial Poverty Standards .. . .... . ... . ....... . ..... . .... . .... . .............. 158 

Table 116: State Medicaid Recipients and Expenditures by Eligibility Category: Fiscal Year 1976 .. ..... ...... 159 

Table 117: State Medicaid Expenditures in South Texas ................ ................................ 160 

Table 118: Medicaid Services Covered by Ten Largest States. June 1976 ............................. .. . .. 161 

Table 119: Title XIX Medical Screening Statistical Report 1976: 
Totals for the State and The Greater South Texas Cultural Basin ... .. .. . ....... . .............. 163 

Table 120: Title XIX Medical Program: Total Eligible. Screened and Referred ... .. ........................ 164 

Tabjc 121: Title XIX Medical EPSDT Program: Medical Summary ............... . ... .. ....... . ..... . ... 165 

Table 122: Referral Rates for Ten Highest Problems ........ ............................................ 168 
Table 123: Total Number Screened for Ten Highest Problems .... ... ..... ...................... ......... 168 

Table 124: Title XIX Medical EPSDT Program Projections of Screening Referrals 
in the Greater South Texas Cultural Basin ......... . ... . ......... . ... . ..... . .... . .... . ...... 169 

Table 125: Estimates of Referral Rates for Nine Main Problems in Below-Poverty Population in Project Area . 170 

Table 126: 32 Selected Direct Health Service Delivery Programs ............... ....... ................... 171 

Table 127: State Expenditures for Direct Health Care Programs and Services, FY 1975 ............... ...... 172 

Table 128: Prevalence of TDH Recommended Services in Local Health Departments in 1974 .. . ..... . ....... 173 

Table I29: Property Tax Revenue in Six Largest Hospital Districts in Texas ............... , .. .... ......... 174 

Table 130: Combined City-County Expenditures for Direct Health Care 
in South Texas: Fiscal Year 1975 . . ........................... . ... .. ............ . ....... . .. 175 

Table 13 I: Local State and Federal Expenditures for Personal Health Services in South Texas ........... .. .. 176 

Table 132: Illnesses and Treatments Specific to Mexican-American Culture . . .............................. 182 





List of Maps 

Map I: Percent of Each South Texas County Which is Mexican-American, 1970 ....••..........•.....•......3 

Map 2: Per Capita Income of Texas Counties, 1972 .....................................................12 

Mpa 3: Distribution of Hepatitis in South Texas, 1974-1976 ..............................................27 

Map 4: Distribution of Tuberculosis in South Texas, 1974-1976 ...........................................28 

Map 5: Distribution of Aseptic Meningitis in South Texas, 1974-1976 .....................................29 

Map 6: Distribution of Amebiasis in South Texas, 1974-1976 .............................................30 

Map 7: Principal Metropolitan Counties in South Texas .................................................34 

Map 8: Selected Low Income Census Tracts for Bexar County ............................................37 

Map 9: Selected Low-Income Census Tracts for Nueces County ...........................................38 

Map 10: Cities in Cameron County ...................................................................39 

Map 11: Low Income Areas in Brownsville .............................................................40 

Map 12: Low Income Areas in Harlingen .............. ~ ...............................................41 

Map 13: Low Income Areas in San Benito .............................................................42 

Map 14: Cities in Hidalgo County .....................................................................43 

Map 15: Low Income Areas in Edinburg ...............................................................44 

Map 16: Low Income Areas for McAllen, Pharr, and Mission ............................................45 

Map 17: Low Income Areas in Weslaco and Mercedes ...................................................46 

Map 18: Low Income Areas for Webb County ..........................................................47 

Map 19: South Texas Border Counties and Neighboring Mexican Municipios ..............................62 

Map 20: In-Migration to Mexican States, 1970 .........................................................63 

Map 21: Locations of Mental Health Services in South Texas ............................................96 

Map 22: EPSDT Rate Screened to Total Eligible Population: 
Greater South Texas Cultural Basin ....................... ................................. 166 

Map 23: EPSDT Rate Referred to Total Screened: 
Greater South Texas Cultural Basin ........................................................167 


List of Figures 
Figure I: Population Pyramid for Mexican-Americans in South Texas ......................................8 

Figure 2: Population Pyramid for Anglos in South Texas .................................................9 

Figure 3: Population Pyramid for Tamaulipas ..........................................................65 

Figure 4: Relationship of Education and Income to Physical and Mental Development .......................80 

Figure 5: EPSDT Program Flow Chart .......... . .................................................... 162 



Introduction 

The subject of this Policy Research Project is one which has become of increasingly greater interest to citizens and policymakers in Washington, Austin, South Texas, and even Mexico City. Improving the health and social conditions of Mexican-Americans in South Texas and all along the U.S.-Mexican border has been defined as an important objective by the current Administration.• Concurrently there is concern that existing methods of financing care for the very poor in Texas leave a large gap in that many families below the poverty level are denied access to most necessary preventative and much curative medical care. Finally there is concern that if investment in health promotion and in preventative measures is not made in the large pool ofpredominantly young Mexican­Americans in South Texas, the cost to their families and to society at large in the coming years will be very great, as their productive years will be cut short and the period of dependency and poverty extended. 
In this report we focus on the health status, the needs, and the programs developed to treat and ameliorate these needs of Mexican-Americans in the forty-county South Texas area. In several chapters we extend our discussion to Mexican-Americans in Texas as a whole and to Mexi­can nationals in the adjacent border cities of Matamoros, Reynosa, and Nuevo Laredo. 
Study Area 
The project chose to concentrate on the forty-county Greater South Texas Cultural Basin as our study area. This area, which is summarily described as "South Texas" throughout the text, is bounded on the east by the Gulf of Mexico and on the south and west by the Republic of Mexico. The total South Texasareacoversalmost47,000 square miles, an area larger than many states. References to "border counties" mean the eight South Texas coun­ties which adjoin Mexico, while the term "Rio Grande Valley" refers to Cameron and Hidalgo counties, situated on the U.S./ Mexico border and closest to the mouth of the Rio Grande. 
•See, for instance, U.S. Department of Health. Education, and Welfare, Review of the Health Situation: United States-Mexico Border Recommendations for Bilateral Cooperation, a Joint Effort of the United States, Mexico, and the Pan American Health Organization, January 1979. 

Population 
There are limitations to data describing the population of South Texas-the information is not current and to some extent not reliable. The most recent population count was the 1970 Census, and consequently some of our information is seven to eight years old. Also, the U.S. Bureau of the Census reports that the 1970 census under­counted many minority groups. According to the Bureau, many minorities could not be located because ofseasonal migration or other reasons. Beyond this, however, prob­lems exist with the manner in which the Bureau identified Spanish-origin persons in general and Mexican-Ameri­cans in particular. This has compounded the undercount problem. Thus, there may be an absolute undercount of the total South Texas population (of which Spanish­origin persons are a part) because of the high percentage of Mexican-Americans in that region. 
Finally, there may be a systematic undercount of certain groups within the Mexican-American population, such as young adult males and migrants and seasonal farmworkers. The result would be a distortion of data presented in subsequent chapters on income, education, sex ratios, and other statistics. Such distortion would be greater than if the undercount were random. The relia­bility of population data on Mexican-Americans is further brought into question because it is based on a 15 percent, and for certain information, a 5 percent sample in the 1970 Census. 
Rates given throughout this document for diseases, health resources, and other data divided by population are based on population projections from the 1970 Census. The absolute undercount of Mexican-Americans com­pounds the problems of making an accurate population projection, which even under the best conditions is diffi­cult to guarantee. The purported high rate of illegal immigration to the region from Mexico further compli­cates the process of making accurate projections. 
In this report, persons defined by the U.S. Bureau of the Census as "White Spanish-Speaking or Spanish­Surnamed"are described summarily as "Mexican-Amer­icans." The Census definition "Negro" is described as "Black." All other persons are labeled "Anglo." 
In 1970 South Texas had a recorded population of 

1,958,291, of which 53.5 percent were Mexican-Americans 
Table 1 
Population and Ethnic Distribution of 40 South Texas Counties 
Total %Mexican-County Population %Anglo American 
Aransas 8,902 69 .3 26.6 Atascosa 18,792 48 .0 5l.l Bandera 4,747 90.6 9.2 Bee 22,737 58.4 39.l Bexar 830,460 47.9 45.3 Brooks 8,005 19.9 79.9 Cameron 140,368 23.3 76.2 Comal 24,165 69.7 29.0 Dimmit 9,039 17.6 81.7 Duval 11 ,722 15.3 84.5 Edwards 2,107 56.0 43.8 Frio 11, 159 30.3 69.1 Gillespie 10,553 69.9 9.8 Guadalupe 33,554 63.8 27.1 Hidalgo 181,535 20.7 79.l Jim Hogg 4,654 8.0 91.9 Jim Wells 33,032 35 .2 64.0 Karnes 13,462 56.0 41.0 Kendall 6,964 79.2 26.3 Kenedy 678 21.5 78.5 Kerr 19,454 82.8 13.3 Kinney 2,008 22.3 72.2 Kleberg 33,166 51.9 43.9 La Salle 5,014 21.4 78.4 Live Oak 8,697 58 .2 40.4 McMullen 1,267 41.4 58.6 Maverick 18.093 9.6 90.3 Medina 20,249 50.8 48.5 Nueces 237,544 51.8 43 .6 Real 2,013 76.2 23.6 Refugio 9,494 52.4 38.0 San Patricio 47 ,288 49.3 49.1 Stark 17,701 2.1 97.9 Uvalde 17,348 48.6 50.7 Val Verde 27,471 40.8 56.6 Webb 72,859 13.9 85.6 Willacy 15,570 24.5 75.l Wilson 13 ,041 57.4 41.5 Zapata 4,352 8.5 91.5 Zavala 11 ,370 18.1 81.6 
Total 1,958,291 42-4% 53.5% 
%Black 
4.0 .9 .2 
2.5 
6.8 .2 .4 
1.2 .7 .2 .3 .6 
.4 
9.1 .2 
.l 
.8 
3.0 
.4 .0 
4.2 
.2 

3.9 
5.5 
1.4 .0 .l .7 
4.6 .2 
9.6 
1.6 
.0 .6 
2.8 
.5 .4 

1.1 
.o .3 
4.1% 
Table 2 
Population of South Texas Standard Metropolitan Statistical Areas, 1979 
1970 SMSA Counties Population 

San Antonio Bexar, Comal, Guadalupe 888,179 
Corpus Christi Nueces, San Patricio 284,832 
McAllen-Pharr-Edinburg Hidalgo 181 ,535 
Brownsville-Harlingen-San Benito Cameron 140,368 
Laredo Webb 72,859 
Source: U.S. Census, 1970 
and 42.4 percent were Anglos.• Population projections to 1975 indicate that, with a total of 2,045,100 persons, South Texas constituted 17 percent of the 1975 Texas population. According to these projections, the South Texas population grew by4.2 percent from 1970 to 1975, while the rest of the state grew by 7.8 percent. 
Approximately 80 percent ofthe region's population in 1970 resided in Standard Metropolitan Statistical Areas (SMSAs) (see Table 2). This was true for both Anglo and the Mexican-American residents. In 1975, approximately 77 percent of the region's population was located in SMSAs. There were, in 1975, 43.7 persons per square mile in the state. It should be noted, however, that outside of the SMSAs the population per square mile is a sparse 
12.8 persons. Some counties, such as McMullen, have less than one person per square mile. Two of the SMSAs (Brownsville-Harlingen-San Benito and McAllen-Pharr­Edinburg) have large portions of their population living in rural areas outside the major·cities, leading to sot® confusion in characterizing these SMSA counties as , urban or rural. 
The percentage of Mexican-Americans in South Texas 
increased from 46.8 of the total population in 1960 to 53.5 
in 1970. The percentage of Mexican-Americans in rela­
tion to the total population of each of the forty counties 

Source: U.S. Census, 1970 in South Texas is shown on Map l. 
•Table I presents the 1970 population of each of the forty South Texas counties by ethnic group. 
Introduction 

Map 1 
Percent of Each South Texas County Which is Mexican-American, 1970 


Source: U.S. Census. 1970 
Research Strategy 
Having defined the population for study, policy re­search project members identified a number of research issues. These fell into three categories-socioeconomic and health conditions; mental health, nutrition, and migrant farmworkers programs; and health resources and financing of health care in South Texas. 
Our research required communication with federal and state agencies, with organizations and agencies within Mexico, with regional and local officials and administra­tors, with educators, and with interested individuals and groups. Information was gathered through interviews, from computer tapes and census materials, and from public and private agency documents. The resulting indi­vidual reports from project members were reviewed within the group and substantially rewritten, and are here edited into nine chapters grouped into three sections. 
Section I, "Socioeconomic and Health Conditions," consists of four chapters. Chapter l, depending primarily upon census information, describes the income, housing, employment, education, and age structure characteristics of the Mexican-American population of South Texas. This description makes it very clear,thata. large number. of the Mexican-Americans in South Texas are among the poorest persons in the United States. Chapter 2examines mortality and morbidity in South Texas. This analysis builds on an earlier study of state-wide mortality and morbidity by ethnicity conducted at the School of Public Health in Houston. The chapter then incorporates data from death certificates in 1975 by age, sex, and ethnicity in South Texas. Morbidity from various causes in South Texas is mapped by county. Comparisons and inferences are drawn from the data. Chapter 3 focuses on urban areas in South Texas With particular attention being paid to socioeconomic and health conditions of Mexican­Americans and of residents of very poor neighborhoods. Finally, in Chapter 4 we examine conditions in South Texas border counties and compare them to conditions in Northern Mexico. This comparison is made so as to put conditions in South Texas into context with health conditions in the populated area closest to South Texas and also because residents of Northern Mexican munici­pios are often likely to work in, or to emigrate to the United States. 
In Section II, "Selected Health Topics," nutrition, mental health, and migrant programs are examined in relation to health care and health status in South Texas. Chapter 5 "Nutrition and Mexican-Americans," reviews the literature on the relationship between nutrition and health, discusses some limited findings with regard to Mexican-Americans, describes existing programs in Texas designed to improve nutrition, details a limited case study in San Diego of their comprehensive school nutrition program, and reports some findings on research done at the Robert B. Greene Hospital in San Antonio. Chapter 6, "Mental Health Services and Mexican-Americans," de­scribes programs and their staffing undertaken by the Texas Department of Mental Health and Mental Retar­dation, relates these programs to needs in South Texas, and in an appendix at the back of the report discusses some of the characteristics of folk medicine in South Texas. Chapter 7, ..Health Care for Migrant Workers," details some of the health problems of migrant workers and discusses federal and state programs which exist to ameliorate some of these problems. 

In Section III, "Health Program Resources and Finan­cing," we discuss the health professionals and facilities and their distribution in South Texas in Oiaptet 8, and in Chapter 9 look at health financing with particular emphasis on federal, state, and local programs. Each of these chapters documents the differential availability of resources, real and financial, to improve the health status of Mexican-Americans. 



SECTION I 
Socioeconomic and. Health Conditions 


Chapter 1 
Socioeconomic Conditions Among 
Mexican-Americans in South Texas 

The Mexican-American population of South Texas has distinctive characteristics which identify it as worthy of special study. This distinctiveness in income; educa­tion; age distribution; birth, death, and fertility rates; and housing conditions is documented below. After consider­ing the particular characteristics of this population it is not unreasonable to expect that requirements for health services and facilities and government programs might be different as well. 
Much of the data presented are based on, or derived from, the 1970 U.S. Census. In the introductory section of this volume, limitations to the Census data are dis­cussed, including their relative datedness and· problems with their reliability. Specifically, a probable undercount of Mexican-Americans and of certain groups within the population may distort the data presented here. Further­more, population projections based on the 1970 Census may compound errors. 
For these reasons, the researchers deliberately chose to ignore small differences in various rates between different ethnic and geographic groups, although these differences may show on the .tables presented in the report. 
Tables in this chapter give rates on all counties in South Texas. The reader will note negative rates for some statistics on Anglos. These negative statistics, appearing for counties in which the overall population of Anglos is quite small, result from the method used for determining population breakdowns. Mexican-Americans are selected from the total population by means of a sample rather than a full enumeration. Anglos are determined by sub­tracting Mexican-Americans and Blacks from the total population, under the assumption that there are very few "other" ethnic groups or races in the area. Thus, sample ·error.s which yield an unduly high number of Mexican­Americans will result in a negative number of Anglos. In general, this problem with the data may be ignored because it occurs only in a few very sparsely settled 
counties. 
Components of Population 
Population data of interest to health researchers and planners include birth and death rates, fertility rates, and the age and life expectancy of a particular population. These variables are often at once dependent and indepen­dent variables in explaining the health status of a group of people. 
Crude birth rates and crude death rates are valuable as indicators of population growth and structure. In 1970 the crude birth rate for South Texas Mexican-Americans was 23. 7 births per 1,000 persons, while for Anglos it was 
14.9 per 1,000 persons. 
Crude death rates are not available by ethnic 1roup for South Texas. Fonner• cakulatcd these ratesforthe Te):. • population by ethnic groups in 1970, and his findings may generalize to South Texas, since that area contains well over half the Mexican-Americans in Texas. Fonner found that crude death rates in 1970" were 9·.92 deaths per 1,000 Anglo males and 6.70 per 1,000 Mexican-American males. The death rate of Anglo females was 7.28per1,000 while Mexican-American females had a rate of only 4.68 per 1,000. 
The differences in birth and death rates between the two populations are due in part to differences in their age structures. As may be seen in the age pyramids in Figures I and 2, the Anglos are older and have a much lower fertility rate than the Mexican-Americans. In fact, the pyramid for Mexican-Americans resembles those of developing countries where there has been a marked decline in infant and child deaths and where fertility has not yet been reduced. In such populations, the number of people is increasing rapidly, median ages are falling, and youth and total dependency ratios are high.2 
Several reasons for this phenomenon among Mexican­Americans may be offered. First, infant mortality has declined substantially over the last decades. Second, major epidemic diseases have been brought under control during the same period. Third, socioeconomic conditions, particularly education and income, have shown improve­ment since 1950 among Mexican-Americans in Texas.J These three factors have contributed to a lowering of the death rate. However, fertility remains high, as shown below, and consequently there has been rapid expansion at the base of the pyramid as: ( 1) more infants survive the first years of life, and (2) more young women survive the child-bearing age. 
One measure of lifetime fertility, the number ofchildren ever born per 1,000 women ever married, shows the overall difference between Anglo and Mexican-American childbearing experiences (sec Table 3). In 1970, this rate Mc!xican-American Health Care in South Texas 
Fi1ure 1 
Population Pyramid for Mexican-Americans in South Texas 


75-+ 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 





4 13 12 II 10 9 8 7 6 5 4 3 2 0 2 3 4 5 6 7 8 9 10 11 12 13 14 l S 
(in percent) Males Females 
Source: U.S. Census, 1970 
Socioeconomic Conditions 

Figure 2 
Population Pyramid for Anglos in South Texas 


75-+ 70-74 65-69 
60-64 
55-59 50-54 45-49 
40-44 35-39 30-34 
25-29 20-24 15-19 10-14 5-9 0-4 



11 10 9 8 7 6 5 4 3 2 0 2 3 4 5 6 7 8 9 10 11 
(in percent) 
Males Females 

Source: U.S. Census, 1970 
Table 3 
Fertility Rates Among the Anglos and Mexican-Americans in South Texas 

1970  
Total  SMSA  Non-SMSA  
Mexican- Mexican- Mexican- 
Anglo  American  Anglo  American  Anglo  American  
#Children ever born per I000 women ever married 1  2852  4743  2842  4710  2899  4877  
#Children born in 1970  
per 1000 women aged : 2  
15 to 19  65  95  64  96  70  93  
20 to 24  178  249  175  250  190  242  
25 to 29  149  225  160  230  99  205  
30 to 34  69  138  69  141  68  127  
35 to 39  24  79  25  80  24  75  
40 to 44  5  27  5  27  6  28  
Sources: I. U.S . Census, 1970  

2. Texas Department of Health Resources, unpublished data on age of mothers when giving birth. 
Table 4 
Sex and Age Characteristics of Ethnic Groups in South Texas 1970 
All Counties  SMSA Counties  Non-SMSA Counties  
Mexican- Mexican- Mexican- 
Total  Anglos  Americans  Total  Anglos  Americans  Total  Anglos  Americans  
All Persons  1,958 ,291  830,80 I  1,047,969  1,567,764  662 ,765  831,909  390,527  168,054  216,060  
Males per  
100 Females  95.4  98.3  93 .1  95 .1  98.4  92.5  96.8  97.8  95.6  
'7<: Persons 19  
or Younger  43.4  33 .5  51.2  43.7  34 .1  51.4  42.l  31.5  50.4  
% Persons 65  
or Older  8.2  11.6  5.5  7.6  10.6  5.2  }0.4  15.3  6.6·  
Median Age  23.4  30.2  19 .0  23.1  29.4  18.9  24.5  34.3  19.3  

Source: U.S. Census, 1970 
Socioeconomic Conditions 

was 2,852 for Anglos as compared to 4,743 for Mexican­Americans. These rates were higher in SMSA counties than in non-SMSA counties, and the margin between Anglos and Mexican-Americans was somewhat greater in the non-SMSA counties. 
Table 3 also shows a different measure of fertility: the period fertility, which is the number of children born in a particular year per 1,000 women in a specific ·age group, indicating fertility at different ages. Mexican-Americans had a higher rate than Anglos for all age groups, but the difference is greatest during the later years. Thus, the average Mexican-American mother has children over a longer period than does the average Anglo mother. 
Another way of looking at age structures is provided by Table 4. As may be seen, Anglos in South Texas had a median age of 30.2 years, while Mexican-Americans had a median of only 19.0 years. The disparity between ages is greater in rural than in metropolitan areas, suggesting an exodus of younger Anglos from rural areas. In South Texas, 11.6 percent of the Anglos were 65 years of age or older. For Mexican-Americans, this portion of the popu­lation constituted only 5.5 percent. Over half the Mexican­American population was under twenty years old, com­pared to·· one'-third" of the Anglo-population. 
A final component of population is life expectancy. Data are not available for South Texas, but Fonner's data for Texas as a whole will give some indication of differences between the ethnic groups. Fonner found that life expectancy at birth for Anglo males was 67.6 years and for Mexican-American males, 67.4 years. Anglo females had a life expectancy at birth of 76. 7 years and Mexican-American females, 74.0 years.4 Of interest is that Mexican-American males and females have a nar­rower gap between their life expectancies than do Anglo males and females. Also, Fonner found that Mexican­American and Anglo males had similar life expectancies at ages 15, 35, and 65, but that among females Anglos had higher expectancies at all ages than did Mexican-Amer­icans. 
Mexican-Americans in South Texas, then, are generally much younger than Anglos. This is due to high fertility and to declines in death rates. In part as a result of this condition, the aggregate health service needs of Mexican­Americans differ from those of Anglos. The larger num­ber of children and the higher fertility rates suggest a greater need for pediatric and obstetric services. Anglos, on the other hand, have a relatively greater need for geriatric care. A particular mix of health services suitable for Anglos is therefore not necessarily appropriate to serve the large group of low-income Mexican-Americans. 
The differing age structures of the two populations also 

suggests differences in disease rates. As a group, Mexican­
Americans have more aggregate risk of early childhood 
diseases, of maternity-related ailments, and of deaths by 
violence (which occur more often among young adults). 
Anglos have a higher aggregate risk of the degenerative diseases of old age, such as cancer, cirrhosis of the liver, and heart ailments. 
Given the age structure and the fertility of Mexican­Americans in South Texas, their numbers may be expected to increase over the next few decades. In-migration, although not discussed here, will have an added effect on this increase. Unless there is an increase in the Anglo fertility rate (which is doubtful) or a heavy increase in Anglo in-migration, Mexican-Americans will make up an increasingly larger percentage of the total South Texas population in years to come. 
Socioeconomic Conditions 
Socioeconomic conditions may be seen as both a cause and a result of health conditions. Poor health conditions may affect socioeconomic conditions in three ways: (I) by causing an interruption in or termination of employment (especially for the head of a household); (2) by preventing a person from learning or participating in those activities which would increase income and education; and (3) by causing a person to spend a disproportionate amount of income on maintaining health status or curing disease or injury: 
Adverse socioeconomic conditions may affect health status in the following ways: (I) by subjecting a person to unhealthy environmental conditions (e.g., crowded hous­ing, lack of treated drinking water or sewerage); (2) by depriving a person of the education necessary to under­stand preventive measures in disease control and general physical well-being (e.g., lack of knowledge about nutri­tion, not understanding germ theory); (3) by limiting a person's ability to afford health care and thus limiting the care received; (4) by barring a person from health care services (e.g., through racial discrimination or inability to travel to facilities); and (5) by leading a person, through ignorance and desperation, to seek types of health care which ultimately might cause him or her harm (e.g., some folk medicine practices). 
It is generally accepted that persons with low income are more likely to become ill than persons with higher income. It is also known that low-income persons are less likely to seek medical help when they are sick. Poverty is common among Mexican-Americans in South Texas, as may be seen in Table 5. In 1970, 37.9 percent of all Mexican-American families in South Texas had incomes below poverty level. This figure was lower in SMSA areas 
(35.3 percent), but in the non-SMSA areas, nearly half 
(47.9 percent) of all Mexican-American families were in poverty. In some counties, the percentage of Mexican­American families under the poverty level was astrono­mical: in La Salle, it was 65.2 percent; in Wallacy, 64. l percent; and in Dimmit, 62.2 percent. Of all families below poverty level in South Texas, over 80 percent were Mexican-American. 
As Map 2 indicates, the South Texas region is the 
Map 2 
Per Capita Income of Texas Counties, 1972 

D s1,000-$ I ,999 \.'\ $2,000-$2,999


"""' 
~ 
~$3,000-$3,499 iii $3,500-$3,999 
$4,000 or over 
Socioeconomic Conditions 
Table 5 

Income and Poverty Characteristics in South Texas 
1970 

All Counties SMSA Counties Non-SMSA Counties 
Total  Anglo  Mexican-American  Total  
Number of  
Families  453,538  220,596  215 ,515  361,172  

Mean Family 
Income $ 8,465 $10,902 $ 6,176 s 8,802 

Per Capita 
Income $ 2,207 $ 3,357 s 1,338 $ 2,290 

Families less than 
Poverty 23.5% 8.8% 37.9% 22.0% 

Families less than 
75% Poverty 16.1% 5.6% 26.3% 15.0% 

F amities less than 
125% Poverty 31-.4% 13;0% 49.4% 29.6% ' 

Source: U.S. Census, 1970 

Table 6 
Percent of Labor Force Unemployed in South Texas SMSAs, 1976 

Percent SMSA Unemployed* 
Laredo 15. l McAllen-Pharr-Edin burg 10.9 Brownsville-Harlingen-San Benito 10.4 San Antonio 7.3 Corpur Christi 6.5 
*Average of 12 months 
Source: Texas Business Review, February, 1977, p. 6. 
poorest in Texas. The three SMSAs along the Rio Grande border are the poorest in America: McAllen-Pharr­Edinburg (with an annual personal income per capita of $2,343); Laredo ($2,516); and Brownsville-Harlingen­San Benito ($2,607). In fact, these populations are among the poorest of all Mexican-origin persons in the country. The percentage ofall U.S. Mexican-origin families under 
Mexican-Mexican-

Anglo Total Anglo
American American 

174,037 170,595 92,366 46.559 44,920 
$11,371 $ 6,454 $ 7,928 $10,410 s 5360 
$ 3,482 $ 1,396 s 1,875 s 2,884 s 1,115 
8.0% 35.3% 29.4'7'· l l.6'K 4 7.97< 
5.3% 24.3'.k 20.2% 1.1'1i: 33.77< 
l l'.9% 46.5%' 38.5% 17.0% 60.5'7c 
poverty in 1970 was 24.4 percent; in Texas, it was 35.6 percent.5 
Comparisons of the income of Mexican-Americans in South Texas with that of Anglos indicates wide dispari­ties. The mean family income of Mexican-Americans was 
56.7 percent of that of Anglos in 1970; in non-SMSA counties it was nearly half that of Anglos. Per capita income differences were even greater: Mexican-Americans had 39.9 percent the per capita income of Anglos overall. 
Poverty is often a reflection of unemployment. and unemployment rates in South Texas are among the highest in the state. The unemployment rates for the SMSAs in the region indicate that unemployment is greatest in the border areas (see Table 6). Given the low socioeconomic status of Mexican-Americans as a whole, it may be expected that their unemployment rates are significantly higher than the rates of Anglos in South Texas and therefore are higher than the average unem­ployment rates presented in Table 6. 
Educational levels among Mexican-Americans also are low, as may be seen in Table 7. Comparison with the Anglo population again reveals wide disparities between the two ethnic groups. Anglos were nearly four times more likely to have completed high school than Mexican­Americans. Mexican-Americans were eighteen times more likely not to have had any formal schooling. While the difference in educational attainment between the two 
14 Mexican-American Health Care in South Texas 

Table 7 
Education of Penons 25 and Older in South Teus 1978 
All Counties SMSA Counties Non-SMSA Countie1 
Mexican-Mexican-Mexican-
Total Anglo Total Anglo Total Anglo Americm
American American 
Persons 25 and Older 942,713 473,583 430,921 747,356 339,663 372,579 195,357 101,004 91,258 
% with no Education 8.2 0.9 16.8 7.8 0.9 15.9 9.9 1.0 20.1 
% with 8th Grade or less 42.0 21.0 65.6 40.2 19.3 63.8 48.3 27.0 72.6 
% with 12th Grade or more 18.7 29.1 7.7 19.7 33.6 7.5 14.8 23.3 5.8 
Source: U.S. Census, 1970 

Table 8 
Housing Characteristics in South Texas 1970 
All Counties SMSA Counties Non-SMSA Counties 
Mexican-Mexican-Mexican-Total Anglo American Total Anglo ·American Total Anglo 1
American Total Occupied Units 537,298 278,582 236,544 428,079 220,087 186,999 109,219 59,674 49,545 
Persons per Room (% of all Occupied Units) 

less than 1 80.9 94.6 64.4 81.l 94.8 64.7 63.3
80.0 94.0 
1 to 1.5 10.8 4.2 18.5 10.7 4:0 18.7 

11.0 15.0 17.9 

1.5 or more 8.4 1.2 17.7 8.1 LI 16.6 9.3 l.S 18.8 
% Occupied Units without ... 

piped water 4.1 3.1 5.5 3.1 2.2 4.5 7.7 6.4 9.3 flush toilets 8.3 5.2 12.6 5.9 3.5 9.4 17.4 24.8
11.4 
Source: U.S. Census, 1970 groups was Jess in non-SMSA areas than in SMSA areas, the differences were still extreme. 

Crowded housing, another indicator of poverty, and also connected to the spreading of contagious diseases, was found to be common among Mexican-Americans. As Table 8 indicates, 17. 7 percent of the occupied Mexi­can-American housing units had 1.5 persons or more per room. Crowding was more often a problem in non­SMSA areas. Of all occupied Mexican-American housing units, 5.5 percent had no running water, while in non­SMSA areas 9.3 percent lacked this service. Fully 12.6 percent of the Mexican-American homes had no flush toilet; 25 percent of the non-SMSA Mexican-American homes lacked this facility. 
In some parts of South Texas, a very large percentage of Mexican-American homes lack running water and sewerage facilities. For example, a recent survey of sixty­five unincorporated Mexican-American communities known as colonias in Cameron and Hidalgo counties indicates a total population ofabout 34,000 persons, with 54 percent of the houses lacking treated drinking water; none had sewers.6 
Lack of sewerage is also a problem in cities. For example, in Brownsville, a city of over 50,000, there were 1,300 open-pit privies in 1976. Of all its housing units, 46 percent were in violation of the city's housing and building codes.7 
Differences between Anglo and Mexican-American homes in South Texas are extraordinary. Mexican­American homes were fifteen times more likely than Anglo homes to be overcrowded. They were nearly twice as likely not to have running water, and over twice as likely not to have toilets. 
In view of the relationships between poverty and health, the socioeconomic status of a large portion of the Mexi­can-American population in South Texas indicates a number of potential health problems. These problems may be summarized as follows: 
-The low income of many Mexican-Americans gives them little money for medical services. Lack of funds may require the foregoing of medical services or reliance on assistance from others (i.e., family, friends, charities, or public funds). 
-The lack offormal education among many Mexi­can-Americans suggests that they are less likely to be aware of and practice modern preventive health care. The low income of many if not most Mexican­Americans makes the practice of preventive health care difficult. 
-Crowded housing and lack ofbasic services, such as water and treated sewers, result in a greater potential for the spreading of communicable dis­eases among many Mexican-Americans. Lack of these facilities also makes preventive health prac­tices difficult. 
Socioeconomic Conditions 15 

Consequently, a system of health care delivery which includes preventive health services and health education and which is designed for relatively well-educated middle­income Anglos probably will not meet the needs of low­income Mexican-Americans. Rather, the development of an appropriate health system must be predicated upon the health risks and health needs which exist in the Mexican-American population and must take into ac­count the age distribution, income, and education of Mexican-Americans. 
References 

1Edwin Fonner, Jr., "Mortality Differences of 1970 Texas Residents: A Descriptive Study" (Master's thesis, School of Public Health, The University of Texas Health Science Center at Houston, 1975), pp. 47-5~. 
2w.s. Thompson and D.T. Lewis, Population Problems (St. Louis: McGraw-Hill: 1965), pp. 110-11. 
3Harley L Browning and S. Dale.Mclemore.A StaJ.istical Profile of the Spanish-Surname Population of Texas, Bureau of Business Research, University of Texas, 1964., p. 30 (Educa­tion) and p. 48 (Income) for the 1950aRd 1960data; U.S. Census reports, 1970. 
4Fonner, "Mortality Differences," pp. 78-81. 
~u.s. Census Bureau, Persons of Spanish Origin in 1970, US Govt Printing Office, Washington, D.C., June 1973. 
6Colonias in the Lower Rio Grande Valley ofSouth Texas: A Summary Report, Policy Research Project Report No. 18 (Austin: Lyndon B. Johnson School of Public Affairs, 1977). 
'Interview with Mario Moreno, City Planner, Brownsville, Texas, 1977. 

Chapter 2 

Mortality and Morbidity in South Texas 
Measurement of the health status of a population necessarily begins with consideration of what constitutes "good" or "bad" health, Ideally, a definition of "good" health would describe a state of physical and mental well­being. While such a positive definition is conceptually appropriate, it is also difficult to use as a measure. Another way of describing "good" health is in terms of absence of disease. Such a negative definition is less satisfying, but is more easily measured. 
The information needed to measure health within this latter framework would be data on deaths and diseases. Such information may come from vital records, records of communicable disease, accident statistics~ household surveys, scientifically conducted medical examinations with population sampling, records of public hospitals and clinics, or screening programs such as those conduc­ted among school children, military personnel, and other special groups. 
To date, the vast majority of health information about Mexican-Americans in South Texas is from vital records such as death certificates. Available survey and medical screening data are limited to small towns or small popula­tions within major cities, and do not provide a compre­hensive view of the health of Mexican-Americans in the area. In this chapter, vital records and communicable disease reports are relied upon as providing the most comprehensive view of health in South Texas. 
Methodology 
Mortality data which we present here comes from two sources. The first of these is Edwin Fonner's study of the mortality experience of Texas residents in 1970. 1 In that study, Fonner combined information found on death records forthe years 1969, 1970, and 1971 ,and from them calculated age, cause, and sex specific rates for Anglos, Mexican-Americans, and Blacks. He was able to calculate age specific rates for each ethnic group because of the availability of U.S. Census data on age for 1970. Fonner's findings are based on Texas as a whole. However, they are easily applied to Mexican-Americans in South Texas, because in 1970 South Texas contained 56 percent of all Spanish-surnamed persons in the state. 
The second source is a study this project conducted of 
1975 mortality data specific to South Texas. Because there are no data available on age for each ethnic group in 1975, we are not able to compute mortality rates. How­ever, 1975 information is more current, and adds more to what is known about health conditions among Mexican­Americans. 
The information source used here is death certificates obtained in machine-readable form from the Texas Department of Health Resources. Each certificate con­tains records on age, sex, county of residence, ethnicity, and primary cause of death. These included data on 17,641 deaths, of which 10,217 occurred among Anglos and 6,289 among Mexican-Americans. 
Specific causes· of death are· calculated as a percent of all causes of death within each group as follows: 
o .. 
lJ 
x JOO 
where number of deaths from cause j occurring in group i 
D· number of deaths from all
l 
causes occurring in group i. 

This method does not allow fully accurate statements of the prevalence of particular causes of death. However, the method does point out differences in the death experi­ence (and thus in the health experience) between Anglos and Mexican-Americans, and among various age groups. 
There are, of course, some limitations to this use of mortality data, particularly as it pertains to Mexican­Arnericans in South Texas. To begin with, the data on ethnicity, as shown on the death certificates, was coded by persons rather than by machine.• In the case of Mexican-Americans, the result may be an undercount. At least one study shows that machine coding of Spanish surnames yields a much more accurate enumeration of Mexican-Americans than does coding by hand.2 Also, the causes of deaths as reported on death certificates are 
•Machine coding uses a computer program to recognize and select Spanish surnames from among other surnames. 
determined by physicians or coroners. Because poor persons are less likely to use physicians, those who determine the causes of death for some Mexican-Amer­icans may have less information available to identify causes.3 Finally, because mortality statistics onlµeport ailments and conditions which have been fatal, they cannot present a total picture of health conditions. 
The primary cause of death, as verified by the Texas Department of Health Resources (TDHR) is available from each death certificate. Primary cause is defined as the disease or injury which initiated the train of morbid events leading directly to death, or the circumstances of the accident or violence which produced the fatal injury.4 In order to reduce the data into more manageable cate­gories, causes of deaths were aggregated into discrete groups according to the format used by the TDHR in its annual vital statistics reports. These categories are differ­ent from those used by Fonner, but are sufficiently similar to allow some comparison. The cause-of-death categories and their corresponding three-digit Interna­tional Classification of Diseases (ICDA)5 codes are shown in Appendix 8. Fonner's classifications according to the four-digit ICDA code are shown in Appendix C. 
Data.on infant deaths..comes. from unpublished reports . of the Texas Department of Health Resources. Infant mortality rates are calculated for the years 1970 through 1975 in the following manner: 
o. 
I 
--x 1,000 infant mortality rate 
B· 

I 
where 
o. I number of deaths in a particular year to ethnic group i 
number of live births in a particular year to ethnic group i 
There are limitations to this use of infant mortality data. Again, coding of ethnicity was done by hand , and thus there may be an overall undercount of Spanish surname births and infant deaths. Also, there may be under­reporting of Mexican-American infant deaths along the border. This could occur, for example, when Mexican women cross the border to have their children in the United States. If the mother reports that her residence is in Mexico, the birth is not recorded as a resident birth and thus does not become part of the South Texas area's registered births. There are indications, however, that many Mexican mothers give a U.S. address when they deliver. In these cases, the births are added to the number recorded for South Texas. However, should the mother return to Mexico and should her infant die in Mexico, the death would not be recorded in Texas. The result would be a deflation of the denominator in the infant death rate algorithm, creating an artificially low infant mortality rate. Also, some infant deaths in the border counties may go unreported if the parent or parents do not wish to come into contact with public officials. A .. shoebox" burial may be the fate of some Mexican-American infants who die during the first year of life. Even if this should occur only a few times a year, it would significantly reduce the infant mortality rate, since the number of infants who die (the numerator of the algorithm) is miniscule in comparison to the number of live births (the denominator). Finally, there are reports that birth certifi­cates are saleable commodities along the U.S.-Mexico border, so some Mexican infants may be falsely reported as having been born in Texas. 

Teller and Clyburn6 found that infant mortality rates were unreasonably low in border counties between 1964 and 1972. The situation does not appear different in 1975. Given the extremely low socioeconomic status of Mexican­Americans in that area, these researchers have difficulty in accepting the official rates as truly representative ofthe situation. There have been major changes in infant mor­tality rates in non-border counties since 1972. a further cause. for. skepticism. These concerns will be examined in greater detail. 
Cause-specific infant mortality rates are calculated for the year 1975 as follows: 
o..
IJ 

--x 10,000 = cause specific infant mortality rate 
where 
o.. = number of infant deaths from cause j
IJ 
in ethnic group i 
Bi = number of live births for ethnic group i 
For overall mortality, five age groups are examined. 

These are: 0 to 14 years; 15 to 29 years; 30 to 44 years; 45 
to 64 years; and 65 or more years. These age groups are 
the same as those used by Fonner in his study, and a 
comparison is made. These groups also have relatively 
distinct structures of mortality. For example, although 
deaths in the I to 14 years group may be misrepresented, 
in that they largely consist of infant deaths, there are 
some ailments and conditions, such as congenital ano­
malies. which are most accurately represented by this age 
category. 
Morbidity data are from reports published by the 

Texas Department of Health Resources on reportable 
communicable diseases.7 Data for the years 1974, 1975. 
and 1976 were obtained and combined to smooth out 
year-to-year fluctuations. Rates per 100,000 persons are 
calculated as follows: 
Mortality and Morbidity 

J. 
problem of selective underreporting, which might occurJ x 100,000 = disease morbidity rate in several ways. First, the poor are more likely to use 
3{P) 
public health services where the reporting of a venereal disease is assured. Wealthier persons, who tend to use where private health services, may be able to .. cover up"the fact that they have such a disease, thereby avoiding embar­}. J number of incidences of disease of rassment. Similarly, in the border counties, many of these 
disease j during 1974, 1975, and 1976 persons may cross the border for treatment. 
On the other hand, ailments such as amebiasis (amoebic 3(P) = population in 1975 multiplied by 3 dysentery) may be underreported among the poor. Symp­toms of mild dysentery may be accepted as a fact of life 
Information is not available on the ethnicity of persons within a very poor group of people. They may seek reported to have communicable diseases. However, many medical care only when their condition becomes very of these diseases have etiologies which indicate that they severe. To the extent that they do not seek care, the illness occur more often among a poor population. Since Mexi­is underreported. can-American families make up 76.6 percent of the poor The more rare and serious ailments such as typhoid in South Texas, it is reasonable to assume that many of and typhus are probably reported by doctors as often as these diseases are occurring among that group. Also, they are found in all income groups. clinicians and health officials report that they observe higher rates of many of these diseases among Mexican­
Mortality
Americans than among Anglos. 
Morbidity data have several problems. To begin with, Table 9 shows Fonner's breakdown of the ten leading not all cases of particular diseases are reported. This is causes of deaths from 1969 through 1971 for Anglos and particularly true of venereal diseases. More severe is the Mexican-Americans throughout Texas. For all sex and 
Table 9 

Ten Leading Causes of Deaths to Texas Residents by Sex and Ethnicity 1969-71 
Percent of All Causes 
Anglos  Mexican-Americans  
Cause ofDeath  Males  Females  Males  Females  
lschemic Heart Disease Neoplasms, Total Accidents Cerebrovascular Disease Other Respiratory Diseases Digestive Diseases Other Heart Diseases Influenza and Pneumonia Diseases of Arteries Certain Causes of Perinatal Mortaligy Diabetes Mellitus Infective and Parasitic Diseases Ill-defined conditions  33.49 17.58 10.94 8.94 4.00 3.62 3.53 3.01 2.75 2.24 ( 1.19) (0.86) (1.86)  29.83 18.23 6.54 14.79 ( 1.80) 3.77 3.35 3.52 3.67 1.93 2.23 (0.86) (1.55)  21.44 12.49 18.48 7.39 (2.01) 5.04 3.33 4.10 (2.09) 6.27 (2.46) 3.36 3.31  20.70 16.43 6.78 9.32 (1.60) 4.82 3.15 4.88 (2.44) 6.20 5.41 3.30 3.30  

Note: Figures in brackets indicates that the particular cause was not among the leading ten for that particular sex and ethnic group. 
Source: Fonner, Edwin Jr., Mortality Differences of 1970 Texas Residents: A Descriptive Study, Master's Thesis, School of Public Health, The University of Texas Health Science Center at Houston. September, 1975. Page 39. 
Mexican-American Health Care in South Texas 
Table 10 
Cause Specific Death Rates for Mexican-Americans Standardized to Those for Anglos, Texas, 1969-71 
Anglos Mexican-Americans Crude Death Rate Standardized Death Rate 
Cause ofDeath Males Females Males Females 
All Causes 991.86 728.36 995.01 862.80 
Infective and Parasitic Diseases 8.59 6.28 26.87 18.70 
Neoplasms, Total 174.41 132.97 143.72 147.73 
Trachea, Bronchus, Lungs 58.44 13.00 33.83 14.12 Other Digestive Sites 17.17 13.24 24.52 26.02 Large Intestine, Rectum 17.12 18.62 10.39 9.58 Lymphatic and Hematopoietic 18.97 14.48 13.71 10.27 Prostate 15 .86 11.38 Breast 24.47 19.53 Ovary 9.40 9.18 Cervix Uteri 5.38 12.59 
Diabetes Mellitus 11 .84 16.24 27.96 52.95 
All Circulatory Diseases 501.80 395.77 472.70 407.62 Hypertension 7.58 9.08 8.37 13.31 Ischemic Heart Disease 332.19 217.23 256.78 224.99 Diseases of the Arteries 27.25 26.73 24.41 27.5 I Cerebrovascular Disease 88.69 107.68 88.97 99.87 Other Heart Diseases 34.98 24.42 38.42 31.00 Other Circulatory Diseases 11.11 10.69 9.75 10.94 
Influenza and Pneumonia 29.90 25.63 36.87 36.85 Other Respiratory Diseases 39.67 13.12 22.75 14.08 Digestive Diseases, Total 35.89 27.51 53.03 41.52 Congenital Anomalies 8.74 7.47 10.76 8.02 Perinatal Mortality 22.25 14.07 27 .81 18.21 Accidents 108.59 47.64 143.26 37.63 
Source: Fonner, Edwin Jr., Mortality Differences. of 1970 Texas Residents: A Descriptive Study, Master's Thesis, School of Public Health, University of Texas Health Science Center at Houston. September, 1975. 
ethnic groupings, heart disease and cancer were the from ailments related to perinatal mortality, infective leading causes of death. After these, differences appear and parasitic diseases, and other causes not necessarily among the groups. Accidents (which, in Fonner's cate­associated with old age, such as influenza and pneumonia, gorization, include deaths by suicide and homicide) are digestive diseases, and diabetes mellitus. the third-ranked killers of Anglo and Mexican-American Certainly the age structure ofthe two populations does males. For Anglo and Mexican-American females, cere­much to explain the differences between them. The effect brovascular disease ranks third and accidents a somewhat of age structure simply means that, in an older Anglo distant fourth. The reasons may be that females are less population, more people will be at risk of dying of exposed to situations leading to death by external causes degenerative ailments associated with old age. In the than are males. Also, because females live longer than Mexican-American population, more people will be at males, they are more likely to be at risk of developing risk of dying of ailments not associated with old age. Age such degenerative ailments as cerebrovascular disease. controls will help to adjust for this effect. Fonner accom­Cerebrovascular disease ranks as the fourth leading cause plished this adjustment by calculating the crude death of death among Anglo and Mexican-American males. rates by causes for Anglos and using that rate to standar­
After these four leading causes ofdeath, Anglos appear dize the Mexican-American rates by causes. s The results 
to die more often of other degenerative ailments, such as are shown in Table IO. There are, ofcourse, limitations to diseases of the arteries and other respiratory diseases. this type of standardimtion. 
Mexican-Americans, on the other hand, die more often The most apparent phenomenon shown in Table IO is 
Mortality and Morbidity 

Table 11 Ten Leading Causes of Deaths to South Texas Residents by Sex and Ethnicity, 1975 
Cause ofDeath 
Neoplasms, Total 
Heart Disease• Ischemic Heart Disease Other Heart Diseases 
Cerebrovascular Disease Diseases of Arteries Influenza and Pneumonia Bronchitis, Emphysema and Asthma Certain Causes of Mortality 
in Eady Infancy 
Death by Violence• Accidents Suicides Homicides 
Infective and Parasitic Diseases Diabetes Mellitis All Other Causes 

Percent ofAll Causes 
Anglos Mexican-Americans 
Males Females Males Females 
20.20 20.40 14.89 18.95 
35.12 34.67 28.88 29.44 
30.31 29.54 24.41 23.57 
4.81 5.13 4.47 5.87 
8.32 13.83 7.16 9.66 
4.96 4.14 ( 1.81) ( 1.83) 
2.90 3.06 2.77 3.52 
2.34 ( 1.09) (0.85) (0.64) 
(1.03) (0.78) 3.89 3.75 
11.70 6.01 17.69 6.45 
7.67 3.98 11.93 5.08 
2.95 1.56 (1.65) (0.38) 
(1.08) (0.4 7) 4.11 (0.99) 
(0.85) (0.81) ( 1.59) 2.32 
(1.05) 2.01 3.54 5.31 
11.53 13.20 16.93 18.13 
n=5738 n=4479 n=3650 n=2639 
*The categories "Heart Disease" and "Death by Violence" are in this table for the interest of the reader. They are not considered in the ranking of the ten leading causes of death. 
Note: Figures in brackets indicate that the particular cause was not among the leading ten for that particular sex and ethnic group. 
Source: Data on death certificates obtained from the Texas Department of Health Resources. 
the uniqueness of the mortality experience of Mexican­American females. While Anglo men have higher or similar rates for most of the degenerative diseases in comparison to Mexican-American men, Mexican-Amer­ican women have higher rates than Anglo women for all degenerative ailments save cerebrovascular disease.• 
Even after standardizing for age, Mexican-Americans have higher death rates for those conditions not (or not necessarily) associated with old age. These include infec­tive and parasitic diseases, diabetes mellitus, influenza and pneumonia, perinatal mortality, congenital anoma­lies, and digestive diseases. Mexican-Americans also have higher death rates from cancer in other digestive sites. 
Table 11 shows the ten leading causes of deaths in 1975 
*Here, all neoplasms are treated as a unit. As seen in Table 10, Anglo women have higher death rates from neoplasms of the large intestine and rectum, lymphatic and hematopoietic tissues, breasts and ovaries. 
for each sex for both Anglos and Mexican-Americans in South Texas. Diabetes mellitus is more often responsible for deaths among Mexican-Americans than among An­glos, as are infective and parasitic diseases, accidents, homicides, and certain causes of death in early infancy. Anglos have higher percentages of cancer, heart disease, diseases of the arteries, bronchitis, emphysema and asth­ma, and cerebrovascular disease. These differences in mortality rates are similar to those found between Anglos and Mexican-Americans in Fonner's study. 
Of interest is the high rank given to deaths from accidents and to a lesser extent homicides among Mexican­American males. As will be seen shortly, this occurred in almost all age groups. Perhaps there is a high correlation between the large numbers of Mexican American men in agricultural work and deaths by accident. 
Also of interest is the fact that the three major causes of death among Anglo males account for 67.0 percent of all deaths in that group, while among Mexican-American men they account for only 61.S percent of ail deaths. Among Anglo females the figure was 68.9 percent, and among Mexican-American women it was 58.0 percent. Thus, Mexican-Americans suffu deaths from a relatively wider range of causes than do Anglos. This difference is greatest for women. 
Information is not available for developing age stan­dardized death rates, such as those used by Fonner. Thus, deaths from specific causes can be discussed only as a percent of total causes. Infant deaths are examined here separately. 
As may be seen in Table 12, infant mortality rates for both Anglos and Mexican-Americans have fallen since 1970, with Anglo rates decreasing from 18.0 infant deaths per thousand live births in 1970 to 15.1in1975. Mexican­American rates also fell, from 20.2 in 1970 to 14.5 in 1975. 
This decrease may result from simple year-to-year fluctuations, or it may result from changes in social conditions. As pointed out in earlier discussion, these figures should be viewed with some skepticism. For example, the infant death rates among Mexican-Ameri­cans in many border cities appear to have fallen below those. of Anglos. This was not the case in 1964 and 1970, as noted by other researchers. Certainly the previously given argument for underreporting in border counties does not apply to the non-border areas. Thus, a better explanation is that the fall of infant mortality rates in non-border cities is a result of improved neonatal care facilities made available since 1970. These neonatal facili­ties are high technology systems located in many public and private hospitals, and they can effectively intervene to save the lives of newborns at risk. The development of a neonatal intensive care system in the Robert B. Green Hospital, a unit of the Bexar County Hospital District, appears to have been responsible fora tremendous reduc­tion in at-risk neonatal mortality. In 1969, prior to the development of the intensive care system, the neonatal death rate at Robert 8. Green was twenty-five deaths per one thousand live births. This fell to 13.1 in 1971.9 Since the Robert B. Green is the principal public hospital in the area and is used extensively by low-income Mexican­Americans, the savings of only a few neonates could effectively lower the infant death rate. Similarly the rapid increase in food stamps and other funds for nutrition of pregnant mothers may have helped reduce the infant death rate. 

Thus, there are two plausible explanations for the relatively low infant death rate among Mexican-Ameri­cans. The first relates to underreporting of deaths, sug­gesting that the data are not highly reliable. The second relates to the newly available services which have effec­tively intervened in the problem of neonatal mortality. This intervention has the laudable effect of reducing 
Table 12 
Infant and Neonatal Mortality Rates Per 1000 Uve Births by Ethnicity in South Texas, 1970-1975 
Anglos Mexican-Americans 
Infant Neonatal Infant Neonatal Infant Neonatal Mortality Mortality Infant Neonatal Mortality Monality Year Deaths Deaths Rate Rate Deaths Deaths Rate Rate 
1970 '277 244 18.0 14.6 620 426 20.2 13.9 1971 278 225 18.8 15.2 621 423 19.4 13.2 1972 228 rs8 16.2 11.3 589 411 19.1 13.3 1973 222 181 16.9 13.8 533 378 17.5 12.4 1974 214 162 16.5 12.5 591 440 18.0 13.4 1975* 194 133 IS .I 10.4 461 324 14.5 10.2 
*Data on deaths for 197 5 are taken from machine-readable sources from the Department of Health Resources. The$C figures are slightly higher than those reported in unpublished vital statistics information. 
Source: Texas Department of Health Resources, unpublished data. 
Mortality and Morbidity 
Table 13 

Cause of Specific Infant Mortality Rates Per 10,000 Live Births by Ethnicity in South Texas, 1975 
Number of Births 
Number of Deaths 
Cause ofDeath 
Infective and Parasitic Diseases Enteritis and other Diarrheal Diseases Septicemia 
Avitaminoses and other nutritional deficiencies Meningitis Influenza and Pneumonia Congenital Anomalies Certain Causes of Mortality in Early Infancy Birti:J. Injury Symptoms and Ill-Defined Conditions All External Causes Accidents 
Sources: 

Total Anglos Mexican-Americans 
44,740 12,849 31,789 
717 194 461 
Rate per 10,000 Live Births 

8.7 2.3 10.4 
4.9 2.3 5.0 
2.9 4.1 
0.4 0.6 
2.5 3.1 2.2 
8.0 7.0 7.2 
31.5 35.8 26.7 
81.4 73.2 75.5 
47.6 50.6 42.2 
12.5 10.1 7.6 
7.4 11.7 4.7 
6.0 7.8 4.4 
For Deaths: Data on death certificates obtained from the Texas Department of Health Resources. For Births: Texas Department of Health Resources, unpublished data. 
overall infant mortality, but it is intervention at a particu­lar stage ofdeath and does not extend to the overall death experience of that group. Modern medical technology may intervene in specific parts of the life cycle for specific ailments. However, this technology does not necessarily bring improvement across the spectrum of the life cycle, so that infant mortality has ceased to be an effective measure of health status in much of the developed world. Therefore, because infant mortality rates are unreliable in some parts of South Texas and invalid measures of health in others, no great weight should be given them in estimating the overall health of the region. 
There are, of course, differences in infant mortality between the metropolitan and nonmetropolitan areas in South Texas. In the SMSAs, infant mortality rates for Mexican-Americans fell from 19.0 deaths per 1,000 live births in 1970 to 14.0 in 1975. In the non-SMSA areas, the drop was from 20.5 to 15.0 per 1,000 live births in the same period. There is likelihood that the figures are more reliable and valid in the non-SMSA areas than in the SMSA areas, resulting from fewer Mexican national mothers coming to rural areas to have children, and from a lack of sophisticated neonatal intensive care systems in rural hospitals. The lower socioeconomic status of people in rural areas, and the relative paucity of medical care, may explain the higher infant mortality rates in nonmetro­politan counties. 
Cause-specific infant mortality rates are calculated for 1975, comparing Anglos and Mexican-Americans. As may be seen in Table 13, Mexican-American infants have higher rates of death from infective and parasitic diseases, influenz.a and pneumonia, certain causes of mortality in early infancy, and avitaminosis and other nutritional deficiencies. All Anglo infant deaths from infective and parasitic diseases were due to enteritis and other diarrheal diseases, while Mexican-Americans suffered from a broad­er spectrum of those conditions. 
Deaths among persons under fifteen years of age are shown in Table 14. Certain causes of mortality in early infancy were the leading causes of death for both Mexican­Americans and Anglos, but they accounted for a larger percentage of Mexican-American deaths. Infective and parasitic diseases were greater causes of death among Mexican-Americans. 
In the young adult age group aged fifteen to twenty­nine, violence was the leading cause ofdeath to persons of both sexes and both ethnic groups. These deaths by violence (accidents, suicide, and homicide) accounted for 
80.29 percent of the Anglo male deaths and 81.69 percent of the Mexican-American male deaths .. This high ranking 
Table 14 ~ 
Five Leading Causes of Death to South Texas Residents by Age Group, Sex amt Ethnicity, 1975 3:: 
·~ Percent ofAll Cau1e1 Percent of A II Cawes ~· 
I 
Af181os Muican-A merlcrms A"6IOI Mexican-A merican1 >
a 
n
Cause ofDeath Males Females Malts Female1 Cau1e ofDeath Males Females Males Females 
:i. 
~ 
Individual• 14 yean of aae or youn1er n'"l91 n=l31 n•37l n•266 lndiYlduala 45 to 64 years or a1e n=l568 n•775 nc9J3 n•537 0 
::c:
Certain Causes of Mortality in Heart Disease• 37.95 20.90 35.05 26.07 g
Early Infancy 30.89 26.72 38.27 37.22 lschemic lfeart Diseue 35.72 16.00 30.12 19.55 ::;" Accidents 21.43 24.08 14.29 I 3.16 Other Heart Diseases 5.23 4.90 (4.93) 6.52 ::r Con1enital Anomalies 18.85 19.08 17.52 14.29 Death by Violence• 12.12 13.68 12.60 (5.21) Neoplasms, Total 4.71 9.16 2.91 (4.89) Accidents 5.42 (4.65) 8.65 (3.72) 0 
Influenza and Pneumonia 4.71 3.82 4.31 5.64 Suicide 6.12 8.52 (1.53) (0.56) ~ Infectious and Parasitic Diseases ( 1.56) .. (2.29) 2.97 5.27 Neopl~sms, Total 27.04 37.81 20.48 29.43 s· AU Other Causes 17.85 14.85 19.67 19.53 Cerebiova1eular Diseaae (3.32) 6.71 6.02 7.64 
tll 
Diabetes Mellitus (0.89) ( 1.94) (3.83) 7.45 0 lndividuala IS to 29 yean of a11e n•290 n• 99 n•349 n• 94 Cirrho~s of Liver (3.50) (3.13) 6.02 (4.10) ·=
-
::r
All Ot~er Cauaes 15.18 15.83 16.00 20.10 
Death by Violence• 80.29 64.17 81.69 54.25 Accidents 58.97 40.40 52.44 39.36 lncli'dcluala 65 yean or older n-3454 n•3360 n•1609 n•l764 Suicide 12.07 I 5.1 S 8.31 5.32 
r 
Homicide 9.25 8.62 20.92 9.57 Heart Diaeaae• 39.40 41.01 39.46 37.97 Neoplasms, Total 7.24 13 .13 3.44 11.70 lac:hemic Heart Diaeaae 34.19 35.65 33 .73 31.39 Infective and Parasitic Diseases (0.34) -2.29 (3.19) . Other Heart Di1eaae1 5.21 5.36 5.73 6.58 M.;or Cardiovucular Diaeues 3.10 4.04 3.44 11.70 Neoplplm1, Total 19.46 16.88 18.14 17.09 Complications of Prepancy -(2.02) -5.32 Cerebrova1eular Diaeaae 11.90 16.70 10.88 12.80 AU Other Causes 9.03 16.64 9.16 20.22 Diaeu-1 of arteries 4.46 5.24 (3.06) (3.04) 
Diabetes Mellitu1 (1.27) (2.11) 4.93 5.97 lndlriduala 30 10 44 yean of aae n•231 n•ll I n•249 n•l33 AU Other C1uae1 23.!l I 18.06 23.53 23.13 
Death by Violence• 44.60 30.63 53.81 21.81 Accidents 21.65 14.41 30.12 15.04 Suicide 14.29 16.22 (5.22) (0. 75) 
Homicide 8.66 -18.47 6.02 •ne c1tel0rin "HMrt DIM-.. and "D11th by Violenc." are placed ill thil table for the 
H..rt Diaeaae• 21.65 31.54 11.24 13.53 convenience of readen of thil report. They are not colllidered In the ranldna of tit• ten llChemic Heart Diaeaae 18.61 -7.23 9.02 leaclinl CIUIM. Other Hnst Diae11111 (3.04) 6.31 (4.01) 4.51 
Neoplum1, Tola! 13.85 25.23 5.22 16.31 ..Pial&na in brackets indicate that th• putlcular cau• wu not amona the leadina tea for 
Cmibrovaacular Diaeeae (4.76) (3.60) (3.21) 4.51 tat particular sex and •tllaic lfOUP· 
Diabetes M.Wtu1 (0.43) 3.60 (0.80) (3.01) 
Cinholia of Uver (I.73) (0.90) 7.63 (3.01) SOll?CI: Dita on death certlflcat• oblllnecl from th• Tua Dapartment of Health ll'" 
AU Other C1u111 12.!18 29.73 18.09 27.82 IOllfCll. 

.~ 
Mortality and Morbidity 
Table 15 

Reportable Communicable Disease Rate per 100,000 Population, 
Texas and South Texas, 1974-76 

S-iuth Texas  Balance of Texas  
Average  Average  
Disease  Number  Annual Rate  Number  Annual Rate  
Hepatitis, All Forms  2,552  41 .60  8,844  29.90  
Tuberculosis  1,902  31 .00  5,463  18.46  
Meningitis, Aseptic  204  3.33  698  2.36  
Amebiasis  117  1.91  344  l.16  
Typhus, Endemic  85  1.39  12  0.04  
Encephalitis, Infectious  70  l.14  77  0.26  
Brucellosis  23  0.38  71  0.24  
Leprosy  22  0.36  29  0.10  
Typhoid Fever  8  0.13  42  0.14  
Diptheria  4  0.07  12  0.04  

Source: Texas Department of Health Resources, Texas Morbidity This Week, 1974, 1975 and 1976 Annual Summaries. 
for violent death is not a complete surprise. The age group under examination is perhaps the healthiest in the life cycle. The diseases of early childhood are past and the degenerative conditions of old age have not yet come into play. However. the high ranking for homicides among Mexican-American men from fifteen to twenty-nine years of age. representing 21 percent of all deaths in that group, is important to note. 
Two other phenomena stand out in the fifteen to twenty-nine age group. First. about 5 percent ofdeaths to Mexican-American women in this age group resulted from complications of pregnancy, as opposed to 2 percent of deaths to the Anglo women. A partial explanation is that the Mexican-American women are at risk earlier and more often during this part of the life cycle. As shown earlier (Table 3). the age of Mexican-American mothers is, on the average, yoynger than that of the Anglo mothers; and the fertility rate for Mexican-American women is higher than for Anglo women in this age group. Lower incomes and in all probability lack of adequate nutrition and prenatal care are probably related to these differences in pregnancy-related deaths. The second nota­ble phenomenon within this age group is that infective and parasitic diseases cause a higher proportion ofdeaths among Mexican-Americans. 
Deaths among persons age thirty to forty-four are also shown in Table 14. Death by violence is the leading cause for Anglos of both sexes and for Mexican-American men, but cancer is the leading cause ofdeath for Mexican­American women. 
It is within the forty-five to sixty-four age group that degenerative diseases begin to play an important part in the death experience. This may be seen in the increase in deaths from cancer and heart disease, with the exception of heart disease among Anglo women. Accidents play a smaller part in the forty-five to sixty-four death experi­ence, and homicide is not among the five leading causes of death in any age group. Deaths from cerebrovascular disease, diabetes mellitus, and cirrhosis of the liver occur among Mexican-Americans more often than among An­glos during this period. 
Deaths to those over sixty-five are also shown in Table 14. With the exceptions of diabetes mellitus and disease of the arteries, the death experiences of Mexican­Americans and Anglos are fairly similar. This similarity is apparently the case among the elderly populations of all countries and all ethnic and socioeconomic groups. 
Morbidity 
The occurrence ofcertain communicable diseases must be reported, by law, to public health authorities. Some barriers to actual reporting, or even to discovery, are discussed earlier in this report. 
Table 15 compares communicable disease rates for South Texas with rates for the balance of Texas in the combined years of 1974, 1975, and 1976. For each disease. except typhoid fever, rates were higher in South Texas than elsewhere in Texas. The four most prevalent diseases (hepatitis, tuberculosis, meningitis, and amebiasis) are presented by county in Table 16. 
Map 3 shows the distribution of hepatitis in South 
Table 16 
Morbidity Rates per 100,080 Population for Hepati~ Tuberculollis, Meningitis and Amebiasis in South Texas Comaties, 1975 
County 
Aransas 
Atascosa 
Bandera 
Bee 

* 	
Bexar Brooks 

* 
Cameron * 

Comal 
Dimmitt 
Duval 
Edwards 
Frio 
Gillespie 


* 	
Guadalupe 

* 	
Hidalgo Jim Hogg 1.28 Jim Wells Karnes Kendall Kenedy Kerr Kinney Kleburg La Salle Live Oak McMullen Maverick Medina 

* 	
Nueces Real Refugio 

* 	
San Patricio Starr Uvalde Val Verde 

* 	
Webb Willacy Wilson Zapata Zavala 


South Texas Balance of Texas 
Hepatitis (All Forms) 
37.0 
7.2 
14.8 
23.9 
37.8 
43.5 
55.0 
22.1 
122.2 
2.6 
53.4 
3.9 
36.8 
45.8 
7.1 
4.8 
23.1 
9.6 
5.2 
52.8 
27.9 
57.7 
10.3 
24.5 
35.7 
31 .8 

43 .7 


52.5 
93.0 
390.9 
41.6 
29 .9 

Tuberculosis 
19.9 
34.2 
7.4 
34.4 
19.5 
108.7 
70.5 
13.0 
51.9 
23 .6 
30.5 
13.1 
8.9 

52.6 
27.9 
23.8 
52.4 
18.2 
15.3 
11.5 
10.4 
85 .8 
32.3 
23.4 
20.6 
49.1 
64.6 
18.4 
59.0 
46.4 
46.0 
33.6 
18 .9 
38.4 
31.0 
18.5 
Meningitis Amebiasis (Aseptic) 
2.9 
1.8 
7.4 
1.5 
6.4 1.0 
3.6 
10.3 
1.3 
2.0 .4 5.3 
2.0 
1.0 

3.3 
1.7 


2.4 
4.8 
1.7 
2.9 1.5 
2.7 .7 
.7 1.4 
3.4 
1.7 
1.1 .4 
2.3 
7.8 
3.3 1.9 
2.4 1.6 
* Denotes county in SMSA Soun.:es: 

Texas Department of Health Resources, Texas Morbidity This Week, Annual Summaries for 
1974, 1975 and 1976. Office of Information Services, Office of the Governor, Population Projections for Texas Counties: 1975-1990, Austin, 1972. 

Mortality and Morbidity 

Map 3 
Distribution of Hepatitis in South Texas, 1974-1976 


County Rates as Percent of Texas Rate: 
D 0-50 ~/, 51-100 -150
Ifl I I01 151-200
=== 
II 200 or more 
Total Texas Rate: 31.65 cases per 100,000 persons South Texas Rate: 41.60 cases per 100,000 persons 
Mexican-American Health Care in South Texas 
Map 4 Distribution of Tuberculosis in South Texas, 1974-1976 


····· 
County Rates as Percent of Texas Rate: 
D 0-so 111 I 51-1 oo % 101-150 
• 
151-200 
200 or more 
Total Texas Rate : 20.46 cases per 100,000 persons 
South Texas Rate : 31.00 cases per 100 ,000 persons 

Mortality and Morbidity 

Map5 Distribution of Aseptic Meningitis in South Texas, 1974-1976 
County Rates as Percent of Texas Rate: D 0-50 

[IJ]

• 
51-100 
101-200 
200 or more 

Total Texas Rate: 2.51 cases per 100,000 persons 
South Texas Rate: 3.33 cases per 100,000 persons 

Map6 
Distribution of Amebiuis in South Texas, 1974-1976 

.·. 

County Rate as Percent of Texas Rate: 
D  0­ 50  
[]]]  51·100  
a  101-150  
~	151-200 200 or more


• 

Total Texas Rate: 1.28 cases per 100,000 persons 
South Texas Rate: 1.91 cases per 100,000 persons 

I 

Texas. In 1975,• the overall Texas rate was 31.65 cases per 100,000 persons. Zavala, Dimmit, and Wilson coun­ties had over 200 percent of the Texas rate. Rates were generally high in most of the counties along the border and in the urban counties. 
Map 4 shows the distribution of tuberculosis. The overall Texas rate in 1975 was 20.46 per 100,000 persons. Eleven South Texas counties had over 200 percent of this rate and five had over 150 percent. Rates were particularly high along the border. 
Map 5 shows the distribution of aseptic meningitis in South Texas. The statewide rate for this disease in 1975 was 2.53 cases per 100,000 persons. The rate for South Texas was 3.33 per 100,000 persons. Six counties exceeded the Texas statewide rates. Most of these were in the northern area of the region, including Bexar and sur­rounding counties. 
Map 6 shows the distribution of ame~iasis across South Texas. The 1975 Texas rate, including South Texas, was 1.28 cases per 100,000 population. Thirteen counties in South Texas exceeded this rate in 1975. Hidalgo, Cameron and Bandera counties had over 200 percent of the state rate, and Kendall County had over 150 percent of the state rate in 1975. 
Rates of encephalitis infections (see Table 15) were 

much higher in South Texas ( 1.14 per 100,000 population) 
than in the balance of the state (0.26). Rates of leprosy 
and diptheria also were higher in South Texas. Ofninety­
seven cases of endemic typhus reported in Texas from 
1974 through 1976, eighty-five (88 percent) were reported 
in South Texas. 
Summary 
Clearly, Mexican-Americans and Anglos have very different mortality and morbidity experiences. These differences are in part due to the older age of the Anglo population (30.2 median years as opposed to 19.0 years for Mexican-Americans). However, the data for 1970 developed by Fonner for all Texas residents, and the data for 1974, 1975, and 1976 studied here, clearly indicate that age alone does not account for the differences in mortality between the two ethnic groups. These differen­ces occurred in all age groups, but were less pronounced in the oldest age group. The following are the major dissimilarities between Anglos and Mexican-Americans given control for age: 
I. 	Mexican-American men were more likely to have "death by violence" (including accidents, suicides, and homicides) ranked in leading causes of mortality for all but the very youngest and very oldest age groups. Homicides constituted a significant propor­tion of these deaths. Suicide, however, was more 

•Signifies data for 1974, 1975, and 1976 combined. 
Mortality and Morbidity 

often a leading cause of death among Anglos, parti­cularly Anglo women. 
2. 	
Mexican-American women were more likely than Anglo women to have many of the degenerative ailments. This difference was not found between Anglo and Mexican-American men. 

3. 	
Diabetes mellitus and infective and parasitic diseases were more likely to be listed as major causes ofdeath among Mexican-Americans of nearly all age groups. 

4. 	
Rates of reportable communicable diseases were higher in South Texas than in the rest of Texas. Given the etiologies of many of these ailments, they are more likely to occur among poor people. Most of the poor people in South Texas are Mexican-Amer­icans. 

5. 	
Mexican-Americans appear to be dying ofa relatively broader spectrum of ailments and conditions than are Anglos. 


Conclusions 
Having demonstrated that differences in the mortality experiences of Anglos and Mexican-Americans cannot be explained· entirely by age differences, other explana­tions must be sought. Possible explanations fall into three basic categories of differences: socioeconomic con­ditions, genetic composition, and cultural traits among the two ethnic groups. 
Socioeconomic factors offer the best explanation for most differences in mortality experiences. Many more Mexican-Americans than Anglos are poor and most of the illnesses and conditions found are associated with poverty. Tuberculosis and infective and parasitic diseases may relate to poor housing, lack of pure water, poor nutrition, and similar factors. Diabetes mellitus can be treated and often controlled, but usually, interaction with physicians is necessary for diagnosis. Socioeconomic status may also explain the higher homicide rates among Mexican-American men, as homicide is more likely to occur in low-income urban neighborhoods. The relatively high incidence of accidents among Mexican-American men may be explained in part by the fact that they are more often employed in low-paying and hazardous work (especially in agriculture). 
Culture may play a role in differences between groups in several ways. The religion of Mexican-Americans may serve to reduce the number of suicides. Different views of what constitutes "good" or "bad" health may prevent individuals from seeking medical care until an illness becomes very severe. Both poverty and culture may determine diet, which affects health status. 
Genetic differences may occasionally explain differen­ces in health conditions between ethnic groups. One example is sickle cell anemia, a condition found among some Blacks, but extremely rare among other groups. Research in this area is limited. However, to date, no such differences are known to exist between Anglos and Mexi­can-Americans, although genetics may in part explain differences in diabetes rates. 
Thus, socioeconomic factors appear to be the major determinants in the different health experiences of Mexi­can-Americans and Anglos. Cultural or genetic differen­ces may exist which cause some of the differences which we observe. Whether these differences cause worse or better health status for Mexican-Americans is impossible for us to determine. 
References 
1Edwin Fonner, Jr., "Mortality Differences of 1970 Texas 
Residents; A Descriptive Study" (Master's thesis, School of 
Public Health, The University of Texas Health Science Center 
at Houston, 1975). 

2R. W. Buechley, "A Computer Program that Distinguishes 
Spanish Surnames," unpublished report, New Mexico Cancer 
Center, University of New Mexico, Albuquerque, N.M .• 1973. 
cf. Fonner, "Mortality Differences," p. 19. 

JThe fact that Mexican-Americans in Fonner's study and in 
this study had higher rates than Anglos for death from symp­
toms and ill-defined causes supports this thesis. 

4 Harold F. Dorn, "Mortality,'' in The Study of Population: 
Inventory and Appraisal, ed. P.M. Hauser and O.D. Duncan 
(Chicago: University of Chicago Press, 1959), pp. 437-71. 

5U.S., Department of Health, Education, and Welfare, Na­
tional Center for Health Statistics, International Classification 
of Diseases, 8th ed. (Washington, D.C.: U.S. Government · Printing Office, 1%8). 
6Charles Teller and Steven Clyburn, "Texas Population in 
1970: Infant Mortality," Texas Business Review 40, no. IO 
(October 1974), pp. 240-46. 

7Texas Department of Health Resources, Morhidity This 
Week, 1974, 1975, and 1976, Annual Summaries. 

KFonner's method of standardizing for age with nineteen age intervals: 
19 Directly standardized death rate = I: mjpj x I 00,000 j=l p 
where . m = d.p. , the age specific death rate in the jth age inter-
J J . val for each sex and ethnic group being adjusted; 
P· = 	number of individuals in the jth age interval of
J 
the standard population; 

p 	total number of individuals in the standard popu­lation 
9National Academy of Sciences, Institute of Medicine, Panel on Health Service Research, David M.Kessner, Project Direc­tor, Infant Death: An Analysis by Maternal Risk and Health Care, Washington, D.C.. 1973, p. 141. 






Chapter 3 
Conditions in Urban Low-Income Areas in South Texas 
In earlier chapters we examined socioeconomic and health conditions in South Texas, in comparison to the rest of Texas, and among Mexican-Americans in compar­ison to other persons in South Texas. This chapter focuses on urban areas in South Texas. Socioeconomic and health conditions are reported with special attention to Mexican-Americans and to residents of very poor neighborhoods. 
Relationships among social, economic, and health conditions are complex and poorly understood. Thus, this study bypasses the issues of how these conditions relate and assumes a purely descriptive stance in hope of stimulating public dialogue and actions toward improv­ing human conditions. 
Urban Areas 
South Texas contains five Standard Metropolitan Sta­tistical Areas (SMSAs) as defined by the U.S. Bureau of the Census. Three of these cover single counties; two extend across county lines. In this study, only the princi­pal counties of each SMSA are considered. Northern­most is San Antonio, Bexar County (see Map 7). South­east, on the coast, is Corpus Christi, Nueces County. At the southern tip of Texas, at the mouth of the Rio Grande, is Brownsville-Harlingen-San Benito, Cameron County. Immediately up-river is McAllen-Pharr-Edin­burg, Hidalgo County. Finally, to the west is Laredo, Webb County. For the reader's convenience, these areas are discussed in this order throughout the chapter. 
According to the 1970 Census, these five urban counties had a joint population of 1,462, 766 (see Table 17). The principal cities, for which the SMSAs are named, con­tained 1,099,531 persons, more than 75 percent of the counties' population. Bexar County was by far the most populated, containing 830,460 persons in 1970. Almost four-fifths of Bexar County residents lived in San Antonio. Nueces County had 237 ,544 persons, with 8(;. l percent living in Corpus Christi. 
Cameron and Hidalgo counties are not typical for Texas SMSAs, as they do not have single central cities. Brownsville, the largest city in Cameron County, con­tained only 37.4 percent of the county's 140,368 residents. Hidalgo County encompasses several small to medium­sized cities. In 1970, only 21 percent of Hidalgo County residents lived in McAllen, the largest city. Only 38.9 percent lived within the three largest cities. Thus, Hidalgo and Cameron counties exhibit a curious blend of urban and rural characteristics. The dispersed population sug­gests a rural community. However, the overall popula-
Table 17  
Population of Urban Areas in South Texas, 1970  
County  Principal City(ies)  City(ies) as percent of County  
Bexar  830,460  San Antonio  654,153  78.8%  
Nueces  237,544  Corpus Christi  204,525  86.1%  
Cameron  140,368  Brownsville-Harlingen-San Benito  101,201  72.1 %  
Hidalgo  181,535  McAllen-Pharr-Edinburg  70,628  38.9%  
Webb  72,859  Laredo  69,024  94.7%  
TOTAL  l,462,766  1,099,531  75.2%  
Source: U.S. Census, 1970  


Mexican-American Health Care in South Texas 
Map7 
Principal Metropolitan Counties in South Tens 

Note that only the most populated county of each SMSA is examined in this chapter. 
Urban Low-Income Areas 
Table 18 

Population Changes in Urban Counties in South Texas, 1960-1975 
County 1960 1970 1960-1970 1975 1970-1975 %Change Estimates % Change 
Bexar 687,475 830,460 +22.3% 862,900 + 3.9% 
Nueces 221,573 237,544 + 7.2% 256,100 + 7.8% 
Cameron 151,098 140,368 -7.1 % 135,800 3.3% 
Hidalgo 180,904 181,535 + 0.3% 175,600 -3.3% 
Webb 64,791 72,859 +12.5% 92,700 +27.2% 
TOTAL 1,205,841 1,462,766 +21.3% 1,523,100 + 4.1% 
Sources: 
U.S. 
Census, 1960 

U.S. 
Census, 1970 



Office of Information Services, Population Projections for Texas Counties 1975-1990, Office of the Governor of Texas, 
Austin,May , 1972. 

tion and density of both city and noncity areas clearly Table 19 compares population changes of the three evidence the urban nature ofthese counties. Webb County largest South Texas border cities-Brownsville, McAllen, is more similar to other SMSAs, having a central city, and Laredo. The data suggest that after rapid urban Laredo, which contained 94.7 percent of the county's growth in the 1950s and 1960s, that growth tapered off by 1970 population. 1970. Although the population of Cameron and Hidalgo 
From 1960 to 1970, the total population of these coun­counties reportedly decreased from 1960 to 1970, the ties increased by 21.3 percent (see Table 18). The greatest population of their largest cities increased. This suggests increase occurred in Bexar County (22.3 percent). Webb that, although there is some out-migration from the two County increased by 12.5 percent. Relatively small increases counties, there also is in-migration to the cities from occurred in Nueces County (7.2 percent) and Hidalgo either rural areas in the two counties, elsewhere in Texas County (0.3 percent). Cameron County reportedly de­or the U.S., or from Mexico. creased in population by 7.1 percent. 
No count of population is available since 1970. Popu­

Methodology
lation estimates, which are tenuous at best, were formerly 
available from the Office of Information Services in the This chapter examines socioeconomic and health con­
Office of the Governor of Texas. 1 The last estimates ditions among Mexican-Americans and in selected low­
available for 1975 suggest that the combined population income areas within the five urban counties. The descrip­
of the five counties increased by 4.1 percent from 1970 to tive data presented here are from several sources. 
1975. The greatest increase was in Webb County (27.2 Data on social and economic conditions are from the 
percent). The combined population of both Hidalgo and 1970 Census Reports on Standard Metropolitan Statisti­
Cameron counties was estimated to decrease by 3.3 per­cal Areas. The data describe population, ethnic composi­
cent from 1970 to 1975. tion, sex and age distribution, educational achievement, 
Such a decrease in population, if these projections , income, and employment and housing conditions. For based on Census data are to be accepted, is curious. each variable, comparison is made between ethnic groups However, there are reasons to doubt their accuracy. county-wide and between the lowest income neighbor-· First, the Census may be expected to undercount minori­hoods and the balance of each county. ties, 2 and the border area is largely inhabited by Mexican­Data from three sources describe birth rates; infant, Americans. Second, other population subgroups, such as fetal, and maternal mortality rates; and incidences of young adult males, migrant farm workers, and illegal hepatitis, tuberculosis, gonorrhea, syphilis, amebiasis, aliens, are likely to have been undercounted. , salmonella, and shigella. Data on Bexar County were 
Table 19 
Population Increases in Brownsville, McAllen and Laredo, 1910-1970 
Brownsville McAllen Laredo 
% % % 
Year Population Increase Population Increase Population Increase 
1910  10,517  
1920  11, 791  12.1  5,331  
1930  22 ,021  86.8  9,074  
1940  22,083  0.3  11,8 77  
1950  36,066  63.3  20,067  
1960  48,040  33.~  32,728  
1970  52,522  9.3  37 ,636  
Source: 1970 U.S. Census  

published by the San Antonio Metropolitan Health Dis­trict.3 Information on Nueces County was made available by the Corpus Christi-Nueces County Health Depart­ment.4 Data on the three bordeF counties (Cameron, Hidalgo, and Webb) are from a study by Reuel H. Waldrop and John G. Bruhn.s That study identified low­income areas, block by block, in selected border cities. Selection of low-income areas was by visual assessment of external housing conditions.6 Health conditions over a two-year period, 1972 and 1973, were then compared for low-and high-income areas of each city. 
The available health information usually covers more than a single year, and is more rece~t than 1970. Where data are available for more than a single year, averages are used to determine incidences of health conditions. A more serious problem results from the lack of recent population counts which might be used to determine rates for the respective conditions. Although population estimates are available for entire counties,7 no estimates are available for subcounty areas, the subject of this report. Thus, in computing rates for most health condi­tions, a 1970 population denominator is used. 
Naturally, some error is expected to result from this procedure. To the extent that the population of the respective counties increased between 1970 and the year for which health conditions are reported, the rates pre­sented in this report are inflated. Thus, in comparing counties, the reader should note that if the 1975 popula­tion estimates are accepted, rates are likely to be inflated in Bexar, Nueces, and Webb counties and deflated in Cameron and Hidalgo counties. 
However, because this study compares low-income areas with overall counties, the approach inhibits some bias. If the population of a selected low-income area rates established for low-income areas and overall coun­ties are valid. Only if the population of the low-income area increased in proportion to the overall county popu­lation are the differences between established rates · · suspect. 
14,855  
22,710  52.9  
70.2  32,618  43.6  
30.9  39 ,274  20.4  
69.0  51 ,910  32.3  
63.1  60,678  16.9  
15.0  69,024  13.8  

In Travis County, which is north of the South Texas area, the U.S. Bureau of the Census conducted a test census in 1976. Although the population of Austin, Tra­vis County's major city, increased by 21.5 percent from 1970 to 1976, the population of the three lowest income census tracts actually decreased by an overall 12.8 per­cent. Of these three census tracts, Tract 9, which was 70 percent Mexican-American in 1970, decreased in popula­tion by 16.4 percent. These decreases occurred despite an overall proportional increase in the city's Mexican­American population. If similar population decreases occurred in low-income areas of South Texas urban counties, then the differences found in the rates of poor health conditions between low-income areas and overall counties are understated in this report. 
In greatest jeopardy are data comparing ethnic groups for each county. As discussed earlier, the number of Mexican-Americans is very likely increasing in propor­tion to the total South Texas-. population. Thus, rates. comparing Mexican-Americans and Anglos should be viewed with some skepticism. 
Despite the above-stated limitations to the data pre­sented in this report, conditions among Mexican-Ameri­cans and among other ethnic groups differ so consistently, and to such extraordinary degrees, that their significance cannot be dismissed. 
Selecting Low-Income Areas 

decreased or held constant in proportion to the popula­No entirely consistent formula was used to select low­tion of the overall county, then the differences between income census tracts. The values used in selection were 
Urban Low-Income Areas 

that the census tracts be at the lowest end of the scale in terms of median family income; that the population of the census tracts be predominantly Mexican-American; and, if at all possible, that the census tracts be grouped to form a .. neighborhood." Limitations also resulted from the variable availability of data on health conditions in each county. 
In Bexar County, seven census tracts were selected for study: tracts 1103, 1105, 1106, 1601, 1701, 1702, and 1703. The median family income in these census tracts ranged from $2,347 to $4,738, and the tracts roughly form a neighborhood near the downtown area of San Antonio (see Map 8). Several other census tracts had comparable median family incomes, but they were excluded from consideration for several reasons. Some contained large numbers of poor black residents, which might have clouded data concerning Mexican-Americans. Other tracts were excluded because they are at the periphery of what might be called a "neighborhood." 
In Nueces County, six census tracts were selected: 
Map 8 
Selected Low Income Census Tracts for Bexar County 



1701 
West Commeree 

1702 
1703 
Tampico 
Laredo 
1601 




OrientaJ 

tracts 4, 9, IO, 11, 15, and 16. Median family incomes in these tracts ranged from $3,510 to $5,547. They form a neighborhood in downtown Corpus Christi (see Map 9). Tracts 2 and 3, in the same area, were excluded because they have very few residents. Tract 17, with comparable income, was excluded because ofa large number of Black residents. Tract 50, also with comparable income, was excluded because it lies outside the city limits. 
In Cameron, Hidalgo, and Webb counties, along the Rio Grande, census tracts were selected to duplicate as much as possible the areas identified as low-income by Waldrop and Bruhn ( 1975). However, because that study grouped areas by blocks rather than by census tracts, the study areas do not entirely coincide. 
In Cameron County, a modest fit was achieved. Twelve census tracts (105, 109, 110, 111, 116, 117, 128, 134, 137, 138, 139, and 140) were selected (see Map 10). Only those two portions of the tracts which are situated within the cities of Brownsville, Harlingen, and San Benito (the areas studied by Waldrop and Bruhn) were included for study.• Several census tracts or portions of census tracts located outside the three cities were excluded despite their low incomes. The decision to exclude rural census tracts may obscure disparities within the county. The median family incomes of the twelve selected census tracts ranged from $3,118 to $4,~I. 
A less than satisfactory fit was achieved in Hidalgo County. Census tracts 201, 204, 205, 206, 211, 215, 216, and 237 were chosen for study (see Map 14). Tracts 201 and 204 are outside the three largest cities (McAllen, Pharr, and Edinburg), but were included in this study because they cover much of the city of Mission, which was studied by Waldrop and Bruhn. The portion of tract 237 lying outside Edinburg was included. However, only 
*Maps 11, 12, and 13 compare the low-income areas selected by census tracts with low-income areas selected by blocks for Browns­ville, Harlingen, and San Benito. 

Map9 
Selected Low-Income Census Tracts for Nueces County 


-------Corpus Christi City Limits Low Income Census Tracts 
the portion oftract 205 which lies within the McAllen city limits was included.• Several other census tracts were excluded despite their low incomes because data on health conditions were not available for those areas. The median family incomes in the selected census tracts ranged from $3, 711 to $4, 101. 
•Maps 15, 16, and 17 compare low-income areas selected by census tracts and by blocks. Note that no census tracts include the cities of Weslaco and Mercedes, which were studied by Waldrop and Bruhn. 
Urban Low-Income Areas 

In Webb County, an excellent fit was achieved. Tracts 
' I, 3, 4, 5, 6, 7, 8, 9, 12, 13, and 14, with median family incomes ranging from $2,908 to $6,320, form a neighbor­hood covering most of Laredo (see Map 18). The area very closely duplicates the low-income area studied by Waldrop and Bruhn. Tract 4, with a median family income of $6,320, was included because most of it was identified as low-income by Waldrop and Bruhn. As the tract contained only 222 persons in I 970, the relatively high income is not expected to affect results significantly. 

Mexi:an-American Health Care in South Texas 
Map 11 
Low Income Areas in Brownsville 


-------High Income Area Boundary ----City Limits 
Urban Low-Income Areas 

Map 12 
Low Income Areas in Harlingen 

--. 

I 
' 

I I 
I I I 
,I I I _________, 
Our Selected Areas 
Waldrop & Bruhn 
-----High Income Area Boundary 
---City Limits 

Map 13 Low Income Area in San Benito 
Our Selected Areas 
~ Waldrop&. Bruhn 
-------High Income Area Boundary ---City Limits 
Urban Low-Income Areas 

Map 14 
Cities in Hidalgo County 


· th Texas 
Mexican-Amenca

. n Health Care in Sou . ­
Low Income MapAreas151·n Edinburg 
Our Selected Areas ~Waldrop & Bruhn --High Income Area Boundary ____ City Limits 
Urban Low-Income Areas 

Map 16 
Low Income Areas for McAllen, Pharr, and Mission 

McAllen 


Our Selected Areas Waldrop & Bruhn -----High Income Area Boundary ---City Limits 



.... 
.. .. 
..... 
... 
... Wesl~co 
' ' ' ' 
...... 
I ',
I .. I ' 

~ 
Map 17 Low Income Areas in Weslaco and Mercedes 
~ ~ 

£' 
::l 
> I 
3 
(1) 
"'1 
~· 

::l 
(1) 
= 
e:..
....
::r 
Q
n "'1 
(I' 
I I 
I --l 
::l
... -... 
C/'J
0 
-
s 
::r 
;;l 
•I I .,:• "' ;.: 
Ill 
I ,-•I
I I I I 
I 

J I
I 

~~·-I•-1I 
~ 
'"------­
-,-~
' \ 
,~ ~: ~: L-~ ! I ~ 
I 


~ 
Waldrop & Bruhn
~ 
High Income Area Boundary 
City Limits 

Note : No Low Income Areas were selected for Welsaco and Mercedes. 
M l'l'l'CU l.'.S 



Urban Low-Income Areas 

Map 18 
Low Income Areas for Webb County 

WEBB COUNTY 


Our Selected Areas 
Waldrop & Bruhn High Income Area Boundary 
Mexican-American Health Care in South Texas 
Socioeconomic Conditions 

The forty-four selected low-income census tracts coti­tained 16. 7 percent of the total 1970 population ofthe five counties (see Table 20). Jn Bexar County, the low-income areas chosen represented only 7.1 percent of the county's population. In Webb County, the areas represented 65.2 percent of the population. 
Mexican-Americans comprised 54.2 percent of the combined 1970 population of the five counties. The border counties had proportionately more Mexican­American residents than did the nonborder counties. In Webb County, 85.6 percent of the residents were Mexican­American as compared to 43.6 percent of Nueces County residen!s. 
The border counties had very few Blacks. However, a sufficient number of Blacks lived in Bexar and Nueces counties (6.8 percent and 4.6 percent) to make difficult a direct comparison of Mexican-Americans to the balance of the population. . For these two counties, data is pre­sented fo r Blacks when available and informative. 
Mexican-Americans comprised 91.1 percent of the 
total 1970 population of the selected low-income census 
tracts (see Table 2L). The smallest.percentage ofMexican-· 
Americans occurred in the Nueces County low-income 
area ( 81.3 percent); J1.4 percent of the residents in this 
area were Black. Although Blacks comprised more than a 
minute proportion of low-income area residents in both 
Nueces and Bexar counties, on the whole the selected 
low-income areas may be viewed as Mexican-American 
neighborhoods.· 

Within each county, Mexican-Americans were gener­ally younger than the overall 1970 population (see Table 22). The median age for Mexican-Americans ranged from 18.4 years in Hidalgo County to 20.3 years in Webb County. The median age for the overall county populations ranged from 22.0 years in Hidalgo County to 
24.1 vears in Nueces County. Within the low-income areas-in each county, Mexican-Americans were slightly older than Mexican-Americans elsewhere in that county, although still younger than the total population. 
In all but one county, more than 50 percent of the Mexi­can-American residents in 1970 were under age twenty (see Table 23); in Webb County, the percentage was49.5. In low-income areas, a slightly smaller percentage of Mex ican-Americans were under age twenty. In Bexar and -..;ueces counties, there were relatively fewer Black persons under age twenty in low-income areas than in other county areas. Because very few Black persons lived in border counties. data is not presented for Blacks in those areas. 
Relatively fewer Mexican-Americans county-wide were age forty-five or older than were the rest of the counties' inhabitants (see Table 24). The Mexican-Americans in low-income areas were more often older than Mexican­Americans elsewhere in the counties. A large proportion of Black persons in low-income areas of Bexar a~ Nueces counties were age forty-five or older ( 40.4 percent and 34.4 percent). 
Lack of formal education was widespread in South Texas urban areas, especially among Mexican-Americans. This was particularly so in low-income areas. The most serious case was Hidalgo County, in which 59.3 percent of all persons twenty-five years of age and older had not completed ninth grade (see Table 25). Of the Mexican­Americans in that age group, 75. 7 percent had less than a ninth grade education. For residents of low-income areas of Hidalgo County, tile corresponding figure is 77.5 per­cent. Black persons (in Bexar and Nueces counties)appear relatively well educated, at least in relation to the first nine years of schooling. 
A tremendous disparity in income is evident. The 
Table 20 
Population of Selected Low-Income Areas 1970 
Mexican-
County %Black %Anglo
%A .
mencan 
Bexar 91.8% 4.9% 3.3% 
Nueces 81.3% 11.4% 7.3% 
Cameron 92.8% 0.7% 6.6% 
Hidalgo 93.9% 0.3% 5.8% 
Webb 93.6% 0.1% 6.3% 
TOTAL 91.1% 3.2% 5.7% 
Source: U.S. Census, 1970 
Table 21 
Ethnic Composition of Selected 
Low-Income Areas, 1970 

County Low-Income Area %ofCountyPopulation 
Bexar 59,355 7:1% 
Nueces 37,564 15 .8% 
Cameron 60,081 48.2% 
Hidalgo 39,378 21.7% 
Webb 47,487 65.2% 
TOTAL 243,865 16.7% 
Source: U.S. Census, 1970 

Urban Low-Income Areas 

Table 22 
·Median Ages of Mexican-Americans in Low-Income Areas 1970 
Low-Income Areas County-Wide Mexican-Mexican­
County All Persons

American American 
Bexar 20.8 20.7 19.9 
Nueces 19.9 22.7 19.2 Cameron 20.8 19.9 18.7 Hidalgo 19.0 19.9 18.4 Webb 20.5 21.5 20.3 Source: L'.S. Census, 1970 
Table 23 Percent of Persons Under Age 20 by Ethnicity, 1970 
Low-Jn come Area  County-Wide  
County  Mexican-American  Black  All Persons  Mexican-American  Black  
Bexar  48.8  30.1  47.1  50.2  44.0  
Nueces  50.6  43.4  47.5  51.6  44.9  
Cameron  49.8  52.9  
Hidalgo  53.4  53.6  
Webb  47.3  49.5  

Source: C.S. Census, 1970 

Table 24 Percent of Persons Age 45 and Older, by Ethnicity, 1970 
Low-Income Area County-Wide Mexican-Mexican-
County Black All Persons Black
American American 
Bexar 25.9 40.4 27.7 19.2 25.5 Nueces 21.8 34.4 25.7 17.4 26.3 
Cameron 22.9 19.0 Hidalgo 23.8 18.4 Webb 25 .5 23.8 
Source: U.S. Census, 1970 
All Persons 
24.0 
24.l 
n.o 
21.0 
22.0 
All Persons 
42.4 
43 .0 
41.3 
48.2 
46.5 
All Persons 
25.2 
24.7 
25.5 
23.8 
23.5 

Table 25 P\!rcent of Persons 25 Years and Older with Less Than Ninth Grade Education, 1970 
Low-Income Areas  Mexican- 
County  All Persons  American  
Bexar  74.6  59.3  
Nueces  64.3  59.3  
Cameron  70.2  69.5  
Hidalgo  77.5  75.7  
Webb  67.5  63.1  

Source: U.S. Census, 1970 

Table 26 
Median Family Income in Dollars, 1970 

Low-Income Areas 
Mexican-
County All Families American 

Bexar 4244 6495 Nueces 4574 5949 Cameron 3780 4074 Hidalgo 3735 3958 Webb 4100 4445 Source: U.S. Census, 1970 
Table 27 Average Persons per Household, 1970 
Low-Income Areas Mexican­
County 	All Households American 

Bexar 3.71 4.21 Nueces 3.76 4.36 Cameron 4.16 4.64 Hidalgo 4.09 4.77 Webb 4.09 4.25 
Source: U.S. Census, 1970 
County-Wide 
Black  All Person1  
34.3  34.6  
37.8  32.9  
53.1  
59.3  
57.5  

County-Wide Black All Families 
5474 	8045 
5158 	8168 5068 4776 4978 
County-Wide Black All Households 
3.20 	3.40 
3.32 	3.48 
3.92 
4.14 
4.00 
Urban Low-Income Areas 

median family incomes for counties in 1970 ranged from $4.776 in Hidalgo County to $8,168 in Nueces County (see Table 26). Among Mexican-American families, medi­an income ranged from $3,958 to $5,949 for the same two counties. Families in low-income areas fared only a little worse than Mexican-Americans throughout each county. While median income is computed for Black families only in Bexar and Nueces counties, Black families in these areas appear to earn less than Mexican-American families. 
The measure of median family income is qualified by the size of families. Although data on family size is not available, data on size of households may have some bearing (see Table 27). In 1970 Mexican-American house­holds were larger than other households, suggesting an even more serious economic situation than is suggested by family income figures alone. Black households (in Bexar and Nueces counties) were generally smaller than other households. 
Another view of the extent of poverty is obtained from figures on the percent of families with incomes below poverty level (see Table 28). The county with the least extensive poverty in 1970 was Bexar County, where 15.9 percent of all families had incomes below poverty level. Of Mexican-American families in Bexar County, 25.1 percent lived below the poverty level. Hidalgo County had the most extensive poverty, with 42.0 percent of all families and 52.8 percent of Mexican-American families having incomes below the poverty level in 1970. Pov­erty in selected low-income areas was more extensive than poverty among Mexican-Americans county-wide. 
The percent of the civilian labor force which was unem-
Table 28 
Percent of Families Below Po-verty Le-vel, 1970 

County -Wide 

Low-Income Areas  
County  A II Families  Mexican-American  Black  All Families  
Bexar  43.5  25.1  30.1  15.9  
Nueces  40.8  30.6  33.5  17.1  
Cameron  52.1  49.7  38.5  
Hidalgo  55.2  52.8  42.0  
Webb  47.6  43 .6  38.4  

Source: U.S. Census, 1970 Table 29 Percent of Ci"Vilian Labor Force Unemployed, 1970 
County-Wide Low-Income Areas 

Mexican­County . All Persons Black All Persons
American 
Bexar 7.7 4.8 5.8 4.2 Nueces 6.1 5.4 3.7 4.2 Cameron 8. 9 7.9 6.6 Hidalgo 7.5 7.1 
5.9 Webb 7.6 7.1 
6.8 
Source: U.S. Census, 1970 

Mexican-American Health Care in South Texas 
ployed in 1970 is also disparate (see Table 29). Mexican­Americans were more often unemployed than the general population, and the highest unemployment rates occurred in low-income areas. From data on Bexar and Nueces counties, Black persons appear to have been employed less often than Mexican-Americans in Bexar County, and more often in Nueces County. 
Mexican-American homes in 1970 were much more crowded than the homes of the general population (see Table 30). "Overcrowding" is measured as the percent of occupied housing units with more than one person per room in 1970. Occupied housing units in low-income areas were much more often overcrowded than homes elsewhere in each county. With the exception of Bexar County, homes in low-income areas were slightly less often overcrowded than were Mexican-American homes in general throughout each county. This outcome may result from the slightly greater proportion of older per­sons who lived in low-income areas and who may have lived alone in more cases. 
Table 31 shows figures which represent the percent of all occupied housing units lacking some or all plumbing facilities. Relatively few homes in Bexar and Nueces counties lacked plumbing facilities. However, in the bor­der counties, such conditions were common. In Hidalgo County, 25.5 percent of all homes lacked at least some plumbing facilities. Among Mexican-American homes the figure increased to 34.4 percent. Low-income areas suffered more often than other areas in each county, although not as often as the Mexican-American popula-

Table 30 
Percent of Occupied Housing Units with More Than One Person Per Room, 1970 

County-Wide

Low-Income Areas  Mexican- 
County  All Units  American  Black  All Units  
Bexar  30.4  29.9  15.6  15.l  

Nueces 29.4 34.5 16.1 16.2 Cameron 37.3 41.9 28.9 Hidalgo 39 .8 45.3 33.7 Webb 36.0 36.1 30.9 
Source: U.S. Census, 1970 

Table 31 Percent of Occupied Housing Units Which Lack Some or All Plumbing Facilities, 1970 
County-WideLow-Income Areas 

Mexican­County All Units Black All Units
American 

Bexar 19.7 10.9 6.3 5.7 Nueces 6.6 11.3 4.9 4~8 Cameron 28..0 30.7 21.9 Hidalgo 31.6 34 .3 25.5 Webb 21.0 18.8 17.7 
Source: U.S. Census, 1970 
Urban Low-Income Areas 

tion in general, except in Bexar County. This outcome may result from the inclusion of rural areas in the county­wide comparisons. 
Health Conditions 
Health conditions studied include infant mortality and reportable diseaies. Birth rates are computed per one thousand women ages fifteen through forty-four in 1970, despite the fact that data on number of births are for more recent years. The reasons for this calculation (and the consequences) are discussed earlier in this chapter. In general, the relative rates for areas are suspect only if the number of women in low-income areas increased in proportion to the number of women elsewhere in each county. This observation holds true for most of the data in this section. 
Also, the reader should note that data for low-income areas in Cameron, Hidalgo, and Webb counties are taken from Waldrop's and Bruhn's study, and that they do not precisely coincide with the low-income areas described in the preceding section on socioeconomic conditions. 
Birth rates in low-income areas were much higher than birth rates elsewhere in the major cities (see Table 32). Rates in low-income areas of the three border counties were higher than rates in low-income areas of the two northern counties. This difference may be an artifact of internal population changes in the various study areas. 
Perhaps a more accurate view of fertility is available from 1970 figures on lifetime fertility of women ages fifteen through forty-four ever married (see Table 33). Comparing Mexican-Americans with the remainder of the population of Cameron, Hidalgo, and Webb coun­ties, one finds the higher fertility rate among Mexican-
Table 32 Live Births in Specified Years Per 1,000 Women Ages 15 Through 44 in 1970 
Cities (County) Year Low-Income Area Balance of City(ies) 
San Antonio (Bexar) 1971-75 Ave. 133.3 118.0 Corpus Christi (Nueces) 1969-73 Ave. 136.8 97.3 Brownsville-Harlingen-San Benito 
(Cameron) 1972-73 Ave. 157.7 136.8 McAllen-Pharr-Edin burg (Hidalgo) 1972-73 Ave. 165.1 116.9 Laredo (Webb) 1972-73 Ave. 156.3 134.7 Sources: San Antonio Metropolitan Health District, Vital Statistics, 19 71-1975. 
Corpus Christi-Nueces County Health Department, Unpublished Data. Waldrop and Bruhn, 1975 (for Cameron, Hidalgo, and Webb Counties). 
U.S. Census, 1970 

Table 33 Fertility in Three Border Counties, 1970 
Women El'er Married 

Ages 35-44  Children Ever Born  Average  
County  Mexican-American  Other  Mexican-American  Other Mexican-American  Other  
Cameron  5,791  1,739  29,265  5,3 78  5.05  3.09  
Hidalgo  7,341  2,020  38,259  6 ,968  5.35  3.45  
Webb  3,204  535  14,951  1,482  4 .67  2.77  

Source: U.S. Census, 1970 

Americans is consistent. In each of the three counties, Information is not available for fetal deaths in po~ Mexican-American women, on the averge, have at least areas of San Antonio and Corpus Christi. Data are avail­one and a half times as many children as non-Mexican­able, however, for poverty areas in major border cities American women. (see Table 35). Despite the relatively low number of 
Infant deaths are compared to live births in the same cases, fetal deaths were overwhelmingly more common in years. Low-income areas consistently had higher infant low-income areas in comparison to other city areas. In death rates than other areas in the major cities (see the cities within Cameron County, the low-income neigh­Table 34). Infant mortality rates in low-income areas borhoods had greater than four and one-half times the ranged from 17.0 per 1,000 in Laredo poverty areas to rate of the balance of the cities. Data for San Antonio, 
36.0 per 1,000 in Hidalgo County poverty areas. comparing ethnic groups, suggest that fetal mortality 
Table 34 Infant Deaths Per 1,000 Live Births in Specified Years 
Low-Income City(ies) Years Area Balance ofCity # Rate # Rate San Antonio 1971-75 Ave_ 30 19.2 225 16.8 Corpus Christi 1969-73 Ave. 22 20.9 60 16.4 
Brownsville-HarlingencSan Benito 1972-73 Ave. 70 36.0 19 14.7 McAllen-Pharr-Edin burg-Mission­Mercedes-Weslaco 1972-73 Ave. 33 J7_9 20 12.5 
Laredo 1972-73 Ave. 30 17.0 7 14.3 Sources: San Antonio Metropolitan Health District, Vital Statistic, 1971-1975. Corpus Christi-Nueces County Health Department, Unpublished Data. Waldrop and Bruhn, 1975 (for Cameron, Hidalgo and Webb counties). Table 35 Fetal Deaths Per 1,000 Live Births in Specified Years 
Low-Income City(ies) Years Area Balance ofCity # Rate # Rate 
Brownsville-Harlingen-San Benito 1972-73 Ave_ 55 28.3 8 6.2 McAllen-Pharr-Edinburg-Mission­Mercedes-Weslaco 1972-73 Ave. 36 19.5 8 5.0 
Laredo 1972-73 Ave. 27 15.3 3 6.1 
Mexican-Black AngloAmerican 

#  Rate  #  Rate  #  Rate  
San Antonio  1971-75  121  12.9  23  20.3  50  11.3  
Sources: Waldrop and Bruhn, 1975 .  

San Antonio Metropolitan Health District, Vital Statistic, 1971-1975. 
Urban Low-Income Areas 

rates are slightly higher for Mexican-Americans in com­and Laredo, and for Texas as a whole. Rates for Mexican­parison to Anglos, and much higher for Blacks. Americans are compared to those of Anglos. The respec­
Information on neonatal deaths is available for most tive rates for the two ethnic groups vary substantially, as cities; data for San Antonio are for the entire Bexar there is an insufficient number of such deaths in a single County (see Table 36). Except for Bexar County, low­year to identify a pattern. Rates for Texas as a whole income areas had higher neonatal mortality rates than suggest that Mexican-Americans suffer higher rates of did other areas. fetal deaths than Anglos, and lower rates of infant and 
Table 37 presents infant, fetal, and neonatal mortality neonatal deaths. rates per 1,000 live births in 1975 for Brownsville, McAllen, The number of tuberculosis cases in certain years is 
Table 36 Neonatal Deaths Per 1,000 Live Births in Specified Years 
City or County Year Low-Income Area Balance ofCity or County 
# Rate # Rate Bexar County 1971-75 Ave. 20 12.5 202 12.6 Corpus Christi 1969-73 Ave. 16 15.2 44 12.0 Brownsville-Harlingen-San Benito 1972-73 Ave. 47 24.2 16 12.3 McAllen-Pharr-Edin burg-Mission­
Mercedes-Weslaco 1972-73 Ave. 23 12.4 17 10.6 Laredo 1972-73 Ave. 27 15.3 7 14.3 Sources: San Antonio Metropolitan Health District, Vital Statistic, 1971-1975. 
Corpus Christi-Nueces County Health Department, Unpublished Data. Waldrop and Bruhn, 1975. 
Table 37 
Infant, Fetal and Neonatal Deaths Per 1,000 Live Births 
in 1975 for Selected Border Cities 

Neonatal  
Births  Infant Deaths  Fetal Deaths  Deaths  
#  Rate  #  Rate  #  Rate  
Brownsville  
Anglo  253  10  39.5  2  7.9  8  31.6  
Mexican-American  2,208  43  19.5  11  16.8  34  15.4  
McAllen  
Anglo  160  l  6.3  -0­ -0­ 6.3  
Mexican-American  1,181  25  21.l  16  13.5  14  11.9  
Laredo  
Anglo  192  3  15 .6  3  15.6  2  10.4  
Mexican-American  1,995  19  9.5  19  9.5  15  7.5  
Texas  
Anglo  119,404  1,781  14.9  1,014  8.5  309  11.0  
Mexican-American  64,028  950  14.8  796  12.4  663  10.4  

Source: Texas Department of Health Resources 

Mexican-American Health Care in South Texas 
compared to size of population in 1970 (see Table 38), a as to account for the entire differences in tuberculosis . comparison with some drawbacks. Low-income areas rates. have substar tially higher rates than other areas within Rates are computed for tuberculosis, and they suffer each county. Rates in Hidalgo and Cameron counties are the same liabilities. Hepatitis of course can be either much highe1 than rates in the other three counties, a serum or infectious and we don't distinguish between disparity wt.ich reaches startling proportions in low­them here. Low-income areas consistently had much income area:;. The rates may indicate population growth higher rates than other areas (see Table 39), with the 
between 1970 and the year in which data are reported. differences being too great for attribution to population However, it is unlikely that populations in low-income changes alone. The greatest disparity was in Cameron areas of the!e two counties increased in such magnitude County, where low-income areas experienced more than 
Table 38 
New Active Tuberculosis Cases in Specified Years Per 100,000 Persons in 1970 
Low-Income Area  Balance ofCounty  
County  Years  #  Rate  #  Rate  
Bexar  1971-75 Ave.  28  46.5  138  17.8  
Nueces  1973  22  58.6  32  .  16.0  

Cameron 1972-73 Ave. 54 98.4 26 30A Hidalgo 1972-73 Ave. 42 82.0 36 27.6 Webb 1972-73 Ave. 27 50.l 4 21.l 
Sources: San Antonio Metropolitan Health District, Vital Statistics, 1971-1975. Corpus Christi-Nueces County Health Department, Unpublished Data. Waldrop and Bruhn, 1975. 
U.S. Census, 1970. 

Table 39 Hepatitis Cases in Specified Years Per 100,000 Persons in 1970 
Balance of Low-Income Area City or County City or County Year # Rate # Rate Nueces* 1973 29 77.2 82 41.0 
Brownsville-Harlingen-San Benito 1972-73 Ave. 45 82.0 9 19.4 McAllen-Pharr-Edin burg­
54 105.4 23 40.3

M ission-M ercedes-W eslaco 1972-73 Ave. Laredo 1972-73 Ave. 32 59.4 7 36.8 
*Nueces County data includes infectious hepatitis only 

Sources: Corpus Christi-Nueces County Health Department, Unpublished Data Waldrup and Bruhn, 1975 . 
U.S. Census, 1970. 
Urban Low-Income Areas 

four times the rate of the balance of major cities. The areas are surprisingly low (see Table 41 ). Perhaps the highest rate was in Hidalgo County low-income areas. relatively large poor population in Nueces County living 
Data are available for amebiasis, shigella, and salmo­outside the target neighborhood partially accounts for nella (considered jointly) for only three counties. Low­this outcome. Related research in Austin shows a similar income areas had much higher rates than other areas (see pattern.~ The greatest poverty discrepancy was in Hidalgo Table 40). Little difference was found between areas County where low-income areas had a syphilis rate within Nueces County. more than seven times that of the balance of major cities. 
Syphilis rates were much higher in low-income areas Rates in low-income areas of both Hidalgo and Cameron than in the balance of the cities or counties, with the counties were exceptionally high. exception of Nueces County, where rates in low-income Gonorrhea rates were also higher in low-income areas 
Table 40 

Amebiasis, Shigella and Salmonella Cases in Specified Years Per 100,000 Persons in 1970 
Balance of  
Low-Income Area  City or County  
City or County  Year  #  Rate  #  Rate  

50.6 44.0 

Nueces* 1973 . 19 88 
Brownsville-Harlingen-San Benito 1972-73 Ave. 66 120.2 10 21.6 
""­
·;:.., 
. t. 

McAllen-Pharr-Edin burg-Mission-Mercedes-Weslaco 1972-74 Ave. 28 54.6 2 3.5 
*Data for Nueces County include Shigella and Salmonella only. 

Sources: Corpus Christi-Nueces County Health Department, Unpublished Data Waldrup and Bruhn, 1975. 
U.S. Census, 1970. 

Table 41 Syphilis Cases in Specified Years Per 100,000 Persons in 1970 
Balance of Low-Income Area City or County City or County Year # Rate # Rate Bexar 1971-75 Ave. 60 101.8 402 52.2 19 50.6 174 87 .0 
Nueces 1973 ·Brownsville-Harlingen-San Benito 1972-73 Ave. 119 216.8 20 43.2 McAllen-Pharr-Edinburg-Mission-Mercedes-Weslaco 1972-73 Ave. 96 187.3 15 26 .3 Laredo 1972-73 Ave. 55 102.l IO 61.3 
Sources: San Antonio Metropolitan Health District, Vital Statistics, 1971-1975. Corpus Christi-Nueces County Health Department, Unpublished Data. Waldrup and Bruhn, 1975. 
U.S. Census, 1970. 

Table 42 
Gonorrhea Cases in Specified Years Per 100,000 Penons in 1970 

Balance of Low-Income Area City or County City or County Year # Rate # Rate 
Bexar 1971-75 Ave. 268 451.9 2,149 278.7 
Nueces 1973 172 457.9 990 495.0 
Brownsville-Harlingen-San Benito 1972-73 Ave. 209 380.7 21 45.4 McAllen-Pharr-Edin burg-Mission-Mercedes-Weslaco 1972-73 Ave. 99 193.2 8 14.0 Laredo 1972-73 Ave. 86 159.6 10 61.3 
Sources: San Antonio Metropolitan Health District, Vital Statistics, 1971-1975. 
Corpus Christi-Nueces County Health Department , Unpublished Data. 

Waldrup and Bruhn, 1975. 
U.S. Census, 1970. 

than in other parts of cities or counties, again with the exception of Nueces County (see Table 42). The greatest discrepancy was in Hidalgo County, where low-income areas had almost fourteen times the rate of other cities. Overall rates were highest in Nueces County. 
Discussion 

In reviewing the socioeconomic data, it is evident that conditions among residents of the selected low-income areas differ substantially from conditions among residents elsewhere in each county. However, conditions among poverty area residents, who are predominantly Mexican­American, do not differ greatly from conditions among Mexican-Americans throughout each county. For some variables, Mexican-Americans county-wide suffer harsh­er conditions than do residents of low-income areas. Thus, to the extent that socioeconomic and health condi­tions follow similar patterns, data on health conditions in low-income areas may index the general health conditions among Mexican-Americans in the three border counties. In Cameron and Hidalgo counties this outcome may result from the exclusion of many rural low-income areas. 
Most of the health data presented here warrant some criticism, because no account is made for demographic changes between 1970 and the years for which health data are given. The exceptions to this comment are the data on infant, fetal, and neonatal mortality, where rates are established using live births in comparable years. For other health data, error exists only to the extent that low-income areas have increased poulation in proportion to total county or city population. 
Despite the above criticism, the discrepancies between the low-income areas and other parts of the cities or counties are of such extreme magnitude that population changes cannot account for the total differences. The discrepancies, in many cases, would still be evident even if low-income areas had doubled or quadrupled their popu­lations between 1970 and the years in which health condi­tions are recorded, usually 1972 or 1973. This is especially true for Hidalgo and Cameron counties on the border, where the discrepancies are the greatest. 
Earlier chapters in this volume demonstrated that socioeconomic and health conditions are much harsher in South Texas than elsewhere in Texas. The most serious conditions were found in counties along the border. This chapter has demonstrated that conditions among Mexi­can-Americans in urban areas are much more severe than conditions among other residents of those communities, and that conditions in low-income neighborhoods are much harsher than conditions elsewhere in urban coun­ties of South Texas. 
Urban Low-Income Areas 

References 


'Office of the Governor of Texas, Office of Information Services. Population Projections for Texas Counties: 1975­1990. Austin, 1972. 
2u.S. Commission on Civil Rights, Counting the Forgotten: The 1970 Census Count of Persons ofSpanish Speaking Back-1:round in the United States, Washington, D.C.: U.S. Govern­ment Printing Office, 1974). 
3San Antonio Metrop<>litan Health District, Vital Statistics, 1971-1975. Bexar County and City of San Antonio. 
"'Corpus Christi-Nueces County Health Department, unpub­lished data for years 1969-1973. 
SReuel H. Waldrop and John G. Bruhn, Health Manpower and Health Professions Education in South Texas: A Regional Partnership. (Galveston: Area Health Education Center, Uni­versity of Texas Medical Branch at Galveston, 1975). 
6Reuel H. Waldrop, Socioeconomic Stratification in Com­munit.1• Health, Atlanta: Center for Disease Control, 1971). 
70ffice of the Governor of Texas, Population Projections. 
'Roy McCandless, "Social and Health Conditions in East Austin," in "Three Reports on Health and Human Services in Austin and Travis County," Independent Research Project Report, Lyndon B. Johnson School of Public Affairs, Univer­sity of Texas at Austin. July 1977. 



Chapter4 
Conditions in South Texas Border Counties and Neighboring Northern Mexico 
The United States and Mexico share a 1,600-mile border stretching from the Pacific Ocean to the Gulf of Mexico. This chapter examines one area along that boundary: the adjacent areas of South Texas and North­ern Mexico.• 
The border area of South Texas consists ofeight Texas counties and fourteen municipios, nine in the Mexican state of Tamaulipas, and five in the state of Coahuilat (see Map 19). A municipio is a political jurisdiction analagous to a county in the United States. 
Demographic and health conditions are compared for the two sides of the border. Available health resources are examined, assessment is made of the border's impact on demand for health services and on health conditions in South Texas, and avenues for international cooperation are explored. 
Population Change 
In 1970, the eight Texas counties had a combined population of 461 ,319, while the municipios had a popu­lation of 712,923 (see Table 43). Both sides of the border have experienced substantial growth since 1950. However, population increases on the Mexican side of the border have been greater. The largest municipios have grown faster than the largest counties. For example, Nuevo Laredo, Tamaulipas, increased its population by 154 percent from 1950 to 1970. The neighboring Webb County, Texas, increased by only 30 percent. The greatest increase on the U.S. side was in Val Verde County, with a 65 percent growth from 1950 to 1970. The population on both sides of the border increased more from 1950 to 1960 than from 1960 to 1970. 
Between 1950 and 1970, Mexico's northern border region has grown faster than all other parts of Mexico (see Map 20), with the exception of the Federal District, containing Mexico City. Because these population in­
*For a description of health and health programs along the entire U.S.-Mexican border, see Humberto Romero Alvarez, Health 
creases occurred chiefly in urban areas, this rapid growth resulted in severe problems for the Mexican border cities. Population growth: 
Table 43 

Populations of South Texas Border Counties and Neighboring Mexican Municipios 
1950, 1960, 1970  
1950  1960  1970  
Texas Counties  
Cameron  125 ,170  151,098  140,368  
Hidalgo  160,446  180,904  181 ,535  
Kinney  2,668  2,452  1,934  
Maverick  12,992  14,508  18,093  
Starr  13,948  17,137  17 ,707  
Val Verde  16,635  24 ,461  24 ,4 71  
Webb  56, 141  64,791  72 ,859  
Zapata  4,405  4,39 3  4,352  
Tamaulipas Municipios  
Camargo  25 ,84 5  29,3 19  15 ,416  
Guerrero  3,073  4,237  4 ,249  
Gustavo Diaz Ordaz  n/a*  n/a  18 ,261  
Matamoros  128,34 7  143 ,043  186,146  
Mier  12,984  5,914  6,193  
Miguel Aleman  n/a  12,872  18,218  
Nuevo Laredo  59,496  96 ,043  151 ,253  
Reynosa  69,428  134,86 9  150,786  
Rio Bravo  n/a  n/a  71,389  
Coahuila Municipios  
Ciudad Acuna  13 ,540  22 ,317  32 ,500  
Guerrero  3 ,237  3,391  2,650  
Hidalgo  693  1,040  619  
Jimenez  8, 111  7,113  8,445  
Piedras Negras  31,665  48,408  46,698  

Without &undaries, United States-Mexico Border Public Health 
*Municipio not established as a separate entity at that time. 
Association, Mexico, 1975. 
t A sparsely settled municipio in the state of Nuevo Leon also lies 

Sources: U.S. Census Reports; 1950, 1960, 1970
within the studied region. Since there are no roads or settlements of 
Censo de Mexico; 1950, 1960, 1970 (Official

any appreciable size in the adjacent portion ofthis large municipiu, 
it is not included in this study. Census) 

Map 19 South Texas Border Counties and Neighboring Mexican Municipios 
. . . exacerbated the traditional problems caused ·by the anarchic development of most of the cities, especially in the peripheral areas, the so-called shanty-towns. In addi­tion, and this is the most far-reaching consequence, the solution of the very serious problem of providing public services is becoming more difficult and is adversely affec­ting public health conditions.• 
The booming Northern Mexico population results from both natural increases and from in-migration. 
Crude death rates in the border municipios are rela­tively low, indicative of a demographic transition com­mon to developing countries. This transition results from marked reductions in infant and child deaths, without a corresponding decrease in fertility rates. In such coun­tries, populations are increasing rapidly, median ages are 
Border Counties and Northern Mexico 

falling, and youth and total dependency ratios are high.2 As long as such countries can increase (and distribute) GNP in proportion to population increase, such pheno­menal growth is viable. However, Mexico's GNP increase has lagged behind its population growth, and the result has been fewer resources per individual. 
This extreme growth has created many problems in Mexico. The Mexican government has introduced and is closely administering a signficant population control effort through family planning. It should be noted, how­ever, that it will be difficult, if not impossible, to halt Mexico's high population growth rate in the near future. In 1970, more than 45 percent of the population of most large municipios in Northern Mexico were under fifteen years of age (see Table 44). A 1975 population pyramid 
Map 20 
In-Migration to Mexican States, 1970 

t Average Rate 00 Greater Than Average Rate 

Mexican-American Health Care in South Texas 
for the state of Tamaulipas (see Figure 3) suggests that even if the population in the lower age cohorts were to multiply only at their own replacement level, total popu­lation would continue to grow rapidly over the next few decades. 
Since World War II, Mexico's policy toward the nor­thern border has been one of economic development. Development programs include the National Border Pro­gram (PRONAF) and the Border Industrialization Pro­gram, designed to promote tourism and industry. These programs created new jobs in the region and thus exercise a "pull" for immigrants from the rural interior of Mexico who are "pushed" out of their home regions by high unemployment. Unfortunately, aggregate expectation of employment, as expressed by the total number of immi­grants, has exceeded the increases in available jobs. High unemployment in the border cities has resulted. 
The proximity of the United States also acts as a "pull" factor for immigration from the interior of Mexico to the northern border. First, tourism and U.S. investments in Northern Mexico create jobs in that region.• Second, proximity to the United States offers Mexican nationals the opportunity to work in or immigrate to the U.S. The strength of this "pull" factor should not be underesti­mated. For example, Dillman (1968) found that a large proportion of the wages of Mexico's border city residents were earned in the United States (see Table 45). He noted that these wages may be earned by Mexican citizens or by 
U.S. citizens residing in Mexico. 
Another indicator of the attraction of the U.S. / Mex­ico border is the volume of illegal alien commuters and illegal immigrants. These constitute an unknown percen­tage of the work force on the U.S. side of the border. However, that percentage is estimated by many to be quite high. 
*It should also be noted that the heavy retail trade of Mexicans making purchases in U.S. border cities increases jobsand money on the north side of the Rio Grande. The prosperity ofthese cities may depend on this international trade. 

Table 44  
Population Under 15 and Over 64 Years of A1e for Selected  
Municipios and Counties Along the U.S.-Mexico Border, 1970  
Under  Over  
15  64  
Total  
Population  N  %  N  %  
Municipios  
Piedras Negras  46,698  20,577  44.l  1,947  4.2  
Ciudad Acuna  32,500  14,880  45 .8  1,086  3.3  
Matamoros  186,146  84,733  45.5  6,123  3.3  
Nuevo Laredo  151 ,253  68,331  45.2  5,594  3.7  
Reynosa  150,786  70,127  46.5  4 ,091  2.7  
Counties  
Cameron  140,368  50,253  35.8  11,983  8.5  
Hidalgo  181 ,535  66,077  36.4  1,200  6.6  
Maverick  18,093  6,961  36.4  14,193  8.5  
Val Verde  24,471  9,420  38.5  1,742  7.1  
Webb  72 ,859  26,421  36 .0  5,799  8.0  

Sources: U.S. Census, 1970 Censo General de Mexico, 1970 
Border Counties and Northern Mexico 

Figure 3 
Population Pyramid for Tamaulipas 


15-19 
10-14 
5-9 
0-4 


16 14 12 10 8 6 4 2 0 2 4 6 8 10 12 14 16 (in percent)
Males Females 
Source: Servicios Coordidados de Salud Publica, Ciudad Victoria, Tamaulipas, unpublished data. (Estimates based on 1970 census of Mexico.) 
Tllble 45 
Percent of All Waps Earned in die 
United States by Workers Raidinc in Four 
Border Municipios, 1968 


Municipio 	Percent of Wages Earned in U.S.A. 
Nuevo Laredo 	31% 
Matamoros 	30% 
Piedras Negras 	23% 
Reynosa 	22% 

Source: Dillman, C.D. "The functions of Brownsville, Texas and Matamoros, Tamaulipas: Twin Cities of the Lower Rio Grande" Ph.D. diss., University of Mich­igan, 1968, p. 182. 
Thus, both natural population increases and in-migra­tion from central Mexico are responsible for tremendous population growth along Mexico's northern border. This growth will very likely continue for some years. 
Socioeconomic Conditions 

Data on socioeconomic conditions among Mexican citizens living near the U.S. border indicate that their standard of living is lower tban that of Mexican-Amcri­cans residing in South Texas. In the fourteen border municipios, the median wage of male workers was S8'iO per year in 1970, according to the Mexican Census. Median earnings of Mexican-Amcric:ans families in T eus border counties ranged from $3,088 to $4,859. 
Unemployment figures from the 1970 Census of Mex­ico are somewhat unreliable due to problems in reporting and underreporting.l Table 46 shows unemployment rates for two border Mexican states and three municipios. Subemploymeot (employment on a part-time basis orfor less-than-minimum wages) is also shown. The high un­employment rates indicate a substantial problem. Urquide and Villarreal estimate that the true rate of unemploy­ment in 1970 was no less than seven percent all along the U.S.-Mexican border, and that the rate of subemploy­ment in the same region was 16.l percent.4 
Quality of housing also may indicate socioeconomic conditions. Data from the 1970 Mexican Census indicate that there was a mean of 2.1 persons per room in all municipios 'households, and that 43.6 percent ofall occu­pied dwelling places were without bathrooms having run­ning water. Figures for eighi netgbboring Souto Texas border counties, although not entirely comparable, sug:­gest that the avergc number of penons per Mexican­American household ranged from 3.9 in Zapata County to 4.8 in Starr County. In the eight border counties, 29.9 percent of Mexican'."Amcrican households lacked some or all plumbing facilities, while in the state ofTamaulipas as a whole 54.3 percent of the homes were not connected to a sewer line. s 

Unemployment and Subemployment in Selected Areas of Northern Mesko, 1971 
Economically Unemployed Subemployed Active Plllce Persons N % N 
" 
States 

Coahuila 283,351 12,753 4.5 45,624 1_5.8 Tamaulipas 383,380 13,885 3.6 56,585 18.4 
Municipios 

Matamoros 49,467 2,617 5.3 
Nuevo Laredo 39,659 1,454 3.7 Reynosa 3 7 ,242 l,368 3.7 Source: Secretario de lndustria y Comercio, Zonas Fronterizas de Mexico: Perfil Socio­
economico, Nuevo Laredo, Tamaulipas 1974. 
' 


Border Counties and Northern Mexico 
Table 47 
U.S. to Mexico Border Crossings in 1973 

Laredo to Nuevo Laredo  10,235,865  
Brownsville to Matamoros  12,606,034  
Eagle Pass to Piedras Negras  7,970,829  
McAllen to Reynosa  4,168,493  
Del Rio to Cuidad Acuiia  2,293,662  

Source: The Colonias of the Lower Rio Grande Valley of South Texas: A Policy Perspective, Lyndon B. Johnson School of Public Affairs, University of Texas at Austin, 197 7. The vast majority of these crossings from the United States to Mexico are made by returning Mexicans. 
Separated from the mainstream of their respective nations' population and commerce by substantial distan­ces, the two border areas are joined by the Rio Grande and a unique blend of socioeconomic and health condi­tions. The border area is an internally dynamic system with intertwined conditions which are not severed by an arbitrary demarcation of national boundaries. In this light, the rapid population increases in Northern Mexico and the age distribution of the population of the munici­pios and their economic and housing conditions have some significance for the border counties ofSouth Texas. 
The rapid population increase is not met by an equal increase in available public services such as treated drink­ing water and sewers. The result is a Mexican population with many health problems, and endemic communicable disease located a few hundred feet across the Rio Grande. High unemployment and high dependency ratios com­bined with relatively low educational levels among resi­dents of Northern Mexico exacerbate health problems, and bear further consequences for South Texas counties. 
The border is an artificial line and cannot act as a barrier to the population on either side. The volume of border crossings (see Table 47) suggests ample opportu­nity for transmission of communicable diseases to and from both sides. Given equally healthy populations, the traffic poses no great problem. However, the socioeco­nomic conditions and poor housing and sanitation in Northern Mexico suggest a much higher rate of certain communicable diseases than might be found in the popu­tion of the U.S. side of the border. 
Health Conditions 
Mortality and morbidity records provide the basis for discussion of health conditions on both sides of the U.S.­Mexico border. Such records, however, often lack accu­racy. Errors may result from incomplete registration or from mistakes in collection of data or diagnosis ofcondi­tions. There are problems of comparability between the 
U.S. data and that of Mexico, and in some cases data are 
Table 48 
Age-Specific Mortality Rates for Selected Border Municipios 

Age Group Under 1 year 1 to 4 years 5 to 14 years 15 to 24 years 25 to 44 years 45 to 64 years 65 years and over 

in 1973 and Texas in 1970 
Matamoros Nuevo Laredo Reynosa Texas 
36.7 82.9 65.3 21.4 
2.1 3.6 3.1 LO 
0.5

0.5 
0.6 0.7 

1.5 
2.3 1.9 1.4 


3.1 2.9 3.8 2.4 
14.0 11.3 13.6 9.2 
54.8 68.4 50.1 54.8 
Sources: Servicios Coordinados de Salud Publica, Victoria, Tamaulipas. Unpublished (Based on 1973 population estimates). Vital Statistics, Texas Department of Health Resources, 1970. 
U.S. Census Reports for Texas, 1970. 

Mexican-American Health Care in South Texas 
not available for one or the other side of the border. The for three of the largest municipios are shown in Ta~k,:. 48. researchers cannot be sure of the quality of the data for Comparable data are not available for Texas counties. either side. It should be noted, however, that data for Data for Texas as a whole, when compared to the munici­Northern Mexico were more often available and readily pios, indicate that mortality rates in Northern.Me1.1.ico are_ useable than data for South Texas counties. This is much higher during infancy and early chlldhood, and' probably because local health programs in Mexico are somewhat higher during the adult years offifteen through _ more accountable to central authority than are the pro­sixty-four. grams in the United States and in Texas, and thus they The five leading causes of death in 1973 for the three must provide more information on a regular basis. Health largest municipios and the three largest counties are planners in the U.S. should be envious of the Mexican shown in Table 49. In all areas heart disease was the first system. leading cause of death. 
The second leading cause ofdeath was malignant ne~ 
plasms (cancer) in all three Texas counties and in the 
Mortality 

municipio of Matamoros. Cancer ra~ed fifth in Nuevo Mortality records are probably the best indicators of Laredo and Reynosa. In these two municipiostbesecond­health status in the region. Age-specific mortality rates ranked cause of death was influenza/pneumonia (jointly 
Table 49 
Five Leading Causes of Death for Sel~ted Texas Border Counties and Neigh.boring Municipi,~ 
1~3 ----	--. 
ls.t Cause. 2nd.Caus.e 3rd Cause 4th Cause 5th <;ause 
Counties 

Cameron Heart Disease 	Malignant External Causes2 Cerebrovascular Certain Causes Neoplams Disease of Infant Death 
(32.8) l (IS.I) ( 9.7). ( 7 .6) (3.8) 
Hidalgo Heart Disease Malignant Cerebrovascular External Causes Influenza and Neoplasms Disease Prieunionia 
(30.S) (14.9) (I0.1) ( 10.0) (4.S) 
Webb Heart Disease Malignant External Causes Cerebrovascular Diabetes 
Neoplasms Disease Mellitus 

(29.4) (I6.4) ( 9.6) ( 8.6) (6.0) 
Municipios 

Matamoros Heart Disease Malignant External Causes Colitis and Influenza and Neoplasms Gastroenteritis Pneumonia 03.3) ( 10.4) ( 9.0) ( 8.1) (7.9) 
Reynosa Heart Disease Influenza and External Causes Colitis and Malignant 
Pneumonia Gastroenteritis Neoplasms 

(14.3) (11.8) ( 11.3) (10.9) (7.6) 
Nuevo Laredo Heart Disease Influenza and Colitis and External Causes Malignant 
Pneumonia Gastroenteritis Neoplasms 

(20.4) ( 12.0) (I 0.9) 	(6.6) (4.9) 
1Deaths per I 0.000 population. Note that the category "Symptoms and lll-defined Causes" is excluded. 
2Includes accidents, homicide, suicide and all other external causes. 
Sources: Texas Department of Health Resources, Texas Vital Statistics 1973 

Servicios Coordinados de Salud Publica, Ciudad Victoria, Tamaulipas, Mexico. Unpublished data. 
Border Counties and Northern Mexico 

reported in data on municipios). Because no major out­breaks of influenza were reported on either side of the border during the last few years. it is safe to assume that the vast majority of cases were pneumonia. 
Gastroenteritis and colitis were among the four leading causes of death in all the municipios, but were not among the five leading causes for counties. These diseases strike infants particularly hard, and the infant mortality rates for the municipios suggest that these were in large part infant deaths. On the other hand, cerebrovascular dis­ease, which ranks high in the counties, is not shown as a major cause of death in the municipios. 
One reason for the particular structure of the mortality experience of the municipios is the age distribution in those areas. The relatively young population in the muni­cipios means that there are fewer older persons and more young persons "at risk." Since there are no age/cause specific rates available that would allow cross-compari­son, it is not possible to filter out the effect of age on the mortality experience of either side of the border. Still, it may be assumed that the relatively fewer deaths in the municipio from such degenerative ailments as cerebro­vascular disease results at least partially from the smaller elderly population in the municipios. The high rate of influenza/ pneumonia deaths in municipios is also related to the age distribution factor, as these diseases are major causes of death for infants in the municipios. 
Figures on infant mortality by cause are shown in Table 50. Comparison is possible only between residents of two border municipios in 1973 and Mexican-Ameri­can residents of all forty South Texas counties in 1975. Such a comparison admittedly would be weak were it not for the magnitude of differences between the Mexican and U.S. populations. 
To begin with, influenza and pneumonia were the lead­ing causes of death among the Mexican infants, but these ailments ranked only fourth in the Mexican-American population. Pneumonia is a common cause of death during both the neonatal (0-28 days of life) and the postneonatal (28-365 days of life) stages ofinfancy. How­ever, death from pneumonia occurs more often during the postneonatal stage. Because postneonatal mortality is closely related to socioeconomic status, the compara­tively poor socioeconomic conditions in the municipios explains the high ranking of these diseases in causes of infant death. The magnitude of difference between the 
Table 50 
Cause-Specific Infant Mortality for Selected Municipios in Mexico 1973, and for Mexican-Americans in South Texas 1975 
Tamaulipas Reynosa Nuevo Laredo Cause n rate1 n rate1 n rate1 
Gastroenteritis 710 968 82 1033 95 1346 Certain Causes of Infant Death 560 764 62 781 85 . 1204 Influenza and Pneumonia 532 725 99 1248 109 1544 Congenital Anomalies 103 140 14 176 13 184 Avitaminosis 85 116 7 88 12 170 Heart Disease n/a2 11 138 39 552 Anemias 16 22 n/a n/a Number of Births 73,344 7,935 7 ,058 1deaths per 100,000 live births 2data not available Sources: Servicios Coordinados de Salud Publica, Ciudad Victoria, Tamaulipas, Mexico. Unpublished data. 
Texas Department of Health Resources, unpublished data. 
Mexican-
Americans 
in South Texas 
(40 counties} 

1
n rate
16 52 240 787 23 75 85 279 2 7 3 10 3 30,469 

Mexican-American Health Care in South Texas 
Mexican and the U.S. populations is phenomenal when considering influenza and pneumonia together: the Rey­nosa rate is seventeen times higher and the Nuevo Laredo rate is twenty times higher than the rate for Mexican­Americans in South Texas. 
Gastroenteritis also is a disease of the postneonatal stage of life and is closely associated with environmental factors, such as contaminated water supply and inade­quate sewage disposal. Gastroenteritis was the second most common cause of death among the Mexican infants, and the rate for infants in the two municipios was more than twenty times that for Mexican-American infants in South Texas. 
Avitaminosis and other nutritional deficiencies are logically related to socioeconomic status, although re­search has not firmly identified a relationship. These are minor causes of infant deaths on both sides ofthe border, but it should be noted that they are more prevalent on the Mexican side. 
Only for congenital anomalies does the Mexican-Amer­ican rate rise above that of the municipios. This may be explained in part by the fact that in a healthier population more fetuses with congenital anomalies will survive to term than in a less-healthy population. This may mean that nonviable infants are dying in the fetal stage in Mexico, but are carried to term and dying shortly after birth in the Mexican-American population. 
In summary, more residents of the Mexican munici­pios are dying of communicable diseases and diseases associated with low socioeeonomic status than are com­parable U.S. populations. This is due in part to differen­ces in the age structure of the two populations and in part to the poorer sanitary conditions in the municipios. 
Morbidity 
Morbidity data (information on reportable communi­cable diseases) are shown for selected border municipios and Texas border counties in Table 51. The data are derived from reports issued by the Border Epidemiologi­cal Bulletin of the U.S.-Mexico Border Health Associa­tion and from morbidity reports of the Texas Depart­ment of Health Resources. The diseases are reportable by law in both countries. 
There are limitations to the use ofdata on communica­ble diseases. These were discussed earlier, but a brief reiteration may be helpful here. First, data are never complete, due to underreporting. Also, diagnostic and reporting practices may differ not only between coun­tries, but also among the many reporting units (doctors, 

Table SI 
Reportable Communicable Diseases in Selected Municipios and Counties 

1975 
Number of Cases 

Hepatitis Typhoid Measles Brucellosis (All Forms) 
Municipios  
Nuevo Laredo Reynosa Matomoros Ciudad Acuna Piedras :\'egras  9 2  
Counties  
Hidalgo ~1 averick Starr Val Verde Webb Cameron  


2  
1  1  2  
2  
14  
4  3  
3  105  
8  
7  
6  
3  44  
8  58  

Gonorrhea  Syphillis  
1 3 7 3 4  5  
165 1 8 124 296  54 11 5 47 144  


Source: For Mexican Data: Field Office U.S.-Mexico Border Association, Border Epidemiological Bulletin, PAHOfWHO May, 1976. For Texas Data: Texas Dept. of Health Resources, Texas Morbidity This Week , Annual Summary for 1975. 
' 

Border Counties and Northern Mexico 
. -­

clinics, health departments). The reliability of the data presented here has not been tested, and the researchers are aware that the information may have serious deficien­cies. Therefore. only the broadest inferences will be made. 
Study of the raw data in Table 51 indicates major differences in the morbidity experiences of the Mexican and the Texas border populations. First, typhoid was reported in N uevo Laredo and Reynosa in 1975, but was reported nowhere in the Texas counties. Brucellosis (un­dulent fever) is apparently a problem in Cuidad Acuna and Piedras Negras, but is less so in other Mexican municipios and much less so in Texas counties. The vector for brucellosis is usually infected livestock, and the disease is most commonly transmitted to humans through contact with these livestock or ingestion ofunpasteurized dairy products. 
According to Table 51, hepatitis in every form is more prevalent in the border counties than in the municipios. However. the conditions which lead to the spread of hepatitis are prevalent on both sides of the border: over­crowding. untreated water, and untreated sewage. Thus, there is every reason to believe that hepatitis is prevalent on both sides of the border, and it must be assumed that the low figure for the municipios is a product of under­reporting. 
Several factors other than underreporting may operate to make the Mexican venereal disease rate appear lower than that of the U.S. counties. First, by law in Mexico, prostitutes are required to receive regular VD checkups by public health officers. While enforcement may vary, in areas officially designated for prostitution such screening is conducted. 
A second factor is that Mexicans are better able to treat venereal disease without a physician. This is because most of the drugs required for treatment are available across the counter in Mexican pharmacies, while in the United States a prescription is required. This may not operate to lower the incidence of the disease, but it would affect reporting. 
A third factor is the well-documented, serious epi­

. demic of venereal disease now underway in the United States. The simple fact may be that the U.S. has a higher incidence of these diseases than Mexico. Some of the suggestions for cooperation made by the joint study group include improving notification and followup with contacts on both sides of the border, implementing sex education programs for high risk groups such as stu­dents, military trainees, factory workers, and prostitutes, and establishing counseling services for teenagers on both sides of the border where problems relating to their age can be discussed.6 
Tuberculosis data for both sides of the border are available, although only general comparison may be made between the two populations (see Table 52). loci-
Table 52 

Rates of Tuberculosis Per 100,000 Persons in Selected Border Counties and Neighboring Municipios, 1972-74 Averages 
Municipio 1973 Ave. Annual Rate/ County Population Cases 100,000 
Matamoros 199,750 76.0 38.1 Cameron County 137,627 76.7 55 .7 
Reynosa 161,784 75.7 46.8 Hidalgo County 177,974 67.3 37.8 
Nuevo Laredo 166,782 79.0* 4 7.4 Webb County 84,746 36.7 43.3 
Total Municipios 528,316 230.7 43.7 Total Counties 400,347 180.7 45.1 
*Indicates that data for one of the three years are not available. 
Sources: Number of Cases: Servicios Coordinales de Salud Publica, Cuidad Victoria, Tamaulipas, Mexico, Un· published data. Texas Department of Health Resources, Texas Morbidity This Week, Annual Summaries for 1972, 1973, 1974. Population Estimates: Servicios Coordinales de Salud Publica, Cuidad Victoria, Tamaulipas, Mexico, Unpublished data. Office of Information Services, Population Pro· jections for Texas Counties: 1975-1990. Office of the Governor of Texas, May I 972. 
dence of tuberculosis is very high on both sides ofthe Rio Grande with roughly the same rates on each side. Crowded housing, already shown to be a problem in the border counties, certainly contributes to the prevalence of this disease. 
Data on communicable diseases presented in Table 53 were made available by health officials of the Mexican state ofTamaulipas. This information includes a number of conditions which are not normally reported as com­municable diseases in the United States. It should be noted that the data in this table are for the most prevalent diseases in each year for each municipio. Thus, there are data missing for some diseases from year to year. 
Gastroenteritis was the most reported condition in all the municipios in 1972, 1973, and 1974. Also often reported were other ailments common to young children­scabies, pinworm, and ringworm. These are generally associated with poor personal hygiene, poor sanitation, low socioeconomic status, and a low level of health edu­cation. Comparable data for this group ofconditions are 
Table 53 
Reported Communicable Disease Rates Per 100,000 Persons in the 
Municipios of Matamoros, Reynosa and Nuevo Laredo 
1972-74 Averages 

Matamoros Reynosa Nuevo Laredo 
# Rate # Rate # Rate 
Gastroentoritis 1,613 807.3 149 91.9 ' 28.67 1,718.8 Influenza 67 33.4 62A 38.0 689 413.3 Scabies 619 310.1 134A 82.8 458A 274.3 
Measles 212 106.1 35A 21.6 197A 118.1 Ringworm 104 52.1 59 36.3 89 53.6 Mumps 94 47.2 c c 69A 41.l 
Chickenpox 61B 30.5 25B 15.5 112 67.2 Tuberculosis 76 38.1 76 46.8 79A 47.4 Gonorrhea 48 24.0 23 14.2 c c 
Pinworm c c 25 15.7 c c 
Typhoid c c 8B 4.9 c c 
Syphillis 24 12.0 10B 6.2 c c 
Alndicates that data for one of three years are not available. 
Blndicates that data for two of three years are not available. 
Clndicates that data are not available for any of three years. 
Source: Servicios Coordinales de Salud Publica, Ciudad Victoria, Tamaulipas, Mexico. Un­published data. 
Table 54 
Hospital Beds, Doctors and Nurses Per Thousand Population for 
Selected Municipios in 1977, and Counties Along 
the U.S.-Mexico Border 

Hospital Beds Doctors* Nurses N Rate N Rate N Rate 
Municipios 

Matamoros 264 1.24 104 0.49 182 0.86 Reynosa 384 2.23 191 1.11 287 1.67 Nuevo Laredo 309 l.57 143 0.73 147 0.75 
Counties 

124 0.91 281 2.07 Hidalgo 473 2.69 113 0.64 389 2.22 Webb 286 3.09 41 0.44 141 1.52 
Cameron 746 5 .49 
*\fexico data include oral surgeons. 

Sources: Servicios Coordinados de Salud Publica, Ciudad Victoria, Tamaulipas, Mexico. Unpublished data . 
not available for Texas. But, as in the case of hepatitis, it is reasonable to believe that they are fairly common among segments of the population on both sides of the border. In a later chapter in this document, diarrheal conditions and scabies are shown to be reported in rela­tively high numbers among low-income Mexican-Ameri­can children. Many physicians in the Lower Rio Grande Valley report that diarrheal ailments are common among the children of the poor in the area. 
Of interest in tbe discussion of communicable diseases is the recent outbreak ofrabies in Laredo and its Mexican sister city, Nuevo Lare.do. The Laredo health authorities reported fifty-four cases of animals infected with rabies from November 1976 through March 1977. Five cases were reported in Nuevo Laredo during the same period. Although underreporting may be partially responsible, the lower number of cases in Mexico is most likely due to the more stringent measures taken by the health officials in that country. In Nuevo Laredo, health workers went from house to house to encourage vaccination ofanimals. Also, 100 percent of captured stray dogs were destroyed, and poison was set in the streets (with appropriate pre­cautions to insure that no humans were harmed) to kill hundreds of stray dogs. 7 
As a beginning the joint study group proposes that the border area should be redefined to broaden the geo­graphical area on which data will be collected and re­ported. They propose the counties should mutually decide which diseases will be kept under surveillance and work together to collect information, promote the reciprocal use of existing laboratory facilities in order to accelerate the confirmation of diagnosis, and include vector sur­veillance in the epidemiological surveillance activities.8 
Summary ofHealth Conditions 
Definite differences exist between the mortality and morbidity experiences of residents of the Mexican muni­cipios and those of the Texas counties. In large part, these differences result from the differing age distributions. The higher proportion of young persons on the Mexican side of the border leads to a lower rate of degenerative diseases associated with the aging process. However, cer­tain communicable diseases and conditions associated with poverty are more prevalent in the municipios than in the Texas populations. This is particularly true of much infant mortality. 
Declines in many communicable disease rates will occur when water and sewer services are installed in all parts of the border municipios and when the problems of crowded housing are resolved. Further declines will come from improved socioeconomic conditions. However, there is room now for effective intervention without waiting for economic improvements. Whether Mexico can accomp­lish these improvements in the near future is not certain. 
Border Counties and Northern Mexico 

Already, substantial Mexican public revenues are going to the border regions. Mexico's willingness to pour an even greater share of its resources into the area seems unlikely, as the rest of the country has equal or worse problems. 
The heavy in-migration of poor persons from the rural interior of Mexico to the border regions provides ample opportunity for transmission of communicable disease. Detection and treatment of human vectors among the immigrants is difficult, as is detection of diseases among persons crossing the international border. Programs for vaccination and screening on both sides of the border, however, reduce the prevalence of communicable dis­eases in both Northern Mexico and South Texas. 
U.S. and Mexican Health Care Systems 
Mexico has what U.S. citizens would term "socialized medicine." In the area of health, Mexico is fundamentally different from the United States. The Mexican Political Constitution "has given special emphasis to the protec­tion and promotion of health within a social context. ''9 Since 1917 there have been departments on the Mexican federal level which are responsible for public health and for delivery of health services to the populace. This was not true in the United States until fairly recently, and even now health services are provided by the government to only a part of the U.S. population. 
A second distinguishing feature ofthe Mexican system is that it is to a certain extent responsive to centralized federal authority. With the exception of private facilities and services, all health services in Mexico are part of this system. In contrast, the U.S. health delivery system is characterized by control by a number of different levels of government. 
The Mexican health delivery system is divided into three main parts: (I) Social Security institutions, includ­ing the Mexican Institute of Social Security (IMSS) which provides coverage to more than fifteen million workers in industry, commerce, and the service sector, and the Institute of Social Services and Security for Employees of the State (ISSSTE) which consolidates health services for roughly four million federal employees; 
(2) public health services through the Ministry of Health and Assistance (SSA): and (3) the private sector. Those using the social security programs are workers and their families. This system is financed in large part by em­ployee payroll deductions and employer contributions. Approximately one-third of all Mexicans are covered by this system.1° The remainder ofthe populace is dependent on services offered through the Secretaria de Salubridad y Asistencia (SSA) or through the private sector. The SSA is expected to provide health care to 60 percent of the population, yet it commands barely 3 percent of the total health care expenditures.11 
Mexican-American Health Care in South Texas 
Social Security beneficiaries are free to use private 
doctors. Many, however, use the services of doctors, 
clinics, and hospitals sponsored by their particular social 
security institutions. Thus, there are hospitals and clinics 
for government workers, for workers of PEMEX (the 
national petroleum concern), and for groups of private 
workers. The SSA maintains its own clinics and hospitals. 
In the state of Tamaulipas in 1976, 49.6 percent of the 
population made use of SSA health services; 30.4 percent 
used the social security institutions; and 15.0 percent used 
private sector services.12 

The Northern Mexico area bordering Texas has higher 
ratios of hospital beds and physicians to population than 
does the rest of Mexico,13 with some variation from 
community to community. Canga attributes this out­
come to the higher salaries received by border Mexicans 
and to the influx of U.S. citizens who seek health care in 
Mexico, thus providing a higher income to physicians in 
that area. 

Information on health resources for the three largest 
border municipios and for the neighboring Texas counties 
is presented in Table 54. The municipios of Matamoros, 
Reynosa, and Nuevo Laredo each have lower rates of 
hospital beds to population than do the adjacent Texas 
counties. This is true also for the number of nurses in the 
area. However, Reynosa and Nuevo Laredo have higher 
rates of physicians to population than the adjacent 
Hidalgo and Webb counties. Matamoros, despite its 
medical school, has relatively fewer physicians than does 
Cameron County. The number of physicians in all the 
border municipios is overstated due to the inclusion of 
oral surgeons. 
Use of U.S. Medical Services by Mexicans 

Interviews with hospital officials in Cameron and Webb counties reveal that Mexican nationals make up at least some portion of the hospitals' patients. Estimates are about 5 percent. This figure has decreased some since the devaluation of the peso. Also, many of the more well-to­do Mexicans travel to Dallas, San Antonio, and Houston for health care, as do wealthy U.S. citizens in Texas and those who reside along the border. 
U.S. public and private nonprofit hospitals with emer­gency rooms report that they will treat any acute case that arrives at their door, including a Mexican national. A public health nurse in Laredo reports that Mexican nationals use the public clinic there despite efforts to screen them out. However, an estimate of the degree of usage by Mexican nationals is not available. In Laredo, little effort is made to eliminate Mexican children from receiving immunizations at the public clinic because, as the nurse suggested, "This is a little thing and will help both sides of the border." 
Numerous interviews with officials and citizens along the U.S. side of the border suggest that illegal aliens use public health facilities. While verification is difficult, there is no reason to doubt that this occurs. 
Neither of two hospital financial officers interviewed indicated that collecting bills from Mexican patients was any great problem. 
Use of Mexican Health Facilities by U.S. Citizens 
During the course of this research, nearly every U.S. health official interviewed was asked if U.S. citizens use Mexican health facilities. All responded affirmatively. The extent of this traffic is unknown. However, at least two officials claim that half ofthe residents of Laredo and Eagle Pass seek health care in the neighboring cities of Nuevo Laredo and Piedras Negras. 
Two reasons generally given for seeking medical care in Mexico were the lower prices and the more convenient office hours of Mexican doctors. Another important rea­son is that Mexican-American patients seek medical assistance from doctors who speak the language-a very important factor to anyone who wishes to explain his or her ailment. Not a single U.S. doctor interviewed said that U.S. citizens go to Mexican doctors for higher qual­ity care than is available in the U.S. In fact, U.S. doctors generally had a low regard for many oftheir counterparts in Mexico. On the other hand we know of some fully insured Mexican-Americans on the U.S. side who go to American-trained Mexican doctors on the Mexican side in the belief that they are the best physicians in the area. 
According to one dentist, U.S. citizens will travel across the border for medical care because it is cheaper there. However, he said that quality work costs about the same on both sides. He did note that Mexican dental clinics advertise in U.S. newspapers, a practice that local 
U.S. dental societies want to see ended. One U.S. doctor said that Mexican doctors maintain a two-tiered price system--a higher one for ' U.S. citizens and a lower one for Mexicans. 
International Cooperation 
Cooperation between U.S. and Mexican officials is best exemplified by the United States-Mexico Border Health Association. The ·Association is part of the. Pan ,_ .. American Sanitary Bureau of the Pan American Health Organization, which in turn is part of the World Health Organization of the United Nations. The Association has concentrated on eliminating the communicable diseases most amenable to public intervention. These include smallpox, yellow fever, and malaria. The Border EpUie­miological Bulletin , a monthly publication of the Associ­ation, reports on outbreaks of major communicable diseases on both sides of the border and serves as a communication device for health officials in the United States and Mexico. 
Through the auspices of the Border Health Associa­tion, groups of health officials from Mexico and the U.S. gather regularly to exchange ideas and discuss common problems. While these meetings have few direct effects on health care or public health, they have several important indirect effects. These include the sharing of information among professionals and the fostering of relationships between people who jointly might resolve common prob­lems. Any actual international cooperation in resolving health problems appears to take place on an informal rather than a formal basis. 

In the past, there also have been binational meetings of groups of nurses and doctors, sponsored by respective professional associations. These appear to be largely social gatherings, although tours of facilities are some­times part of the programs. 
The resolution of border health issues demands com­

munication between authorities and unity of action. At 
present, much of the interaction and cooperation between 
U.S. and Mexican public health officials transpires unof­ficially. Like most unofficial networks of communica­tion, this one is based on familiarity among individuals and some understanding of the other country's govern­mental and bureaucratic systems. As Sloan and West point out in their paper, "Public Policy Cooperation Among the U.S.-Mexican Border Cities," such an ideal situation is not always found, especially as the situations on both sides of the border grow more complex.14 
As population growth exacerbates urban complexity, a need arises for a more finely tuned structure for secur­ing commitments. The border area needs more official lines of communication between local U.S. and Mexican officials. Interaction between public officials might take the form of joint water treatment programs, sewer dis­tricts, public housing programs, or other measures to combat communicable diseases. However, such actions require substantial investment of public money, and local governments on both sides ofthe border are not equipped to finance the necessary investment without great gener­osity on the part of federal and state governments in both countries. 
Conclusion 
It now appears that the establishment ofthe Southwest Regional Border Commission and the new initiatives the Carter and Clements administrations are taking with respect to South Texas could potentially provide some of the resources required. It is to be hoped that these activi­ties will develop into a system which will reduce mortality and morbidity on both sides of the border and will enhance the quality of life of the predominantly young population which lives there. 
Border Counties and Northern Mexico 75 

References 

1H.R. Alvarez, Health Without Boundaries (Mexico City, Mex.: U.S.-Mexico Border Health Association, 1975). 
2W.S. Thompson and D.T. Lewis, Population Problems, 5th ed. (New York: McGraw-Hi!, 1965). 
3V.L. Urquidi and S.M. Villarreal, "Economic Importance of Mexico's Northern Border Region," in Views Across the Border: The United States and Mexico, ed. Stanley R. Ross (Albuquerque, N.M.: University of New Mexico Press, 1977). 
4A less strict interpretation would place the percentage of subemployed workers at 9.2 percent. Ibid. 
su.S., Department of Health, Education, and Welfare, Re­view of the Health Situation on United State-Mexico Border and Recommendations for Bilateral Cooperation (Washington, D.C., January 1979), table 27. 
6lbid .• pp. 32-33. 
'United States•Mexico Border Public Health Association, Border Epidemiological Bulletin (PAHO/ WHO) (May 1976), supplement. p. 5. Also based on interviews with officials of the Laredo-Webb County Health Department, 1977. 
8U.S., Department of Health, Education, and Welfare, Re­view. p. 31. 
9Alvarez, Health. 
IOJ bid. 
11 Secretaria de Salubridad y Asistencia (SSA), Atlas de la 
Salud de la Republica Mexicano (Mexico City, Mex., 1973), p. 

90. In much of this discussion we have drawn on an unpublished paper by Vivienne Bennett entitled "Health Care in Mexico," written for the Lyndon B. Johnson School of Public Affairs, 1978. 
12servicios Coordinados de Salud Publica, Ciudad Victoria, Tamaulipas, Mexico (unpublished data) 1976. 
13P. Canga, "Impact of the Mexican Border Industry Program on the Texas Border Economy," AIDC Journal 12, no. I (January 1977). 
1•J.S. Sloan and J.P. West, "Public Policy Cooperation Among the U.S.-Mexican Border Cities," n.d. (unpublished). 





SECTION II 
Selected Health Topics 


Chapter 5 
Nutrition and Mexican-Americans 
The Impact of Nutrition on Health The relationship between nutrition and health is firmly established. Malnutrition (including under-nutrition, over-nutrition, and malabsorption)• is often associated with and can hinder healing in conditions not directly caused by malnutrition.• Good general nutrition does not obviate the need for other forms of health care. Other health care problems such as traumatic injury, genetic aberration, and communicable disease will still exist. However, most other conditions heal more readily if the patient is well-nourished.2In fact, there is strong evidence that communicable diseases are more prevalent among malnourished.persons. Some. 
researchers have e:v.en.theo.~ rized that some communicable diseases may have malnu­trition as one of their prerequisites.l Some diseases and conditions which are shown to be wholly or partly caused by malnutrition include heart disease, infections of all kinds, mental retardation, lower intelligence, avitaminosis, anemia, cirrhosis of the liver, and obesity.4 Health problems exacerbated by poor nu­trition include diabetes mellitus, heart diseases, dysentery, amebiasis, and tuberculosis. With the exception of coro­nary artery disease, which exists in all income groups, all of these diseases are more prevalent among low-income families in the United States.5 In fact, rising per capita income in the United States is sometimes cited as a major cause for the falling incidence of diphtheria and tubercu­losis within this century.6 Therefore, one expects to find more nutrition-related disease among the Mexican-Americans in South Texas because, as a group, their income level is quite low. In 1975, Teller and Rodriguez7 found that Mexican-Ameri­cans, in their sample, had twice the cases of amebic dysentery Anglos had, while dying of undetermined causes (often related to nutritional deficiency) at a rate three times that of Anglos. Death rates attributable to diabetes mellitus (also related to dietary patterns) were almost three times higher among Mexican-Americans than among Anglos. Researchers suggest that some subpopulations are more susceptible to malnutrition (and thus poor health) than 
*Under-nutrition results from eating too little of one or more nutrients, and over-nutrition from eating too much of one or more nutrients; malabsorption is the biological inability to use properly the foods one cats. 
others. These groups include pregnant and lactating women, children under six, and older persons.• This is supported by a Texas Health Department study in 1970­72 which shows that 67 percent of all deaths attributable to nutritional deficiencies were to children under five and persons over 74. For Mexican-Americans in Texas, 77 percent of such deaths were to the very old and young.9 
The question of how, exactly, nutrition affects health still remains. There is little dispute that a pregnant woman must eat well to ensure optimal growth and development of her child. 10 Some research even suggests that the nutri­tion of a woman during pregnancy might have its effects upon her grandchild, regardless of the diet of the grand­child and its mother.1 1There is also reason to believe that some risk factors in childbearing, such as closely spaced or numerous pregnancies, are synergistically related to nutrition. For example, low-income couples may deliber­ately have large families because they see their children suffer, and even die (often from disease related to poor sanitation and malnutrition), and they want to ensure that some number of them will survive to a healthy adulthood.12 
Further, low income, poor housing, and limited educa­tion tend to be interrelated, even in their variations. Consequently, researchers in nutrition policy use these three indicators as surrogates to estimate the nutritional status of a population. u 
Evidence from surveys conducted in the United States supports the existence of a relationship between nutri­tional status and income/education/ sanitation. Many studies show lower-income individuals to have more nutrition-related deficiencies than higher-income persons. Racial and ethnic groups also differ in prevalence of nutritional deficiency, most likely due to the relatively low income level of minorities in the United States. Not only are Blacks and Mexican-Americans more likely to have lower incomes than Anglos, they also tend to have higher rates of nutritional deficiencies. 
To date, only one nationwide study has examined the nutritional level of low-income families to pinpoint these deficiencies. The Ten State Nutrition Study, as it was called, was conducted between 1968 and 1970; it surveyed low-income families in ten states.'4 The researchers per­formed both biochemical and anthropometric (size, height, weight) measurements, and recorded a twenty-four hour 
Mexican-American Health Care in South Texas 
recall of what each subject ate. Each of the ten states was 
classified as high-or low-income, based on the mean 
Poverty Income Ratio of the state samples. The sample in 
Texas was drawn to study low-income, mainly Mexican­
American, persons. The data suggested a relationship 
between nutritional deficiency and income level. 

Another recent study supported by the U.S. Depart­
ment of Agriculture15 found that as socioeconomic status 
increased, consumption of iron-rich foods and fruit also 
increased. Average hemoglobin levels also rose with 
socioeconomic status and were highest among Anglo 
children. The general conclusion was that most nutri­
tional risk was clustered in low socioeconomic groups in 
the United States, and that general lack of food (quantity) 
was the main problem rather than diet choices.16 This 
confirms other research findings concerning the relation­
ship between adequacy of diet and income level. 17 

In 1931 Jet Winters, a nutritionist surveying the diet of 
Mexican-Americans in Austin and San Antonio, reached 
a similar conclusion. She found that Mexican-Americans 
ate a fairly well-balanced diet, but they did not have 
enough food to avoid some nutritional deficiencies. The 
test group was especially deficient in iron, vitamin A, and 
calcium.is The Ten State Nutrition Study also found ·. deficiencies among all low-income groups. However, 
Mexican-Americans had more deficiencies in vitamin A 
and less in vitamin c than other low-income groups. 
Also, all low-income populations tended to be smaller in both height and weight than higher-income groups. 
An exception to the size differences was found among low-income adult women, both Black and Mexican­American. Both groups exhibited a much higher rate of obesity in all the studies cited above. This finding is consistent with a New York study in which women falling into the low socioeconomic category had a rate ofobesity six times greater than women from high socioeconomic groups.'9 Again, this nutritional problem (obesity) can cause or aggravate health problems. 
The preliminary findings of the First Health and Nutri­tion Examination Survey (HANES) in 1971-7220 were very similar. Persons at high risk of malnutrition were found among the poor, especially preschool children, women of childbearing age, and the elderly (over sixty years). Children in the income group above poverty were taller, heavier, and had greater median triceps skinfold thicknesses (a measurement of fat). But again, obesity was more often found among the adult poor, especially among women, and vitamin deficiencies were more often found among the poor and minority groups. The Women, Infants, and Children (WIC) Medical Evaluation Report by the University of North Carolina found these same relationships.21 
In general, the nutritional level of Mexican-Americans follows this p·attern, with low income, low educational 

Figure 4 
Relationship of Education and · Income to Physical and Mental Development 

Poor sanitary High disease 
conditions ____...., 

level 

level, and poor sanitation tending to be correlated with low nutritional status.22 Quantity, not quality, of diet emerges as the main problem among low-income groups.23 
Research suggests that the poor nutritional status of low-income Mexican-Americans can be attributed to dietary patterns. Nutrition education programs have been shown to be ineffective, in part because they are written in English or do not account for Mexican-American culture and nutritional patterns.24 However, there is no evidence to indicate that these educational programs can have much effect without an improved income/ sanitation/ educational level in enhancing nutritional status. In some instances, a community might exhibit certain diet prefer­ences which could be translated into a local nutrition education program. However, Mexican-American culture may not be sufficiently uniform for such a program to be widely adaptable.2s There are several reasons for this. Recent immigrants from Mexico, who live in a largely Spanish-speaking community, have stable dietary pat­terns that may not be amenable to change through nutritional education alone. But these patterns vary widely depending upon the section of Mexico each family calls home. As a family stays in the United States longer, other factors, s.uchas.ad.vectising andcontact.w.ith other culture. groups, affect its diet. 
Thus, income, and. consequently sanitation and educa­

tion levels, appears to be the most stable predictor of 
nutritional status. 
A World Health Organization bulletin on nutrition 

and mental development provides a good summary of the 
relationship between socioeconomic status and health.26 
Although no one has yet determined the relative impor­
tance of these factors statistically, there is wide agreement 
that they all are related in the manner described in 
Figure 4. 
One final component of nutritional status largely un­explored in the United States is the promotion of breast­feeding. Much research has been done and conclusions developed, but little public policy direction has emerged. Among developing nations, the nutrition agencies have encouraged breast-feeding, with the rationale that sanita­tion and educational levels do not affect the quality of breast milk. Even malnourished mothers can provide milk that is nutritious, for the milk receives nutrients before the rest of the body.27 Breast-feeding is not only nutritional, but anti-infectious (the milk is sterile and provides many immunities), costs little, and is of contra­ceptive significance (nursing mothers are less likely to conceive).28 In the United States, however, little has been done to use this information. Some nutritionists do advocate breast-feeding (e.g., some WIC nutritionists). However, the thrust of infant feeding programs has been to improve formulas and to educate the mothers in their use. In fact, the idea for WIC (Supplementary Feeding Program for Women, Infants and Children) arose from a project in Baltimore in which mothers were given iron-
Nutrition 

fortified formula. Because early childhood is a time of high nutritional risk, and because breast-feeding is usually the safest, most nutritious, and least expensive way to meet an infant's nutritional needs, perhaps it should receive more attention in nutrition programs. 
Nutrition Programs in Texas 
Texas has developed a number of nutrition programs over the last two decades. The programs, which primarily provide food or entitlements to food to the poor with particular emphasis upon the young and the aged, are administered through the Texas Department of Human Resources, the Texas Education Agency, the Texas Department of Health, the Division of Extension (USDA), and the Governor's Commission on Aging. These pro­grams are usually administered on a community or school level, and are rarely coordinated at either the state or local level. To understand the range and size of these programs, it is easiest to look at the major ones, breaking them into school nutrition and community nutrition categories. Tables 55A and 55B, which follow this section, show levels of expenditure and participation for the major programs. for the. state. as.. a whole .. and, .where possible, for South Texas. Mexican-American participa­tion statewide or in the study area is given when the information is available. 
School Nutrition 
There are several somewhat overlapping programs which have to do with nutrition in the schools. 
The oldest and the largest program is the National School Lunch Program (PL 79-396). Since 1946 indivi­dual school districts have had the option of participating in this federally funded program. The program was begun to rid the government of agricultural surpluses in a socially acceptable way, but today it is continued for its own merits despite the fluctuating U.S. food surplus. Since 1973 the states have received reimbursement for all school lunches based upon the cost of living index. In FY 1977, reimbursement was thirteen cents for type A lunches, ten and one-half cents for breakfasts, and six cents for milk. The Type A lunch includes four ounces of cooked meat, a vegetable, a fruit, bread, and milk. Thre is some leeway for allowing students to choose between the fruit and the vegetable if they desire, but both must be offered. Commodities and district contributions, usually through the student fee for lunch, make up the re!>t of the cost of the meal. Since 1965 there has been a provision for students from low-income families to receive free or reduced-price lunches based upon a sliding scale with size of family and income. This scale is amended with the cost of living index and follows the poverty guidelines. Stu­dents from families whose incomes are up to 175 percent of poverty receive free lunches. Students from families 
Table 55a 
Expenditures for Major Nutrition Programs in Texas 

Statewide South Texas Expenditures Per Capita Expenditures Per Capita 
School Lunch/Breakfast (a) 
Sept. '75-June '76 $116,551,593 $9.89 $39,381,377 

Non-Food Assist. Program (a) 
fy 1976 812,013 .68 640,500 

WIC (b) 
fy 1977 26,000,000 2.20 N/A 

Expanded Nutrition (c) N/A................................................... . 

Elderly Nutrition 
fy 1975 (d) 3,818,728 .32 1,529,452 

Budget 1977 10,375,888 .88 3,381, 113 
Commodities 
fy 1976 (e) 26,828,490 2.28 7,433,692 

Food Stamps (f) 
Bonus$ 
fy 197 5 317,528 ,000 2.69 99,283,000 

Table 55b 
Participation in Major Nutrition Programs in Texas 
All Race/Ethnicity Groups (g, h) Mexican-American (h) 
Per Total Per Per Total Per Total 1,000 Study 1,000 Total 1,000 Study 1,000 State pop. Area pop. State pop. Area M-A Pop. 
School Lunch/ (a, i) Breakfast Sept. '75­June'76 6S3,067 SS 210,154 89 N/A N/A N/A N/A 
WIC (b, j) 51 ,947 4 40,000(k) 17 39,110 3 27,572 24 
Expanded Nutrition (1, c) 27,005 2 9819 4 13,131 8,704 8 
Elderly (d) Nutrition 2,8S0,380 N/A N/A N/A 1,710,228 N/A N/A N/A fy 1975 (meals served) (meals served) 
est. 1977 20,894 2 6,808 3 5,744 .49 4,561 4 (persons served) (persons served) (persons served) (persons served) $16.69 
2.72 
.64 
1.43 
3.15 
42.09 
Per 1,000 Total Pop. in Area 
N/A 11 4 N/A 2 

Food Stamps (f, m) l ,086,1S6 92 432,586 183 N/A N/A N/A N/A N/A 
Nutrition 

whose incomes are 175 to 195 percent of poverty receive reduced price lunches. The difference between eligibility for free lunch and for reduced-price lunch is small, which explains the low participation in the reduced-price pro­gram. 
In 1975 the Summer Feeding Program was added for schools where 33 percent of the children qualify for free or reduced-price lunches. This program provides for meals in periods when school is not in progress. 
Non-food assistance began in 1973 and provides federal money for equipment (stoves, refrigerators, etc.) to facili­tate the other nutrition programs. Schools have the same eligibility requirements as for the Summer Feeding Pro­gram. 
All the free and reduced-price provisions of the law were made permanent in 1975. In Texas, the Texas Education Agency School Lunch and Child Nutrition Division administers these programs. 
Since 1975, through the Child Care Food Program (PL 94-lOS), it has been possible for states to assist nonprofit food service programs for children in institu­tions providing child care. Until September 1977, this program was administered in Texas by the USDA Regional Office in Dallas. Since that time, the' Texas Department of Human Resources, Commodity Division, has administered the program. 
A Special Milk Program (PL 84-690) began in 1954. This program is especially useful to districts where no school lunch is served (there is only one in South Texas), as milk is included in the School Lunch Program. Districts can also sell milk to students at the reduced price if the students bring their lunches. In 1970 the milk program became part of the Child Nutrition Act. 
In 1966 Congress passed the Child Nutrition Act to establish a breakfast program in the schools. The formula for participation is the same as for the Summer Feeding Program. Until recently this program has not grown much in Texas. However, there is now a push in the regional office of the USDA in Dallas to expand partici­pation. In 1977 the Texas Legislature passed a bill (HB 136) mandating participation of all eligible schools. 
The impact of these school nutrition programs is illus­trated in detail in the case study of the San Diego Independent School District in this chapter. 
Community Nutrition 
A wide variety of other nutrition programs have been developed over the last decade to provide food and/ or nutrition education to groups thought to bemost in need. 
In 1972 the Special Supplementary Feeding Program for Women, Infants and Children (WIC) (PL 92-433) Mexican-American Health Care in South Texas 
Footnotes for Expenditures and Participation Tables SSa and SSb  
a.  Texas Education Agency, Child Nutrition Programs, data gathered from computer print out sheets.  
b.  WIC Program, Division of Maternal and Child Health, Texas Department of Health Resources, February, 1977.  
c.  Expanded Food and Nutrition, Texas Agricultural Extension Service, Texas A&M, College Station, February, 1977.  
d.  Governor's Committee on Aging, Office of the Governor, January, 1977.  
e.  Commodity Distribution Division, Texas State Department of Public Welfare, September, 1976.  
f.  Food Stamp Division, Texas State Department of Public Welfare, Statistics, 1975.  
g.  Population taken from the 1974/75 Texas Almanac.  
h.  County and area population from Population Projections for Texas Counties: 1975-1990, May, 1972 , Population Re­ 
search Center, University of Texas at Austin.  
State  11 ,790,000  
Area  2,359,000  
M-A population in Area  1, 141 ,219  
i.  Total students eligible for free/reduced price meals, source same as (a) above.  
j.  Participation in December, 1976 .  
k.  Caseload for 1977.  
I.  Based on percent participation per county as of June, 1976 . Does not reflect total served per year.  
m.  Average monthly participation, fy 1975.  

was added to the School Lunch Act to provide food and nutritional counseling for pregnant and lactating women and for children through age five. This money is funneled through the Texas Department of Health and given to clinics in low-income neighborhoods which provide full­pregnancy and early-childhood health care. The monthly food package is available to health clinic clients who are deemed by competent health workers to be at nutritional risk. In Texas, projects are funded according to the degree of poverty in the client's neighborhood. The region of which Texas is a part had unspent money in 1977. As in the Breakfast Program, there is a push to spend this money. 
Begun in 1935, the Commodity Distribution Program (PL 74-320) provides surplus commodities to govern­mental institutions, schools, programs for the elderly, and WIC participants. The Secretary of Agriculture can also draw upon Section 32 funds (from U.S. customs pay­ments) to buy needed supplies that are not available through the commodities purchase program, or to meet an unforeseen hunger crisis. The Texas Department of Human Resources, Commodity Division, administers this program in Texas. 
The. present Food Stamp. Program.(PL 88-525) was begun in 1964 after a pilot project was successfully run in eight areas in 1961. This was not the first food stamp program. Between 1935 and 1943 a similar program existed. but it was abandoned when surplus foods virtually disappeared due to increased world demand for food. In 1971 Congress mandated the extension of food stamps to all nonparticipating countries by USDA indirectly. Eligi­bility for the program is automatic for Social Security Insurance households and Aid to Families with Depen­dent Children households when all members of the house­hold are receiving aid. Food stamps are administered in Texas by the Department of Human Resources, Food Stamp Division. 
In 1968 the national Expanded Nutrition Program was 
begun to provide nutrition education for residents of 
limited-income neighborhoods. In Texas it is administered 
through Texas A&M University, where the USDA Divi­
sion of Extension is headquartered. Using the citizens of 
the community as teachers, the program is publicized and 
the teaching is done in homes and schools, and through 
4H clubs, PTAs, etc. The nutrition education materials 
are prepared by USDA, and the teachers are trained and 
supervised by USDA workers. usually home economists. 
The Older Americans Act of 1976, building on Nutrition 
for the Elderly (PL 92-258), provided for congregate 
feeding programs as part of the general program for the 
aging (Title VII). Ten percent of the money for congregate 
meals may be used to deliver meals to persons who are 
unable to attend due to illness. However, none of the 
money is available to the "meals on wheels"-type pro­
grams which are operated by nonprofit organizations to 
provide meals on a regular basis to homebound elderly 
persons. 
As is apparent from Tables 55a and 55b, programs for the poor have a high representation in South Texas due to the large number oflow-income persons in the popula­tion of these forty counties. No total comparisons are attempted because different programs have different funding periods. The programs listed above receive most of their funding from the federal government. In some cases, all the money is federal (e.g., WIC). In other cases, the state or community must provide some of the neces­sary administrative funds (e.g., food stamps, commodity distribution, nutrition for the elderly). 
Other Nutrition Programs in Texas 
There are parts of other programs in Texas which should be considered part of the public sector nutrition activity in Texas, but they are difficult to characterize and virtually impossible to cost. These programs are discussed in a general way to acknowledge their contribution to the system of nutrition policy in Texas. 
The Texas Department of Health administers several general programs. The State Nutritionist oversees and consults with the nutritionists in the ten health regions. These nutritionists, numbering thirteen in 1976, conduct nutrition screening and counseling, but no direct service is available to correct any problem that is discovered. The patients may be referred to a clinic for remedy. 
Nursing homes in Texas are required to have a nutrition­ist in order to be licensed. The Department of Health administers the licensing. Some nutritional inspection occurs in hospitals in which Medicaid and Medicare patients are treated (twenty-one were investigated in 1976). In addition, WIC employed twenty-eight nutri­tionists statewide. 
Nutrition is a component in the health curriculum necessary for graduation from a Texas high school. In addition, many elementary schools include nutrition in their health curriculums. Some school lunch administra­tors (e.g., in Austin and Irving) involve students in special nutrition education projects such as meal planning. How­ever, in all cases, nutrition education must compete for time with other parts of the curriculum. As a result, the amount of time spent on it varies considerably from classroom to classroom. The Texas Education Agency, School Lunch and Child Nutrition Division, does not . monitor such nutrition programs or projects. , 

In recent years Texas medical schools have begun requiring at least one nutrition course in their curriculums. The University of Texas at San Antonio Medical School and the UT Medical Branch at Galveston were among the first in Texas to do so. However, as most doctors now practicing in Texas were not required to study nutrition, nutrition-related maladies may often be neglected or inadequately treated. 
In 1974 HEW reported that there were 946 employed 
members of the American Dietetic Association in Texas. 
Of this total, 454 worked in hospitals, 66 in other health 


Mexican-American Health Care in South Texas 
can-American community. Samples were taken at random within low-income census tracts in Duval Countv. Two tracts in San Diego and one in Benavides were sampled. 
Duval County was only one of ten South Texas counties sampled in that study. The samples selected from each of these counties are roughly comparable as to size and composition. The families chosen were asked to come to a mobile health clinic where socioeconomic data, diet recall information, anthropometric measurements, and biochemical test results were collected for each individ­ual. Table 57 summarizes findings in Duval County and compares them to the remaining nine counties in the study area. 
Although the Duval County sample had roughly the same number of families and the same percentage of Mexican-Americans as those in each of the other counties, the income level of the Duval sample was slightly lower and the education level was somewhat higher. In terms of 
Table 57 

Comparison of Nutrition Status of A Sample of the· Population of Duval County With Nine Other Counties in South Texas 
Duval  Nine Other  
County  Counties**  
Total N tested  173  1778  

%persons tested from families with 
Jess than $3,000/yr. income 54.8% 53.0% 

% persons tested from families with 
homemakers who had less than 

6 years education 38.0% 56.0% 
% of tested persons who 
were Mexican-American 100.0% 99.0% 

vitamin and mineral deficiencies 
discovered per persons 
examined .06 .25 

clinical signs of malnutrition 
discovered per person 
examined .38 1.31 

*South Texas was sampled in July, 1968. 

**Nueces, Bexar, Uvalde, Frio, Dimmitt, San Patricio, 

Guadalupe, Hidalgo, Cameron. 


Source: Data provided by Dr. William McGanity, University of Texas Medical School, Galveston, Texas; from 1968-70 
ten state nutrition study. 
malnutrition citings and total nutrition deficiencies, Duval was much lower than all but Uvalde County and not significantly different from Uvalde. 
There are methodological criticisms which may be leveled at the Ten State Nutrition Study and at the pulling of county statistics from a nation-wide study.» However, there is no reason to believe that these problems· would bi~s these results to Duval County's advantage in the area of nutrition. 
It cannot be said that the improvements in nutritional level are solely attributable to the school feeding programs, as the educational level may account for the differences. One physician who has been practicing in San Die'go since the early 1930s said he had seen a marked improve­ment in the health status of the residents. He said he feels that the main contribution of the school lunch program was in introducing the community to a wider variety of foods. "It's no joke that in the old days the main diet was tortillas and beans. If you'd walked into one hundred homes in 1938 you'd find beans on over 50 percent ofthe tables for breakfast. "31 He said he does not think that is true today. He ~es the free/ reduced-price lunch and breakfast programs as nutrition education by example, and· guessed, that before· the program began many· of the ·· children who did not eat at the school did not eat lunch at all. In addition to school food and nutrition education, he sees the general rise in the health status of the community as the result of somewhat higher incomes, which are still very low, and of a reduction in the isolation of Duval County residents. 
A number of observers report improvements in com­munity conditions in the last decade. The manager of food handlers in the San Diego Independent School District, who for eighteen years has been employed in the cafeteria, said that the free/ reduced-price lunch program immediately increased daily participation from seven hundred to fourteen hundred. She said that the children she saw were happier and more talkative. Their eyes looked brighter and their skin color was better within just a few weeks.32 The woman who has been Area Consultant for the Texas Education Agency School Lunch and Nutrition Division since 1954 stated that it was not uncommon to see cracked lips and hair that looked like straw (both are sigrts of malnutrition) duringHhe 19SOs' and early 1960s.33 She said the improvement was gradual, beginning in 1959 when the school lunch program began in San Diego. However, she had noticed a change in the energy level of the children in general since 1966 when the free lunch program began. 
The superintendent of schools said that performance· on standardized tests has improved over the years anct-i that far more students complete high school and go on t<>; college. He stated that the presence of food programs in the schools was one of many contributing factors to the improvement in achievement, listing improved teaching and curriculum as two other important variibles.34 

Nutrition-Related Problems Faced by Many Mexican-Americans in South Texas 
The principal nutrition problems faced by Mexican­Americans in South Texas come most often from lack of adequate quantities and varieties of food. Two condi­tions associated with poor nutrition that are far more prevalent in the Mexican-American community than among other groups in South Texas are vitamin A deficiency and diabetes. 
Several studies have found widespread vitamin A dcffi­ciencies in 30 to SO percent of Mexican-American children examined.ls This vitamin A deficiency among Mexican­Americans is especially troublesome when considered in conjunction with a particular study conducted in South Texas. A team of nurses, doctors, and nutritionists ran an experiment from 1970 through 1972 and found that the level of vitamin A deficiency was not significantly altered after administering vitamin A supplements to a chosen population for two years.l6 Absorption of vitamin A is dependent upon certain proteins (amino acids), so the persistence of the vitamin deficiency may well be caused by protein deficiency. 
A. far.. more severe problem. is.. the extremely high. incidence of diabetes amongst the Mexican-American population. Using 1975 mortality data from the Texas Department of Health, a much larger percent of deaths are attributable to diabetes mellitus among the Mexican­American population than among the Anglo population (see Table 58). This is especially disturbing when one realizes that not only are persons with diabetes mellitus often determined to have died from other causes, but frequently, especially among poor populations, diabetes goes undetected.37 Furthermore, the relatively younger Mexican-American population would be thought to have less diabetes than the Anglo since adult onset of diabetes does not develop until age thirty-five or forty. 
A study of average 1969-71 mortality rates standardized for age differences (see Table 61) also shows higher rates for Mexican-Americans than for Anglos across Texas.ls In addition, when one compares this data to 1973 statistics for the United States as a whole, it is clear that Mexican­Americans are at a far greater risk than the rest of the population. In all cases, females have greater risk of diabetes mellitus than males and Mexican-Americans have greater risk than Anglos. 
In 1975, the National Commission on Diabetes in its report to Congress revealed that the prevalence of diabetes among low-income populations is much greater than among higher income groups (see Table 59). This was true despite their observation that statistics on diabetes are generally poo~ and underestimate the prevalence, especially among low-income groups.39 The Commission also found that diabetes is more frequently found among nonwhite populations. 
Further, adult onset of diabetes mellitus seems to be 
Nutrition 87 

highly correlated with obesity, though the exact mechan­ism is not known,40 and both diabetes and obesity appear to be genetically linkcd.41 In a study in downtown Man­hattan, Dr. Albert Stunkard and colleagues found obesity to be seven times more frequent in lower-class than upper-class groups. This led them to conclude that what-
Table 58 
Ethnic Comparison of Mortality Data for Diabetes Mellitus 
Anglo Mex-Am 
Male Female Male Female 

Percent of 1975 Deaths from Diabetes in South Texas • 1.05% 2.01% 3.54% 5.31% 
Average 1969-1971 Deaths from Diabetes per 10,000 persons in Texas•• 1.18 1.62 2.80 5.30 
All Persons Male Female 

1973 Deaths from Diabetes per 10,000 persons in 
U.S. 1.43 2.57 
*Not age adjusted. Juvenile and Adult 
**Mexican-American rates are age adjusted so Anglo rates. 
Sources: Texas Health Department, 1975 data. Former, Edwin, Jr., Mortality Differences of 1970 Texas Residents: A Descriptive Study, Master's Thesis, School of Public Health, University of Texas Health Science Center at Houston; Sept. 1975. 
Table 59 
Prevalence of Diabetes Mellitus by Family Income Level, 1975 

New Cases Total Cases Family Income per 1,000 per 1,000 
Total 3.0 20.14 less than $5,000 yr. 4.5 40.2 45,000-9,999 yr. 3.4 20.2 over $10,000 yr. 2.2 13.7 
Source: DHEW, Report of the Commission on Diabetes, Vol. III, Pg. 2, 1975. 
Mexican-American Health Care in South Texas 
ever its genetic and biochemical determinants," ... obe­sity in man is susceptible to an extraordinary degree of control by social factors. "42 In a discussion ofdiet therapy for diabetes, Dr. John Davidson notes that obesity not only is highly correlated with diabetes, but being over­weight increases the need for insulin.43 This puts an even greater strain on an already malfunctioning system, making the diabetic manifestations worse. 
Patients at the Robert B. Green Hospital 

Given the relationship among income, ethnicity, obe­
sity, and diabetes, one must wonder if ethnicity in fact has an independent influence upon the occurrence ofdiabetes in the Mexican-American population. Although definitive proof cannot be given, our study at the Robert B. Green Hospital in San Antonio suggests that even when income is held constant, there seems to be a higher occurrence of diabetes among Mexican-Americans. Table 60 suggests that the proportion of Mexican-Americans with diabetes at the Robert B. Green Family Practice Clinic is higher for most age and sex intervals than the proportion of either Blacks or Anglos who have diabetes. These data are. limited by the very low numbers of Anglos and Blacks diagnosed as diabetic. Also, results may reflect self­selection in the seeking of clinic services. Of particular interest in Table 60 is the relatively high rate of diabetes among Mexican-American males as compared to Mexi­can-American females. These results are similar to those of a study of mortality rates in San Antonio in 1970 which showed little sex difference in mortality rates from dia­. betes.44 This finding differs with Texas as a whole and South Texas estimates which we cite above. It is impor­tant to remember that Table 60 exclusively represented very poor families, so the poverty variable is held some­
what constant. 

Table 61 adjusts the figures for Mexican-Americans by 
assuming that they have an age distribution equivalent to 
the Anglo distribution. With this adjustment, the differ-· 
ences in diabetes rates between Mexican-Americans and 
Anglos increases. 

Before further describing the study of Robert B. Green 
Clinic patients, a brief description of the treatment of 
diabetes might be useful to the reader. Diabetes, the 
inability of the body to produce enough insulin to metabo­
lize blood sugar (glucose) has been classified into two 
categories. Juvenile onset diabetes (JOO) is a metabolic 
imbalance which shows up early in life and always re­
quires insulin in treatment. The adult onset variety (AOD) 
is the same metabolic imbalance but usually is more 
easily controlled, often by diet alone.* Researchers now 
*Modern medical terminology has replaced the terms juvenile onset and adult onset diabetes with insulin dependent and non insulin dependent diabetes. (These terms are not exactly synonymous because rarely juvenile onset will not be insulin dependent and occasionally adult onset diabetes will require insulin. 
feel that the genetic linkages for AOD and JOD are discrete, and that, while AOD is frequently correlated with obesity, JOO is not. Until recently, AOD was often controlled with oral agents called hypoglycemics, drugs which reduce the blood glucose level. However, in 1970­71 the University Group Diabetes Program produced a report showing a significantly increased rate of cardio­vascular death among patients treated with these drugs. Although the validity of these findings has been ques­tioned, the report resulted in a greater emphasis on dietary control of diabetes. A diet tn:atment project at Grady Memorial Hospital in Atlanta claims a high rate of success (about 80 percent). The intensive regime includes fasting, diet counseling, small group contact, special cookbooks, and a team of doctors, clinicians, and nutri­
tionists for each group of patients.45 
The physicians of the Robert B. Green clinic have become concerned about the use of hypoglycemics to control AOD for the same reason mentioned above: the possible adverse effects from the drugs, especially among cardiovascular patients. This is of special concern among this group of patients, since diabetes is a prevalent disease at Robert B. Green and 57 percent ofthe diabetic popula­tion is.also diagnosed as hypertensive, a cardiovascular. condition. 
In addition to being concerned about the use of hypo­glycemics, the physicians felt that diet control had been least effective among the part of the diabetic population with the largest incidence: Mexican-American females. Therefore, in this study, we sought to determine whether there are any differences among the diet-controlled dia­betic population that are not reflected in the diabetic population of the Green Clinic as a whole, especially regarding sex and ethnicity. Only AOD were sampled, since JOO diabetics must take insulin. 
It was found that the more severe the disease, the less likely it was that diet alone would control adult onset diabetes; but that diet therapy alone in severe cases was more common than expected. No signficant relationship between diet control and ethnicity or sex was found. 
Some State-Level Initiatives 
Necessary state-level initiatives-which appeartto emerge from our analysis include the following: 
-An attempt should be made to coordinate nutri­
tion programs more completely and to help local 
agencies learn of all the different, and somewhat 
competing, options open to them. A corollary to 
this is that health and nutrition programs must be 
more strongly interrelated; 
-School nutrition programs are of great impor­
tance, and the 1977 Legislature took a very useful 
step in mandating participation in school break­
fast programs; 
Nutrition 
Table 60 

Percent of Patients Ever Diagnosed as Diabetic by Ethnicity, Sex, and Age Groups 
Robert 8. Green Family Practice Clinic 

Anxlo.~ Blucb Mexican-Americans 
1"1'111Ufl'  Mule  /;emu/<'  Male  Female  Male  
.·lgc (;l'tll//I.~  #•  ~Y,. •*  #  %'  #  N /"  #  %  #  %  #  %  
()  14  81  -0­ 71  -0­ 158  -0­ 183  -0­ 1457  0.2  1443  0.2  
1:1  29  Sh  3 .6  48  (i .3  157  -0­ 109  -0­ 1108  I.7  860  1.3  
30  44  35  1 1.4  1l)  -0­ 8'>  7.'I  18  5.6  656  9.6  362  9.7  
45  5'1  28  14.3  14  -0­ 84  26 .2  26  I 5.4  388  22.9  208  25 .0  
h0 anti ovn  23  13.0  13  7.7  60  16.7  14  7.1  233  31.8  172  26.2  
.TOTAi  223  5.8  170  2.4  548  7.1  350  1.7  3842  6.5  3045  4.8  

* l'otal numhl'T of patients in group. 
**l'nl'l'lll of p<.1tients l'Ver diagnosed as tliabetic. 
Snurn·: Robert B. Green Hospital. San Antonio 
Table 61 Age Adjusted Rates of Diabetes Among Clinic Patients 
Anglo Mexican-A merican Female Male Female Male Age Groups Numher•• Percent••• Number Percent Number Percent Number Percent 
0-14 81 0% 71 0% 1,395 0.2% 1,221 0.3% 15-29 56 3.6% 48 6.3% 965 2.1% 825 1.8% 30-34 35 11.4% 19 0% 604 8.8% 327 9.2% 
45-59 28 14.3% 19 0% 482 22.0% 326 27.0% 60+ 23 13.0% 13 7.7% 2,396 31.3% 223 27.8% 
TOTAL 223 5.8% 170 2.4% 3,842 8.0% 2922 
*Mexican-American age distribution is adjusted to that of Anglos **Number of Total Patients in Group ••*Percent of Paitents in Group Ever Diagnosed as Diabetic 
Source: Robert B. Green Hospital, San Antonio 
Mexican-American Health Care in South Texas 
-More must be learned about the reasons for the 
higher incidence of vitamin A deficiency and dia­
betes in the Mexican-American population; 
-Increased programs of health and nutrition edu­
cation should be encouraged both in schools and 
in the community. 

Many of these activities are already underway, and with growing interest in nutrition and health in all sectors of society it is to be hoped that positive programs will emerge. 
References 

'Jean Mayer, "The Dimension of Human Hunger," Scientijic American 235, no. 3 (September 1976); and N.S. Scrimshaw, 
C.E. Taylor, and J.E. Gordon, Interaction of Nutrition and Infection (New York: World Health Organization, 1968). 
2Scrimshaw et al. , Interaction. 

.llbid. See also Mayer, "Human Hunger;" and lilstitute of Nutrition of Central America and Panama, Workshop, Ameri­can Journal of Disease of Children 129 (May 1975). 
•Scrimshaw et al.. Interaction, and Mayer, J ., op cit. 

5U.S .. Congress, Senate, Select Committee on Nutrition and Human Needs, Diel Related to Killer Diseases, 94th Cong., 2d sess., 1976. 
6lbid. 

7Charles H. Teller, Romeo Rodriguez, and Steve Clyburn, "Physical Health Status and Health Care Utilization in Texas Borderlands," mimeo, University of Texas, April 1975. 
MU.S ., Department of Health, Education, and Welfare, Na­tional Center for Health Statistics, Preliminary Findings of the First Health and Nutrition Examination Survey, U.S., 1971 ­1972, Anthropometric and Clinical Findings, 1975. Also, U.S., Department of Health, Education, and Welfare, Health Ser­vices and Mental Health Administration, Ten State Nutrition S1udy. 1968-1970, Center for Disease Control, 1972. 
9Texas Department of Health, Records and Statistics Divi­sion, "Deaths Attributable to Avitaminosis and Other Nutri­tional Deficiencies, 1970-1972" (Austin, 1975). 
IO Proceedings of the International Conference on Nutrition, Alan Berg, Nevin Scrimshaw and David Call eds., Nutrition . .Vational Development and Planning, MIT Press, Cambridge, Mass., October 19-21, 1971 . and "Symposium on Malnutrition and Infection During Pregnancy," Proceedings of Workshop Institute of Nutrition of Central America and Panama, Ameri­can Journal of Diseases of Children vol. I (May 1975). pp. 549­
580. 
11 Editorial, " Maternal Nutrition and Low Birth Weight," Lancet 2(7932) (September 6, 1975): 445. 
12National Research Council, Food and Nutrition Board, Committee on International Nutrition Programs, Subcommit­tee on Nutrition and Fertility, Nutrition and Fertility Interrela­tions, Implications for Policy and Action, Washington, D.C.: National Academy of Sciences, 1975); and David Rush, "Mater­nal Nutrition During Pregnancy in Industrialized Societies," American Journal of Diseases of Children, 1975, pp. 430-34. 
UAlan Berg, "Increased Income and Improved Nutrition: A Shibboleth Examined," International Development Review 12, no. 3 (1976); and Erik Eckholm and Frank Record, "The Two Faces of Malnutrition," World Watch Report, no. 9 (1976). 
•4 U.S., Department of Health, Education, and Welfare, Ten State Nutrition Study 1968-70. See also James Carter, The Ten State Nutrition Survey: An Analysis (Atlanta: Southern Re­gional Council, 1974). 
ll"Supplement: A Study of Nutrition of Pre-School Children in the U.S.A., 1968-70," Pediatrics 53, no. 4, Part II. 
16lbid., p. 433 . 
17 Nutrition. National Development, and Planning, p. 115, 166-67; H. Peter Chase, et al., "Nutritional Status ofMexican­American Migrant Farm Children," American Journal ofDis­eases of Children 22, no. 4: 316-24; and Eckholm and Record, Two Faces. 
18Jet Winters, Health and Nutrition Report of Mexicans, University of Texas Bulletin No. 3127, Bureau of Research in the Social Sciences, Study no. i, July 15, 1931. 
' 9Albert Stunkard, "Social Class and Obesity,"in The Pain of Obesity (Palo Alto, Ca.: Bull Publishing Co., 1976), pp. 137-52. 
20U.S., Department of Health, Education, and Welfare, Preli­minary Findings. 
21U.S .. Department of Agriculture, Medical Evaluation of The Special Supplementary Food Program for Women, Infants, and Children, July 15, 1976. 
22Robert Bradfield and Thierry Brun. "Nutritional Status of California Mexican-Americans," American Journal ofClinical Nutrition 23, no. 6 (1970): 798-806.; Chase, et al., "Nutritional Status."; William McGanity, "Nutrition Survey in Texas," Texas Medicine 65 ( 1969): 40-49; and A.Taber Moustafa M.D., and Gertrude Weiss, "Health Status and Practices of Mexican­Americans," Mexican American Study Project Advance Re­port 11, University of California, Los Angeles, Graduate School of Business Admin., February 1968. 
23Fred Powledge, "Getting a Handle on the Drinking Water Problem," New South (Fall 1973); John P. Walter, "Two Poverties-Many Hungry Indians: An Economic and Social Study of Nutrition," American Journal of Economics and Sociology 33 (1974). 

..;.,:...: ....· 
l•Ruth Barrios, "Nutrition Education in Sacramento County for the Americans of Mexican Descent," Aztlan I, no. 2 (Fall 1970). 
l~Armand J . Sanchez, "The Definers and the Defined," El Grito 4, no. 4 (Summer 1971 ): 4-11. Nathaniel N. Wagner, and Marsha J. Haug, Chicanos, Social and Psychological Perspec­tives, C.V. Mosby Co, St. Louis, 1976. 
W'The Problem of Malnutrition," World Health Organiza­tion Chronicle, 28, no. I (1974): 3-7. 
27"Lactation and Composition of Milk in Undernourished Women," Nutrition Review 33, no. 2: 42-43. Feb. 1975. 
lKDerrick Jelliffe and Patrice Jelliffe, "Human Milk, Nutri­tion and the World Resource Crisis," Science 188, no. 4188 (May 1975): 557-61. 
29U.S., Department of Health, Education, and Welfare, Pub­lic Health Service, Health Resources Administration, National Center for Health Statistics, Health Resources Statistics, 1975. 
30Carter, Ten State Nutrition Survey . Telephone interview with William McGamity, M.D., UT Medical Branch at Galves­ton, December 1976. 
! 1[nterview with Philip Dunlap, Sr., M.D., San Diego, Texas, December IO. 1976. 
-' 21nterview with Lena Gonzales. San Diego, Texas, December 
9. 1976. 
33Telephone interview with Kitty McLaughlin, Regional Nu­tritionist Texas Education Agency, January 1977. 
14lnterview with Ramon Tanguma, San Diego, Texas, Decem­ber 9, 1976. 
·15 Lora Beth Larson, Janice Dodds, Donna Madoth, and H. Peter Chase, "Nutritional Status of Children of Mexican Amer­ican Migrant Families," Journal of the American Dietetic Association 64:1 (January 1974); Chase et al., "Nutritional Status . .. Migrant Farm Children."; E.M. Lantz and Pat Wood, "Nutrition of New Mexico, Spanish Americans and 'Anglo' Adolescents: Part I-Food Habits and Nutrient Intakes," Jour­nal o,fthe American Dietetic Association 34, no. 2 (February 16, 1958): 138-44; Ibid., "Part II-Blood Findings, Height, Weight Data, and Physical Condition," pp. 145-53. 
J6 Larson, et al., "Nutritional Status." 
HGeorge Tokohata, Wilda Miller. Edward Digonand Thomas Hartman, "Diabetes Mellitus: An Underestimated Public Health Problem," Journal of Chronic Diseases 28, nos. 123-25 (Janu­ary 1975); U.S., Department of Health, Education and Welfare, 
Report o.f the Commission on Diabetes to the Congress ofthe United States. vol. 111, pt. 2. 1975. 
JKEdwin Fonner, Jr., "Mortality Differences of 1970 Texas Residents: A Descriptive Study" (Master's thesis. School of 
Nutrition 

Public Health, University of Texas Health Science Center at Houston, September 1975). 
39Tokohata, et al., "Diabetes Mellitus." 
• 0John K. Davidson, "A New Look at Diet Therapy," Diabetes Forecast, May-June 1976; Thomas Skillman and Manuel La­govinis, Diabetes Mellitus, College of Medicine, Ohio State University, Upjohn, 1976. 
41 Robert Tattersau and Stefan Fajans, "Prevalence of Diabetes and Glucose Intolerance in 199 Offspring of Thirty-seven Con­jugal Diabetes Patients," Diabetes 24, no. 5 (May 1975): 452­62.; Mary Moore, Albert Stunkard, and Leo Strole, "Obesity, Social Class, and Mental Illness," Journal of the American Medical Association, 181 (1962): 926~6. 
•2/bid .. p. 966. 
4JDavidson, "Diet Therapy." 
44 Michael P. Stern and Sharon Parten, "Comparison of Car­dio-Vascular Disease Mortality in Spanish Surname and Others in San Antonio, Texas," Report issued from Department of Medicine, The University of Texas Health Science Center at San Antonio, 1977 (mimeo). 
•soavidson, "Diet Therapy." 

Chapter 6 


Mental Health Services and 
Mexican-Americans 

..Mental health" and "mental illness" are terms with different meanings to different cultures and schools of thought. Mental health is influenced by both biological and cultural factors and is highly variable in definition, time, and place.1 
Given this variability, "mental health" and "mental illness," in this chapter, are used in the same sense that the pertinent state or local agencies use the terms. The Texas Department of Mental Health and Mental Retardation (TDMHMR) usually categorizes diagnoses as "mental health," "mental retardation," "drug abuse," "alcohol­ism," and "other." Most providers of mental health services in Texas are involved in one .ot: more of these . areas. 
Unlike physical illness, the consequences of mental illness are not easily measured. Poor physical health may be reflected in morbidity and mortality rates. However, the consequences of poor mental health and inadequate treatment are largely invisible. 
This chapter is a brief and somewhat limited examina­tion of the "fit" between the provision of mental health services and the mental health needs of Mexican-Amer­icans of South Texas. We briefly discuss some of the distinct needs of Mexican-Americans and identify several groups (women, adolescents, migrants, and the elderly) who may be particularly in need of services. The Texas mental health system is reviewed in broad strokes, employ­ment of Mexican-Ame.ricans is examined, and the utiliza­tion of services by Mexican-Americans in South Texas is discussed. With the exception of several innovative pro­grams, we do not examine in great detail the composition of programs at the local level; although alcoholism, drug abuse, and mental retardation programs are equally important, we did not have the resources to study these issues. An appendix to the report as a whole on curandis­mo (Mexican-American folk medicine) supplements the discussion in this chapter. 
Considerations in Serving Mexican-Americans 
Mexican-Americans as a group are economically, demographically, and culturally distinctive. Each of these distinctions has, to varying degrees, an effect on the need 
··' for the availability of mental health services. Economically, widespread poverty among Mexican-Americans, particularly along the South Texas border, may be expected to both increase the need for mental health services and limit the ability of the population to acquire those services. The large proportion of young Mexican-Americans suggests that the types of services needed and the intervention strategies may differ substan­tially from those in the rest of Texas. 
Padilla and Ruiz, at UCLA and the University of Missouri, respectively, defined five consideratiOns, which are roughly defined as "cultural," and which may affect the degree to which mental health resources are able to serve many Mexican-Americans effectively. These consi­derations include: 
-poor communication skills in English 
-the poverty cycle-limits of education, income, 
social status, housing, and political influence; 
-the attempt to adjust to the transition from a rural 
culture to an urban one; 
-for some, seasonal migration; and 
-stresses of acculturation to a sometimes hostile 
and/ or prejudicial culture.2 
To this list must be added other considerations. The conflicts between traditional medical beliefs and con­temporary mental health care techniques, for example, may present barriers to provision of mental health ser­vices. Many Mexican-Americans do believe at least some aspects of curanderismo, folk medicine, as administered by local healers. Such healers, using a combination of herbal, religious, and scientific techniques, most likely have positive effects on the mental health of their patients, even if such benefits unintentionally accompany treat­ments meant to cure physical ailments. 
Problems may arise when primary care personnel fail to understand or respect these beliefs. Trotter and Chavira ( 1975) stress that "the only way a health care practitioner can successfully treat the whole man is to understand the social framework that surrounds the biologial events of illnesses.''3 They suggest that this is true for both physical and mental illnesses. 
Belief in curanderismo affects an individuals's interpre­ation of physical and mental illness. The individual may be less likely to seek out "professional" mental health services and less receptive to "modern" methods of treat­ment. 
Perhaps the most useful aspect of folk medicine's practice results from the curandero s understanding of the patient's language and culture. The healer's presence can provide a sense of security, protection, wish gratifica­tion, or religious absolution. While many professional psychiatrists, psychologists, and sociologists recognize the potential benefits curanderismo may have for mental health, others are skeptical. Regretably the potential benefits of folk psychiatry are not fully realized. 
Another important cultural consideration is the con­cept of la fami/ia, the extended family. Among many Mexican-Americans: 
To be a member of la fami/ia is to have that all important feeling of belonging, secure psychologically in the know­ledge that parents, brothers, and sisters, as well as mem­bers of the extended family, are equally concerned with one's physical and emotional well-being. The interrela­tionship between mental well-being and belonging to la familia is self-evident in that for centuries the familia has been the cohesive and protective force of the Chicano culture.4 
While this description of lafamilia is perhaps idealized, the different family systems among Mexican-Americans certainly bear upon an individual's interpretation of problems and solutions, as well as upon an individual's activity in seeking out and making use of mental health services. The 1975 Denver Conference on Chicano Mental Health, for example, concluded that la familia has a considerable effect on the type of mental care needed or sought.5 Relying on la familia as a primary source of emotional reassurance, many people may not bother to use other sources of mental health care. 
The geography and demography of South Texas create serious barriers to provision of services. Although the area encompasses five metropolitan areas, South Texas, which is larger than many states, contains many small communities surrounded by vast unpopulated areas. Almost 20 percent of the South Texas population live outside of the five SMSAs. Fifty-five percent of these persons are Mexican-Americans. The vast area and scat­tered population of South Texas present serious trans­portation barriers to delivery of mental health and other services. 

The mixture of urban and rural demography is particu­larly acute in Hidalgo and Cameron counties along the border. Although the counties have a combined popula­tion of 321,903, the largest city, Brownsville, has only 52,522 persons, and only 53.4 percent of the population live in the six largest cities for which the two SMSAs are named. If the three neighboring municipios on the Mexi­can side of the border were included, these two SMSAs would have had a 1970 population of 730,224. Poverty combined with geographic distance to service providers creates transportation difficulties which are not resolved by the scant private and public transportation resources. 
Mental Health and Migrant Farmworken 
There are virtually no hard data on the extent of the mental health problems of migrant farmworkers. How­ever, extrapolating from socioeconomic and occupational data, one can suggest that of all the working poor, migrant farmworkers run the greatest risk of physical and mental disorders. In addition to empirical studies of specific mental health problems, the President's Commis­sion on Mental Health (PCMH) has probed their under­lying socioeconomic and environmental causes. The PCMH maintains the position that "mental health is the interaction between the individual and the social environ­ment." Mental dysfunction, then, may be a result of an inability to deal with societal problems. The report by PCMH points out, for example, that the constant uncer­tainty of employment, as well as social and economic powerlessness, may produce mental health problems for migrant farmworkers. The fact that migrants are predomi­nantly of a racial or ethnic minority status may produce extra stress for the individuals living in a society where dominant members often fail to recognize cultural varia­bility. Environmental factors such as overcrowded hous­ing, malnutrition, undereducation, social isolation, and exposure to toxic chemicals have been shown to increase the rates of mental disorders, as well as institutional racism, exploitation, and exposure to the natural hazards of the environment. This holistic approach not only provides a better understanding of causes but also gives a framework by which we may judge the efficacy ofexisting programs. 
Beca~se the mental health problems of migrant farm­workers are not sufficiently well understood, those pro­grams which do exist are hampered. Providing adequate mental health services for migrants involves not only increasing the number and extent of services but also overcoming problems ofaccessibility and utilization. The PCMH report. lists among the problems migrant farm­workers have in obtaining services (1) their unawareness of their need for the services; (2) the stigma attached to receiving service; (3) lack of transportation; (4) lack of evening hours in service agencies; (5) inability to afford services; (6) language and cultural differences.6 In addi­tion, it has been noted that the lack ofa uniform definition of "migrant farmworker" makes c,:ligibility requirements diverse among different programs and across state bor­ders. This is confusing to the migrant person and hampers the administration of such programs. In general, over­lapping jurisdictions, duplication of resources, and lack of coordination of existing federal programs demonstrate a failure to address properly the needs of migrant farm­workers. 
The Mexican-American Elderly 
In addressing mental health problems of the Mexican­American elderly, we are again faced with a lack of information. Despite obvious problems, little research has been done to determine the particular needs of the Mexican-American elderly population. This group is often poor and has little formal education. As first generation immigrants, many of them do not speak English and are deeply attached to the Mexican values and beliefs they brought with them. They have had to live with social and cultural changes, societal-technological changes, and often with rural-to-urban changes. In addi­tion to changes associated with aging, these transitions may produce strains with which they find it difficult to cope. 

Adolescents 
The mental health needs of Mexican-American adoles­cents also lack proper recognition. Adolescence has tradi­tionally been a vulnerable period in life due to rapid personal changes and changes in societal and parental demands on young persons. In addition to problems normally associated with this period of transition, the Mexican-American adolescent is exposed to stresses caused by a cultural, economic, and social minority status. He or she may have difficulty coping with sex role rigidity or strong family unity. Educational status within the community may be low and the high school drop-out rate is often high. Unwanted or unplanned pregnancies are frequent among Mexican-American adolescents, as avaifability of contraceptives is scarce and moral pressure against their use is strong. The risk of complications in such teenage pregnancies is high. 
Another health risk results from poor nutritional habits which, as in any population, often lead to obesity. Drug and alcohol abuse may also be common. South Texas has no facilities which direct their services specifically toward the mental health needs of adolescents. 
Facilities and Services 
Several types of facilities treat the mentally ill in Texas. Eight state hospitals provide both outpatient care (through fifty-four outreach clinics) and inpatient care. The majori­ty of clients are classified as seeking mental health ser­vices, although some are treated for mental retardation, drug abuse, and alcoholism. 
Texas has twelve state schools for the mentally retar­ded. While the schools emphasize care and training ofthe retarded, they do treat a small percentage of mentally ill persons. Mentally retarded clients needing long-term treatment and training are usually placed in state schools rather than in state hospitals. 
For the less afflicted, Texas has four state centers for human development, providing outpatient and short­term inpatient care. The centers provide diagnostic servi­ces to persons who may be retarded, mentally ill, or have 
• r an addiction problem. Often the services they provide are an alternative to long-term schools and hospitals. 
Mental Health Services 

The twenty-seven community mental health centers (CMHCs) located in large and mid-sized Texas cities, provide a wide range of mental health, mental retarda­tion, and drug abuse and alcoholism services. Funded by federal, state, local, and private monies, the centers were organized with seed money from the federal CMHC Act of 1963. Most of the centers serve more than a single county, and together the twenty-seven CMHCs theoreti­cally cover 81 percent of the state's population. In prac­tice, however, prospective clients in a given catchment area may be quite distant from the nearest center. This is particularly true in portions of the Panhandle, East Texas, and South Texas. 
Other facilities include the Texas Research Institute of 
Mental Sciences in Houston, and three private facilities 
under contract to TDMHMR. 
Within the forty-county South Texas area, several organizations treat the mentally ill. The Veterans Admin­istration has a psychiatric unit in its San Antonio hospital, and many other hospitals provide some psychiatric care. Several mental health projects are run by private organi­zations, often funded in whole or part by the federal government, foundations, or other resources. 
Most mental health services, however, are funded or administered by TDMHMR. Of the eight state hospitals, two are in South Texas. One of the state's twelve schools, three of the twenty-seven CMHCs, and one of the four other major facilities all are located in South Texas. 
In the forty-county South Texas area, twenty-three mental health outreach clinics operate as administrative and treatment extensions of state hospitals and commu­nity mental health centers. These clinics are in addition to those clinics operated in the same cities as the administra­tive entity. The clinics are often located in small, aging buildings, and overcrowding of both staff and clients is a frequent problem. The services of the supervising state hospitals or CMHCs can be obtained through the out­reach clinics. However, in many cases, these services are not directly provided at the clinics themselves, and travel to the state hospital or CMHC is necessary. Outreach clinics provide case management monitoring of therapy and drugs, and after-care services. They may also provide psychiatrist visits once or twice a week and may contract with local physicians. Outreach clinics do not necessarily provide "outreach" in terms of treatment within the community. To begin to receive their services the patient must first go himself to the clinic or be referred by an institution or practioner. This is significant in view of the previously discussed geographic and transportation bar­riers to service delivery. 
Geographically, the clinics are widely dispersed, cover­ing most major population centers (see Map 21 ). Eighteen counties have neither a major facility nor an outreach clinic. Together thes.! counties have a population of 160,000, 48.4 percent of which are Mexican-American . 
· In the past decade, locally available services have 
Mexican-American Health Care in South Texas 
Map 21 Locations of Mental Health Services in South Texas 

increased greatly. Yet, some areas still remain distant from these services. More important, there is a need for greater coordination among those services that do exist. In effect, five separate outreach systems administered by five different agencies operate in South Texas. The Nueces County Community MHMR Center, the Tropical Texas Center for MHM R, Kerrville State Hospital, San Antonio State Hospital, and the Rio Grande State Center all have separate outreach systems. Each system theoretically is responsible for a separate geographic area. In practice, however, there is some overlap. In some instances, only a few miles separate units which perform the same services, but are administered by different facilities. In Browns­ville, for example, both the Tropical Texas Center for MHMR and the Rio Grande Center for MHMR operate 
drug treatment clinics. 
In the City of Gonzales, the Gonzales County Mental Health Outreach Clinic is administered by the San Anto­nio State Hospital (SASH). In the same town, the Gonza­les County MHMR Activity Center operates under the Travis State School in Austin. While the latter is more concerned. with mental retardation treatment, there is some overlap. A similar case is the City of Seguin, where a mental health clinic and a mental retardation clinic operate in the same building, but are administered by two different major facilities (SASH and the Austin State School). 
Often, one facility's outreach clinics maybe unaware of what another facility's clinics are doing. In interviews, several administrators and direct care staff in Valley facilities expressed the opinion that this situation prevents the mental health system from better serving the residents of the Lower Rio Grande Valley. 
Most significantly, the rural outreach clinics existing as five administratively separate units are unable to serve the truly rural areas of South Texas. Little attempt can be made to serve the population living outside the towns because outreach clinic resources already are stretched to their limits. To cover the rural areas of South Texas, "outreach" is needed in the most literal sense of the word. To serve low-income persons, migrants and persons in rural populations, programs will have to travel to the people; individually, each outreach system cannot muster the staff and expense for such an effort. 
With greater cooperation between the clinics and with the backing of TDMHMR's central office, comprehensive geographic coverage would have a better chance of being realized. The Texas state government has made consider­able progress in bringing mental health care to citizens of small towns, but coverage is not complete. More central­ized, ambitious planning is required to fully utilize the potential of the outreach systems currently in place. 
Equally important is the planning and administrative capacity within each outreach system. The two largest such systems in South Texas are operated by the San Antonio State Hospital and the Rio Grande State Center 
Mental Health Services 

for MHMR. Each system is managed by an outreach coordinator. Each system's coordinator is too busy with "crisis-response" planning and other short-range work to perform much needed longer-range planning functions. 
In sum, mental health services are available in many rural South Texas communities. Through state hospital and CMHC outreach programs, contact is made with many persons in need of treatment. However, because of shortages of funds, facilities, and professionally-trained staff, referral to a major(and usually distant) state facility may be the only recourse available to those needing inpatient care. Due to the administrative decentralization of the outreach system and little direction from the TDMHMR headquarters, rural staffs are left to pursue their goals as best they can. 
Expenditures for Mental Health 
In Texas, appropriations for TDMHMR in the 1976­77 biennium totalled $590,203,248. This amount includes only those monies appropriated by the Texas Legislature, and does not include State Medicaid or Medicare contri­butions. State Schools and Hospitals together spent more than 70 percent of the TDMHMR budget (see Table 62). While these facilities do include some outreach services, the bulk of these funds go to inpatient services. Caseloads in State Hospitals and Schools are much lower than in other facilities; however, per client costs are much greater. Grants-in-aid to Community Mental Health Centers account for only 11 percent of the total TDMHMR 
budget. 
In addition, many TDMHMR and CMHC projects 
receive federal funds. HEW special grants for mental 
health and mental retardation activities in the forty­
county South Texas area totaled $4,663,624 in FY 1977. 
Of this, $3,590,343 (77 percent) went to TDMHMR and 
associated facilities. 
Contributions by the State of Texas to community 
mental health centers are only part of the centers'funding 
supply. This is intentional on the part of both the state 
and federal governments. 
P.L. 88-164, Title II, the Community Mental Health Centers Construction Act of 1963, was the federal govern­ment's initial attempt to encourage community-based services. A report to the Senate Committee on Interstate and Foreign Commerce explained the Title's intent: 
It is planned that the CMHC's will transfer the care of the mentally ill from State custodial institutions to commu­nity facilities and services . . . ' 
The act provided federal seed money, in the form oftwo­year construction grants to community mental health centers. These centers were to be funded jointly by local, state, and fe:leral grants, but local boards of directors were to be responsible for administration of the centers. 
Table 62 
Stale of Texas Appropriations for TDMHMR, 1974-77 

1974-75 Biennium 1976-77 Biennium Item Cost %of Total Cost %of Total 
Central Office $ 14,667,227 4.0 $ 19,975,499 3.4 
State Centers for Human Development (3) 3,812,461 I.I 11 ,799,854 2.0 
Mental Hospitals and Centers (8) 125,070,815 34.4 180,134,705 30.5 
Schools for the Mentally Retarded (12) 145,719,599 40.1 239,789,963 40.6 
State Grants in aid to CMHMR Centers (27) 28 ,437,532 7.8 64,737,050 11.0 Construction 28,794,686 7.9 27,475,735 4.7 Other 16,868,836 4.6 46,310,442 7.9 
TOTAL $363,371,156 100.0 $590,203,248 100.0 
Source: Texas Legislative Budget Office, Fiscal Size-Up of Texas State Services 1976-77 Biennium, p. 154. 
Table 63 
Sources of Funds for Community Mental Health Centers, FY 1975-77 (In Millions of Dollars) 
FY 1975 FY 1976 FY 1977 Funding Source Amount Percent Amount Percent Amount Percent 
Local (public and private) $13.5 30% $19.4 32% $19.2 26% 

State Grants-in-Aid and 
other State aid $15.6 35% $29.l 48% $40.0 55% 
Federal $15.4 35% $12.4 20% $14.1 19% 

TOTAL $44.5 100% $60.9 100% $73.3 100% 

Sources: FY 1975, Texas Legislative Budget Office, Fiscal Size-up 1976-77, p. 63. FY 1976-77, Sources of Financial Support and Organizational Information ofBoards of Trustees Operating CMHMR 
Centers, 1976 and 1977 editions, Community Services Division, TDMHMR. 
In Texas, the 59th Texas Legislature responded to P.L. 88-164 with a reorganization of public mental health and mental retardation resources. Effective September l , 1965, the Mental Health and Mental Retardation Act (popularly referred to as H.B. 3)created theTDMHMR. This agency's responsibility covered state mental health and mental retardation institutions, which would con­tinue to be funded almost entirely with state funds. 
Community mental health centers were another matter. The legislative intent of P. L. 88-164 was to transfer a large share of the financial responsibility for CMHCs to local communities. TDMHMR, while having a Division of Community Mental Health Services, is only one of three conduits, along with federal and local sources, for CMHC funds. 
H.B. 3 clearly states that, along with the reorganization of Texas mental retardation administration, there would be an emphasis on locally administered and funded services. 
The legislature declares that the public policy of this is to encourage local agencies and private organizations to assume responsibility for the effective administration of mental health and-mental· retardation services, with the· assistance, cooperation, and support of the Texas Depart­ment of Mental Health and Mental Retardation created by this Act. 

As did the Federal Community Mental Health Centers Construction Act of 1963, the 1965 Texas Act empha­sized botn decentralized community services and signifi­cant local funding and control of these centers. 
Section 4.03 of the Texas Act reemphasized that the State would only partially fund community mental health centers. 
A community center is eligible to receive State grants-in­aid if it qualifies according to the rules and reguldtions of the Department. It is specifically provided, however, that the Department may require that such grants of State funds be matched by local support in such proportions and amounts as may be determined by the Depart­ment . . (TDMHMR) shall periodically ... make such adjustments, upward or downward, as may be necessary to apportion such operating costs between the State government and the community centers. 

This would seem to have assured that the State would not become the dominant force in community mental health; the wording of P.L. 88-164 two years earlier had guaran­teed the federal government similarly would not be dominant. 
In 1968, however, the Texas Attorney General ruled that the state-local matching funds requirement was illegal. 
TDMHMR may not legally impose an arbitrary require­ment on all (Community Mental Health) Centers to 
Mental Health Services 

match with local revenues on a 50-50 basis each grant-in­
aid as a condition of eligibility for such aid.s 
In other words, TDMHMR cannot order CMHCs to match TDMHMR grants-in-aid. As a consequence, com­munity-based financial support for CMHCs has not been growing in proportion to state and federal aid. The State as of FY 1977 was the major source of funding. Table 63 which lists budgeted rather than expended income, illus­trates this trend. Federal monies have declined slightly since 1975, since the initial flurry of CM H C construction has ended. Local-dollar funding has increased, but has decreased as a percent of the total costs. Between FY 1975 and FY 1977, the State share of CMHC funding grew by 20 percent, becoming by far the major source of funds. 
Both P.L. 88-164 and the Texas Mental Health and Mental Retardation Act, two years later, emphasized the importance of community-based services, local adminis­tration and planning, and community financial support. The rationale was that local outpatient and short-term inpatient treatment would be more effective, efficient, and humane than long-term institutionalization. How­ever, P.L. 88-164 perhaps unrealistically assumed that two years of. federal funding per center would·be suffi-' cient. The federal government reduced its commitment to CM HCs too rapidly. Equally important is the 1968 Texas Attorney General's opinion, which voided the state-local matching funds requirement and forced the State to fill the financial gap created by reduced federal funds. 
The result may be fortunate for many localities, who by themselves were unable to fill the funding gap. However, a major goal of both P.L. 88-164 and H.B. 3, community responsibility for mental health and mental retardation services, has been thwarted. The high percentage of CMHC funds that originate from the State (55 percent) may be a serious obstacle today preventing the centers from becoming the truly community-based services they were intended to be. 
Paradoxically, while state funding is the largest com­ponent of Texas CMHC budgets, the percent of the TDMHMR budget devoted to such community services is still quite small, which is consistent with the national trend. Nationally, CM HCs receive only 5 percent of the mental health dollar. Over the past decade, hospitals for the mentally ill have significantly reduced their inpatient populations; however, the dollar has not followed the patient. Community mental health centers and State Hospital outreach services have increased their caseloads during the same period, although not necessarily with former State Hospital inpatients. Moreover, State Hos­pital costs have not decreased. The reasons are several. First, fixed overhead costs, such as maintenance and utilities, cannot be reduced . Second, inflation has nulli­fied savings from lower patient populations. Third, staffs can be reduced only to a certain degree. Finally, because mental institutions in Texas historically have been over­
-·~ 
100 Mex1can-American Health Care in South Texas 
crowded, underfunded, and understaffed, a reduction in patient population serves no humanitarian purpose if accompanied by a reduced institutional budget. 
Speaking of the nation as a whole, one representative of the National Institute of Mental Health (NIMH) noted that communities near major facilities generally become economically dependent on the facilities for jobs and business. This dependence is often translated into politi­cal resistance, through locally elected politicians, when attempts are made to reduce or eliminate the facility. A Harvard study believed this to be true in Texas, adding that centralized facilities are often sources of patronage jobs for local politicians.9 
Manpower for Mental Health 

In 1947 Congress legislated federal funds for training of direct care mental health personnel. These funds, used to train clinical specialists and other personnel, were appropriated yearly thereafter. In 1969 the NIMH funds committed to training totaled $120 million, and the Nixon Administration began attempting to phase this program out by legislation or impoundment. By FY 1976 the appropriation had dropped to $85.1 million and, according to NIMH, a number of manpower-related problems resulted. 
One problem is the "inadequate production, distribu­tion, and utilization of manpower for services to under­privileged and/ or minority populations." To answer this need, NIMH chief Bertram Brown asked Congress to increase manpower training funds, stating that: 
NIMH stands for mcetin& the mental health needs of minority populations, and places a bi&h priority on appropriate manpower development propams for minor­ity groups. We do not stand for syatema of aervice or training opportunities that arc limited by cultural bar­riers. •o 
Substantial effort will be required to meet this goal. In 1974 the Spanish-Speaking Public Health Service Work­ers Organizations (a coalition of HEW profe11ional staff members) issued a paper notina that only 1.5 percent of the Health Services and Mental Health Administration's total staff is Spanish-sumamed.11 The report urged greatly increased efforts to recruit and develop Spanish-American 
health professionals at the federal level. 
Clearly, much more than ethnic commonality between patient and provider is necessary for adequate mental health care. The fact that a provider is Mexican-American does not insure that he or she is sensitive to pertinent language and cultural considerations. Similarly, ethnic differences between staff and clients do not alone suggest lack of appreciation for these considerations. As The Chicano Plan for Mental Health asserts: 
It is not enough to bring mental health centers to the barrios and staff them with Spanish-speaking Chicano mental health practitioners, or for the barrio community to give input to or control mental health centers in the barrios , if the net result is nothing more than s•Jbstitution of brown faces for white, and Spanish for English. The changes needed are far more basic than provision of mental health services by Chicano practitioners who can 

Table 64 
TDMHMR Personnel Statewide on June 30, 1976 

Job Category 
Officials and Administrators Professionals Paraprofessionals 
Office and Clerical Totals (includes other job categories) 

Anglo Mexican-American Black 
# % # % # % 
305 93.6 16 4.9 5 1.5 
2617 88 .9 174 5.9 150 5. 1 
5,766 58.2 1,137 11.5 2,997 30.3 
2,059 82.7 250 10.0 181 7.3 
15,439 67.8 2,468 10.8 4,878 21.4 
*Excludes temporary personnel and 183 other minorities. Source: Governor's EEO Office, State of Texas 
Mental Health Services J0 I 
speak Spanish to their clients. The continued use of the medical model in diagnosing mental health needs of Chi­canos is the first issue that must be examined.12 

The plan notes that the medical model for mental health care uses words like "deviant" and pathological" to dualize behavior as rational or irrational, functional or dysfunctional. Suggesting that these words and dualities have no existence in the barrio, the plan recommends that mental health services be adapted to Mexican-American culture, and that the culture not be forced to adapt to the treatment. 
Nevertheless, manpower statistics can be a useful indi­cator, if one realizes that such data represent only one aspect of much broader issues. For mental health care to better serve the needs of Mexican-Americans, providers at all levels should be aware of the importance of these cultural considerations. Adequate representation of mi­nority groups at all levels of service, particularly at the administrative level, is one way to foster such awareness. 
The data in Table 64 on Texas mental health personnel were reported to the Equal Employment Opportunity Commission (EEOC) by TDMHMR. Information is presented here for only four of eight reported job cate­gories. According to the EEOC, t-he categories encom­pass the following education and / or experience: 
Officials and Administra1ors: Occupations in which em­ployees set broad policies, exercise overall responsibility for execution of these policies, ... direct individual departments . . . or provide spc;cialized consultation. 
Professionals: Occupations which require~specialized and theoretical knowledge which is usually acquired through college training or through work experience and other training which provides comparable knowledge. 
Paraprofessionals: Occupations in which workers per­form some of the duties of a professional or technician in a supportive role, which usually require less formal train­ing and / or experience than normally required for profes­sionals or technical status. Such positions may fall within an identified pattern of staff development and promotion under a "New Careers" concept. 
Office and Clerical: Occupations in which workers are r~~ponsible for internal and external communication, recording and retrieval of data and / or information and other paperwork required in an office.13 

The data are not categorized by type of treatment given (i.e., mental health, mental retardation, drug abuse, alco­holism), since many personnel treat more than one of these problems. The first three categories of personnel (Administrators and Officials, Professionals, and Para­professionals) represent most of TDMHMR's policy­making and direct treatment personnel. The final cate­gory, Office and Clerical, is included to contrast with the other three. 
While 16 percent of all TDMHMR mental health out­patients in FY 1976 were Mexican-Americans, and 12 percent of the 8/ 3 l / 76 inpatient population were Mexican­Americans, only 4.9 percent of all officials and adminis­trators working for TDMHMR as of 6/ 30/76 were Mexican-Americans. Not all of these sixteen Mexican­American administrators are in s~atewide policymaking positions. Figures for the Austin SMSA, which include TDMHMR headquarters and local facilities, show that, of the ninety-nine officials and administrators in the Austin area, only two are Mexican-Americans. Thus, while 4.9 percent of the officials and administrators state­wide were Mexican-Americans, only 2 percent of officials and administrators in the Austin area were Mexican­Americans. 
Statewide EEO data for the category of "profession­als" are only slightly better, with 5.9 percent Mexican­Americans. For paraprofessionals, the figure is 11.5 per­cent. In both cases, Mexican-American representation is substantially less than the 16 percent of mental health patients who are Mexican-Americans. 
The U.S. Department of Health, Education, and Wel­fare recently approved TDMHMR's EEO plan for the central office, while TDMHMR is working on similar plans for its other facilities. Nevertheless, real progress has yet to be made. Of new persons hired in FY 1976, Mexican-Americans were still proportionately underrep­resented (see Table 65). Professional and paraprofes­sional Mexican-Americans were hired less often than their staff representation; and Officials and Administra­tors and Office and Clerical personnel are hired only slightly more often than their staff representation. Thus, 
Table 65 
TDMHMR New Hires FY 1976 Mexican Americans 
Austin Statewide SMSA 

Job Category  #  %  #  %  
Officials and  
Administrators  2  7.1  0  0  

Professionals 56 5.3 11 5. I Paraprofessionals 586 9.8 156 11.3 Office and Clerical IOI 10.7 29 12 .1 Totals (inc. other 
categories) 1,177 9.8% 286 11.1% Source: Texas Governor's EEO Office 
Table 66 
Clients Receiving Mental Health Services of AU Texas CMHCs in 1976 
TDMHMR Clients Texa1 Population Ethnicity Number % Number % 
Mexican-American 8,845 15.2% 2,059,671 18.4% Black 10,091 17.3% 1,395,853 12.5% Other 39,356 67.5% 7,739,892 69.1% Total 58,292 100% 11,195,416 100% Sources: 
TDMHMR,Data Book 1976. 
U.S. Census, 1970 

Table 67 
Clients Receivinc Mental Health Services of South Texas CMHCs in 1976 
CMHC Clients Texas Population Ethnicity Number % Number % Mexican-American 3,753 55.4% 1,047,699 53.5% Black 581 8.6% , 79,350 4.1% Other 2,445 36.1% 831,589 42.5% Total 6,779 100% 1,958,638 100% Sources: 
TDMHMR,Data Book 1976. 
U.S. Census, 1970 

Table 68 State Hospital Population and the Texas Population 
White Hispanic Black Other Total 
Percent Number Percent Number Percent Number Percent Number Percent Nipnber 

In residence 8/31 /76 71.6 (4235) 12 (710) 16 (947) .3 (18) 100 (5916)• 
Texas population 68.7 18.4 12.5 .4 
100 Sources: U.S . Census and Data Book 1976 *Numbers do not add due to rounding. 
if the assumption is made that attrition among Mexican­Americans is roughly equal to their staff representation, then the percent of TDMHMR professional and para­professional staff which are Mexican-Americans de­creased in 1976. The percent of Officials/ Administrators and Office/ Clerical personnel who are Mexican-Ameri­cans only slightly increased. In Austin, no Mexican­Americans were added to the statewide policymaking staff. 
A serious underutilization of a more general nature does exist. Studies of the potential "at risk" and the immediate "in need" Texas populations suggest that far more Texans of all ethnicities currently may need mental health care than are receiving it. 
On May 6, 1976,a special TDMHMR task force issued their study, Report ofthe Task Force on Prevalence and Service Requirements for Mental Health/ Mental Retar­dation. The report concluded that, based on several recent studies, at least 20 percent of the adult population should be considered "at risk" (i.e., having the potential to develop mental illness). In addition, the report con­dudes that currently roughly "IO percent of the adult population should be considered 'in need' of professional mental health services·:" The report notes that these figures are conservative estimates.14 
Another needs assessment, made by the Joint Commis­sion on Mental Health of Children in 1976, estimated that IO to 13 percent of the nation's children may be afflicted by various emotional problems. is Other reports suggest the rate may be much higher in urban ghettos, perhaps rising to 70 percent. Of these numbers, only a very small proportion actually receive professional help. 
In Texas, slightly more than 58,000 clients obtained mental hea~th services from community mental health centers in 1976 (see Table 66). Of these, 8,845 or 15.2 percent were Mexican-American, which is interpreted here as equivalent to TDMHMR's use of the term "His­panic." 
In 1970, Mexican-Americans comprised 18.4 percent of the Texas population. Thus, there is some discrepancy between Mexican-Americans as a proportion ofcommu­nity mental health clients and as a proportion ofthe total Texas population. Black persons, on the other hand, use community mental health services substantially more often than other ethnic groups. 
In the forty-county South Texas area, community mental health centers provided mental health services to 6,779 clients in 1976. Of these, 3,753 or 55.4 percent were Mexican-Americans (see Table 67). This is slightly great­er than the percentage of the forty-county population which was Mexican-American-53.5 percent. 
Thus, the mental health services of community mental health centers are slightly underutilized by Mexican­Americans statewide. However, for South Texas, Mexi­can-Americans make a slightly greater use of those mental health services. This slightly greater use would perhaps 
Mental Health Services I03 

disappear or reverse if comparison were made with popu­lation estimates which indicate a rapidly growing Mexi­can-American population since 1970. 
Institutional data reveal a different pattern. The popu­lation of the state's eight mental hospitals has diminished substantially in recent years (from 15,872 at the end of FY 1960 to 5,916 at the end of FY 1976). Over 71,000 clients received community mental health care from all facilities in FY 1976; and 26,735 ofthese were residents of the state mental hospitals at one time or another during the year. At the end of the fiscal year, 5,916 people were in residence. While Mexican-Americans represented 18.4 percent of the 1970 Texas population, they represented only 12 percent of the state hospital inpatients on August 
31, 1976 (see Table 68). This discrepancy would increase 
if account were made for the rapidly increasing Mexican­
American population since 1970. 
Looking at the TDMHMR hospital inpatients by place of residence, it appears that, while 17.5 percent of the Texas population lives in the forty South Texas counties, only 16.6 percent of the hospital inpatients are from those counties (see Table 69). 
Of perhaps greater concern than the underrepresenta­tion (or overrepresentation) of one ethnic group or geo­graphic area, is the underutilization of mental health services by al/ethnic groups. As noted, TDMHMR's task force on needs assessment concluded that at least 20 percent of the adult population should be considered "at risk" and IO percent of the adult population should be considered "in need" of treatment. Such treatment might be on an inpatient or outpatient basis. Translating these percentages into numbers suggests that more than 2.2 million Texans are "at risk" and I.I million "in need." The 1,119,542 persons theoretically "in need" of mental health care is over eleven times the actual number of clients in 1976 (see Table 70). Obviously, this does not 
Table 69 

County of Residence of 
State Hospital Inpatients, 8/31/76 

Balance of Total South Texas Texas Texas 

Mental Health 
Inpatients 16.6% 83.4% 100% 

State Population 
(1970) 17.5% 82.5% 100% 

Sources: TDMHMR, Data Book 1976 
U.S. Census, 1970 
Table 70 
Texas Needs Assessment, Mental Health Clients, and Population 

Population  20%  10%  Number Total  
(1970)  "at risk"  "in need"  Mental Health  
Area  Clients (1976)  
Total Texas  11,195,416  2,239,083  1,119,542  97,995  
South Texas  1,958,638  391,727  195,864  undetermined  

Sources: 

Report of the Task Force on Prevalence and Service Requirements for Mental Health/ Mental Retardation, May 6, 1976 TDMHMR, Data Book 1976 
U.S. Census, 1970 

Table 71 
Bexar County CMHC Clients and Populations 
Anglo Mexican-American Other Total 
Bexar Co. CMHC 
Clients Receiving 
Mental Health 
Services, 1976 31.4% 54.4% 14.1% 100% 

San Antonio 
Population, 1975 
Estimates 39.4% 51.8% 8.8% 100% 

Bexar County 
Total Population, 
1975 Estimates 43.7% 48.1% 8.3% 100% 

Sources: TDMHMR, Data Book 1976 San Antonio Metropolitan Health District, Vital Statistics, 1971-1975 
prove that over one million Texans require immediate counties. Table 70 does give some indication, however, mental health care, since the data are rough and in part that present caseloads could, and perhaps should, be speculative. Also, the 97,995 figure does not include much higher. caseloads of curanderos, physicians, social workers, TDMHMR itself is aware of this possibility. Accord­clergymen, or psychiatrists and psychologists in private ing to its own figures, it estimated in 1975 that 26 percent practice. These non-TD M H MR personnel are important of the population (3,200,000) are "at risk," while 743, 748 to mental health care delivery. However, accurate esti­are considered "in need." Of these, 430, 120 of those "at mates of caseloads are not available. Psychiatrists and risk" and 90,315 "in need" were children or adolescents.16 psychologists in private practice are too expensive for Furthermore, TDMHMR rates South Texas areas as most Mexican-Americans in South Texas and, in any having a very great need for mental health services in case, are rarely accessible outside Bexar and Nueces comparison to other areas ofTr.xas. To distribute NIMH 
Mental Health Services I05 

Table 72 
Bexar County CMHC Clients by Age Groups 

0-19 y ears  
Mental Health Clients,  
1976  23.4%  

Total Population-
Bexar County, 1970 44.0% 

Mexican-American 
Population, 19 70 50.2o/c 

Sources: 

TDMHMR, Data Book 1976 
U.S. Census, 19 70 

funds provided by P. L. 94-63 to community mental health centers, TDMHMR uses a formula based largely on estimates of need for services. The state is divided into eighty~one catchment areas, and each is assigned a prior­ity ranking. Of the ten areas judged most in need, six are in South Texas. Nine of the first eighteen are in South Texas. Of the total of eighty-one priority ranks, only one South Texas area ;s ranked as less needy than the median. 17 
Earlier in this chapter. the Bexar County Mental Health and Mental Retardation Center was cited as an agency with exceptional sensitivity to the needs of Mexican­Americans. That judgment is made partially because the center provides community mental health services to Mexican-Americans in excess to their proportion of the city or county population. Of 1976 community services clients receiving mental health services, 54.5 percent were Mexican-Americans (see Table 71 ). This compares to 
51.8 percent of the San Antonio population and 48.1 percent of the Bexar County population which are Mexi­can-American. Calculating the same data in a different manner reveals a similar result. When the number of Spanish-surnamed clients of the Bexar County CM H C is compared to the total San Antonio Mexican-American population, one finds that 0.50 percent of the total Mexican-American population used the center in FY 1976. By comparison, 0.38 percent of the Anglos in San Antonio used the center in the same period. 
The age distribution of the Bexar County CMHC clients, however, suggests that the center fails to meet the needs of Mexican-American children in particular and all children in general (see Table 72). While 44 percent ofall Bexar County residents and 50 percent of Mexican­Americans in 1970 were under age 20, only 23.4 percent of the Community Mental Health Center's clients receiv­ing mental health services were under twenty in 1976. 
20-64 years 65+ y ears Total 
68.7%  8.0%  100%  
48.3%  7.6%  100%  
44.7%  5.1%  100%  

This suggests that services are unduly concentrated on older persons, an observation which is pertinent in view of the great percentage of Mexican-Americans who are 'ess than twenty years old. 
A more concrete example is San Antonio State Hospital (SASH). With its geographically diverse inpatient popu­lation of 766 persons on August 31 , 1976 (45.2 percent from Bexar County, 36.9 percent from other South Texas counties, and 17.9 percent from the rest of the state). the majority of SASH work involves treatment of the men­tally ill. At the end of FY 1976, 68.5 percent of the SASH population was classified as mentally ill. The SASH personnel classifications are shown in Table 73 . While 
37.5 percent of the SASH staff are Mexican-Americans, many of these are in maintenance or clerical positions. Only 11 percent of the administrators and 15.7 percent of professionals are Mexican-Americans, compared to 43.2 percent of the patients. 
The Rio Grande State Center for Mental Health and Mental Retardation is in Harlingen and serves twelve counties with seven outreach clinics. Mexican-Ameri­cans are served in greater proportion than their percentage of the total population of those twelve counties. Mexican­Americans constitute 77 percent of the population and 85 percent of the center's patient visits. Although Mexican­Americans represent 82.5 percent of the center's direct treatment staff, they represent only 44.4 percent of the administrative staff. 
In the forty-county South Texas area, slightly more than half the population lives in two counties (Bexar and Nueces), while the rest live in the other thirty-eight counties. The great majority of mental health care profes­sionals, however, are located in Bexar and Nueces coun­ties. In other words, the thirty-eight county area, which includes three SMSAs, i~ severely underserved, relative 
Table 73 
SASH Personnel as of 3/23/77 

Anglo Mexican-American Black Other Job Category # % # % # % # % Officials, Administrators 14 77.8 2 l 1.0 5.6 5.6 Professionals 136 76.4 28 15.7 12 6.7 2 I. I Paraprofessionals 104 27.2 180 47.1 97 25.4 .3 Office and Clerical 69 47.6 58 40.0 17 11. 7 .7 Totals (includes 
other categories) 480 41.6 433 37.5 234 20.3 7 .6 Inpatients 359 46.9 331 43.2 73 9.5 3 .4 Source: Governor's EEO Office 
Table 74 
South Texas Population and Professional Mental Health Penonnel 
Bexar and Nueces Thirty-eight Total South Texas Counties Counties Category # % # % # % Total Population (1970) l ,958,638• 100 l ,068,004 54.5 890,634 45.5 Number of Psychiatrists l ll 100 100 90.l 11 9.9 Number of Psychologists 314 100 274 87.3 40 12.7 Number of Social Workers 302 100 255 84.4 47 15.6 So.urce: 
U.S. Census 1970 
TDMHMR, State Plan for Mental Health, 1977 


to Bexar and Nueces, in the way of ,mental health care drug/ alcohol treatmCtit pers0nnel, is only slig~tly better. , 
professionals. Table 74 demonstrates this imbalance. The This imbalance may prove to be detrimental to penons 
figures include employees ofTDMHMR, Department of of any ethnic background in South Texas, but it appears 
Human Resources, and local agencies, plus psychiatrists to be more harmful to Mexican-Americans. According to 
and psychologists in private practice. the 1970 U.S. Census, only 54.2 percent of the forty­
In 1970, only eleven psychiatrists practiced in the county area's Mexican-Americans live outside Bexar and 
thirty-eight county area, compared to one hundred prac­Nueces counties, compared with 45 .5 percent of the total 
ticing in Bexar and Nueces. Forty psychologists served population. In other words, 54 percent of the forty­
the thirty-eight counties, while 274 practiced in Bexar county area's Mexican-Americans live in thirty-eight 
and Nueces. The situation for social workers, who fre­counties served by eleven psychiatrists, forty psycholo­
quently serve as crisis counselors, referral sources, and gists, and forty-seven social workers. 
. 
Thus, not only are Mexican-Americans underrepre­

sented in professional and administrative positions with­
in TDMHMR, but Mexican-Americans in thirty<ight of 
the forty South Texas counties have available few mental 
health practitioners of any ethnicity. 
From interviews with people both within and outside TDMHMR, there appears to be insufficient sensitivity at TDMHMR's higher levels concerning cultural, econo­mic, and social considerations regarding Mexican-Amer­ican mental health. The absence of an office of minority affairs at TDMHMR headquarters leaves a gap that cannot be filled piecemeal by other departments. Coordi­nated, goal-oriented research and evaluation, specifically applied to the needs of minorities, can only be conducted by a specific office charged with the task. 
Services for Mexican-Americans 
A few programs were found to be directed specifically toward Mexican-Americans. Three of these programs are in San Antonio, and suggest the possible innovation and sensitivity to needs of Mexican-Americans, given a proper combination of funds, intent, and hard work. These programs include the Bexar County MHMR cen­ter, a joint project of the Mexican-American Unity Coun­cil and the University of Texas at San Antonio, and the Barrio Clinic's Early Prevention Screening Diagnosis and Treatment (EPSDT) program, which is not specifi­cally for mental health, but does identify developmental and emotional problems. 
Since opening in 1971, the Bexar County MHMR Center has developed an ambitious variety of mental health, mental retardation, drug abuse, and alcoholism treatment programs. Mental health care is offered at fourteen locations, including five nursing homes, scattered throughout the city. These services include outpatient therapy, short-term inpatient treatment, young parent counseling, child abuse counseling, creative arts pro­grams, nursing home therapy, delinquency counseling, and other services. The center has specific, detailed goals for each program and for specific services. Administra­tive and primary care staff reflect San Antonio's ethnic composition, while the several advisory boards include many health consumers. Fees are on a sliding scale. 
An example of an excellent match between consumers' needs and programs provided is the Barrio Comprehen­sive Child Health Care Center, located in the predomi­nantly Mexican-American southwest section of San An­tonio. As part of its EPSDT program, the clinic uses psychological assessment in the family's predominant language to pinpoint developmental or emotional prob­lems among children six years or younger. During one reporting period, the clinic found that 5.2 percent of children tested needed further diagnosis or treatment. Educational therapy or remedial classes, conducted by a 
Mental Health Services 107 

bilingual instructor, have markedly improved the motor skills, intellectual functioning, language, self-help, and social development of 70 percent to 90 percent of those enrolled.18 By adapting to the special cultural, geographic, and economic conditions of the ba"io, the program attempts to reach a severely underserved population. The 
5.2 percent of children found in need of treatment were fortunate. That 70 percent to 90 percent of them could be helped was encouraging. That programs like it can only serve a tiny percentage of a population demonstrably in need is a social and economic waste to Mexican-Ameri­cans and to the community at large. •9 
These two programs highlight factors concerning men­tal health care for Mexican-Americans. Each program attempts to appreciate the cultural background of Mexi­can-Americans. The Barrio Clinic, for example, found that some "developmentally retarded" children were in fact normal: certain psychological tests were found to have been insensitive to language and cultural differences among ethnic groups. Each program involves Mexican­American clients, either by locating in a Mexican-American neighborhood or by specifically seeking Mexican-Ameri­can clients. Mexican-American community members are involved in policy and program development. Staff development, especially regarding paraprofessionals, is given high priority. Limited funds, and the uncertainty of continued, regular funding, make recruitment and reten­tion of qualified personnel difficult. 
Use of Mental Health Services 
A frequent observation by administrative and treat­ment personnel, when interviewed by this author, is that community mental health services are underutilized by Texas citizens, particularly Mexican-Americans and other minorities. This underutilization has been termed perhaps the most formidable obstacle to providing men­tal health care to Mexican-Americans. Researchers found that Mexican-American sample populations in Texas (1960) and California (1969) use mental health services less than the general population.20 
Data on use of mental health services, however, seem to modify this thesis. Community mental health centers and other community programs were designed in large part to serve people previously unable to secure mental health services because of financial or transportation problems. User data indicate that Mexican-Americans in Texas as community mental health clients represent only slightly less than their proportion of the general popula­tion. In some areas, such as San Antonio, there is no evident underutilization of community mental health ser­vices by Mexican-Americans. On the other hand, Mexi­can-Americans clearly make less use ofinpatient facilities than their proportion of the total population in Texas and in South Texas. 
···~ 
Conclusion 

Further involvement of Me&ican-Americans in the diagnosis and treatment of mental illness is but one of several necessary steps to be taken in this area. In addi­tion. services appropriate to the individual's age. accul­turation. sex, and life situation have to be better developed and provided toensure that many individuals are able to cope and to thrive ill their daily lives. This chapter has provided some of the primary data necessary for those who will be planning what to do next. 
References 

•U.S. Congress, House. Subcommittee on Health and the Environment. A Discursiw Diction11ry of 11«1/th Care, Mth Cong.• 2d scss.• 1976, p. 103. 
2Amado A. Padilla, R.A. Ruiz, and ll. Alvuez,"Community Mental Healtll Servia:s for the Spaaish-Speating/Sernamm Population,.. A.mnk"" Psychologist (September 197S), p. 891. 
Jfto6Crt Ti'ottcc and JUan Ctiavinl, Giff ofH"tW;ng (Edin­
burg, Texas: Pan American University, 1975). p. 49. 

4Ruben Duran, ed., ..The Chicano Plan for Mental Health" (Paper presented at the Denver Conference on Cbic::ano Mental Health, March 197S), p. 3. 
5/bid. 

6 President's Commission on Mental Health. Tosic Pruwl 
Repor11 Submi11u to the Presidnrt's .Commission on Mmtlll 
Health, vol. 3 (1978) Appendix, .. Hispanic Americans," ftp. 
902-951; .. Migrant and Seasonal Farmworten,"pp. 1191-1313. 
7U.S., Congress, House and Senate, .. Legislative History of 
P.L. 88-164," 88th Cong., 1st sess., 1963. 

•Opinions ofthe Attorney GeneralofTexas, Opinion #M-314, 
December 13, 1968, p. IS33. 

9Ronald T. Luke. '"The Sources of Innovation in State 
Government: Rehabilitating the Texas Mental Health System." 
(Ph.D. dissertation. John F. Kennedy School of Government, 
Harvard University. 197S), p. S. 

•OBcrtram Brown, unpublished paper on MH/MR manpower 
training programs, National lnstiblte of Mental Health, n.d. 

11spanish-Speaking Public Hcahh Service Workers Organi­
zation, ..Position Statement on Reahh Issues Concerning the 
Spanish-Speaking Surnamed Population of the U.S." (Wash­
ington, D.C.: Department of Health, Education and Welfare, 
1974), p. 2. 

12ouran . .. Chicano Plan." p. 9. 
UEEOC Form 164, -State and Local Government Informa­tion (EEG-4) lastruction Booklet." 
14Texas Department of Mental Health and Mental Retarda­tion, "Report of tbe Tuk Force," May 6, 1976, p. S. 
1sJoint Commission on Mental Health of Children, Crisis in Child Menial H«llth; Chal/mgf' for die 1970s {New York: Harper and Row, 1970). 
16Texas Department of Mental Health/Mmal Retal"datiail, ..Report of the Tut Force," p. S. 
•7'.feir.as Departmebl of Mental Hcaltb/ Mental 1tetarilatida, 
Texas State P/'111 for Co~Mnua/ HHlth SttVia 1977, October I, 1916, p. VI-20 Dd f). Vi-28. 
11Harry Martin et al., •EPSDT Demomrration Projects: A'il Interim Evaluation, April 1974-March 1975" (San Antonio: Health Services Research lnstihlte, University ofTens m.Jtb Science Center, 1976), pp. 72-73. 
"Padilla et al., "Comrmmity Mental Health Strvbs,"tt. 8t2. 
20E. Gartley Jaco, tflt> Social~ofMmtfll 000;­tlen A-hychitllric Swwy of r,.xm (New York: Ritiletl Sage Foundation, IWIO); Mlarvin Kamo and Rohtrt B. &lgerton, 
•Pm:eptiofts of Mahl Tihltss in l Mexic:an Amcriean Coll\­munity," Archives ofGmmil Psycir;tnry 20 (February 1969): 233-38. 
a 


Chapter 7 
Health Care for Migrant Workers 

An estimated 250,000 migrating farm workers (almost all of whom are Mexican Americans) live in South Texas.' Because of both their numbers and the severity of their health problems, health care for migrant workers and their families deserves special attention in any ac­count of health care for Mexican-Americans in South Texas. The chapter begins discussing, so far as possible, the health problems of migrants in South Texas and the context in which these health problems arise. The chapter then concludes by reviewing the existing programs which provide services to migrants. 
Health Problems of Migl'.ants 
The health problems of migrant workers and their families are related to their low level of income (median family income of migrants in South Texas was estimated to be below $4,000 in 1975), to poor housing and sani­tary conditions, to the nature of the work itself, and to their migratory patterns. A Field Foundation survey team in 1970 took medical histories and gave physical examinations to one thousand four hundred migrant and seasonal farmworkers and their families in Hidalgo and Starr counties.2 This survey found dental problems to be virtually universal, malnutrition to be common, and undiagnosed cases of many treatable diseases to be ram­pant. In regard to the severe degree of malnutrition among children examined, Dr. Raymond Wheeler said: 
In one tiny rural settlement, with a medical student assisting me, I spent an entire day examining one family after another. It was a shattering experience. 
Their dietary histories were all the same-beans, rice, tortillas, and little else. The younger children, especially, were undersized, thin, anemic, and apathetic. The mus­cles of their arms were the size of lead pencils-a sign of gross protein malnutrition. Many had evidence of multi­ple vitamin deficiency . . .. 
The children we saw that day have no future in our society. Malnutrition since birth has already impaired them physically, mentally, and emotionally. 
They do not have the capacity to engage in the sus­tained physical or mental effort which is necessary to succeed in school. learn a trade, or assume the full responsibilities of citizenship in a complex society such as ours.1 

Since the inception of migrant health centers and federal food programs, some of this deprivation has no doubt been reduced. However, there is still evidence that many health care problems are common to the migrant population which are relatively unknown in most other populations. A major problem for many migrants, both in the home base area and in the migrant stream, is the quality of housing, water, and sanitation available to them. 
In the home base areas in South Texas, many migrants live in co/onias-unincorporated, poor, rural communi­ties which usually are isolated, have small and generally inadequate dwelling units, and have no access to clean drinking water or to sanitary sewage disposal. Research­ers in 1976 identified sixty-five colonias in Cameron and Hidalgo counties. With an average household size of 5.5 persons, the total colonia population in these two coun­ties was estimated at 34,000.4 In a sampling of all the colonias identified, it was discovered that: 
An estimated 57 percent of all colonia houses do not receive treated water. although 45 of the 65 colonias identified in the study had access to treated drinking water. Of the households surveyed, 46 percent obtained water from a public supply system, 40 percent from wells, 6 percent from irrigation ditches, and 7.5 percent from other sources. Of the households surveyed, about half disposed of sewage by cesspool or septic tank and about half by outhouse. None of the co/onias has access to a sewage treatment facility.s 
People choose to live in colonias because they are inexpensive, provide a way to live near relatives, and permit the acquisition of some equity in land and house. Although the conditions in many colonias are deplora­ble, they are not nearly as bad as the colonias across the Rio Grande in the municipios of Reynosa, Matamoros, and Rio Bravo. 
For many migrants the sanitary conditions in the labor camps and in other available facilities on the migrant stream may be worse than conditions in the colonia or barrio. Migrant labor camps in Texas since 1975 have had to be registered and inspected annually by the Texas State Department of Health Resources. Since then several camps have been closed; and of the 217 existing camps, 153 are licensed.6 In the migrant stream out of state, conditions are frequently even worse, with migrants often living in automobiles, isolated from neighboring com­munities, and lacking even the minimal support system available to them in the colonias at the home base area. Further, migrants often discover that places of accom­modation along the road are difficult to find and overly expensive to use. The only overnight rest stop in the country is in Hope, Arkansas, and it is extensively used by Texas migrants who happen to be travelling on that stream.7 Gross violations of health conditions in migrant labor camps continue despite federal regulations that prohibit such violations.s 
Migratory farm work is a hazardous occupation. For one thing, farmworkers may travel thousands of miles during the course of a work season, risking injury through auto accidents. However, the principal hazards of migra­tory farm work are in the harvest fields and in food processing facilities. The death rate for persons employed in agriculture is third following mining and construc­tion.9 Between eight hundred and one thousand farm­workers are killed annually during the course of their work, according to the Food and Drug Administration, an(j.as.many as-ninet.y.thousand.are injured-each-yeaF by-­
.. · J;CstH:iCie poisoniligs. 
10 Farmworkers also suffer two times the occupational disease rate of workers in all other industries. 11 The ex-tensive use ofpesticides has often-been meRtioned as a 
_ ,, ~hly. significant factor. PestiCides, particulatry when improperly used, are a serious threat to the health of migrant workers, as they can be easily absorbed through the unbroken skin or inhaled. There are several docu­mented cases of growers totally disregarding the safety of farmworkers by allowing laborers to enter recently sprayed fields prematurely or even allowing spraying to be done while the workers are in the fields.12 Migrant children are constantly exposed to the same hazards that their parents encounter, and a few others as well. Children who are exposed to the rigors of work in the fields can become extremely fatigued and highly sus­ceptible to diseases. Even if the children do not work, migrants may not have access to day care facilities; conse­quently, children are often left at home unsupervised, or are left in a locked car, where they suffer the ill effects of heat.13 Finally, migrant children are often more suscepti­ble to accidents involving farm equipment, since they are less familiar with equipment than their parents; this is particularly true of children left unattended. Farmworkers are vulnerable to various other types of occupational hazards. According to Robert Gomez, Direc­tor of the Migrant Health Project in Hidalgo County, Texas (1977), disabling back injuries are frequently diag­nosed among migrants who do stoop labor, and among migrant food processors who do much heavy lifting. In addition, many accidents and some deaths occur from mishaps involving agricultural equipment. In Texas, agri-
Table 75 Texas: Work Injury Survey; 1970 Summary 
Frequency  Severity  
Major Industry  Rate•  Rate••  
Agriculture  24.90  1,606  
Mining  17.52  1,722  
Construction  26.02  2,090  
Manufacturing  14.99  853  
Transportation  26.23  2,468  
Communication  2.74  128  
Utilities  6.14  1,411  
Wholesale Trade  8.46  784  
Retail Trade  6.52  314  
Financial, Insurance,  
Real Estate  2.78  101  
Services  8.34  529  
All Industries (except  
agricutlure)  13.94  979  

Source: 	Texas Department of Health, Division of Occupa­tional Safety.Annual Report 1971 (Austin: Texas Department of Health, 1972). 
*Number ofdisabling injuries per million exposure hours. **Number of days lost as a result of work injuries per mil­lion exposure hours. 
cultural work ranks a close third behind construction and transportation as the occupation having the highest dis­abling injury frequency rate (see Table 75). 
The health of migrants is affected not only by poor housing, low incomes, and bad working conditions, but by poor health habits and limited knowledge about nutri­tion and sanitation as well. Commenting upon the causes of malnutrition and other health problems in Cameron and Hidalgo counties, one member of the Field Founda­tion survey team said: 
For every case of health hardship we saw involving lack of physicians, inadequate funds, or improper food, we saw a balance of patients who, for sociocultural reasons or lack ofeducated health "awareness"failed to seek care. Perhaps in the culture of poverty, failure to seek reflects in the hopelessness of poverty, the apathetic despair of a culturt" which had done without for so long that even the aspiration for care is lost.14 

It is difficult to characterize the migrants as a group. Traditionally, migrants were thought to be a mix of native-born persons and recent legal immigrants or un­documented aliens. Many immigrants from Mexico still settle just across the border; but many others travel directly to Chicago, the Pacific Northwest, or Los An­geles without going through the traditional transition in the Lower Rio Grande Valley.is Similarly, for many the pattern of migration has changed. The demand for mi­grant labor has abated substantially with increased mech­anization, and possibly with the increased regulation of the use of migrant labor. In addition, the classic descrip­tion of the choices facing large families has been altered: 
Apparently size of family is associated with the need to migrate. When the family becomes too large for the earning of one worker to support all its members, the household head looks for work that will permit· other members to contribute to the family income. Conversely, families stop migrating when enough members obtain local employment and it no longer pays to migrate. They are as likely to obtain permanent employment in one of the work areas as at the home base.16 
While economic needs are still a major factor in deci­sions by individuals to join the migrant stream, many of the opportunities and options available to migrants have changed somewhat. One factor is increased noncash assistance such as food stamps and school feeding pro­grams which reduce the amount one must earn to obtain the bare necessities of life. Local growers were reportedly strongly opposed to initiation of the Food Stamp pro­gram in South Texas, in part because the program reduced the need of farm workers to borrow money from growers during the off-season. In some cases repayment of these loans was promised in the form of future unpaid labor, a practice prohibited by law. 
The migrant health projects and some other programs have also improved the conditions of migrants. However, many health problems remain. In late 1977, a team from the Area Health Education Center at the University of Texas Medical Branch at Galveston carried out a medical screening program in an elementary school in the town of Hidalgo, County of Hidalgo. As can be seen in Table 76, the results are somewhat worse than would be encoun­tered in the average middle-class school district. To these statistics must be added the realization that these were the children who were well enough to go to school. 
Health Programs for Migrants in South Texas 
Because so many of the migrant farmworkers' health problems are rooted in living and working conditions, medical care delivery programs alone are not sufficient to address adequately the health problems of these people. Accordingly, in any discussion of health care programs 
Migrant Workers 111 
Table 76 
Health Problems in 
Hidalgo School Children 


Selected Problems  
Identified  Grades  
(N=242)  (N=J37)  {N=86)  
K-2  3-4  5-6  
#  %  #  %  #  %  

Dental Problems 114 78 42 Ear Problems 60 33 30 Orthopedic Problems 41 32 12 Obesity 27 20 23 Developmental Delay 19 40 Lice 27 25 14 Short Stature 26 12 IO Skin Problems 22 10 8 Well Child 20 4 12 Urinary Problems 19 14 11 URI 27 7 0 Opthamoiogic 12 7 12 Scabies 10 11 6 Genital 13 5 7 Blook 10 2 6 Thyroid 13 4 Behavior 11 2 3 
Hard of Hearing 4 3 2 Poor Hygiene 3 Other* 30 27 13 
Source : Area Health Education Center, Galveston 
*Includes speech defect, heart murmur, seizure disorder, muscle weakness, tonsilitis, school problems, allergies, nose bleeds. 
for migrants, some attention must be directed to activities of a more general nature. So that lines of authority and organization may be better understood, we will first examine state programs which may have some impact upon migrant health in Texas, and subsequently examine relevant federal programs. 
State Programs 

State agencies involved with migrant farmworkers in South Texas include the Governor's Office of Migrant Affairs, the Texas Employment Commission, the Texas Rehabilitation Commission, the Texas Department of Health, and the Texas Education Agency. 
The Governor's Qffice of Migrant Affairs (GOMA) is authorized to coordinate the efforts of federal, state, and local agencies to improve the delivery of services to migrant farmworkers. Although the agency is responsible for carrying out other functions. its principal activities involve coordination of migrant affairs programs. 
The Texas Employment Commission (TEC) offers a full range of services for rural residents, including migrant farmworkers. Counseling, testing, placement, referral to training and manpower programs, referral to agencies. and follow-up services are available. 17 In addition, TEC offers an "Annual Worker Plan'" for migrant farmwork­ers. This plan provides assistance to farmworkers in planning itineraries that facilitate the workers' move­ments from one crop to another and allow them to continue their work for the longest possible duration. During the eight years this program has operated, both the number of job openings and the number of farm­workers placed as a percentage of that figure have fallen drastically. It is conceivable that employers of migrant farmworkers are hiring more local farmhands or legal (greencard holders) and undocumented aliens. 
TEC registers migrant crew leaders and attempts to 
acquaint them with federal regulations regarding recruit­
ment, employment, and transportation of migrant farm­
workers. rs In the past, many crew leaders have failed to 
comply with the requirements of the federal law. As a 
result, the Department of Labor in 1975 began a suit 
against violators. This led to a significant increase in the 
number of crew leaders registered in that year. 19 

The Texas Rehabilitation Commission provides voca­
tional rehabilitation services to farmworkers (both sea­
sonal and migrant) who have physical or mental disabili­
ties, are vocationally handicapped. and are employable.20 
The type of services presently offered include: 
-medical evaluation, surgery. and treatment: 
-psychological evaluation; 
-vocational and academic training; 
-work motivation and work adjustment training; 
-on the job training; 
-maintenance and transportation; 
-vocational counseling; 
-job placement: and 
-follow-up counseling. 

Approximately three hundred migrant farmworkers are being served by this program.21 Migrants receive physical restoration services for chronic ailments such as back injuries, hernias, leg injuries, and respiratory ill­nesses. The TRC presently coordinates these services with other state agencies in Colorado, Idaho, Wisconsin, and Minnesota. However, coordination has been diffi­cult because of the continuous relocation of migrant farmworkers. Continuity of services is a major problem with this program, since a migrant's itinerary is subject to sudden changes. Also, once in the stream, migrants are probably reluctant to leave their jobs for any extended period of time and lose potential earnings. 
The program has a yearly budget of$150,000provided by a special HEW grant, with newly established offices in Rio Grande City, San Antonio, and Plainview providing services to migrants and seasonal farmworkers. These three offices recently were incorporated into the TRC General Rehabilitation Program and are now serving referrals from the general program as well. In June 1977, an additional three-year continuation grant ($94,000 yearly) was made available to serve this disabled popu­lation.22 
The Elementary/ Secondary Education Act-Tttle I Texas Migrant Program of the Texas Education Agency (TEA) provides comprehensive educational services to migrant school children throughout the state. While the primary purpose· of this program· is to provide educa-· tional services, health services also are provided. Local schools may apply to TEA for funding of these services. The TEA then allocates the money it receives from the 
U.S. Office of Education to the schools according to need. Each enrolled migrant child is screened by a regis­tered nurse for visual, auditory; dental, and other defi­ciencies. In addition, each child is given a comprehensive physical examination and appropriate follow-up. If any medical treaJment is needed, the child is referred to an available medical facility. In 1977, fifty-three nurses and fifty-six nurses' aides examined approximately 80,000 of the 110,000 migrant students in Texas. TEA allocated approximately $4 million to these medical services.23 
The Texas Department of Health (TOH) historically has offered only one service directly to migrant farm­workers-inspection of labor camps. The General Sani­tation Division is responsible for insuring the provision of safe and adequate temporary labor camp housing for farmworkers and their dependents and is responsible for insuring proper usage and maintenance of such. The division ~ also responsible for maintenance of environ­mental health standards in raw vegetable packing sheds. 
Five labor camp inspectors are employed to inspect the 153 licensed migrant labor camps in Texas. Total expen­ditures for the labor camp inspection program amount to approximately $26,000 in addition to the salaries of the five inspectors. 
According to Troy Lowry of the General Sanitation Division, in 1976 there were 217 camps in Texas; 117 of these had temporary licenses and 36 had permanent licenses. The remaining 64 had either been closed or had expired permits. One of the camps had been charged by the Department of Health with violating Labor Camp Inspection Act regulations and was brought to court. Hopefully, this suit will motivate other violators to comply with TOH regulations. 

In addition, TOH recently secured federal funds to organize a Migrant Labor Camp Sanitation Assistance Program. This program involves identifying places where migrants reside, determining the major health problems, and helping communities obtain help when possible. The 
program's activities include improvement of sanitation practices, health education programs, and documenta­tion of environmental conditions which correlate with migrant afflictions requiring medical or dental services. 
Federal Programs 
The federal government is also involved both in coor­

dinating programs for migrants and direct delivery of 
health services to migrant workers. 
In education, supplementary funds for migrant educa­

tion are available under Title I of the Elementary and 
Secondary Education Act (ESEA), P.L. 89-10, as amen­

ded by the Migrant Amendment, P.L. 89-750.24 
The U.S . . Office ofEducation.(DHEW)developed the Nationwide Migrant Student Record Transfer System to facilitate transfer of migrating children's school records. The system was developed to store and provide a student's cumulative academic and health history regarding atten­dance at up to four schools.2s The heart of the system is a central computer data bank in Little Rock, Arkansas, that can trace each child in school as his or her family migrates from harvest to harvest. The record system is available to any school district which serves migrant children and provides a quick-response "critical data record" containing the educational information needed by a school to enroll the student. Each participating school is assigned a nearby terminal, used for all trans­actions with the central data bank. Each record contains the child's name, sex, birthdate, and birthplace, and medical history for continuity of his or her health care. A child's record can be supplied to school officials and health authorities from four to twenty-four hours after a request is made. Among the vital health information provided is information concerning the most recent phys­ical examinations and the child's immunization record. 
The Texas Migrant Council (TMC), funded primarily by the federal government, provides a variety of social services-education, nutrition, manpower and employ­ment, health, and referrals-to migrant farmworkers in the state of Texas.26 TMC has established home-base centers in eighteen cities in Texas, and all are open from September through May each year. During the summer months TMC mobile units follow the migrant popula­tions into the stream, into the midwest-Michigan, Illi­nois, Wisconsin, Indiana, Iowa-as well as into Wash­ington and Oregon. 
Migrant Workers 113 

The most comprehensive health program is connected with the Head Start Program, which was started in 1969, and is funded by the Indian and Migrant Program Divi­sion of the Office of Child Development (DHEW). This program provides health and nutritional education, as well as first aid, medical screenings, dental examinations, psychological support services, and medical referrals. A physician extender, under the direction of a physician, offers primary care services at different clinic sites when there are no local services available. A nurse is assigned to each TMC center in South Texas. TMC has focused its efforts in a ten-county region comprising approximately 116,000 migrants.27 Centers are located in the following Texas towns: 
Alamo La Grulla 
Brownsville Laredo 
Carrizo Springs Lubbock 
Cotulla Mission 
Crystal City Plainview 
Del Rio Raymondville 
Eagle Pass San Benito 
Edcouch Uvalde 
Hereford.. Weslaco 
The National Migrant Health Referral Project began nationwide operation in July 1975, and is currently fund­ed by the Office of Migrant Health, Bureau of Commu­nity Health Services, Rockville, Maryland (DHEW). All DHEW-funded migrant clinics participate in the referral system, which was created to facilitate the continuity of health care for migrants and their families. Referrals are made on an .agency-to-agency basis, so that providers in one locality can provide services to the migrant who requires follow-through health care. In 1975 the project initiated a total of 4,452 referrals, of which 2.556 were completed and processed. The total number of referrals appears to be relatively small, given the scope of the referral project and the total number of migrants nation­wide. The small number of migrants availing themselves of this service may be due to the small number of migrants knowing about the service, to an unwillingness of individual physicians or clinics to forward information through semiofficial channels, to the fact that migrants may receive unofficial care outside the home-base area, or to scheduling problems resulting from bad weather, automotive breakdowns, or unusually good or poor crops. 
There are thirteen federally sponsored migrant health projects in South Texas. These projects were established both because of a shift in orientation away from the "classic" migrant program upstream to larger more com­prehensive clinics in the home-base area, and because care for noncategorically entitled individuals and families was almost nonexistent under the state Medicaid pro­gram. Most of the funds to operate these projects come from the U.S. Department of Health, Education, and Welfare; although one nonfederal source, Catholic Char­ities, does provide substantial funding to one migrant project (Su Clinica Familiar). Collectively these health projects receive $5,400,000 from DHEW for their opera­tions and serve approximately 100,000 migrant farm­workers (see Table 77). Only a portion of the total mi­grant labor force is being served by such health projects. 
The operations of these projects-including services, personnel and operating hours-vary from site to site. The larger projects, such as Su Clinica Familiar, the Hidalgo County Health Care Corporation, the Laredo­Webb County Migrant Association, and the Southwest Migrant Association, provide many more services and are more innovative than the smaller projects. Despite the differences in project operations, these health care providers encounter essentially the same problems. With­out exception, their clients are overwhelmingly poor Mexican-Americans and, except for the clientele of Southwest Migrant Association in San Antonio,• most 
.are from rural areas. 

Migrant health projects also share a common need for certain services. Hospitalization funds are always limited and.in.some instancesare.una:v.ailable • .The. Laredo.~We.bb County Migrant Health Project-which has an experi­mental program with Blue Cross/ Blue Shield funded by the federal government-and the El Valle Community Health Plan-which has a contract with a local hospital­are exceptions. The larger projects are very limited in the number of patients they may hospitalize within a fiscal year. Smaller projects tend to be severely short on, or completely lacking in, hospitalization funds and are thus dependent on local charitable contributions. 
Financial constraints limit the hours that many projects 
can operate. Most projects do not offer their services 
during the evening hours or on weekends. Also, emer­
gency care usually is available only during regular oper­
ating hours. Again, migrant health projects must depend 
upon the availability of local health facilities or the 
volunteer efforts of their own staff to provide these 
services. 

As previously mentioned, the range of health services 
differs from project to project. The Laredo-Webb County 
Migrant Health Project offers its clients virtually all types 
of health care services, including hospitalization. The El 
Valle Community Health Plan also provides a wide range 
of services, made available by contracts with a group 
practice, hospital, nursing home and pharmacies. The 
South Texas Rural Health Services, by contrast, provides 
little more than out-patient clinical services. 

The principal emphasis of migrant health projects in 
South Texas appears to be curative rather than preventive 
health care. Although the larger local projects have a 
preventive health care component that includes nutrition 
*This organization is no longer functioning. 
and sanitation education, family health care, and envi­ronmental services, most projects do not. Most migrant health projects-even the large ones-tend to emphasize the treatment and curing of illness symptoms. This is understandable given the environment that migrants must cope with and the financial constraints of the migrant health projects. The programs are limited in funds and personnel and they often receive little or no help from local and state health officials in combating the root causes of migrant problems. A coordinated effort by these officials could do much to educate the migrant population on sound nutrition and sanitation practices and to reduce some of the environmental causes of health problems. 
Selected Programs 
A number of new and innovative migrant programs and services developed by these federal projects appear to be particularly effective in addressing some health prob­lems of migrants. These services and programs include: the Laredo-Webb County Migrant Health Project; El Valle Community Health Plan; National Migrant Hos­pitalization. ProgJ:am; the Certified Nurse Midwife Pro­ject; the Mobile Medical Service Outreach Program; and the Home Health Services Program. With the exception of the Laredo-Webb County Migrant Health Project, all of these programs were pioneered in Texas by Su Clinica Familiar. 
The Laredo-Webb County Migrant Healtl) Project, created in March 1973, is an experimental prepaid insur­ance package for eligible migrants. The program provides them with ai:nbulatory care and hospitalization; coverage is provided by Blue Cross/ Blue Shield insurance. 2s 
All types of services provided by local migrant clinics (general medical, preventive medical, dental care, etc.) are available to enrolled migrants free of charge. Special­ist services that are not available at local clinics are provided by private physicians on referral-100 percent of the usual, customary, and reasonable charges are paid by Blue Cross/ Blue Shield.29 Patients who prefer to go to their own private physicians when the same treatment is available at the migrant center pay 25 percent of the physician's standard fee, with the balance pJid by Blue Cross/ Blue Shield. 
Migrants are also covered by this insurance plan when they travel upstream. Blue Cross/ Blue Shield issues iden­tification cards to them along with information regarding coverage, nature of services, and reimbursement methods. While they are upstream, migrants receive JOO percent reimbursement for private physician visits and hospitali­zation. 
Enrollment in this program is limited. Only those individuals who meet the migrant status requirement, as defined by HEW regulations, qualify for enrollment. Further, no families with medical insurance (Medicaid, Medicare, employee benefits, or private insurance) quali­fy.JO 

The Laredo-Webb County project appears to offer a good solution to the problem of providing health services to migrants while they are home based; the program also appears to address the problem of continuity of health care. It could, however. encounter two major obstacles: 
I. 	physicians or hospitals that are unwilling to accept these migrants; and 
2. 	lack of adequate health facilities in remote labor camps or farms . 

The results of the program thus far indicate that the migrants enrolled are not being rejected by physicians or hospitals upstream.31 It should be pointed out that 100 percent of all upstream billings, to date, are from private ..,roviders. The reasons for this situation are unclear. It is possible that public medical facilities (including migrant health projects) are not billing Blue Cross/ Blue Shield for services rendered to these migrants. 
The El Valle Community Health Plan is open to the entire city of San Benito and the rural colonia of Los Lagos. The. program. operates. under a contract with a group practice, consisting of San Benito Medical Associ­ates, Dolly Vinsant Memorial Hospital, San Benito Nursing Home, two ambulance companies, and four pharmacies. The contract with the group is based on the concept of prepaid capitation. The El Valle Community Health Plan will reimburse the group on a monthly basis according to a prenegotiated rate per enrollee per month. The group practice, in turn, provides primary outpatient and inpatient medical services to enrollees while they reside in the service area. The enrollees pay a small monthly premium and a reduced fee for service. While upstream they carry identification papers and receive service free. Because many of the migrants spend time in Toledo, Ohio, a fee-for-service type of contract has been negotiated with a clinic there.Ji 
The Certified Nurse Mid~..-ife Maternity Projecr was developed in 1972, by Su Clinica Familiar, a migrant health project in Harlingen, Texas. This program uses certified midwives to provide basic maternity services to migrant mothers. The program was created because of the large number of children being born outside of hospitals or clinics, resulting in area infant mortality and morbidity rates that were among the worst in the nation_JJ The addition of nurse midwives to the staff of Su Clinica Familiar Jed to significant increases in clients requiring natal and postnatal care.34 and has relieved other staff members of some of the burden of providing these ser­vices. Midwives are available twenty-four hours a day, seven days a week through this project to assist in the delivery of babies; obstetrics-gynecology physicians are on call in case of complicated deliveries. 
The use of certified midwives is an innovative concept 
Migrant Workers 115 

that could alleviate a problem endemic to all migrant health projects-the lack oftrained medical personnel. In this way, migrant health projects can increase their ser­vices to migrant mothers and babies and can be less dependent upon the presence of a physician. 
Presently, the University of Mississippi'3 nurse mid­wifery training program is cooperating with Su Clinica Familiar to train some of the clinic's personnel as mid­wives. Meanwhile, some students who have completed basic program instruction are interning at Su Clinica Familiar. The project is aimed primarily toward reaching women who would otherwise use untrained local mid­wives or deliver at home without assistance. 
Project MANO (Medical and Nutritional Outreach) provides health screening and nutritional education to home-based migrants in isolated rural areas, which his­torically have been medically underserved.35 Outreach operations such as Project MANO are effective in deli­vering health services to rural indigents, but they have serious limitations, including: 
-	the number and scope of services mobile units can 
deliver; 

-the number of.visits they can make to a given area · 
and the amount of time that can be spent at any 
one site; 

-	the number of personnel that can be used for a 
single unit. 

Project MANO is temporarily suspended because its mobile van is no longer in working condition. Attempts are being made to raise funds for a replacement. 
Although. mobile clinics, in general, have had relatively little success in meeting the health needs of some rural communities in this country, in 1975 Project MANO received an endorsement from the staff of the federally funded Task Force on Southern Rural Development.36 
Su Clinica Familiar also developed the Valley Home Health Agency, which extends health services to patients · in their own homes. Home health nurses, clinic physi­cians, and local private physicians are involved in the delivery of health services to these individuals. Home nursing services are available every day of the week, twenty-four hours a day. Specialized care is available to patients during regular hours and on weekends and evenings for emergency cases. The success of the Valley Home Health Agency in securing funding from county health departments has stimulated both the Cameron and Hidalgo County Health Departments to initiate services. A substantial proportion of this program's clients are over sixty-five years of age and ordinarily would not have access, due to lack of transportation and finances. to medical care. The program is not sponsored by DHEW migrant health funds; rather it is maintained through third-party reimbursements (principally Medi­care and Medicaid) and private contributions. 
Table 77  - 
°'  
Federally Funded Mi1rant Health Projects  
Area Served  Project Name  HEW Funding (1977-78)  USER Population  Total Number ofEncounten  Description ofServices  ~ ~ ~·  
Cameron Cameron Willacy  Cameron County Migrant Health Project Cameron-Willacy Counties Family Health Services (Su Cllnlca Familiar and El Valle Community Health Plan)  $ 130,000 1,362,509 710,000 100,000 473,935 115,202  Total Migrant Health Rural Health Initiatives Community Health Centers Balance from Previous Year  9,ooo• 1,588 El Valle 17 ,358 Su Clinlca  18,ooo• 5,600 El Valle 63,018 Su Clinica  Traditional public health services are offered at clinics in San Benito, H111llnaen and Brownsville (medical diagnose• and treatment are not in· eluded). The Brownsville clinic has a Public Health Service dentist. The project also Includes the Port Isabel Housing Project, as well as Satel­lite evening TB clinics at Santa Rose, La Feria, Los Fresnos and Port Isabel The WIC nutrition program had 5,200 participants In 1977. Su Cllnica has clinics In Harlinaen and Ray­mondville which offer comprehensive medical services. •services are also available through Project MANO, a mobile clinic which stops at Port Isabel, Los Fresnos, La Feria, Rio Hondo, and Sebastian. In order to assure continuity of service the project provides for referrals to other programs such as Alcohol Abuse, Public Health and Family Planning.  ::s I >R ::i. ts::s ::r:: fJ ;::: ::r Q ~ s· ~ c:... ::r r  
El Valle is a prepaid medical insurance plan aimed at migrant farm workers from San Benito and the rural colonia of Los Lagos.  
Southern Cameron County  City of Brownsville Urban Health Initiative  306,735  16,000..  25,000..  Services at the clinic include general medical diaanosis and treatment, lab work, x-ray, pharmacy, dental treatment, nutrition educa­tion and paid referrals. The National Health Services Corps provides the pediatrician and in· ternist/famlly practitioner on duty.  
Kinney Uvalde Edwards Real  Del-Rio-Val Verde  81,427  2,142  not available  The clinic offers complete diagnostic, thera­peutlc, and followup medical mvicea wlth re­ferral to private physicians durina non-cllnlc hours.  
Maverick  Maverick County RHI  236,809  not available  not available  
Gonzales  Gonzales County Health Agency, Inc.  230,000 15,000 25 ,000 177 ,502 12,498  Total 2,418• RHI Family Plan Migrant Health From Previous Year  11,115*  The clinic in Gonzales offers scheduled compre­hensive health services and paid referrals.  

Table 77  
continued  
Total Number  
Area Served  Project Name  HEW Funding ( 1977-78)  USER Population  ofEncounters  Description ofServices  
Hidalgo  Hidalgo County Migrant  926,175  Total  13,500*  38,000*  Clinics are located in Mercedes, McAllen and  
and Rural Health  670,000  Migrant Health  Edcouch which offer comprehensive medical  
Initiatives Project  130,000  RHI  services and referrals. The project participates  
126,175  Balance  in the Migrant Hospitalization Demonstration  
program. The Valley Rural Health Associates  
provides the equivalent of 2.5 full time phys!­ 
clans through a contractual arrangement and  
NHSC physician works full time for the pro·  
gram. Referrals are made to dentists on a fee- 
for-service basis; other referrals are partially  
paid by the project.  
Jim Wells  Jim Wells County  70,715  121•  4,704"'  Scheduled comprehensive services are available  
Health Services  at the clinic in Alice. Immunization clinics in  
Orange Grove and Premont are open one week  
day. Referrals to dentist and optometrists avail­ 
able. The program has a WIE Nutrition Program.  
Webb  Laredo-Webb County  750,000  Total  8,962* Migrant  14,473*  The Health Clinic in Laredo offers comprehen- 
Migrant Health  500,000  Special Study  Clinic  sive medical services, provides medical trans- 
Project  Migrant Health  3,149  Migrant  9,383  portation and participates in the WIC nutrition  
Plan  Insurance  supplement program, as well as paid referrals.  
250,000  Migrant Health  Plan  A $20 per family fee is charged to register in  
Clinic  prepaid health insurance program. There are co- 
payments of $20 deductible for hospital and  
M.D. office visit.  
Bee  South Texas Community  475,000  Total  Total**  ••  M.D.s and dentists are paid to work in clinics  
San Patricio  Health Centers Project  325,000  Migrant Health  9,654  33,789  under contract to provide scheduled compre- 
Western Nueces  150,000  RHl/CHC  hensive health services. Oinics are located in  
Sinton, Beeville and Robstown. This is the first year for this three-year project. It replaces the Coastal Bend Migrant Health Project and the  ~ <iQ' i3 ::s- 
Community Council of Bee County R.H.I.  
project. Referrals are partially paid by the project.  ~ 0 .... I";"'  
n  
Frio  South Texas Rural  202,805  Total  This outpatient clinic acquired services of a  ;;!  
La Salle  Health Services  140,000  Migrant  pediatrician in August 1978 and is getting  
Dimmitt  62,805  RHI  underway. Data for number of encounters was not yet available.  -- 
.......  

Area Served  Project Name  
Bexar  Southwest Migrant  
Health Ast0eiallon  

Starr Action Community Jim Hogg Council of South Zapata Texas 
•from previous budget period (1976-77) ••projected for 1/1/77-8/31/78 Source: Project Profilea from DHEW 

HEW Funding (1977-78) 
192,289 

463,650 Total 
210,393 Rural Health Initiative 253,765 Migrant Health 
T,~77 confi1'.ued USER Populatiqn q,422  Total Number ofEncounters 24,452  
6,051 •  14,120*  


-00 
Description ofServices 
f 





i ~­
The project has one outpatient clinic located in San Antonio. The scheduled medical and dental services are protided by physicians and dentists working. on a contract basis. The project oper­ates a WIC and family planning program with ~­11,000 participants. 
= 
Clinics are located in Rio Grande City, Hebbron­[ville, Zapata (RHI clinic) with mobile clinic 
...
::r 
stops at LaCasita, Grulla, Roma, Escobas, El Sauz, Sallneno, San Isidro. Scheduled compre­Q hensive medical service is provided. This pro­~ gram combinea the former migrant health pro­s· grams of Jim Hogg and Zapata counties with rJJ the one for Stur county. The governing boud 0 is now called the Community Action Council of ;. South Texu The program is now in its last year. 
~ 
fl> 
Home Health Services is a relatively new concept in the area of migrant health and is one that is vitally needed. Many migrants reside in isolated areas removed from health facilities; others may be debilitated to the point that intermittent home care is better than institutional 
care. 
Summary 
Migrant workers. then, need health services as much or more than any other group. Because of the clear interest in other parts of the country in minimizing both the spread of infectious disease, and extraordinary medical expenses, the federal government has developed an ex­tensive health pro'gram for migrants. Still, because of their large and changing nl1mbers and the nature of their work, migrants could use additional health services. It may be, however, that clean waterand adequate sewerage facilities in many of the colonias would do more to contribute to improved migrant health than just the addition of more curative services. 
References 

•Texas Governor's Office of Migrant Affairs, Migrant and Seasonal Farmworkers in Texas. Austin, Texas, 1976. 
2U.S., Congress, Senate, Committee on Labor and Public Welfare, Subcommittee on Migratory Labor, Hearings on _Migratory and Seasonal Farmworker Powerksmess. 9 lst Cong .• 
1st and 2d scss., 1970. 
l/bid., P.· 4988. 
4Colonku in tM U>wer Rio Grande Valley ofSouth Texas: .if Summary Report, Policy Research Project Report No. 18 (Austin: Lyndon B. Johnson School of Public Affain, 1977), 
p. s. 
$/bid., p. 9. 
'Texas Department of Health, "Migrant Labor Camps in Texas," 1977. 
7Good Neighbor Commission of Texas, Texas Migrant La­bor: A SIWt:ial Report (submitted to the Governor and Legisla­ture), Austin, 1977, pp. 78-79. 
•Interview with Troy Lowry. Texas Department of Health. January 1977. 
'Texas Department of Public Safety, Accidmt Facts: 1974. 
10James M. Pierce, 1M Condition ofFarmworkers and Small 
Migrant Worken 119 

Farmers in 1974 (Washiopon, D.C.: National Sbarecroppen Fund, 197S). 
11 U.S., Senate, Heari71fls on Farmworker Powerkuneu. 
12A. Baumheicr, 7M MiVlllll FamtWOl'lur: SocMI Pr"6Nf'U, Policies and Rnnrch (Deaver, Colorado: Social Welfare Insti­tute, University of Denver, 1973). 
11/bid. 
14U.S., Senate, Hearings on Farmworlcn Pownleuneu, 
p. S097. 
1'Vemon Bri1P, Walter Fopl, and Fred Sc:bmidt, 17tl Chi­cano Worlcer (Austin: Uni¥ersity of Teus Pren, 1977). 
16Walter Metzler and Frederick Sarpt, Mi6ratOI'}' Farm­workers in tM Mid-Continent Stream, Agricultural Raean:h Service, U.S. Department of Aafic:ulture, in cooperation with Texas Agricultural Experiment Station (Wubington, D.C.: 
U.S. Government Printing Office, 1960) p. 2. 
•7Good Neighbor Commission ofTexas, 1975 Texas Mi6rant Labor Report, Austin, 1975, p. SI. 
llJbid., p. 44. 
19/bid. 
'lll/bid, p. 59. 
2•Texas Rehabilitation Commission, Gm1ra/ and SIWcial Program Staiw Report, Fiscal Year 1977, Austin, 1978. 
22/bid. 
21Telephone interview with Roberto Villarreal, Texas Educa­tion Agency, Austin, Texas, July 2S, 1978. 
MNational Committee on the f.duc:ation ofMipant Cbildrea, "Wednesday's Children: A Report on Propama Funded under the Migrant Amendment to the Elementary and Secondary Act," Albany, New York, 1971. 
2'Juan Ramos, "Migrant Farmworkers," American Journal of Social Work (July 1976): 22. 
26An Opportunity to Choose, Texas Migrant Council Publi­cation, Austin, 1977. 
21/bid. 
21"Expcriment in Prepaid Insurance: It's Working for Mi­grant Families," Texas Medicine (February 1976): 101-105. 
29 [bid.• p. 103. 
'Ml/bid. 
31Georze Walker. with Maurice Oiclt. MWnmt 1181111 C#n Utilization and Costs: 11w Larttlo Expniencr (Houston: Uni­versity of Texas Health Sc:ienc:e Center. 1976). 
32E.J Valk Comm,.,ity Hmlth Plan. •Eucutive Summary. November I, 1973-0ctober 31. 1975." ffartinFn. Teua. 
33American Friends Service Committee. •valley Consumer Planning and Development," Philadelphia. No~ber1976. p. 
2. 
14Intemew with Dan Hawkins. Executive Dim:tor. Su Oiai­ca Familiar, Harlingen. Texas. February Im. 
35Su Oinica Familiar...Annual Report. 1976," Harfuw:a. Texas. . 
SECTION III 

Health Program Resources , and Financing 

Chapter 8 
Health Care Resources in South Texas 

This chapter examines the supply and distribution of medical professionals and medical facilities in South Texas with particular emphasis on their accessability to the Mexican-American population. Although actual util­ization patterns are extremely difficult to ascertain, infer­ences about accessibility may legitimately be drawn from the distribution of resources and of population in the areas. 
Work Force 
Personal health care resources consist primarily of the professional and paraprofessional medical workforce; facilities, and services. The number of professionally active physicians in the United States increased approxi­mately 72 percent between 1950 and 1974. Of the 301,238 active physicians in 1974, 91 percent were engaged in direct patient care. The services provided by these physi­cians were supplemented by 53,879 medical residents and interns. 1 
In 1974, Texas had 10,467 nonfederal, direct patient care physicians and I, 780 residents and interns. South Texas had 16 percent of both the physicians and residents and interns.2 The total number of South Texas direct patient care physicians by specialty by county is provided in Table 78. 
As of 1973 90 percent of the area's physicians, residents, and interns were located in the eight metropolitan coun­ties. The thirty-two nonmetropolitan counties had 23 percent of the area population but only 9.5 percent of the direct patient care physician work force. Although the number of Texas physicians per capita in South Texas equals the figures for the state, the aggregate percentages mask serious shortages in the nonmetropolitan counties. The shortages are evident in Table 79. Non-SMSA coun­ties have a physician shortfall in every category except obstetricians/ gynecologists. Thus, while the area has a proportionate share of the state's available physicians, distribution within the area is uneven and favors the metropolitan counties. 
Further, examination of available data indicates that two counties-Bexar and Nueces-dominate the area in physician resources. Table 80 shows their resources com­pared to the other thirty-eight counties. Together they contain over three-fourths of all area physicians and have more than twice the number of physicians per capita than the other counties. They have approximately one physi­cian per 1.4 square miles whereas the remaining counties have one physician for every 88 square miles. 
The maldistribution of physicians in South Texas is representative of a broader trend. In the U.S~. 7.3 percent of all active physicians serve nonmetropolitan areas which contain 17 percent of the country's population.J There is an increasing trend for physicians to locate in high­income metropolitan areas,4in part due to financial in­centives caused by the health care reimbursementsystem.s Table 81 shows a consistent undersupply of physicians relative to the number of people living in counties with populations under 100,000 in Texas. The reverse is true of counties of 100,000 or more. Counties with 1,000,000 or more residents had the greatest relative oversupply (+9.4%). 
Primary Care Physicians 
Most patients enter the heath care system at the pri­mary care level. The majority of this care is provided by general practitioners (GPs), family practitioners (FPs), obstetricians/ gynecologists (OB/ GYNs), pediatricians, and internists. Services offered at the primary care level include diagnosis and treatment of uncomplicated illness and disease, preventive medical services, minor surgery, and emergency care for problems not requiring special­ized personnel or equipment. 
There is no commonly accepted standard for primary care physician-to-population ratio. The U.S. Public Health Service, however, designates one primary care physician for every 1,500 to 2,000 persons when staffing its primary care centers. When the ratio of civilian population to primary care physician exceeds 4,000 to I, an area is considered to have a critical medical work force shortage. 
Data provided in Table 82 reveal that, in 1973, fifteen South Texas counties had 4,000 or more persons per primary care physician. Only five counties had fewer than 2,000 persons per physician (see Table 83). 
The nonmetropolitan counties had 459 more persons per physician than the metropolitan counties. Bexar and Nueces together had an average person to primary physi­cian ratio of 2,207 to I, while the remaining thirty-eight counties had a combined ratio of2,867 to I (or 660 more persons per primary physician). 
Table 71 
Non-Federal South Texas Physicians En1a1ed in Direct Care as Major Professional Activity: December 31, 1973 
Interns and 

County  Residents  GP  Pedi  OB/GYN  lnte1111ll  Gen. Surgery  Other  Total  
Aransas  0  4  0  0  0  I  I  6  
Atascosa  0  5  0  0  0  0  0  5  
Bandera  0  I  0  0  0  0  0  I  
Bee  0  9  0  0  0  0  0  9  
Bexar  289  185  46  57  89  70  408  1,144  
Brooks  0  4  0  0  0  0  0  4  
Cameron  0  28  6  9  12  15  49  119  
Comal  0  IO  0  0  I  1  3  15  
Dimmitt  0  3  0  0  0  I  0  4  
Duval  0  3  0  0  0  0  0  3  
Edwards  0  I  0  0  0  0  0  1  
Frio  0  2  0  0  0  0  0  2  
Gillespie  0  6  I  I  0  0  I  9  
Guadalupe  I  14  0  0  0  0  2  17  
Hidalgo  I  43  5  7  9  11  37  113  
Jim Hogg  0  2  0  0  0  0  0  2  
Jim Wells  0  11  I  I  I  2  I  17  
Karnes  0  3  0  0  0  I  0  4  
Kendall  0  I  0  0  0  0  0  1  
Kenedy  0  0  0  0  0  0  0  0  
Kerr  0  16  1  1  2  2  15  37  
· Kinney  0  0  0  0  0  0  0  0  
Kleberg  0  6  I  2  2  3  1  15  
LaSalle  0  2  0  0  0  0  0  2  
Live Oak  0  4  0  0  0  0  0  4  
McMullen  0  0  0  0  0  0  0  0  
Maverick  0  5  I  0  0  0  3  9  
Medina  0  7  0  0  0  0  2  9  
Nuece8  28  66  20  14  30  24  138  320  
Real  0  0  0  0  0  0  0  0  
Refugio  0  4  0  0  0  0  0  4  
San Patricio  0  14  I  0  0  0  2  17  
Starr  0  3  0  0  0  1  0  4  
Uvalde  0  10  0  0  0  1  1  12  
Val Verde  0  5  0  0  0  1  3  9  
Webb  0  12  2  4  2  6  15  41  
Willacy  0  3  0  0  0  I  1  5  
Wilson  0  5  0  0  0  0  0  5  
,Zapata  0  1  0  0  0  0  0  1  
Zavala'  0  2  0  0  0  0  0  2  
SMSA Counties  319  372  80  91  143  127  652  1,784  
Non-SMSA Counties  0  128  5  5  5  14  31  188  
Total GSTCB  319  500  85  96  148  141  683  1,972  
Texas  1,980  2,726  597  768  1,081  942  4,353  12,477  

*"Direct patient care as major professional activity" is defined as 50 percent or more time spent in direct patient care. Professionally active physicians only. 
Source: Distribution ofPhysicians in Texas, 1973. Texas Medical Association. Austin, Texas 1974. 
Table 79 

Population and Physician Distribution in SMSA and Non-SMSA South Texas Counties 
Non-
SMSA SMSA South 
Counties Counties Texas 


Percent of Texas Population  3.4%  13 .3%  16.7%  
Percent of Texas Physicians·1  1.8%  14.9%  16.7%  
General Practitioners  4.7  13.6  18.3  
Obstetricians/  
Gynecologists  0.7  11.8  12.5  
Internists  0.5  13.2  13.7  
General Surgeons  1.5  13.5  15.0  
Pediatricians  1.0  13.4  14.4  
Other Specialists  0.7  17.2  17.9  

Source : Calculated from data in Table 78. 
1 Nonfederal, direct patient care physicians. Interns and residents excluded. 
Health Care Resources 125 
Table 81 
Distribution of Physicians in Texas by Size of County Population 
Percentage Percentage 

ofState's ofState's County Population Population Physicians 
Under 5,000 1.2 0.5 5,000-9 ,999 3.3 1.6 10 ,000-19 ,999 7.9 4.3 20,000-49,999 12.6 7.7 50 ,000-99 ,999 11.4 9.8 100 ,000-199 ,999 10.8 12.l 200 ,000499,999 12.l 13.l 500,000-999 ,999 13.6 14.4 Over 1,000,000 27.0 36.4 
Source: 	Profile ofMedical Practice 1974. Center for Health Services, American Medical Association. 
Table 80 
Distribution of Physicians Between Bexar, Nueces, and the 38 Other South Texas Counties 

%ofSouth  Number of  %ofSouth  Physicians  Physicians  
Counties  Texas Population 1  Physicians2  Texas Physicians  per 100,000 pop.  per square mile  
Bexar & Nueces  54.7  1,464  74.2  131  .70  
38 South Texas Counties  45.3  508  23.8  55  .01  

Source: Calculations based on Appendix I. 1 1975 population estimates. Texas Governor's Office of Budget and Planning 2 Includes residents and interns 
Table 82 
Primary Care Physicians Engaged in Direct Patient Care as Major Professional Activity: December 31, 1973 
Population per 

County  GP  Pedi  OB/GYN  Internal  Total  Physician  
Aransas  4  0  0  0  4  2,925  
Atascosa  5  0  0  0  5  3,700  
Bandera  1  0  0  0  1  4,500  
Bee  9  0  0  0  9  2,478  
Bexar  185  46  57  89  377  2,289  
Brooks  4  0  0  0  4  2,300  
Cameron  28  6  9  12  55  2,469  
Comal  10  0  0  1  11  2,327  
Dimmitt  3  0  0  0  3  3,000  
Duval  3  0  0  0  3  4,233  
Edwards  1  0  0  0  l  2,300  
Frio  2  0  0  0  2  6,550  
Gillespie  6  l  1  0  8  1,275  
Guadalupe  14  0  0  0  14  2,414  
Hidalgo  43  5  7  9  64  2,744  
Jim Hogg  2  0  0  0  2  2,600  
Jim Wells  11  1  1  l  14  2,393  
Karnes  3  0  0  0  3  4,667  
Kendall..  l  0  0  0.  1  7,000.  
Kenedy  0  0  0  0  0  0  
Kerr  16  1  1  2  20  962  
Kinney  0  0  0  0  0  0  
Kleberg  6  1  2  2  11  3,164  
LaSalle  2  0  0  0  2  2,900  
Live Oak  4  0  0  0  4  1,600  
McMullen  0  0  0  0  0  0  
Maverick  5  1  0  0  6  3,367  
Medina  7  0  0  0  7  3,243  
Nueces  66  20  14  30  130  1,970  
Real  0  0  0  0  0  0  
Refugio  4  0  0  0  4  2,425  
San Patricio  14  I  0  0  15  3,167  
Starr  3  0  0  0  3  6,533  
Uvalde  10  0  0  0  10  1,990  
Val Verde  5  0  0  0  5  6,100  
Webb  12  2  4  2  20  4,635  
Willacy  3  0  0  0  3  4,833  
Wilson  5  0  0  0  5  2,580  
Zapata  I  0  0  0  1  5,300  
Zavala  2  0  0  0  2  6,950  
SMSA Counties  372  80  91  143  686  2,253  
Non-SMA Counties  128  5  5  5  143  2,712  
Bexar & Nueces  251  66  71  119  507  2,207  
All other South  
Texas Counties  249  19  25  29  322  2,867  
Total South Texas  500  85  96  148  829  2,464  
Texas*  2,726  597  768  1,081  5,172  2,320  
U.S.  51,113  13 ,687  16,219  30,643  111,662  

*Based on estimated population of 12,000,000 in 1973. 

Source: AMA Physician Master-file, 1975. Special Tabulations, Center for Health Services Research and Development, Ameri­can Medical Association, 1974. 
Table 13 

Population Per PrimUJ Care Physician: 
December 31, 1973 

Population per Primary Care Primary Care Area Physicians Physician 
Texas 	5172 2320: l 
South Texas 	829 2464:1 
SMSA counties 686 2253 : l 
Non-SMSA counties 507 2712: l 
Bexar & Nueces 507 2207:1 
Other South Texas counties 322 2867: l 
Source: 	Calculated from data in Distribution ofPhysicians in Texas: 1973. (Austin : Texas Medical Associa­tion, 1974 ). 
One quarter of all South Texas counties are designated by the U.S. Public Health Service as areas with critical medical work force shortages. Portions of three other counties are also designated shortage areas (see Table 84 for a list of designated counties). The thirteen counties so designated have 21.6 percent of the area's population but only three percent of the area's primary care physicians. 
General Practi1ioners (Family Practitioners) 
General practitioners are the most numerous and the 
most widely distributed type of primary care physician. 
They offer a cross section of services to patients, from 
obstetrical, gynecological, and pediatric care, to internal 
medicine and even minor surgery. In many rural areas a 
single general practitioner serves the entire population. 
The importance of general practitioners in South Texas 
cannot 	be overestimated. In 1973, they constituted 90 
percent 	of all active primary care physicians providing 
direct patient care in nonmetropolitan counties. They 
were present in all but four counties and were the only 
primary care physicians in twenty-four of the forty coun­
ties. 
Unfortunately, the number of active GPs in the United 
States declined 26.6 percent between 1963 and 1973. In 
the five years between 1968 and 1973 their numbers 
declined 5.2 percent in Texas.6 
A national movement during the 1960s and early 1970s 
reestablished the importance of GPs by redesignating 
them "family practitioners." The number of family prac­
tice residents has been steadily increasing since 1974 (see 
Table 85). Family practice became recognized as a spe­
cialization in the medical field and family practice resi-
Health Care Resources 127 
Table 84 
List of Medically Undenerved Areas in South Teu1 

Number Designated 1975 Census Tract Census Tracts County Populationf Within County Designated 
Atascosa  18,500  Bexar  59  
Bandera  4,500  Cameron  34  
Bee  22,300  Guadalupe  8  
Brooks  9,200  Hidalgo  39  
Dimmitt  9,000  Nueces  9  
Duval  12,700  San Patricio  10  
Edwards  2,300  Webb  16  
Frio  13,100  
Jim Hogg  5,200  
Jim Wells  33,500  
Karnes  14,000  
Kendall  7,000  
Kenedy  700  
Kerr  20,200  
Kinney  1,900  
Kleberg  34,800  
LaSalle  5,800  
Live Oak  6,400  
McMullen  900  
Maverick  20,200  
Medina  22,700  
Refugio  9,700  
Starr  19,600  
Uvalde  19,900  
Val Verde  30,500  
Willacy  14,500  
Wilson  12,900  
Sources:  
*Federal Register, Vol. 41 , No. 201-Friday, October 15 ,  

1976. 
tPopulation Projections for Texas Counties: 1975-1990, 
May, 1972, Population Research Center, The University of Texas at Austin. 
Table 85 
Total Number of Family Practice Residencies in Texas 
1975-76 200 
1976-77 235 
1977-78 267 
1978-79 335• 
1979-80 398• 
1980-81 532• 

Source : Coordinating Board, Texas College and University System 
•Projections made by Coordinating Board 
dency programs were established. In 1978, the Texas services may be required for women of any age. Some Legislature passed a bill (H.B. 282) which would make obstetricians serve as primary care physicians for their available state funds to create and maintain family prac­patients. tice physiciam in underserved urban and rural areas of The supply ofOB/GYNs in most South Texas counties the state and also to encourage permanent location in is inadequate. Only five metropolitan and four rural underserved areas. counties had practicing OB/GYNs in 1973. Over 184,400 
In 1977 at least half the University of Texas System women aged fifteen and older lived in the thirty-one Medical School graduates went into primary care resi­counties lacking OB/ GYN physicians. dencies, and the goal is to have at least 25 percent of the As Table 86 shows, there were five times as many graduates going into family practice by 1985.7 0 B / G YN s per I 0,000 women in metropolitan counties as 
in rural counties. The ratio of women aged fifteen and 
Obstetricians/ Gynecologists 
over per OB/ GYN was 29,800 to I in the rural counties 

Obstetricians/ gynecologists (OB/GYNs) provide spe­compared to only 6,280 to I in the metropolitan areas. cialized medical care to women ofall ages. Generally only Bexar and Nueces counties had 78 percent of active women in the child-bearing years-ages fifteen to forty­OB/ GYNs in South Texas. The only other county in four-require obstetrical services, while gynecological South Texas approaching their supply in proportion to 
Table 86 
Obstetricians/Gynecologists in South Texas: December 31, 1973 
Estimated Estimated Female Female OB/GYNs 
~..........,,;._ 

Population Population 10~000 Women Women · Number 15 Yelll'S Ages 15 Women 15 through OB/GYNs and over through 44 15 Years 15 through 15+per 44per (1974) (1975) (1975) and over 44 Years OB/GYNs OB/GYN 
I 

Bexar 57 304,600 184,800 1.9 3.1 5,344 3,242 
Nueces 14 89,600 56,200 1.6 2.5 6,400 4,014 
Hidalgo 7 59,800 37.600 l.2 1.9 8,543 5,371 
Cameron 9 47,400 28,800 1.9 3.1 5.267 3,200 
Webb 4 31,800 19,600 1.3 2.0 7,950 4,900 
San Patricio 0 15,900 9.900 0.0 0.0 
Guadalupe 0 12,700 6,800 0.0 0.0 
Comal 0 9,800 4,900 0.0 0.0 0 
Bexar & Nueces 71 394,200 241.000 1.8 2.9 5,552 3,394 
Other South Texas 

counties 25 323,100 188.800 0.8 l.3 12,924 7,552 
SMSA 91 571 ,500 348,600 1.6 2.6 6,280 3,831 
Non-SMSA 5 146,000 81.100 0.3 0.6 29,800 16,220 
South Texas 96 717,600 429,800 1.3 2.2 7,475 4,477 
Note: Includes nonfederal hospitals of office-based patient care physicians only. Does not include interns or residents. 
IAMA Physi.::ian Master File, 1973. Special Tabulation, Center for Health Services Research and Development American Medical Association, 1974. 
Health Care Resources 129 

target population was Cameron County. Four counties-Bexar, Cameron, Hidalgo, and Webb-
As a result of the shortage and maldistribution of registered over 1,000 births to nonresidents in 1975. OB/ GYNs in the area, women requiring obstetrical or Apparently in-migration for birth is not exclusively a gynecological services must rely on general practitioners function of 08/GYN supply, but also a function of or midwives, or travel to anothercounty for these services. geographical setting. As Table 88 shows, Bexar County Travel out of county for birth in 1975 is documented in had the greatest number of physicians but only eighteen Table 87. In the area as a whole, 40 percent or more ofall nonresident births per obstetrician and the lowest number resident births were delivered outside the mother's county of nonresident births of the four counties. Nueces County, of residence. with the second largest supply of 08/GYNs in South 
Table 87 

In-and Out-Migration for Births in South Texas: 1975 
Total Births  Resident  N.esident  Births to  Total  
to County  Births  Births  Non-residents  Births  
County  Residents  In-county  Out-of-county  In-county  Jn-county  
#  %  #  %  
Aransas  160  0  IY  160  100.0  0  0  
Atascosa  389  240  61.7  149  38.3  58  298  
Bandera  61  1  1.6  60  98.4  0  1  
Bee  531  453  35.3  78  14.7  146  599  
Bexar..  17,060  16,868  98-.9  192  1.1 . .  1,017  17 ,855  
Brooks  163  152  93.3  11  6.7  136  288  
Cameron  4,787  4,579  95.7  208  4.3  2,675  7,254  
Comal  463  388  83.8  75  16.2  120  508  
Dimmitt  246  186  75 .6  60  24.4  180  366  
Duval  249  8  3.2  241  96.8  l  9  
Edwards  42  13  31.0  29  69.0  4  17  
Frio  273  225  82.4  48  17.6  46  271  
Gillespie  123  113  91.9  10  8.1  101  214  
Guadalupe  635  363  57.2  272  42.8  53  416  
Hidalgo  6,506  6,282  96 .6  224  3.4  2,078  8,360  
Jim Hogg  96  0  0  96  100.0  0  0  
Jim Wells  616  462  75.0  154  25.0  251  713  
Karnes  205  70  34.l  135  65.9  23  93  
Kendall  196  15  14.2  91  85 .8  7  22  
Kenedy  2  0  0  2  100.0  0  0  
Kerr  262  225  85.9  37  14.l  IOI  326  
Kinney  43  l  2.3  42  97.7  l  2  
Kleberg  641  571  89. l  70  10.0  122  693  
LaSalle  126  62  49.2  64  so 8  l l  73  
Live Oak  93  0  0  93  100.0  0  0  
McMullen  12  0  0  12  100.0  0  0  
Maverick  580  547  94.3  33  5.7  212  759  
Medina  367  159  43.3  208  56.7  45  204  
Nueces  5,048  4,875  96.6  173  3.4  593  5,473  
Real  28  0  0  28  100.0  0  0  
Refugio  145  l  0.7  144  99.3  I  2  
San Patricio  1,049  707  61.4  342  32.6  267  974  
Starr  642  400  62.3  242  37.7  299  699  
Uvalde  364  305  83.8  59  16.2  50  355  
Val Verde  806  784  97.3  22  2.7  287  1,071  
Webb  2,217  2,196  99.1  21  0.9  1,933  4,129  
Willacy  423  257  60.8  166  39.2  19  276  
Wilson  245  167  68.2  78  31.8  l 21  288  
Zapata  110  7  6.4  103  93.6  4  11  
Zavala  213  0  0  213  100.0  30  30  
Source:  

Migration for Birth: Texas 1975. Texas Department of Health, 1976. 
· ·~ 
Table 88 
Sou th Texas Counties Recordin1 
1,000 or More Nonresident Births in 1975 

Number 

Number  Number  Nonresident  
OB/GYNs  Nonresident  Births  
County  Dec.1973  Births  perOB/GYN  
Bexar  57  1,017  18  
Cameron  9  2,675  297  
Hidalgo  7  2,078  297  
Webb  4  1,933  483  

Source: Compiled from data presented in Tables 86 and 87. 
Table 89 
Out of State Residents Giving Birth in S South Texas Counties 
Percent of Nonresident Nonresident Non· Births to Births to Resident Out-ofState Out-ofState Births Residents Women 
Bexar 1,017 41 04% 
C::.meron 2,675 2,394 89 
Hidalgo 2,078 1,648 79 
Nueces 598 12 02 
Webb 1,933 1,726 89 
Source: 	Migration for Birth: Texas 1975. Texas Depart· ment of Health. 
Texas (fourteen), had only 598 nonresident births or an average of forty-three per obstetrician (see Table 89). 
The major problem with nonresident births occurs in the three southernmost counties-Cameron, Hidalgo, and Webb. In each of these the number of nonresident births per obstetrician is extremely high while the OB/ GYN supply is relatively low. 
The pattern of in-migration in Cameron, Hidalgo, and Webb varies radically from that of Bexar and Nueces. Births to out-of-state residents constitute the vast major­ity of in-migration births in these counties, while births to out-of-state residents in Bexar and Nueces counties are a negligible portion of all nonresident births. 
This shortage of obstetricians in Cameron, Hidalgo and, to a lesser extent, Webb, counties is reflected in what many observers have labeled the most pressing health care problem in these counties: difficulties in assuring the adequate provision of pre-and post-natal care, and the supervision of births by trained persons in adequately sterile surroundings. 
A majority of the people interviewed in Brownsville mentioned a lack of publicly supported maternal and child care services as the number one health care problem faced by the poor in the area. s A previous study in Laredo reached a similar conclusion concerning that city. It estimated that 40 percent of the medically indigent preg­nant women in the area did not receive the needed prenatal, child delivery, or postnatal care.9 In McAllen, interviewees did not single out this problem as being near the top of their list of health care problems. However, the extent of this problem in both Brownsville and Laredo leads us to believe that the lack of publicly supported maternal health care is a serious problem throughout the region. 
In Brownsville pediatricians, 08/GYNs, government health officials, the city planner, and private family doctors all stated that those living at or below the poverty level used midwives (usually "lay" or untrained midwives) in well over 50 percent of their deliver~. 
In the South Texas border area, as well as in other places in Texas, a numberofwomen,parteras, specializ.e in midwifery services. In Texas, their role is more signifi­cant than in other states. Although Article 4477, Rule 49-, · of Texas Civil Statutes requires midwives, as well as : physicians and undertakers to register with local repre-. · sentatives of the Texas Bureau of Vital Statistics, formal medical training is not required of midwives. 
Reasons for use of midwives differ. Lee and Glasser (1974) surveyed clients of nine registered lay midwives, attending less than I percent of the deliveries in the Houston community. Women were found to prefer home midwife delivery for both positive reasons (they weren't ill, they felt calmer at home) and negative reasons (ex­pense, fear, distressing previous hospital stays). 10 
Rubel (1970) reports similar reasons given by women in an unnamed South Texas community which he calls "Mexiquito." Although he expressed some concern about the lack of training and supervision for Mexiquito's seven registered midwives, he says a ruore serious problem lies in the fact that the midwives were getting old and were not being replaced. Physicians and a hospital were avail­able to women in the community, but were often said to be less appealing or less accessible than midwives. 
Four reasons for the preference for midwives surfaced in the Mexiquito study. First, midwives were thought to understand the pains and fears of childbearing better than male physicians. Second, some mothers interviewed said they felt embarrassed giving birth in the presence of male physicians. Third, physicians were thought to be less patient than midwives, and apt to hasten birth through 
Health Care Resources 131 

painful methods. Finally, midwife care was said to be generally Jess expensive. 11 
This last reason is substantiated by the LBJ School project's interviews in the border areas, which suggest that the cost ofa midwife delivery is $I SO, while the costs of a doctor's prenatal, child delivery, and postnatal servi­ces vary between $200 and $375, in addition to a~ragc hospital costs of $40(),12 
We estimate that in. 1976 about SO percent of all children born in Brownsville were born outside hospitals without professionally supervised prenatal, child delivery, or postnatal carc. u Our research found that approximately 600 and 1,400 babies respectively were born during 1976 at the two area hospitals, while 4,000 babies were born in the city during the year. Little reliable data exist concern­ing the infant mortality rates or incidence of birth-related defect!' of children born through the use of midwives. However, it is reasonable to believe that lack of any prenatal or postnatal care, combined with delivery by midwives with little or no formal training arc partly responsible for infant deaths and birth-related defects of children in the area.14 
In Laredo, although the percentage of births performed 
without trained personnel supervising prenatal, child 
delivery, and postnatal care is lower than in Brownsville, 
the number is still many times the national average. One 
midwife with whom we spoke said she delivered 1,043 
babies in 1976 in the Laredo-Nuevo Laredo area.• 
During the early months of 1977 the City of Brownsville initiated a twelve-session voluntary course to train mid­wives in the areas-of hygiene, nutrition, and detection of warning signs. Forty-seven of the seventy local midwives took part in the course.is The program came under criticism from several doctors in the area who supported the concept of training midwives, but felt that the twelve­session course was far too short to have a significant effect on the quality of care offered by the lay midwives. 
The main problem related to maternal and child care services should not be viewed as the overuse of lay midwives per se. The problem existing throughout the border region is that there is no system of publicly supported prenatal, child delivery (by midwife or physi­cian), and postnatal services available to those living at or below the poverty level. This lack of publicly supported services forces a majority of the poor in the area to forego needed prenatal and postnatal care. We believe this contributes to the unconfirmed but widely reported high incidence of birth defects among the Chicano population of the region. 
The scarcity and uneven distribution of 08/ GYN physicians in South Texas has serious implications for resident Mexican-American women. On the average, 
•In 1975. 2,187 children were born in Laredo, and in 1973, 7,058 children were born in Nuevo Laredo. With some allowance for increases in both cities. this suggests that this midwife (Mrs. Emma Lopez) attended 10 percent of all the births in the area in 1976. 
they have more children and a longer child-bearing age range than Anglo women. According to 1970 census data, Mexican-American females in South Texas had 4,743 births per 1,000 women ever married while Anglo women had only 2,852 births per 1,000. Thus, Mexican­Americans require obstetrical services more often and undergo the risks of childbirth more frequently than Anglo residents. 
The additional risks are reflected in mortality rates for South Texas. In 1975, 5 percent of all deaths to Mexican­American women aged fifteen to twenty-nine were attri­buted to childbirth complications, compared to only 2 percent of deaths to Anglo women in that age group. In addition, Mexican-American women had higher mortality rates than Anglo women for all degenerative ailments except cardiovascular disease (see Chapter 2-"Mortality and Morbidity;. 
It is clear that Mexican-American women in South Texas have a great need for obstetrical and gynecological care. Their access to such care, however, is limited both by their low financial status and by the low number of 08/GYNs available. The 1970 census revealed that 43 percent of all Mexican-Americans in South Texas lived at or below the poverty level. Women in this income group in Texas are unlikely to have adequate medical insurance or the financial resources to pay directly for 08/GYN physician services. Therefore, accessibility is severely limited. 
The Medicare insurance program is primarily available to the elderly and the disabled, and not to women in their childbearing years. The Aid to Families with Dependent Children (AFDC) Medicaid program is designed to pro­vide medical care for low-income families with children, and in Texas, this assistance is restricted to one-parent families or families with one parent incapacitated. (In I 970 the ratio of Medicaid recipients aged twenty-one to sixty-four to poor adults in Texas was 0.09-second lowest in the nation.)16 Thus, the number ofpoor Mexican­American women eligible for assistance under Medicaid is quite small compared to the number in need. 
Low income not only limits access to local 08/GYNs and to other medical services; it limits the ability to travel out-of-county for care. Lacking adequate financial re­sources, insurance, or eligibility for Medicare or Medicaid, the low-income Mexican-American female must rely on charity care, public health clinics, federally funded local clinics for the poor, or the services of a midwife. 
Pediatricians 
Pediatricians provide medical services to children from birth to about fourteen years of age. Only eleven South Texas counties had practicing pediatricians in 1973, while twenty-nine had none. There arc fewer pediatricians in the area than any other category of primary care physi­cian. 
Data provided in Table 90 indicates that maldistribu­
Table 90 
South Texas Pediatricians by County and by Number of Children Aged 0-14 

Number of  
Number of  Children 0-14  
Pediatricians  per Pediatrician  
County  (1973}1  (1975)2  
Bexar  46  5,953  
Cameron  6  8,747  
Gillespie  2,697  
Hidalgo  5  12,548  
Jim Wells  11,649  
Kerr  2,212  
Kleberg  9,694  
Maverick  7,269  
Nueces  20  4,046  
San Patricio  17,270  
Webb  2  13,796  
South Texas  85  7,853  
S~lSA Counties  80  6,725  
Non-SMSA Counties  5  25,910  
Bexar & Nueces  66  5,375  
Sources:  1 Distribution  of Physicians  in  Texas-1973.  

(Austin: Texas Medical Association, 1974). 

2 Calculations based on estimates of 1975 popu­lation by the Governor's Office of Budget and Planning. 
tion of pediatricians is severe. Over 94 percent of the pediatricians are located in the metropolitan counties. The ratio of children aged zero to fourteen per pediatrician in the rural counties is 25,9!0 to I. As with OB/ GYNs, most of the area pediatricians (769) practice in Bexar and Nueces counties, where the number of children per physi­cian is a more reasonable 5,375 to I. 
With the exception of a few scattered counties, then, the number of pediatricians in South Texas is inadequate. Assuming they work the same number of weeks and have the same number of total patient visits as the average for pediatricians in the West South Central census division,• 
•Based on the national average of 4.1 visits per year to a physician by persons under age seventeen. 
the eighty-five South Texas pediatricians could provide services to less than one-fourth ofthe area's children aged fourteen and under.17 
Access to adequate pediatric care for Mexican-Ameri­can children is limited in South Texas not only by supply but by income as well. Poverty among Mexican-Ameri­cans aged zero to fourteen is especially severe. The lower a child's family income, the less likely he is to have health insurance and the less able his family is to make direct payments for medical services. In short, unless the low­income child receives help from outside the family, he or she is unlikely to receive adequate medical care. 
Mortality data for South Texas children indicate the results of limited access to pediatricians. Causes ofdeath most susceptible to intervention and alleviation by a pediatrician are higher for Mexican-Americans than for Anglos. Table 91 shows the leading causes of death to South Texas children aged zero to fourteen in 1975. Anglo children had higher mortality rates than Mexican­Americans only for accidents, congenital anomalies, and neoplasms. Percentages of deaths from influenza and pneumonia, infectious and parasitic diseases, certain causes of mortality in early infancy, and ..all other causes" were higher for Mexican-American children. 
The number of infant and neonatal deaths in 1975 was 785 for Mexican-Americans and 327 for Anglos. Mortal­ity rates per 1,000 live births, however, were slightly lower for Mexican-Americans, but this may be due to under­reporting of such deaths in South Texas for a variety of reasons. (See Chapter 2, ..Mortality and Morbidity.") 
Clearly, factors such as poor nutrition, inadequate sanitary facilities, and unsafe drinking water contribute to the medical problems of low-income Mexican-Ameri­can children in South Texas. However, the additional factors of limited access and availability of pediatric care also contribute to their health care problems. One impor­tant component of improving health care would be to expand the number and improve distribution of pediatri­cians in this area. 
Internal Medicine Physicians (Internists) 
Internal medicine specialists constitute the second lar­gest group of primary care physicians in South Texas with 148 physicians engaged in direct patient care in the area in 1973. However, the distribution of internists more closely resembles the pattern of OB/GYNs and pediatri­cians than that ofgeneral practitioners. The vast majority 
(143) practiced in five metropolitan counties. Bexar and Nueces, with 54. 7 percent ofthe area's population, had 80 percent of the internists. The other thirty-eight counties shared a total of twenty-nine. To a certain extent, of course, GPs can do more or less what many internists do. In fact internists are often further distributed into sub­specialties such as cardiology and endocrinology, and many South Texas residents would find it difficult to find their way to an appropriate specialist. 
Table 91 

Leading Causes of Death to South Texas Residents Age 0-14: 1975 Percentage of All Causes 
Mexican­Anglos Americans Cause ofDeath Male Female Male Female 
TOTAL DEATHS N=l91 N=l31 N=371 N=266 
Certain Causes of Mortality in Early Infancy 30.89 26.72 38.27 37.22 
Accidents 21.43 24.08 14.29 13.16 
Congenital Anomalies 18.85 19.08 17.52 14.29 
Neoplasms, Total 4.71 9.16 2.97 (4.89) 
Influenza & Pneumonia 4.7L 3.82 4.31. 5.6.4. 
Infectious & Parasitic Diseases (1 .56)* (2.29)* 2.97 5.27 
All Other Cau~es 17.85 14.85 19.67 19.53 
Source: Data on death certificates obtained from the Texas Department of Health. 
*Indicates not one of leading causes of death. 
Osteopaths 
In 1973 Doctors of Osteopathy (DOs) served one South Texas county which had no medical doctor, and supplemented other providers in five metropolitan and ten nonmetropolitan counties. Bexar and Nueces had a majority of the area's DOs with sixty-one (69 percent), and non metropolitan counties had twelve ( 14 percent). 18 
Dentists 
In 1973 there were forty-eight active nonfederal dentists per 100,000 persons in the United States. Texas had forty-four per 100,000 persons, while South Texas had only 32 per 100,000. The South Texas ratio is 34 percent below the national average ratio. 19 
The majority of dentists are located in metropolitan counties. Nine rural counties did not have dentists. For 
Health Care Resources 133 
Table 92 
Dentists in South Texas: 1973 


Dentists  
Number  per 100,000  Population  
Area  Dentists  Persons  per Dentist  

Bexar & Nueces 449 40 :Z,492 
38 Remaining Counties 200 22 4,632 
Non-SMSA Counties 97 23 4,279 
SMSA Counties 552 34 2,953 South Texas 649 32 3,151 Texas 5,392 45 2,226 United States 100,780 48 2,065 
Sources: 	Number and location of dentists in South Texas obtained from Texas Board of Dental Examiners. Number of dentists in Texas and U.S. obtained 
from.National Health Insurance. Resource Book; 1976. Population data obtained from Office of the Governor for projections for 1975 . 

the nonmetropolitan counties with dentists the ratio of population to dentists was more than double the national average. Bexar and Nueces counties had more than two­thirds of the practicing dentists and the most favorable ratios of dentists per person and population per dentist (see Table 92). 
Although most metropolitan counties had an adequate supply of dentists, Webb County had only nine dentists to serve a population of almost 93,000 persons. (Table 93 has a listing of dentists by county in South Texas.) This is no doubt due in part to competition from dentists in Nuevo Laredo. 
Very few Mexican-Americans in South Texas are covered by medical insurance that covers dental care. Nationally, only 17 percent of the population under age sixty-five had some type of dental insurance in 1974. Low-income persons are.least likely to have any type of medical insurance and also lack the resources to pay directly for services. Research shows that as a conse­quence, the number of yearly dental visits per person declines directly with income in every age group but one. The one exception is the $5,000-$9,999 income group for ages seventeen to forty-four, which had slightly fewer visits than that age group making under $5,000 (see Table 94). 
The difference in number of visits by income level per year is greatest for children, as is shown in Table 94. 
Children age six to sixteen in the lowest income group averaged barely one-third the number of visits by the same age group in the $15,000t income category. 
The scarcity of dentists in nonmetropolitan areas is reflected in the number of yearly visits to a dentist by residents of these areas (see Table 94). The number of visits by rural residents is consistently lower than for metropolitan residents in all age groups, as shown in Table 94. 
Given the widespread poverty among Mexican-Ameri­cans in South Texas and the lack of dentists in many areas, it is probable that the Mexican-American popula­tion does not have adequate access to regular dental care. 
Pharmacists 
Pharmacists are among the more numerous health professionals in South Texas. In 1973, 803 professionally active pharmacists resided in the area. As with other health professions, the majority (85 percent) were located in metropolitan counties. Three nonmetropolitan coun­ties-Kenedy, McMullen, and Real-had no pharma­cists. 
Rural South Texas counties had thirty-three active pharmacists per 100,000 persons in 1973. This compared poorly with the national average of 62 pharmacists per 
Table 93 
Dentists in South Texas 

County  Dentists  County  Dentists  
Aransas  4  Kerr  10  
Atascosa  3  Kinney  0  
Bandera  Kleberg  IO  
Bee  7  LaSalle  l  
Bexar  342  Live Oak  10  
Brooks  l  McMullen  0  
Cameron  31  Maverick  l  
Comal  16  Medina  2  
Dimmitt  0  Nueces  107  
Duval  0  Real  0  
Edwards  0  Refugio  2  
Frio  2  San Patricio  9  
Gillespie  5  Starr  0  
Guadalupe  13  Uvalde  5  
Hidalgo  33  Val Verde  7  
Jim Hogg  0  Webb  7  
Jim Wells  6  Willacy  l  
Karnes  4  Wilson  3  
Kendall  4  Zapata  l  
Kenedy  0  Zavala  l  
South Texas  649  

Source: Texas Board of Dental Examiners 
100,000 persons and was considerably lower than the Texas average of 55 per 100,000. The metropolitan coun­ties fared better, with an average of 41 pharmacists per 100,000 persons. 
Optometrists 
Twenty South Texas counties had one or more opto­metrists in 1973; nineteen counties-all of them rural­had none. Bexar and Nueces combined had 60 percent of the area supply and all metropolitan counties combined had 84 percent. 
Registered Nurses 
Registered nurses (RNs) are by far the most numerous 
health professionals in South Texas. The area had 3,827 
full-time RNs and 617 part-time professionally active 
RNs in 1976. (See Table 95 for a survey of full-time RNs 
by rural and urban areas in South Texas.) 
The distribution of RNs follows the pattern established 
in the other health professions. Bexar and Nueces counties 
combined had 70 percent. The thirty-two nonmetropoli­
tan counties had 15 percent. The national average of 
nurses per capita is more than twice tlie ratio that exists iii 
South Texas nonmetropolitan counties. 
Medical Facilities and Services 
Much medical care for poor Mexican-Americans occurs in organized settings such as migrant or county health departments, emergency rooms or hospital outpatient departments. The availability of beds in hospitals, state hospitals, and nursing homes also determines the kind of medical care which is likely to be available. 
Local Public Health Departments 
Low-income persons unable to afford private physi­
cian services often rely on local public health departments 
for certain kinds of medical care. In 1975, local health 
departments delivered medical services to the poor in 
seventeen South Texas counties. Availability, accessibil­
ity, and range of services vary considerably among local 
departments. The ty!'es of services, days and hours of 
operations, clinic location, budget, and eligibility criteria 
are locally determined. 
Fifteen local health departments are associated with 
the Texas Department of Health. As a result, they are 
eligible for training, staffing, financial, and other pro­
gram assistance from the State. (See Table 96 for a list of 
local health departments.) 
Six of the eight metropolitan counties in South Texas 
have local health departments. The metropolitan health 
departments employ 94 percent of all health department 
personnel and offer a wider range of services than rural 
Table 94 

Dental Visits Per Pason Per Year 
by Age, Family Income, and Residence 

Under  Age  Age  Age  
Family Income  Age6  6-16  17-44  45-64  
Under $5,000  N/A  1.1  1.5  1.2  
SS,000-9 ,999  3  1.4  1.4  1.4  
s10,000-14 ,999  .5  2.2  1.6  2.0  
SlS,000+  1.2  3.1  2.1  2.2  

Residence 
Nonmetropolitan 1.6 l .4 1.4 Metropolitan 2.3 1.8 1.9 
Source: National Health Insurance Book, August l 976. 
Table 95 
Registered Nurses in South Texas 

Full-Time Persons Full-Time RNsper per RNs 100,000 Full-Time Area 1976 Persons2 RNs 
Bexar & Nueces 2,673 238 419 Non-SMSA Counties 572 138 726 SMSA Counties 3,255 200 501 South Texas 3,827 187 534 Texas 25,441 212 472 
U.S. (1974) 608,000 289 347 
• 

Sources: 1 Texas Board of Nursing Examiners 
2 Texas Governor's Office population projections for 1975. 
3 National Health Insurance Resource Book, 
August 1976. 
Health Care Resources 135 

departments. In 1975, the eleven rural county health departments employed a total of forty-one employees. Approximately half of these employees are sanitarians or clerks. The number and staffing of rural departments are inadequate to meet the need for primary care for low­income residents. 
Outpatient Clinics 
Local outpatient clinics deliver ambulatory care at the primary level and, in some cases, the secondary level. Publicly owned and operated clinics provide free or inexpensive care to the poor. In some instances a gradu­ated fee may be charged based on family size and income level. Reduced fees and free care, however, are often available to local residents only. Privately owned and operated outpatient clinics usually charge set fees for services provided. 
Outpatient clinics are located in eleven of the forty South Texas counties. The majority (81 percent) are in metropolitan counties. Bexar and Nueces together have twenty-five of the area's thirty-seven outpatient clinics. Twenty-nine counties have none. (See Table 97 for a list of outpatient clinics in South Texas.). 
Emergency Rooms 
Because emergency rooms are often open twenty-four hours a day and do not require appointments, they may be used instead of private physicians or clinics for non­emergency needs by low-income persons. A limited survey conducted in San Antonio in 1977 found that 50 percent of the low-income Mexican-Americans responding would go to an emergency room if they were sick and could not treat themselves. 
Twelve South Texas counties had no emergency medi­cal facilities in 1975. Basic ER units provided the only emergency care in twenty others. Eight counties had intermediate and / or comprehensive units. 
The metropolitan rural disparity noted for other medi­cal resources holds true for emergency rooms. Over 70 percent of all the area's intermediate and comprehensive ER units are located in metropolitan counties. The major­ity of basic ERs are located in rural counties. (See Table 97 for a list of ERs by type of county.) 
Ambulance Services 
Four South Texas counties had no ambulance units in 
1975-Jim Hogg, Kenedy, Kleberg, and Live Oak. Five 
metropolitan counties had seven or more units and thirty­
one counties had between one and six. 
Table 98 shows that the number of calls per unit was 
considerably lower in rural counties while the number of 
units per 100,000 persons was more than three times the 
metropolitan county ratio. The number of calls per 
Table 96  
Local Health Departments  
County  Name ofAgency/Addnss/Phone  Number of Employees  County  Name ofAgency/Address/Phone  Number of Employeer  
Aransas  None  LaSalle  None  
Atascosa Bandera Bee Bexar  Atascosa County Health Dept. P.O. Box 426 Agricultural IDdg. Jourdanton, TX 78026 (S 12) 769-3451 None None (has an independent health dept.) San Antonio Metropolitan Health District 131 W. Nueva Str. San Antonio, Texas 78285 (512) 225-5661  4 422  Live Oak McMullen Maverick Medina  Live Oak Co. Health ·Dept. Drawer 670-Courthouae George West, Tex. 78022 (512) 449-4581 None Maverick Co. and Kinney Co. Office Drawer K Eagle Pass, Texas 78852 (512) 773-9438 Medina County Health Dept. 1502 Avenue K Hondo, Texaa 78861 (512) 426-2534  4 6 4  
Brooks Cameron Comal Dimmitt Duval  None Cameron County Health Dept. 186 N. Sam Houston Blvd. San Benito, Texas 78586 (S 12) 399-1356 , None Dimmitt Co. Office 304 Houston St. Carrizo Springs, Tex. (512) 876-2110 None  44 3~  Nueces Real Refugio San Patricio  Corpus Christi-Nueces Co. Health Dept. P.O. Drawer 9727 1301 Leopard Corpus Christi, 78408 None None San Patricio Co. Health Dept. Box 876 Sodville Ave. Sinton, Texas 78387 (S 12) 364-3308  63 10  
Edwards  None  Starr  None  
Frio Gillespie Guadalupe Hidalgo Jim Hogg Jim Wells  None None None Hidalgo County Health Dept. 1425 S. 9th Str. Edinburg, Tex. 78539 (512) 383-6221 None None  53  Uvalde Val Verde Webb  . Uvalde County and City Health Dept. 119 South St. Uvalde, Texas 78801 Val Verde Co. Office 200 Bridge St. Del Rio, Texas 78840 {S 12) 775·5985 Laredo-Webb Co. Health Dept. P.O. Box 2337 Laredo, Tex. 78041 (SI 2) 723-2051  7 6 47  
Karnes  None  Willacy  None  
Kendall Kenedy Kerr Kinney Kleberg  None None None None (dependent on Maverick Co. Health Dept.) None (independent health dept.)  Wilson Zapata Zavala  Wilson Co. Health Dept. P.O. Box 276, Courthouse F1oresville, Texas 78114 {512) 393-6106 None Zavala Co. Office 309 North 1st Ave. Crystal City, 78839 (512) 374-3010  4 3  
Source:  Mr. David Parks Division of Local Health Services Texas Dept. of Health Nov., 1976.  

Table 97 
Outpatient Facilities in South Texas 

County Clinics Emergency Rooms Inter-Com pre-Barie mediate hensive 
Atascosa 1 
Bee 1 Bexart 19 4 5 2 
Brooks I Dimmit 
Comalt Duval Edwards Frio 2 
Gillespie I 
Guadalupet I 
Hidalgot 4 2 2 Jim Wells Karnes 2 Kendall 1 
Kerr 
Kleberg LaSalle Maverick 
Medina 1 
Nuecest 6 3 3 
Refugio 
San Patriciot 3 
Starr Uvalde 
Val Verde 
Webbt 
Wilson 
Zavala 2 
SMSA Counties Total number clinics 30 15 10 3 %of total 81% 44% 71% 75% Non-SMSA Counties: Total number clinics 7 19 4 %of total 19% 56% 29% 25% 
Area: Total 37 34 14 4 
Number counties with I 1 24 7 3 % counties with 25% 60% 17.5% 7.5% 
Source: 
Texas Hospitals and Related Medical Facilities, Inventory and Utilization, Calendar Year 1975. Texas Department of Health Resources. 
•Excludes state, VA and military hospitals. Includes mental 
health centers. tSMSA Counties 
Health Care Resources 137 

l ,000 persons in metropolitan counties was almost twice the nonmetropolitan rate. 
Greater distances, smaller population centers, and scat­tered population make relatively high numbers of units per population group a necessity in rural areas. The lower utilization rates, however, mean less income per unit. As a result, rural ambulance service must in many cases, depend on volunteer staffing and public subsidization. 
Hospitals 
Hospitals are a major component of the health care system and one of the most costly. They provide secon­dary and tertiary level services which are not generally available in other medical facilities. 
Public spending for hospital care accounted for 56 
percent of all public health care expenditures in 1975. 
Hospital expenses per adjusted patient day rose 16.2 
percent that year, with no change in the average length of 
stay. There was a rise of 1.5 percent in the number of 
inpatient days and a 1.8 percent in admissions. Hospital 
expense increases in 1975 followed a trend begun in the 
mid-sixties. The average annual percentage increase in 
total expense· per· patient day has exceeded-H>-·percent 
each year since 1965.20 
Hospital costs tend to be higher when occupancy rates 
are low. Low occupancy rates mean fixed costs must be 
distributed over fewer patients. Occupancy rates are 
influenced by the number of available hospital beds 
compared to population in a given area. Federal guide­
lines suggest a maximum of four beds per 1,000 persons 
and a minimum occupancy rate of 80 percent, with 
exceptions for rural hospitals. 
Although the average number of beds per 1,000 persons 
was 4.7 for the metropolitan counties combined, only 
Bexar and Nueces exceeded the 4 per l,000 ratio. The 
remaining metropolitan counties ranged from a low 2 per 
1,000 in Guadalupe to 3.9 per 1,000 in Cameron. 
County-wide occupancy rates in the metropolitan 
counties varied from 51.8 percent in Guadalupe to 77.4 
percent in Hidalgo. The average for all metro-counties 
was 62. 7. Only Bexar and Guadalupe had rates below the 
metropolitan average. Nueces County equalled the aver­
age, and the other five metro-counties exceeded it. 
Twenty-three nonmetropolitan counties had one or 
more short-term hospitals; eight had none. Five rural 
counties exceeded 4 beds per 1,000 residents and one­
Kerr-had the highest ratio in South Texas with 7.4 per 
1,000. The combined average number of beds per thou­
sand for rural counties was a reasonable 3.3 per 1,000. 
The average occupancy rate for all rural counties was a 
fairly low 50.4 percent. Occupancy rates are consistently 
low in counties close to metropolitan counties. Rates in 
these counties ranged from a low 20 percent in Medina 
County to 58 percent in Brooks County. Only eight rural 
counties exceeded the metropolitan county average rate 
I 

Table 98 
Ambulance Services in South Texas Metropolitan Counties 

2  2  
Vehicles  Calls  
!SMSA Counties (5 SMSAs)  Est. 1975 Pop.  Vehicles 1975  Calls 19 75  per 100,000 Pop.  Pop. per Unit  per 100,000 Pop.  Calls per Vehicle  

Bexar 862,900 40 43 ,250 4.6 21,573 50 1,081 
Nueces 256,100 11 6,343 4.3 23,282 25 577 
Hidalgo 175,600 9 6,650 5.1 19 ,511 38 739 
Cameron 135 ,800 8 1,645 5.9 16,975 12 206 
Webb 92,700 2 250 2.2 46,350 12 546 
San Patricio 47,500 5 450 10.5 9,500 9 90 
Guadalupe 33 ,800 7 1,300 20.7 4,829 38 186 
Comal 25,600 5 730 19.5 5,120 29 146 
SMSA 1,630,000 87 60,618 5.3 18,736 37 697 
Non-SMSA 415,100 76 8,497 18.3 5,462 20 112 
South Texas 2,045,100 163 69,115 8.0 12,547 34 424 
Sources: 	1975 Population Estimates, Texas Governor's Budget and Planning Office; Texas Department ofHealth, Emergency Medical Services Division. 
of 62.7 percent. (See Table 99 for South Texas hospital normally provided to county residents only. Though statistics for 1975.) other counties may contract for the provision of care to 
There is considerable migration between South Texas their indigent residents, at present the local public hospi­counties for hospitalization. Bexar and Nueces counties, tal cannot legally sue other counties for payment, and with the largest, most sophisticated hospitals in South therefore are not eager to serve indigent patients from Texas, had the greatest amount of in-migration for hospi­other counties. talization and the highest percentage of local residents In May 1975, five metropolitan and twelve rural coun­served in-county in 1975. • ties in South Texas had one or more publicly owned 
The plight of rural residents and hospitals is evident in hospitals. There were three city hospitals, seven county migration statistics. In thirteen of the rural counties with hospitals, two city-county hospitals, one hospital author­hospitals, less than half the resident patients were hospi­ity, and six active hospital districts. Guidelines and fee talized in their own counties. Combined with the nine schedules are locally determined. (See Table IO 1 for a list rural counties with no hospitals, this figure means that of public hospitals by type of county.) between 50 and 100 percent of all resident patients in twenty-two nonmetropolitan counties migrated to other 
State Hospitals 

counties for hospitalization. (See Table 100 for hospital­
ization migration statistics by county.) South Texas has three state mental hospitals, one each 

As with local public health clinics, locally owned public in Bexar, Cameron, and Kerr Counties. They operate hospitals may provide free services or may charge accor­outreach programs in twenty-two area counties to pro­ding to ability to pay. Free or reduced-cost services are vide early treatment and follow-up services to local resi­
dents. There are two state schools for the mentally retarded in

*Data on migration for hospitalization is based on the annual one­
day survey of hospitals of hospital patients conducted by the Texas South Texas, one each in Cameron and Nueces counties. 
Department of Health. They do not provide outreach services. 

Health Care Resources 139 

Table 99 
GSTCB Counties: General, Short-Term Stay Hospital Statistics: 197S 


Licensed  Patient  Occupancy  Beds per  
County  Beds  Days  Rate*  J,000 Populationf  
Aransas  0  0  0  0  
Atascosa  65  12,924  54.5§  3.5  
Bandera  0  0  0  0  
Bee  73  15,542  58.3  3.3  
Bexar:j:  4,389  955,027  57.7  5.1  
Brooks  31  6,569  58.1 §  3.4  
Cameron:j:  536  133,884  68.4  3.9  
Comal:j:  86  20,124  64.l  3.4  
Dimmitt  33  4,666  38.7§  3.7  
Duval  32  3,398  29.1 §  2.5  
Edwards  8  1,147  39.3§  3.5  
Frio  57  9,666  46.5  4.4  
Gillespie  50  13,054  71.5  4.9  
Guadalupe:j:  69  12,837  51.0  2.0  
Hidalgo:j:  482  136,145  77.4  2.7  
Jim Hogg  0  0  0  0  
Jim Wells  131  30,533  63.9  3.9  
Karnes  62  3,877  40.0  1.4  
Kendall  23  3,148  37.5§  3.3  
Kenedy  0  0  0  0  
Kerr  162  37,104  62.7  7.4  
Kinriey  0  0  0  0  
Kleberg  136  18,637  37.5§  3.9  
LaSalle  30  5,468  49.9  5.2  
Live Oak  0  0  0  0  
McMullen  0  0  0  0  
Maverick  77  15 ,695  55.8  3.8  
Medina  59  4,200  19.5 §  2.6  
Nueces:j:  1,62 1  370,925  62.7  6.3  
Real  0  0  0  0  
Refugio  60  6,544  33.8§  6.2  
San Patricio:j:  98  24,750  69.2  2.1  
Starr  44  7,446  46.4§  2.2  
Uvalde  62  12,775  56.5  3.1  
Val Verde  80  20,075  68.8  2.6  
Webb:j:  318  85,524  73 .7  3.4  
Willacy  24  4,015  45 .8  1. 7  
Wilson  44  8,349  52.0§  3.4  
Zapata  0  0  0  0  
Zavala  28  7,500  73.4  2.0  
SMSA Counties  7,599  1,739,2 16  62.7  4.7  
Non-SMSA Counties  1,3 71  252,3 52  50.4  3.3  
All Counties  8,970  1,991,568  60.8  4.4  

Source: Texas Hospitals and Related Medical Facilities: Inventory and Utilization, Calendar Year 197 5. Texas Department of Health Resources. 
*Occupancy rates calculated by dividing "patient days" by "beds." 
tExcludes military, state, V.A. hospitals, and beds available for less than the full calendar year. 
:j:SMSA counties 
§Non-SMSA counties adjacent to a SMSA county 

Table 100 

Greater South Texas Cultural Basin Counties: 
In-Migration and Out-Migration for Hospitalization 

Out-Migrant4  Total  
In-Migrantsf  from this County  County  
to this County  for Hospitalization  Residents  
County  for Hospitalization  Elsewhere  in Hospital  
Aransas  0  58  58  
Atascosa  8  40  85  
Bandera  0  18  18  
Bee  14  28  65  
Bexar  466  77  2,665  
Brooks  l  18  32  
Cameron  38  54  365  
Comal  4  27  64  
Dimmitt  6  27  35  
Duval  0  41  45  
Edwards  0  7  9  
Frio  3  14  40  
Gillespie  9  15  43  
Guadalupe  1  63  94  
Hidalgo  38  58  379  
Jim Hogg  0  8  8  
Jim Wells  14  52  114  
Karnes  1  24  42  
KendaJI  3  23  26  
Kenedy  0  l  l  
Kerr  53  26  72  
Kinney  0  5  5  
Kleberg  7  26  68  
LaSalle  l  9  19  
Live Oak  0  18  18  
McMullen  0  2  2  
Maverick  l  16  67  
i..tedina  2  35  38  
Nueces  322  39  935  
Real  0  7  7  
Refugio  2  19  36  
San Patricio  19  103  159  
Starr  2  15  26  
Uvalde  5  18  50  
Val Verde  14  27  68  
Webb  31  38  222  
Willacy  l  23  30  
Wilson  8  18  32  
Zapata  0  12  12  
Zavala  7  15  35  
SMSA Counties  919  459  4,883  
Non-SMSA Counties  163  665  1,207  
All Counties  1,081  1,124  6,090  

*One day survey conducted on November 13, 1974 
t Includes in-migrants from out of state 

tEighty-six residents from area migrated out of state for hospital services. 
Percent of 
County Patients 
Serviced in 
Home County 

0 52.s• 0 
56.9 
97. l 43.8• 
85.2 
57.8 
22.9• 8.9• 
22.2 
65.0 
65.I 
33.0 
84.7 0 
54.4 
42.9 
11.5• 0 
63.9 
0 61.8• 
52.6 0 0 
76.1 7.9• 
95.8 
0 47.2• 
35.2 42.3• 
64.0 
60.3 
82.9 
23.3 
43.8• 0 
57. l 
90.6 
55. l 
81.5 

Source: One day survey conducted on November 13, 1974, by the Texas Department of Health. 
Health Care Resources 141 

Table 101 Locally Owned Public Hospitals in South Texas: May ts, 1975 
City County City-County Hospital Hospital County Hospital Hospital Hospital District Authority 
Bee x Bexar x Brooks x Dimmitt x Edwards x Guadalupe x Hidalgo x Kleberg x Maverick x Medina x Nueces x Refugio x San Patricio x 
Starr x 
Uvalde x Val Verde x Willacy x 
Total " l 7 2 6 
Metropolitan 0 3 0 
Non-Metropolitan 0 7 3 
Source: Compiled from Government and Personal Health: Volume JI, Texas Advisory Commission on Intergovernmental 
Relations. 

Nursing Homes 
Nursing homes have become increasingly important providers of health care in recent years. The number of skilled nursing homes• in the United States increased 94 percent and the number of beds increased 268 percent between 1963 and 1973. Expenditures for skilled nursing home care grew from $178 million in 1950 to $9 billion in 
Reasons for this growth include the increasing number of older persons in the population, improvements in treatment patterns, and alterations in the family structure. A major influence for growth was the inclusion of nursing home care under both the Medicare and Medicaid pro­grams in the 1960s. 
Nationally, only 1.6 percent ofthe Medicaid and Medi­care patients in nursing homes were Spanish-American in 
*As used in this report. "skilled nursing homes" refer to those certified by Medicare and/ or Medicaid as skilled care nursing facilities or intermediate care facilities, as well as those providing some primary care even though not certified under either program. Custodial care homes are excluded. 
1975 and over 90 percent of all Medicaid and Medicare patients had incomes below $3,0oo.22 
In 1975 only thirteen of the one hundred twenty~ight nursing homes in South Texas were certified for reim­bursement under the Medicare program (see Table 102). Only one of the thirteen was located in a nonmetropolitan county. Surprisingly, the 2, 145 beds in these thirteen facilities constituted over two-thirds of the Medicare­approved skilled nursing facilities in Texas at that time.23 Table 103 lists nursing home facilities and related data for South Texas counties. Nursing home beds in South Texas were fairly well distributed between urban and rural counties in 1975. The metropolitan counties had 73 percent of the area nursing home beds and 74 percent of the area population age 65 and over. On the average, the metropolitan counties had more beds per facility, fewer beds per 1,000 persons age 65 and over, and lower occupancy rates than the nonmetropolitan counties. 
Nonmetropolitan counties had a fair share of area nursing home beds, but distribution was uneven. Eleven of the counties had no nursing homes while six had four or more. The greater utilization rate in rural counties may 
Table 102 

Medicare Certified Skilled Nursing 
Facilities in South Texas 


County Number of Facilities Number ofBeds 
Bexar 	7 1,229 
Cameron 2 	309 
Comal 	160 
Gillespie 	123 
Nueces 	2 324 
SMSA 	12 2,022 
Non-SMSA 	123 
Total 	13 2,145 

Source: 	Texas Hospitals and Related Facilities: Inventory and Utilization, 1975, Texas Department of Health , 1976. 
be due in part to a lack of programs that provide health care in the home or on an outpatient basis in these areas. 
Average county occupancy rates for nursing homes generally exceeded hospital occupancy rates. Only two counties had nursing home occupancy rates of less than 4C' percent, while seven had hospital rates below that level. Eleven counties had nursing home occupancy rates of 80 percent or more, while no county achieved a hospital rate above 78 percent. 
Summary 

This examination of health care resources has revealed two obvious barriers to adequate health care for Mexican­Americans in South Texas: the widespread poverty and the severe maldistribution of medical resources in the area. 
Poverty 

Almost half the Mexican-Americans in South Texas live at or below the poverty level. Because they are poor their health care needs are probably greater than the needs of the general population. The poor are more likely to have greater medical problems than higher income persons. They are also likely to have fewer physician contacts relative to the amount of disability experience, higher hospitalization rates, and longer hospital stays.24 
While poverty suggests a high level of need, it also effectively restricts access to adequate health care services. 
Given limited financial resources and high health care prices, direct personal payment for medical services is not possible for this group. Unfortunately, health insurance coverage-which increases access to services-is gener­ally inadequate or nonexistent among the Mexican­American population of South Texas. Lacking personal resources or health insurance, the poor and near-poor must rely to a great extent on a variety of public and private programs for necessary services and care. 


Available Resources 
Medical personnel, services, and facilities in South Texas are poorly distributed. Most of the rural counties have an absolute shortage of health care resources, while the problem in the SMSA counties is one of location and accessibility. 
Seven of the eight SMSA counties have census tracts designated as medically underserved areas (MUAs)• by the Department of Health, Education, and Welfare. The problem of resource distribution in these areas includes considerations such as the location of a hospital or clinic, the cost of services, days and hours of operation, eligi­bility requirements; and the availability of public trans­portation, all of which can reduce further the accessibility to medical care by low-income persons in urban counties. 
Rural Counties 
Access to adequate health care by Mexican-Americans is severely restricted in most rural counties by the sheer lack of adequate health care resources. Twenty-nine of the thirty-two rural counties in South Texas have been designated as medically underserved areas by DHEW, and ten have been designated as having critical medical manpower shortage areas. Ninety-four percent of the nonmetropolitan population lived in medically under­served counties. Together, the rural counties have 20 percent of the population, 21 percent of the Mexican­American population, and 26 percent ofthe poverty-level population in South Texas. To serve their residents, these counties had only: 
-4.6 percent of the practicing pediatricians, intern­
ists, and OB/ GYNs; 
-14.9 percent of the active dentists; 
-14.9 percent of the practicing pharmacists; 
-14. 9 percent of the full-time registered nurses; and 
-15.6 percent of the optometrists in South Texas. 
*Medically Underserved Area designation is based on an index of medical underservice which is calculated by applying weights to area data on I) the ratio of primary care physicians to populations; 2) the infant mortality rate; 3) the percentage of the population age 65 and over; and 4) the percentage of the population with family income below the poverty line. 
Health Care Resources 143 

Table 103 
Greater South Texas Cultural Basin Counties: Nuning Homes, 1975 

Beds per 

County  Number  Licensed Beds  Occupancy Rate"'  1,000 populationf  
Aransas  0  0  0  0  
Atascosa  5  267  93.0  14.4  
Bandera  1  62  95.0  13.8  
Bee  2  220  69.6  9.9  
Bexar  40  4,735  78.8  5.5  
Brooks  l  100  74.3  10.9  
Cameron  7  904  63.2  6.7  
Comal  3  463  76.8  18.1  
Dimmitt  l  62  100  6.9  
Duval  0  0  0  0  
Edwards  0  0  0  0  
Frio  2  156  40.0  11.9  
Gillespie  4  365  77.8  35.8  
Guadalupe  4  399  74.6  11.8  
Hidalgo  11  967  79.6  5.5  
Jim Hogg  0  0  0  0  
Jim Wells  4  373  86.8  11.1  
Karnes  4  243  94.l  17.4  
Kendall  2  165  71.4  29.0  
Kenedy  0  0  0  0  
Kerr  3  270  91.6  13.4  
Kinney  0  0  0  0  
Kleberg  2  198  60.7  5.7  
LaSalle  0  0  0  0  
Live Oak  I  51  100  8.0  
McMullen  0  0  0  0  
Maverick  I  120  31.1  5.9  
Medina  4  340  68.7  15.0  
Nueces  11  1,481  60.9  5.8  
Real  0  0  0  0  
Refugio  1  64  94.5  6.6  
San Patricio  3  332  76.0  7.0  
Starr  1  100  37.5  5.1  
Uvalde  2  119  99.2  6.0  
Val Verde  2  140  94.2  4.6  
Webb  3  428  84.2  4.6  
Willacy  1  48  94.9  3.3  
Wilson  2  152  62.8  11.8  
Zapata  0  0  0  0  
Zavala  0  0  0  0  
SMSA Counties  82  9,709  74.5  6.0  
Non-SMSA Counties  46  3,614  76.6  8.7  
All Counties  128  13,3 23  75. l  6.5  
Texas 1973  906  73,900  n/a  6.0  

Source: Texas Hospitals and Related Facilities: Inventory and Utilization, Calendar Year 1975. Texas Department of Health Resources. 
*·Based on licensed beds and patient days. 

t Based on Estimates of 197 5 county population by the Governor's Office of Budget and Planning. 
Four counties-Kinney, Kenedy, Mc Mullen, and Rea/­had no practicing physician, nurse, or dentist. 
The availability of medical facilities and services in the rural counties is similar to the availability of medical professionals-ranging from scarce at best to nonexis­tent: 
-twenty-three of the counties had no public health 
department; 
-twenty counties had no public hospitals; 
-twelve had no emergency rooms; 
-eleven had no nursing homes; 
-nine had no hospitals; and 
-four had no ambulances. 
Although it is probably not feasible or even desirable 
to provide all levels of health care within rural areas, 
basic primary care should be available. A rural health 
care delivery system could be developed for South Texas, 
utilizing satellite clinics staffed by physician-extenders 
with links to area medical centers and to more sophisti­
cated levels of care in major hospitals. Physicians could 
be recruited by the development of group physician 
practices, team approaches to health care, and improved 
professional support services designed to prevent the 
professional isolation and excessive workloads charac­
teristic of rural practice. 
Health care programs for Mexican-Americans in South 
Texas should be expanded, with consideration given to: 
( 1) the medical needs and inadequate financial re­
sources of much of the target population; 

i)) 	the need for additional medical personnel, facili­
ties, and services in most rural counties; 

(3) 
the 	need for remedying the maldistribution of 
resources within some counties; 


(4) 
the need to improve accessibility to health care by 
addressing factors other than simple nonavaila­
bility of resources; e.g., eligibility requirements, 
days and hours of operation, transportation, and 
language barriers. 





References 

1American Medical Association, Profile ofMedical Practice, 1974 (Chicago: Center for Health Services, 1974), pp. 103, 106. 
2Texas Medical Association, Distribution of Physicians in Texas, 1973, Austin, 1974, pp. 24, 65-168. 
lCongressional Research Service, Library of Congress, Na­tional Health Insurance, Issues in Public Policy Series(IPP-76-5), November 15, 1976, p. 11. 
'Marjorie Mueller and Robert Gibson, "National Health Expenditures, Fiscal Year 1975," Social Security Bulletin, U.S. Department of Health, Education, and Welfare, Social Security Administration, pub. no. (SSA) 76-11703, February 1976. 
su.S., Congress, House, Subcommittee on Health, Commit­tee on Ways and Means, National Health Insurance Resource Book, rev. ed. (Washington, D.C.: Government Printing Office, 1976). 
6Texas Medical Association, Distribution; p, 26, 
7lnterview with administrators of Coordinating Board, Texas College and University System, 1978. 
seased OD interviews with Adele Bromiley, M.D.; Antonio Diaz, M.D.; Margaret Diaz, M.D.; Fred Avila, M.D.; Gilbert Sanchez; and Richard Leopold; Brownsville, Texas, January and February 1977. 
9 Reuel H. Waldrop, "Meeting Health Manpower Needs of South Texas Planning Region ( 19)," Report of the South Texas Area Health Education Resources Program, June 1973, p. 4.6. 
10F1orence E. Lee and Jay H. Glasser, "Role of Lay Midwifery in Maternity Care in a Large Metropolitan Area," Public Health Reports 89 (November-December 1974), p. 542. 
11 Arthur J. Rubel, "Concepts of Disease in Mexican-American Culture," American Anthropologist 62, no. 9 (October 1970): 795-814. 
12Based on interviews with Margaret Diaz, M.D.; R. Tucker Grau, Brownsville Medical Center; and Emma Lopez, midwife; Brownsville, Texas, February 1977. 
DEstimate based on interviews with R. Tucker Grau (see note 12) and Sam Landau. Valley Medical Hospital, Brownsville, Texas, February 1977. 
1•Based on interviews with Ors. Antonio Diaz, Adele Bromiley, Margaret Diaz, and Fred Avila; and Richard Leopold and Gilbert Sanchez, Brownsville, Texas, January and February 1977. 
Health Care Resources 145 

Data exists on the infant mortality rate in the region, but it is unreliable. No reliable data exist on children born with birth defects in the South Texas region. 
158ased on an interview with RicbaRI Leopold, January 1977; and the .. Proposed Grant for the City-County Clinic in Browns­ville," City of Brownsville, 1976, p. 46. 
16U.S., Department of Health, Education, and Welfare, Papers on the National Health Guidelines: Baselines for Setting Health Goals and Standards, pub. no. (HRA) 76-640, 1976 
11American Medical Association, Profile. This is calculated on the basis of forty~ight hours per week for a year, with 162.5 average total patient visits per week. Authors of this portion were Jack Eheler, Kay Cavalier, Bob Hoyer, and Herm Schmidt of the Education and Public Welfare Division. 
"U.S.• Department of Health, &Jucation and Welfare, Na­tional Center for Health Statistics, Health Manpower: A County and Metropolitan Area Handbook, 1974-1975. pub. no. (HRA) 76-1234, 1976. 
19Texas Board of Dental Examiners, 1974. 
20u.s., House, Resource Book; p, 90, 
21/bid., pp. 19, 32, 37. 
22/bid., p. 286. 
23/bid., p. !05. 
2'Texas Medical Association, National Health Insurance, p. 
15. 

Chapter9 


Government Financing of Health Programs 
in South Texas 

Although personal expenditures and private insurance still account for the largest portion of health expenditures, federal, state, and local funding for health care have increased very rapidly. In 1965, when Medicaid and Medicare were first enacted, the total national expendi­ture for health services was $38.8 billion; governmental expenditures amounted to about $10 billion. In 1977 the comparable national figures were $160.6 billion in expen­diture, of which $67.45 billion was governmental.1 
In South Texas, because of higher unemployment rates and a larger percentage of agricultural and other marginal employment, private insurance does not cover the popu­lation as comprehensively as it does in other parts of the state and nation. As there are limited private funds available to attract adequate and appropriate health care facilities and personnel, the pattern and size of govern­ment health programs are quite important in filling the gaps in the delivery system. 
In this chapter of the report, the patterns of govern­mental expenditure for health care in South Texas are examined. Federal, state, and local programs are dis­cussed. with primary attention to those programs which provide services to the underserved Mexican-American population. 
Federal Expenditures for Direct Health Care Services in South Texas 
There are three relatively distinct types of federal health care expenditures that can be traced to the county level: Medicare, Medicaid, and funds for direct health care services. Medicare is a federally administered hospi­tal and medical insurance program targeted primarily to the nation's elderly population. Medicaid is a state­administered program, partially funded by the federal government, which in Texas provides medical services to persons receiving welfare assistance. Federal funds for direct health care services are available through direct grant programs from the Depanment of Health, Educa­tion, and Welfare (DHEW). 
Of the three funding programs, only the project grants can be targeted directly to particular medical needs of low-income areas, minority groups, or underserved pop­ulations. Expenditures under these grants are the lowest nf the three. As of September 1976 only sixteen South Texas counties had DHEW direct grant projects in opera­tion. DHEW accounted for 6.8 percent of all federal expenditures under the three programs, Medicare contri­buted 57.5 percent, and Medicaid supplied 35.8 percent. 
Medicare 
The largest single source of direct federal health care funding in Texas is provided by the Medicare program. Nationwide, Medicare provides hospital and medical insurance protection for approximately 26.6 million per­sons.2 Recipients include persons sixty-five years of age and· older who are covered· under· the:·Social Security· system; persons under age sixty-five who are disabled and have been receiving cash benefits under the Social Security or railroad retirement program for at least two years and most chronic kidney disease patients under age sixty-five. Medicare is managed by the Health Care Financing Agency of DHEW through contracts with 130 commer­cial insurance companies and Blue Cross-Blue Shield plans which review benefit claims and make payments. 
Medicare is financed and administered by the federal government through trust funds for hospital insurance (HI) and supplemental medical insurance (SMI). After a beneficiary pays a deductible equal to the average cost of a hospital day of care (approximately $169 for 1979), Medicare pays 100 percent of the reasonable costs of hospital care for the first sixty days of hospitalization. After the sixtieth day, copayment requirements are im­posed.3 
The SMI trust fund is financed by contributions from federal general revenue funds and by enrollee premiums. SMI, or "Part B" of Medicare, covers physician fees, some other health services not covered by hospital insur­ance, and a variety of other outpatient medical services and supplies,4 including selected chiropractic services, services provided by independent physical therapists. diagnostic services such as x-ray tests and therapy, labo­ratory tests, ambulance services, extra medical supplies, home health services when there is no prior hospitaliza­tion, and speech therapy services. Under this program, after the enrollee pays an annual deductible of $60, Medicare pays 80 percent of the "usual, customary, and reasonable" charges of a health care provider; the benefi­ciary is responsible for the other 20 percent. A reasonable 
148 Mexican-American Health Care m South Texas 
Table 104 Federal Obliptions and Expenditures for Direct Health Care Services in South Texas 
Total F•d•n1I  Pu Ccpita F•d•r•I  F«l.,./ Eipenditur•s/  
Jl•dicar•• 7-74/6-75  M•dicaidf  DHEl!t' Dinct t  Eipenditun1/  Eip.,.dituns and  OblW.tion1 Per  
CoW1ty  SlllB  Ho1pital bu.  9·74/8-75  Proj~cl Grants 9-76  Obli8atioru  Ob/ilatic>1ut  Powmy i ...i Ruid•nt§  
Aransas  s 201.469  466,279  116,549  784,297  s 67  s 318  
Atascosa  435,756  J,002,940  965,789  192,000  2,596,485  140  416  
BaDclen  148,440  360.706  146,997  656,143  146  708  
Bee  370,556  848.491  653,152  50,000..  1,922,199  86  310  
Bexar  12,079,690  28,341,849  26,917,170  3,815,653  71,154,362  82  429  
Brooks  J48,2n  338,712  372,456  859,390  93  209  
Cameron  2,246,808  5,237,575  4,171,096  1,483,179  13,138,658  97  212  
Comal  604,191  1,393,461  827,064  2,824,716  110  681  
Dimm.in  156.264  360,218  415,414  931 ,896  104  169  
DUYal  255,803  580,649  573,672  1,410,124  Ill  227  
Edwards  53,247  124,146  39,330  216,723  94  208  
Frio  224,507  510,268  520,430  48,133  1,303,338  99  230  
Gillespie  415,762  982,901  596,050  1,994,713  196  1,493  
Guadalupe  683,301  1,580,657  1,074,015  3,337,973  99  447  
Hidalgo  2,748,634  6,389,098  5,524,525  1,494,269  16,156,526  92  186  
Jim Hog  102,799  235,095  145,050  482,944  93  186  
Jim Wells  485,526  1,103,625  1,693,732  60,973  3,343,856  100  319  
ICames  392,289  891,013  772,776  50,000••  2,106,078  150  387  
l:eadall  252;326  591,891·  294-,063  1,138,280.  L6J  962  
l:enedy  12,388  27,859  4,091  44,338  63  130  
l:en  823,917  1,951,138  598,395  3,373,450  167  1,057  
It-,.  43,467  101,663  46,986  192,116  IOI  165  
Kleberg  372,947  853,379  585,346  1,811,672  52  194  
LaSalle  124,968  286.903  220,664  6,599  700,134  121  228  
LiYe Oak  159,958  371,459  190,305  721 ,722  113  348  
Mdlullea  25,211  57,674  7,762  3,307  93,954  104  349  
Mnerick  244,284  594,335  530,326  275,000  1,643,945  81  161  
Medina  458,794  1,065,013  637,680  2,161,487  95  312  
Nueces  2,996,613  6,890,080  8,801 ,593  2,336,236  21,024,522  82  387  
Real  58,680  136,853  32,336  227,869  114  315  
Refugio  190,820  434,510  257,238  882,568  91  360  
San Patricio  708,946  1,629,533  1,327,334  3,665,813  77  238  
Starr  289,490  667,160  558,058  601,997  2,116,705  108  197  
Uvalde  400,766  920,339  551,363  48,000  1,920,468  97  273  
Val Verde  339,260  790,328  672,660  58,364  1,860,612  61  209  
Webb  1,1 70,348  2,731 ,691  2,632,652  1,015,450  7,550,141  81  186  
Willacy  285,361  658,363  403,538  1,347,262  93  163  
Wilson  332,305  790,025  553,386  1,645,716  128  428  
ZapaU  113.231  262,954  130,182  506,367  96  165  
Zavala  181.040  418,869  3~5.094  709,535  1,634,538  118  243  
Total SMSA  $23,238,531  $54,193,944  $51 ,275,449  SI0,144,787  $138,85 2,711  s 85  s 288  
Total non-SMSA  8,099,853  18, 755, 758  13,61 0,870  2,164,908  42,631,389  J03  308  
40 County Total  Ul,338,384  $72,949,702  $64,886,319  s12,309,695  Sl8J ,484,IOO  s 89  s 293  
Soul'Cc?:S :  

Medicate data obtaillcd from Financial Assislancr by G<0paphic Arra: Fl' /975 R•cion VJ , DHEW Pub. No. (05)'76-12. 
Medicaid data obtained from Medical Assistance Program computer printouts by Texas Department of Human Resources. 
DHEW Project Grants data obtained by Herb Rubenstein from Region VJ DHEW Regional Office. 
Notes: 

*Medicue figures are for obliptednther than expended funds. Medicue funds .,., geognphically obligated by DHEW hued on the ntio of m:ipients 
as of January J974 in a county to lite total number of recipients in the state. 

tfederal Medicaid contributions equalled 63 percent of total Medicaid expenditures in Texas in FY 1975. figures denote actual expenditures. 
tl>ittct grants for Family Planning Se~Mental Health, Migrant Health, EMS, and genenl health programs are included. 
§Per capita expenditurcs/obl.iptiam are rounded to the nearest dollu. 

•*One half of a S l 00,000 grant project covering Bee and Karnes Counties.. 

charge is defined as a charge no greater than that levied in 75 percent of the bills for a particular service in the same area. Since JQ76, there has been a limit on the rate at which reasonable charges can rise.s 
Existing Medicare reimbursement rates tend to be higher in higher-income urbanareas with sizeable physi­cian populations. Reasonable charges allowed for sur­geons and certain other specialists have risen at a faster rate than those allowed for primary care physicians. These reimbursement policies provide financial disincen­tives for physicians to enter the primary care specialities or to locate in low-income areas with few physicians such as inner cities and rural areas. These policies may be having an effect on the supply and geographical distribu­tion of physicians in South Texas. Recent statistics indi­cate that almost 55 percent of the nation's physicians are now located in the most densely populated metropolitan areas and serve the needs of a little over 41 percent of the resident population. In contrast, 7.3 percent of physicians are located in rural areas and serve the needs of 17 percent of the population. 
In addition to deductible and coinsurance payments, Medicare beneficiaries may be billed by providers for services not-covered· by the"' program and for charges in excess of established Medicare reimbursement levels. Despite the broad coverage available under Medicare, the elderly made direct payment for almost 29 percent of their personal health costs for an average of approxi­mately $390 per person in FY 1975. 
Data on Medicare funding for South Texas in FY 1975 is provided in Table 104. This table shows that the funds were obligated by county on the basis of the ratio of resident recipients to total state recipients. Allocations per enrollee are approximately equal within the area and between South Texas and the state as a whole. 
Medicare obligations to South Texas for FY 1975 totaled $I 04,288,086, with 70 percent allocated to hospital insurance and 30 percent to medical insurance. Funds set aside for enrollees in SMSA counties equaled 74 percent of total area obligations. This reflects the lower concen­tration of elderly in these counties compared to the nonmetropolitan counties. Nonmetropolitan counties, with only 20 percent of the area's population, contained 26 percent of the South Texas residents aged sixty-five and over. 
Actual per capita reimbursements for services under the Medicare program in Texas for FY 1976 tended to be somewhat lower than the national average (see Table 105). Per capita reimbursements in Texas were consider­ably lower for hospital insurance and slightly higher for medical benefits, with a combined difference of$48 less in payments per recipient. . 
As noted earlier, Medicare funds are not targeted to low-income areas, minority groups, or underserved pop­ulations. However, they do have an effect on the avail­ahilitv of services through the reimbursement mechanism. 
Government Financing 149 

Table 105 
Per Capita Medicare Expenditure: FISC81 Year 1976 

Hospital  Combined  
Insurance  S,MIB  Total  
Texas  $377  $179  544  
U.S.  434  169  592  

Source: Calculated from Health Insurance for the Aged and Disabled: Amounts Reimbursed, by State and County, 1975, U.S. Department of Health, Educa­tion and Welfare, Table 1.1.1. 
Present reimbursement policies appear to have a depress­ing impact on the supply ofproviders in low-income rural and inner-city areas. A considerable proportion of the low-income Mexican-American population in South Texas is concentrated-in suclrareas: Itappears; then; that·­the maldistribution of health manpower indirectly en­couraged by differentiated reimbursement rates directly affects the availability of medical services for low-income Mexican-Americans in South Texas. 
Age is a major factor in eligibility for most Medicare 
benefits, and it is one that favors Anglos over Mexican­
Americans in South Texas. Table I 12 shows that only 5.5 
percent of the Mexican-American population is over 
sixty-five years of age while 11 .6 percent of the Anglo 
residents are sixty-five or older. Although Mexican­
Americans constituted 54 percent of the overall popula­
tion in the mid-1970s they made up only 37 percent ofthe 
over sixty-five population. And, since many Mexican­
Americans were farmworkers or engaged in other non­
covered employment, they and their spouses were less 
likely to be eligible for Medicare. Accordingly, the total 
federal expenditures per poverty-level resident computed 
in the tables within this chapter overstate the amount 
received by Mexican-Americans. Many Medicare recipi­
ents are not poor, and the group of Medicare recipients as 
a whole is disproportionately Anglo relative to the South 
Texas population as a whole. 
Medicaid 
The next greatest source of federal funds for direct health care services in South Texas is the Medicaid program. This program provides medical services for eligible low-income aged, blind, and disabled persons (those receiving supplemental security income) and for families receiving financial assistance under the Aid for Dependent Children (AFDC) program. It is funded 
150 Mexican-American Health Care in South Texas 
through federal and state expenditures and is adminis­tered by the State. Although minimum eligibility stan­dards and services are set by the federal government, state governments determine the scope and extent of the pro­gram through legislative mandate and state appropria­tions. 
Although participation in the Medicaid program is optional, forty-nine states do take part in the program. In order to be eligible for federal cost-sharing, states which choose to participate must provide, as a minimum, the following services: inpatient hospital care; outpatient hospital services; skilled nursing facility services and home health services for persons aged twenty-one and over; Early and Periodic Screening, Diagnosis, and Treat­ment (EPson for persons under twenty-one; family planning services; and physician services. These basic services must be made available to persons receiving federally supported financial assistance under the Supple­mental Security Income (SSI) program or the AFDC program. 
States may elect to expand their Medicaid programs by including additional services and/ or by extending cover­age to medically indigent persons whodo notqualify for federal financial assistance. In order to qualify for federal cost-sharing of an extended program, state Medicaid services for the medically eligible must include either the same package of services required for financial assistance participants or a combination of any seven of the basic services. 
The State of Texas has chosen to provide services beyond the required minimum for financial assistance recipients but has chosen not to extend coverage to other medically indigent eligible individuals. This choice effec­tively excludes poverty-level persons who are single, childless, or members of two-parent families since they are not eligible for federal financial assistance unless they are also aged, blind, or disabled. It also seriously limits the amount of federal funds available for services to the state's indigent population. (A more detailed discussion of the Texas Medicaid program is provided in the section on state expenditures.) 

The federal share of a state's Medicaid payment for services is determined by computing its per capita income for three prior years and comparing it with the national per capita income figure. The federal funding formula provides a higher percentage offederal matching funds to states with low per capita income relative to the national average and a lower percentage to states with high per capita income. The minimum federal contribution is set at 50 percent, the maximum at 83 percent. 
Unlike Medicare, Medicaid is not an insurance pro­gram. Payment for services is made directly to the health care provider rather than to the recipient. There are no coinsurance or deductible requirements and the provider may not bill the recipient for charges in excess of the amount reimbursed by the program for covered services. 
The federal share of Medicaid expenditures for medical services for Texas was slightly more than 60 percent in FY 1975. This percentage has declined to 60 percent for the-· 1977..79. biennium and probably will continue to·-· decline because Texas' per capita income is increasing relative to the nation as a whole. In 1975, federal funding totaled $317, 792, 127, and 20 percent ($64,886,319) of that amount was paid out in South Texas. The proportion of federal Medicaid funds spent in South Texas was 6 percent less than the percentage of the state poverty-level population located in the area (26 percent). As a result, average expenditures per poverty-level resident in Texas as a whole equaled $152, while per capita expenditures in South Texas amounted to only $112. 
The practice of reimbursing health care providers di­rectly makes it difficult to assess Medicaid expenditure patterns at the recipient level. Payment forcare is record­ed by the county where service is provided rather than by the recipient's county of residence. As a result, counties with heavy concentrations of health care providers may show high levels of Medicaid expenditures relative to the number of poverty-level residents and counties with few medical services may show excessively low levels of expenditures despite sizeable poverty-level populations. Thus a county with unusually high per capita expendi­tures may be providing services to sizeable numbers of out-of-county recipients, and counties with extremely low per capita expenditures may simply lack the health care resources necessary to provide services for their Medicaid populations. 
Table 106  
Distribution of Federal Medicaid Funds in South Texas: FY 1975  
Unit  Federal Medicaid Funds Expended  Percent of Federal Medicaid Funds  Percent of Poverty-Level Population  Federal Medicaid Expenditures per Poverty-Leve/ Individual  
SMSA counties  $51,275 ,449  79  74  $119  
Non-SMSA counties  13 ,610,870  21  26  92  
Total  $64 ,886 ,319  100  100  $112  
Source : Appendix I  

Given these caveats, data provided in Table 104 and summarized in Table 106 show metropolitan counties received slightly more federal Medicaid funds per poverty­level person than the rural counties. Per capita expendi­tures were 23 percent higher in metroplitan counties and exceeded the area average by $7 per person. Total ex­penditures were highest in Bexar County and lowest in Kenedy County. 
The state has the latitude to set Medicaid reimburse­ment levels to providers as long as these rates do not exceed Medicare rates. In Texas, reimbursement to prac­titioners for services provided is currently equal to reim­bursement levels set-for similar Medicare services·~ As a· result, the disincentives for rural and inner-city practice and primary care specialties noted in the Medicare pro­gram are built into the Medicaid arrangements as well. In fact, since providers may not bill Medicaid patients for charges in excess of the program's reimbursement level, these limitations serve to constrain the ability of poor areas to compete for physicians. The cap on reasonable charges has now been in effect for three years, and a preponderance of physicians now customarily charge more than the allowable Medicare and Medicaid rates. It is in former low-rate areas that this constraint is felt more severely. Tables 107 and 108 summarize data regarding the poverty population, eligible recipients, and Medicaid expenditures in South Texas in 1975. 
In sum, differential reimbursement schedules, maxi­mum charge limitations, and narrow eligibility require­ments limit the participation of both health care providers and the poor in the Texas Medicaid program. They also limit the flow of federal funds into Texas for what is undoubtedly the most comprehensive health care financ­ing program for the poor in the state. 
Direct Project Grants 
Direct grant funds are available for health care projects from the Department of Health, Education, and Welfare (DHEW). Of the three funding programs discussed, this is the only mechanism whereby federal funds are directly targeted to low-income areas, minority groups, or under­served populations. 
Projects eligible for direct grant funding by DHEW Government Financing l.S 1 
generally fall into one of five major categories. These categories are listed in Table 109 with the amount of funding granted in South Texas as of September 1976. A list of grant projects by county is provided in Table 110. 
Projects in the mental health area received the largest share of the funds. Project grants to five counties totaled more than $4.6 million-mostly for staffing in community mental health centers. Migrant health projects located in nine South Texas counties received over $2.8 million in DHEW grant funds. These counties contained 85 percent of the Mexican-American population and 76 percent of the poverty-level population in South Texas. This is not surprising considering the fact that most migrant workers in Texas are poorly paid Mexican-Americans. The con­centration of projects in these high-minority, low-income counties is an illustration of the flexibility and effective­ness of this funding mechanism in meeting the health care needs of a specific group. 
Grants for general health programs in South Texas totaled almost $2.4 million. Projects in this category included immunization maintenance, family health ser­vices, and rural health services. Two metropolitan coun­ties-Bexar and Cameron-received almost 60 percent of the funds in this category. The remaining 40 percent went to four· -nonmetropolitan· counties:·· Seven·· South · Texas counties received almost $2.0 million from DHEW for family planning programs. All seven had high percent­ages of Mexican-American residents. Funding was heav­ily concentrated in SMSA counties, with a miniscule 6 percent of the funds allocated to non-SMSA counties. 
There was only one active grant for emergency services in South Texas as of September 1976. The Bexar County EMS received $500,000 in DHEW funds for its system. 
The overall level of funding for DHEW grant projects was relatively minor compared to Medicare and Medicaid expenditures in the area. Project grants amounted to only 7 percent of federal expenditures for direct health services. Of the $12.3 million granted in the area, 82 percent went to metropolitan counties, 18 percent to rural counties. The poor showing made by nonmetropolitan counties in total funding and number of active programs may be due in part to a lack of community groups or agencies with the expertise and experience needed to develop and administer federal grant programs. 
Combined Federal Expenditures/Obligations 
Combined federal expenditures and obligations for direct health care services in South Texas totaled $181.5 million in 1976. Medicare accounted for 57 percent, Medicaid 36 percent, and DHEW grants 7 percent of the total. 
Expenditures per poverty-level person is one measure of the impact of the three federal programs on the area's low income population. Expenditures per poverty-level person provided in Table 104 may tend to overstate the 
152 Mexkan-Amcrican Health Care in South Texas 
Table 107  
lbe Poverty Population and Medicaid Recipients in South Tens  
MediaMI Aw~Monthly  
E/;zlble ltttcip~11U by C.t40'>'•  AH C.tqorie1  
SepklnlHr 1974-AOCUJt 1975  
A..,,..,, Monthly  Perc•nt ofPop1d11tion  hrcent ofPopulation  hrcttnt ofPo..ny- 
Cownry  OAA  AFDC  ATB  APTD  Elilibl•  Certified M•dimid  At or Below  kw/Popwlatlon  
Recipwnu  Eli6i/Jlef  PoHrty Lewri  Not Medimid~ll6ible  
Anonus  J03  310  3  60  476  4. 1%  21.1%  80.6%  
AIUCOSd  779  l,OJ4  12  154  l ,9S9  10.6  33.7  68.5  
Bandon  129  SI  2S  205  4.6  20.6  77.7  
Bee  633  933  10  121  1,697  7.6  27.8  72. 7  
Bexar  13,953  49,944  27J  4,307  68,47S  7.9  19.2  58.9  
Brooks  372  608  7  139  1,126  12.2  44.7  72.7  
Cameron  4,766  10,973  104  1,611  17,454  12.9  4S.6  71.7  
Comal  538  43J  3  100  J,072  4.2  16.2  74.1  
Dimmitt  424  81S  6  112  J,3S7  IS.I  61.1  75.3  
Dllftl  711  83J  9  222  1,773  14.0  49.0  71.4  
Edwards  S3  97  19  169  7.3  4S.3  83.9  
Frio  S24  947  7  99  l,S77  J2.0  43.3  72.3  
Gillespi<o  292  9J  2  42  427  4.2  J3.J  67.9  
Guadalupe  938  l,31S  J2  239  2,S04  7.4  
Hida!IO  6,SOO  J6,0J2  J42  1,855  24,509  14.0  49.5  71.7  
Jim Hog  310  271  3  SS  639  12.3  49.8  7S.3  
Jim Wells "ames JCeadall  J,173 685 169  2,237 713 95  J9 8  4J9 133 35  3,848 1,539 299  J J.S J 1.0 4.3  31.3 38.9 J6.9  63.3 71.7 25.4  
Kenedy  7  2  J  3  13  1.9  48.7  96.1  
JCerr  591  373.  3  92.  1,059 .  5.2  IS.8  67.J  
ICinDey  82  124  JS  221  11.6  61.3  8J.J  
JCleberg  546  J,323  7  JS2  2,028  S.8  26.8  78.4  
LaSalle  270  47J  9  86  836  J4.4  53.0  72.8  
LiYeOat  J72  J33  39  345  S.4  32.4  83.3  
McMullen  17  13  4  34  3.8  29.9  87.3  
Mnericlc  738  J,597  14  JS6  2,SOS  12.4  S0.7  75.S  
Medina  546  377  4  J08  1,035  4.6  30.S  84.9  
Nueces  4,349  11,295  8J  1,980  17,075  6.7  21.2  68.4  
llcal  77  68  JS  161  8. 1  36.2  77.6  
llefulio  227  365  s  52  649  6.7  2S.3  13.S  
San Patricio  1,214  2,4J2  27  354  4,007  8.4  32.4  74.1  
Starr  l ,08J  1,294  29  232  2,636  13.4  S4.9  75.6  
lhalde  575  908  II  134  J,628  8.2  3S.4  76.8  
Val Verde  687  1,227  5  158  2,077  6.8  29.2  76.7  
Webb  2,822  4,959  51  646  8,484  9.2  43.9  79.0  
Willacy  587  1,169  J3  162  1,931  13.3  56.9  76.6  
Wilson  492  563  8  117  1,780  13.8  29.8  53.7  
Zapata  254  237  3  64  558  10.5  57.8  81.8  
Znala  467  l, IJ8  10  124  1,719  12.4  48.3  74.3  
40 County A•cnae  48,8S3  117,716  907  14,440  J8J,916  8.9%  28.3%  68.6%  
Stale Annie  225,126  393,390  4,027  63,729  686,273  5.7%  18.8%  69.7%  
40 County AnnllC u  
% of Slate AftHCe  21.7%  29.9%  22.5%  22.7%  26.5%  

Government Financing 153 

Table 108 
Medicaid Expenditures by County, Fiscal Year 1975 


Per Capita  Per Capita  
Medicaid  Average Monthly  Expenditures  Medicaid  Average Monthly  Expenditures  
Total  Number of  Per Eligible  Total  Number of  Per Eligible  
County  Expenditures•  Eligible Recipients  Recipient  County  Expenditures•  Eligible Recipients  Recipient  
Aransas  $ 184,992  476  $ 389  All Texas  
Atascosa  1,532,998  1,959  783  Counties  
Bandera  233,328  205  1,138  (254)  492,240,706  686,273  $717  
Bee Bexar Brooks Cameron  1,036,749 42,725,668 591,200 6,620,787  1,697 68,475 1,126 17,454  611 624 525 379  State Total Less South Texas(214)  389,246,826  504,357  $772  
Comal  1,312,800  1,072  1,225  South Texas  
Dimmitt  659,387  1,357  486  as ~ercent of  
Duval  910,591  1,773  514  State Total  20.9%  26.5%  78.9%  
Edwards  62,429  169  369  
Frio  826,080  1,577  524  
Gillespie  946,111  427  2,216  
Guadalupe Hidalgo Jim Hogg Jim Wells Karnes Kendall  1,704,786 8,769,087 230,238 2,688,464 1,226,629 466,766  2,504 24,509 639 3,848 1,539 299  681 358 360 699 797 1,561  Sources: Expenditures-Texas Department of Public Welfare Com­puter printouts entitled "Total Medicaid Expenditures by County," September .19.74.-August 1975, and "Total State. Medical Expenditures" September 1974-August 1975. Eligible Recipients-Texas Department of Public Welfare computer printout "PD-102 County Ledger."  
Kenedy  6,494  13  500  *Includes  actual  expenditures  for  prescribed drugs, physicians'  
Kerr  949,834  1,059  897  services, nursing homes, x-ray and lab, institutions, other medical  
Kinney  74,581  221  337  expenditures, inpatient hospital, supplementary medical insurance  
Kleberg  929,120  2,028  458  benefits and outpatient hospital. Excludes expenditures for hearing  
LaSalle  350,260  836  419  aids, dentures, and home health aids as they were not available by  
Live Oak  302 ,071  345  876  county.  
McMullen  12,320  34  362  
Maverick  841,787  2,505  336  
Medina  1,012,190  l,o35  978  
Nueces  13,970,782  17,075  818  
Real Refugio  51 ,327 408,315  161 649  319 629  Table 109  
San Patricio Starr  2,106,879 885,806  4,007 2,636  526 336  DHEW Grants in South Texas as of September 1976  
Uvalde  87S,179  1,628  538  
Val Verde Webb  1,067,715 4,178,812  2,077 8,484  514 493  Category  Total Granted  
Willacy Wilson  640,537 878,390  1,931 1,780  332 493  Mental Health Services  $ 4,605,260  
Zapata Zavala  206,368 516,023  558 1,719  370 300  Migrant Health Services  2,808,670  
South Texas  General Health Services  2,399,676  
Counties (40)  $102,993,880  181,916  $566  Family Planning Services  1,996,089  
Emergency Medical Services  500,000  
Total  $12,309,695  
Source: Derived from data in Table 110.  

Table 110 Direct DHEW Project Grants to South Texas as of September 1976 
County 
Atascosa Bexar 
Cameron 
Karnes and Bee 
LaSalle, McMullen, Frio 
Hidalgo 
Jim Wells La Salle 
Program 

Health Area Underserved Project 
l. Community Mental Health 
Centers-Staffing 

2. 
Immunization Maintenance Project 

3. 
Family Planning Services 

4. 
Migrant Health Project 

5. 
N.W. San Antonio Mental 
Health Center-Staffing 


6. 
S.W. San Antonio Mental 
Health Center 



7. 
Children's Mental Services-Staffing 

8. 
Comprehensive Family Planning 

9. 
AACOG Emergency Medical 
Services System 


10. 
Family Planning Services 


11. 
Psychiatric Treatment of Chicanos 


Bexar County Total 
l . Cameron County 
Migrant Health Project 

2. Family Health Services­
Rural Health Initiative 

Cameron County Total 
South Texas Rural Health 
Initiatives Project 
Family Planning Services 

1. 
Migrant Health­
Rural Health Initiative 


2. 
Community Mental 
Health Center-Staffing 



3. 
Mental Health of Children­
Staffing 



Hidalgo County Total 

Jim Wells Migrant Health Project 
Migrant Health Services Project 
Cost 
$ 192,000 
723,503 
35,632 344,338 275,000 
134,994 
506,960 156,420 191,000 
500,000 115,000 98,938 
$3,815,653 
120,670 
1,362,509 $1,483,179 
$100,000 
$72,751 
888,268 502,431 103,570 $1,494,269 
$60,973 
$46,268 
Grantee 
Southwest Migrant Association 
Bexar County Hospital District 
Bexar County Hospital District Bexar County Hospital District Southwest Migrant Association 
Bexar County Hospital District 
Bexar County MHMR Board Mexican-American Unity Council Economic Opportunities Development Council 
Alamo Area COG ELLa Austin Comm. Center San Antonio State Hospital 
Cameron County Health Department 
Catholic Charities, Inc. 
South Texas Family Planning and Health 
Frio, LaSalle and McMullen Counties 
Hidalgo County Health Care Corporation 
Hidalgo County MHMR Center 
Hidalgo County MHMR Center 
Jim Wells County Commissioners Court 
La Salle County Commissioners 
Court 
Government Financing 155 

Table 110 conliml«I 
County 
Maverick 
Nueces 
Starr 
Uvalde 
Val Verde 
Webb 
Zavala 
Total DHEW Project Grants 
Program 
Family Planning Services­Rural Health Initiatives 
1. 
Family Planning Services 

2. 
Migrant Health Services 

3. 
Mental Health of Children-Staffing 

4. 
Mental Health of Children-Staffing 


Nueces County Total 
l. Rio Grande/Kingsville MHMR-
Staffing 


2. 
Migrant Health Services Project 


3. 
Starr County Migrant Health Project 


Starr County Total 
Family Planning Services 
Migrant Health Project 
1. 
Laredo Commission Mental Health Center 

2. 
Child Mental Health Program-Staffing 

3. 
Migrant Health Services 


Webb County Total 
Zavala City Family Health Corporation 
DHEW Grants by Functional Category 

Family Planning Services Grants Mental Health Services Grants Migrant Health Project Grants Emergency Medical Services Grants General Health Programs Grants 
Total 
$ 1,996,089 4,605,260 2,808,670 500,000 2,399,676 
$12,309,695 
Cost 
$275,000 
$950,000 299,619 535,131 551,486 
$2,336,236 
$224,557 356,440 21,000 $601,99.7 
$48,000 
$58,364 
$220,688 
112,714 682,048 
$1,015,450 
$709,535 
$12,309,695 
Grantee 
Maverick County Hospital District 
South Texas Family Corp. Coastal Bend Migrant Council 
Nueces County MHMR Center 
Nueces County MHMR Center 
Rio Grande Center for MHMR Community Action Council of Starr County Community Action Council of South Texas 
Community Council of Southwest Texas 
Del Rio-Val Verde County Health Department 
Rio Grande State Center for MHMR Rio Grande State Center for MHMR Laredo-Webb County Health Department 
Zavala City Health Association 
South Texas Counties With No DHEW Grant Project 

Aransas  Edwards  Kerr  Refugio  
Bandera  Gillespie  Kinney  San Patricio  
Brooks  Guadalupe  Kleberg  Willacy  
Comal  Jim Hogg  Live Oak  Wilson  
Dimmitt  Kendall  Medina  Zapata  
Duval  Kenedy  Real  

.... 
n-~~ri......nt nf He~lth, Education and Welfare, Dallas Regional Office . 
actual level due to the inclusion of Medicare program Table 112 funding. Although Medicare is directly primarily to the elderly, a large number, though far from all, of the Percentage of Persons 65 Years or Older by ColDlty 
eligible persons live at or below the poverty level. Since no data were available on the division of the funds by recipients' income level, all funds obligated by the pro­gram in South Texas were included in the per capita calculations. 
Analysis of expenditures and obligations by poverty­level person reveals a much wider variation of expendi­tures between counties than the straight per capita figure. They ranged from a low of $130 in Kenedy County to $1,493 in Gillespie County. Average expenditures per poverty-level person were lower in SMSA counties and higher in nonmetropolitan counties. 
There was a strong negative correlation between the level of average expenditure per poverty-level person and the percent of the population below poverty level in the metropolitan counties, as is indicated in Table 111 . 
Factors influencing this pattern could be the method of recording Medicaid reimbursements, concentration of medical facilities (especially nursing homes), and/ or a large percentage of persons.uv.er age .sixty"."five in the high expenditure counties. (Table 112 presents the percentage of persons aged sixty-five and over by county.) Whatever the causes, data show that the two SMSA counties with the lowest percentage of persons at or below poverty level, lowest proportion of Mexican-Americans, and 
Table 111 

Federal Health Care Expenditures Per Poverty-Level Person, South Texas Metropolitan Counties 
Per Capita  
Expenditures/  
Percent ofPersons  Obligations  
Below Poverty  per Poverty-Level  
SMSA County  Level  Person  

Bexar 19.2 $429 Cameron 45.6 212 Comal 16.2 681 Guadalupe 22.l 447 Hidalgo 49.5 186 
County 

Aransas Atascosa Bandera Bee Bexar Brooks Cameron Comal Dimmitt Duval Edwards Frio Gillespie Guadalupe Hidalgo Jim Hogg iim Wells Karnes Kendall Kenedy Kerr Kinney Kleberg LaSalle Live Oak McMullen Maverick Medina Nueces Real Refugio San Patricio Starr Uvalde Val Verde Webb Willacy Wilson Zapata Zavala 
Total 
Median Age 
%65 or Older Total 
13.6 
11.7 
18. l 
8.0 
7.5 
7.8 
8.5 
12.5 
9.0 
10.0 
11.9 
10.4 
19.9 
12.0 
7.8 
10.2 
7.6 
12.9 
16.5 
7.8 
23.8 
11.6 
5.8 
10.5 
12.8 
11.5 
6.6 
11.3 
6.3 
14.7 
9.4 
7.1 
8.0 
11.6 
6.3 
8.0 
8.5 
12.6 
13.1 
7.4 8.2% 
23.4 years 
% Mexican­%Anglos Americans 65 or Older 65 or Older 
18.0 3.6 
18.4 5.3 
18.2 17.8 
9.8 6.1 
9.8 6.1 
12.9 6.5 
18.6 5.5 
15.1 6.3 
19.2 6.9 
14.5 9.2 
16.7 5.6 
19.7 6.3 
21.1 8.7 
13.2 5.8 
18.5 
5.0 

19.8 
9.4 


10.5 5.9 
15.9 8.6 
18.2 9.6 
8.2 7.7 
27.4 4.4 
25.7 7.3 
6.0 5.2 
15.5 
9.2 

16.8 
7.3 


21.0 4.8 
10:0 6.3 
15.7 6.7 
8.2 3.9 
16.3 9.7 
11.3 6.1 
9.7 4.5 
18. l 7.8 
17.6 5.8 
7.1 5.9 
7.6 8.1 
17.7 5.5 
16.3 7.4 
18.2 12.6 
13.3 6.1 11.6% 5.5% 
30.2 19.0 years years 

Nueces San Patricio Webb  21.2 32.4 43.9  387 238 186  Source: U.S. Census, 1970.  
Source : Derived from data in Table 104.  

highest percentage of persons sixty-five and over had by far the highest per capita federal expenditures and obliga­tions. The three counties with the highest percentage of Mexican-Americans and the highest percentage of per­sons below poverty level had the lowest. 
State EJpenditures for Per10nal Health Services in South Texas 
State funds are spent for a number of personal health services in South Texas, usually as a match or a require­ment of a federal program. In most cases the state agency funds the provider or institution or local entity such as a county health department, county mental health / mental retardation unit, or local hospital unit. Three state agen­cies have the principal responsibility for funding personal health services. The Texas Department of Human Re­sources (TDHR) administers the Title XIX, Medicaid, and Title XX programs of the Social Security Act. The Texas Department of Health (TOH) administers the Title V program of the Social Security Act, which in­cludes maternal and child health demonstration projects and the crippled children's program; screening under the Title XIX mandated Early and Periodic Screening, Diag­nosis;-and Treatment (EPSDT)-program; and· chronic·· disease screening. In some cases TOH funds home health services and a variety of other programs through its regional offices. The third agency is the Texas Depart­ment of Mental Health and Mental Retardation (TDMHMR), many of whose programs are described in detail in Chapter 6. 
Other health related agencies that serve Mexican­Americans in South Texas include the Texas Commis­sion on Alcoholism, Texas Commission on the Deaf, Texas Department of Community Affairs, Texas Educa­tion Agency, and the State Commission for the Blind.• 
In the following section we will focus primarily on the state Medicaid and related EPSDT programs financed and administered by the Texas Department of Human Resources. In addition we will briefly discuss some of the programs administered by the Texas Department of Health. 
Texas Medicaid Program and 
Health Care in South Texas 
In assessing the impact of the Texas Medicaid program on South Texas we will first examine the way in which the site program is organized, and look into some specific changes regarding physician reimbursement and eligibil­
•This list is not exhaustive. For an excellent description of the organization of Texas state government with regard to health. see: Texas Advisory Commission on Intergovernmental Relations. Gov­ernment and Personal Health, Vol. l, Responsibilities of Texas Stare Government, Austin, 1974. 
Government Financing 157 

ity criteria. Then we will discuss the impact of the new rural health clinic amendments. Finally the operation of the EPSDT program in South Texas will be examined in light of the new Child Health Assurance Program (CHAP) currently pending in Congress. 
After passage of Medicaid, the Texas Medical Assis­tance Act of 1967 was passed. This act permitted the establishment of the Medical Assistance Program to provide medical assistance to persons receiving public assistance. This was to include "all of the health care, services, assistance, and benefits authorized or provided for in such federal legislation.6 
As required by federal law, all recipients of mandated public assistance (SSI and AFDC enrollees) are eligible under this act. In addition, the Texas Department of Human Resources is given authority to extend medical assistance to "such other needy individuals as the State Department may determine in compliance with agree­ments with Federal Government and within the limits of appropriated funds available.7 Thus, TDHR may only extend coverage to those categories of individuals who are financially unable to meet the cost of medical services, for whom state funds are available after the categorical groups have been covered, and for whom matching federal funds are available:S· The groups who-could· po-· 
Table 113 

Relationship Between AFDC, Medically Needy, and Federal Poverty Criteria 
Maximum  
Maximum  Medically  Poi-erty  
Family  AFDC  Needy  Level  
Size  Grant  Income  (Non-Farm)  

I 62.00 83.33 247.50 (I adult)
2 86.00 116.66 327.50
(I child) 2 (adults) N.A. 150.00 327.50 3 116.00 158.33 407.50 4 140.00 191.66 487.50 5 164.00 225 .00 567.50 6* 185.00 250.00 647.50 
*Medically needy ceilings must vary according to family size , regardless of AFDC maximum grant amounts ($300 in Texas. 
Source: Texas Department of Human Resources, Medical Studies Task Force , The Medically Needy in Texas, December 1978, Figure 6. 
tentially be covered include AFDC families with unem­ployed fathers, the medically needy, and persons eligible for but not receiving public usistance. Even though TDHR is authorized to extend coverage to these optional groups, it has chosen not to do so. primarily because of funding limitations.9 According to a recent estimate by TDHR, because of the low level of current welfare payments, and because the maximum eligible "medically indigent" income is 133 percent of welfare payments, only an additional 53,340 individuals in the state of Texas as a whole would be eligible by income. 
Table 113 shows the extent to which AFDC support levels fall below the federal poverty level. Table 114 shows for each option the number of estimated additional enrollees. Finally, Table 115 shows that if the financial eligibility were lifted to two thirds of the federal poverty 
Table 114 
Cost Estimates for Optional Program Expansioos 
Possible Possible 
Number Cost of 
Program Options of Utilizers Expansions 

Under 21 (Categorical 
& Medically Needy) 22,650 $70,668,000 

UF Adults (Categorical 
& Medically Needy 4,125 11,880,000 

AFDC-Adults 
(Medically Needy Only) 8,400 24,192,000 

AFDC Children 
(Medically Needy Only) 12,165 23,356,800 

SSI-Disabled 
(Medically Needy Only) 4,000 31,200,000 

SSl-Aged 
(Medically Needy Only) 2,000 1,920,000 

53,340 $ J65,216,800t 
*At current ~FDC Payment Level (75% of 1969 needs) 
tOf this additional money the federal share (58.35%) would 
be $95,237,003 and the state share (41.65%) would be 
$67,979 ,797. 

Source: Texas Department of Human Resources, Medical 
Studies Task Force, The Medically Needy in Texas, 
December 1978. 

level that the total number of eligibles would increase by 780,570 statewide and the total cost would increase by $550,733,040. About 40 percent of this increased cost would have to be borne by Texas state government. 
Counterbalancing this increase in state expenditures is not only the improved health care which would be re-· ceived by a substantial portion ofthe indigent population, but also the potential reduction in cost to local govern­ments, hospitals, physicians, and health departments currently providing these services free or at a reduced rate. Also, some benefits might accrue from the increased amounts of federal funds which would come into the state. 
In Texas, Medicaid is primarily a program for the aged poor. Table 116 shows that only 20 percent of total expenditures in 1976 went to children and mothers who were eligible under the AFDC program. 
These figures are not unreasonable, as the aged and disabled clearly are the most significant consumers of medical care. Also, many elderly persons who are not initially indigent become eligible after extended stays in nursing homes after their Medicare coverge runs out. In reference to our study population, however, it means that the resources which are spent on Mexican-Americans remain quite limited. As under the Medicare program, the Anglo population in South Texas is skewed toward an older population distribution while the Mexican­American population is on the whole quite young. Table 117 shows state Medicaid expenditures in South Texas in FY 1975. 
Compared with programs in the other nine largest state programs, the Texas program offers the smallest range of services to one of the most restricted populations (see 
Table 115 
Cost of Using Financial Poverty Standards 
Total Number ofEligibles  780,570  
Number of Eligibles Under Age 21  373,790  
Number of Eligibles Age 21 and Over  406,780  

Total Cost $550,733,040 Cost for Eligibles Under Age 21 $148,020,840 Cost for Eligibles Age 21 and Over $402,712,200 
*Computations were based on two-thirds of poverty level. 
Source: Department of Human Resources, Medical Studies Task Force, The Medically Needy in Texas, Decem­ber 1978. 
Government Financing 159 

Table 118). New Jersey and Ohio are the only other states that limit Medicaid to the categorically eligible. The Texas program. however, is quite similar to those of neighboring states. In terms of accessibility of health services, Whitfill suggests that 
...the most significant omission from the Texas Medi­caid program is its failure to cover clinic services or physicians' assistants and nurse practitioners services, although these services may often provide the only health care available in rural areas.10 
The Rural Health Clinic Services Act 
One initiative at the federal level which has been designed to improve access to medical care in rural areas is the Rural Health Clinic Services Act (P.L. 95-210). This act requires that Medicare and Medicaid provide reimbursement for rural health clinic services delivered by physicians, nurse practitioners, or physician assistants (PAs) (if not proscribed by state law), and for many services ordered for patients by these practitioners. In Texas, although this provision will mean that some rural clinics will be more adequately reimbursed, the overall impact of the law is likely to be fairly minimal. This is because· of the limited functions of PAs and nurse· practi-· tioners in Texas. 
Although there is no state law governing certification or use of PAs, the Texas State Board of Medical Examiners officially adopted regulations governing PAs on Novem­ber 2, 1975. These regulations state that both the indivi­dual PA and the supervising physician must apply to the Board for approval; that there shall be only one PA per supervising physician; and that PAs may not have an office separate from the physician. In addition the PA may not prescribe, order, or dispense medication, nor perform any service "without the supervising physician being either physically present or immediately available, except in life threatening emergencies. "11 Nurse practi­tioners in Texas are governed by the Nurse Practice Act, which includes the phrase, "nothing in this chapter per­mits the practice of medicine."12 
EPSDT and Some Proposed Changes 
EPSDT, like Medicaid. is essentially a federal program administered by the states. Each state, after meeting certain federal guidelines, is responsible for determining the eligible population and the services offered by the state's program. The funding mechanism for the program is based on a 75-25 federal state match for administrative expenses. The screening and treatment costs are based on the states' existing Medicaid match, which in Texas is roughly a 60-40 federal / state split. 
States have to meet three federal program require­ments under EPSDT. First, they must inform all families eligible for Aid to Families with Dependent Children (AFDC) of the availability of the EPSDTservices. This is usually.accomplished by posta~ notification or telephone. contact. In some cases families are notified through a system of personal outreach programs. Second, the states must provide or arrange for the provision of the screening services within sixty days for all participants requesting services and provide transportation services if necessary. Third, states must arrange diagnostic and treatment services for all recipients referred for such services during the screening procedure. 
Table 116 
State Medicaid Recipients and Expenditures by Eligibility Category: Fiscal Year 1976 

Total  Percent  
Total  Percent  Federal-State  of  
Eligibility  Recipients  of  Expenditures  Total  
Category  (thousands)  Total  (millions)  Expenditures  
AFDC  350,000  51.0  135,417,260  20.8  
Aged  235 ,000  35.0  349 ,84 7 ,697  54.9  
Disabled  86,000  13 .0  160,675 ,227  24.7  
Blind  4,000  1.0  3,949,350  .6  
Total  675,000  100.0  649 ,889 ,534  100.0  

*Does not reflect all refunds, cancellations, or adjustments. Source: TDHR. Texas Medicaid Reports, 1976. 
Table 117 
State Medicaid Expenditures in South Texas 

State Medicaid Expenditures* 
County 
Aransas $ 68,447 Atascosa 567,209 Bandera 86,331 Bee 383,597 Bexar l 5,808,497 Brooks 218,744 Cameron 2,449,691 Comal 485,736 Dimmitt 243,973 Duval 336,919 Edwards 23,099 Frio 305,650 Gillespie 350,061 Guadalupe 630,771 Hidalgo.. 3,244,562. Jim Hogg 85,188 Jim Wells 994,732 Karnes 453,853 Kendall 172,703 Kened-y 2,403 Kerr 351,439 Kinney 27 ,595 Kleberg 343,774 LaSalle 129,596 Live Oak 111,766 McMullen 4,558 ~1averick 311,461 Medina 374,510 Nueces 5,169,189 Real 18,991 Refugio 151 ,077 San Patricio 779 ,545 Starr 327 ,748 lJvalde 323,816 Val Verde 395,055 Webb 1,546 ,160 Willacy 236,999 Wilson 325 ,004 Zapata 76,356 Zavala 190,929 
South Texas ( 40 counties) $ 38,107,736 
Texas (254 counties) $182,129,061 
Texas less South 
Texas (214 
counties) $144,021,3 26 
Per Capita State 
Medicaid Expenditures 

Per 
Medicaid 
Eligible 

$144 290 421 266 231 194 140 453 180 190 137 194 820 252 132 133 259 295 578 185 332 125 170 155 324 134 124 362 303 118 233 195 124 199 190 182 123 183 137 111 
$209 
$269 
$286 
Per 
Poverty-level 
Person 

$ 	28 91 93 62 95 53 40 
117 44 54 22 54 
262 84 
3.7 
33 95 83 
146 7 
110 24 37 42 54 17 30 54 95 26 62 51 30 46 44 38 29 85 25 28 
$ 66 
Responsibility for the administration of the EPSDT program in Texas rests with the Texas Department of Human Resources (TDHR). Field program management is divided through contractual agreements with the Texas Department of Health (TOH) to provide the actual medical screening services; through individual agreements with private practitioners to provide diagnosis and treat­ment; and through assignment of responsibility to re­gional TDHR offices to provide outreach and case man­agement functions. The EPSDT organization structure is presented in Figure 5. 
Eligibility for EPSDT services in Texas is contingent upon eligibility for Medicaid. Texas limits Medicaid eligibility to those eligible for the AFDC program and to Supplemental Security Income (SSI) recipients (aged, blind, and disabled). In order to be eligible under these categories, a family must also meet income guidelines far below the Office of Economic Opportunity (OEO) poverty guidelines. EPSDT services are offered to the dependent children under the age of twenty-one from families who meet all the eligibility requirements.13 Children eligible under the AFDC program account for more than 95 percent of the 371,604 Texas children eligible for EPSDT in FY 1976. Although annual medical screening is avail­able upon request for any recipient, state program guide­lines encourage annual screening only for children under the age of six and encourage all other recipients to have a medical screening every three years. 
For statistical reporting purposes, TDHR defines the annual eligible population as an average of the separate monthly total population. From this "point in time" rate is derived the "penetration rate," or the percentage of population being screened relative to the total population eligible. For FY 1976, TDHR reported the average num­ber of eligibles statewide to be 262,495, of which 120,6 I 5 were screened . The ratio of these two figures yields an overall penetration rate of 46 percent.14 
The cumulative total of the eligible population for the state of Texas in FY 1976 was actually 371,604.15 This estimate includes all children who entered and left the system in that one year and not simply the average 
Notes tu TahlP 117. 
*In FY 197 5 the State paid 3 7 percent of Medicaid costs. This included expenditures for inpatient, outpatient, and physicians' fees; x-ray, laboratory , and other medical services; prescribed drugs; nursing homes, and other insti­tutions; and SMIB. 
Figures may not add to totals due to rounding. 
Per capita figures were computed by dividing expenditures by population and poverty population. I97 5 population is from Population Projections for Texas Counties 19 75­1990. Poverty population was computed by multiplying 1975 population estimates by 1970 poverty population estimates in the 1970 Census. 
Source: See Table l 08 . 
Government Financing 161 

Table 118 
Medicaid Services Covered by Ten Largest States, June 1976 

so + California + + + + + + + + + + + + + + + + 
so + Illinois + + + + + + + + + + + + + + + + 
so. + Massachusetts.. + + + + + + + + + + + + + + 
so + Michigan + + + + + + + + + + + + 
so 0 New Jersey 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 
so + New York + + + + + + + + + + + + + + + + + 
S4 0 Ohio 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 
SS + Pennsylvania + 0 0 0 + + + + 0 + + + + 
64 0 Texas 0 0 0 0 0 0 0 0 0 
60 + · Wisconsin + + + + + + + + + + + + + + + + + 

3 Number of O's 2 4 4 3 3 2 2 3 2 3 4 2 3 2 2 3 7 Number of +'s 7 6 4 6 6 4 s 6 7 7 6 6 6 7 6 6 7 10 TOTAL 9 10 8 9 9 s 7 8 10 9 9 10 8 10 8 8 10 
For all States: 

21 State Programs (0) 13 21 12 14 12 s 10 s 18 18 lS 14 10 14 11 8 2S 32 State Programs(+) 29 30 22 27 24 14 22 17 2S 2S 23 23 18 27 19 21 2S S3 TOTAL (2) 42 Sl 34 41 36 19 32 22 43 43 38 37 28 41 30 29 so 
Notes: 
0 Offered for people receiving federally supported financial assistance. 

+ Offered also for people in public assistance categories who are financially eligible for medical but not financial assistance. 
(I) 
FMAP-Federal Medical Assistance Program. 

(2) 
Total State Program-forty-nine states (except Arizona), and Guam, Virgin Islands, District ofColumbia and Puerto Rico. 


Source: Data on Medicaid Program: Eligibility, Services, Expenditures 1966-1977, p. 6. 
Figure 5 EPSDT Program Flow Ow1 
HEW 
Social and Rehabilitation Services ,_____ Issues Program Regulations Medical Services Adm. 
Regional Office 
HewfMSA (Dallas) 

Administers Program Regulations and Reviews for Compliance 


Outreach 
!--­

Monitoring Title JffX' M.edical-1--------ContractS' with DPW''· Services 
to Provide Screening 
I 

.. City-County Health Departments --------Provide Screening Regional Mobile Vans 
I 
MEDICAL PROVIDERS Diagnosis and Treatment 
monthly total. The penetration rate calculated using the cumulative total rather than a "point in time" estimate is only 30 percent compared to the 46 percent penetration rate cited above. There are a number of problems in using this cumulative total, however. Some children are in the system for such a short time period that effective outreach is nearly impossible. The law provides for extension of the Medicaid services for a period of three months after a client leaves the AFDC program because ofemployment. Since cumulative totals for the South Texas area could not be obtained, calculations discussed below must be based on the "point in time" total reported. It must be kept in mind that the actual eligible population is sub­stantially larger in both the state and the project area. 
Research has shown that nationally, substantial num­bers of children in EPSDT enter the system, are screened, and referred for treatment, but never receive it. A report by the U.S. House Subcommittee on Oversight and Investigations of the Interstate and Foreign Commerce Committee estimates the national dropout rate between referral and completion of treatment to be about 40 percent of those initially referred for diagnosis.•6 
There are four major screening sites in South Texas. These fixed sites inotude the Sae Antonio Metropolitan Clinic, the Maverick County Hospital Clinic, t.fle Laredo­Webb Clinic, and the Corpus Christi City-County Health Clinic. Screening outside these counties is conducted by TDH mobile screening units. An ethnic breakdown of the children screened in South Texas cannot be determined due to limitations in the EPSDT reporting system. How­ever, the predominant ethnic group in the area is Mexi­can-American. Given the higher incidence of poverty within that group, it would be reasonable to assume that at least a majority of the children in South Texas receiving EPSDT screening were Mexican-American. 
Of the 262,495 children eligible for EPSDT services in 
Government Financing 163 
Table 119 

Trtle XIX Medical Screening Stamtical Report 1976: 
Totals for the State and the 
Greater South Texas Cultural Basin 

Number Number Refe"edfor Screened Diag./Trtmt. 

Children Under 6 Screened  
State  
Male  20,065  5,458  
Female  20,392  4,626  
TOTAL  40,457  10,084  
GSTCB  
Male  6,852  1,650  
Female  6,848  1,415  
TOTAL  13,700  3,065  

All Children Screened State 
Male 57,786 16,320 
Female 82,829 17,968 
TOTAL 140,615 34,288 
GSTCB Male 19,124 4,869 Female 20,902 5,358 
TOTAL 40,026 10,277 

Source: Texas Department of Public Welfare 
Texas (using the .. point in time" method), 80,982 or 30 percent resided in the study area. Of the 120,615 children screened by the EPSDT program in FY 1976, 40,026 were screened in the project area, or 33 percent of the total. Of the children screened, 13,700 were under the age of six (see Table 119)." 
The penetration rate-the number screened divided by the number eligible-was slightly under 50 percent for the project area. The penetration rates for the individual counties of the region, however, range from 19 percent in Live Oak to 68 percent in Jim Hogg County (see Table 120). 
The total number ofchildren referred for diagnosis and treatment of problems encountered in the screening pro­cess on a statewide basis was 34,288, or28.4 percent ofthe total screened. The total number ofchildren referred for diagnosis of problems noticed during screening in the 
·--· --~ ..,.,.., 10 277 or 25.6 percent of the total 

screened. The range in the percentage of cases referred relative to the total number screened varies quite substan­tially, from 4 percent in Zavala County to 34 percent in Bexar County. 
This range is shown graphically in Maps 21 and 22. The counties with the highest referral rates are, with a few exceptions, also the ones with fixed screening sites. The referral rates at these sites are similar to the state referral rates of approximately 30 percent. The referral rates in the counties serviced by state mobile units range from as low as 4 percent to nearly 30 percent. It might be added parenthetically that the House Subcommittee report esti­mated that 45 percent of all children screened nationally were referred for diagnosis and treatment.18 
According to the EPSDT medical screening director, Dr. J. S. Lerro, the screening package is the same through­out the state. 19 It would seem that, if the screening procedure were given and evaluated uniformly, the results of the screen would be fairly constant in populations of similar social, geographic, and economic characteristics. It appears that this is not the case with the mobile units, which would lead one to believe that mobile screening procedures are not being administered and / or evaluated according to the same criteria used at the fixed screening sites. 
The overall results of the screening procedures for both the state of Texas and the project area are shown in Table 121 . Although there is some variation in the screen­ing results, for the most part the statewide data reflect findings similar to those in South Texas. The ten health problems listed below were those most encountered both in the statewide screen and in South Texas. The referral percentages for the ten highest problems within both the state and the project area are shown in Table 122. 
Multiplying the referral rates by the total number of screened children yields the total number of children referred for diagnosis and treatment for each specific problem (Table 123). Multiple diagnoses would tend to reduce the usefulness of this data. The results show clearly the need for a more extensive system of preventa­tive health care. More than one child in every four screened is in need of further diagnosis and treatment. Ten thousand children in South Texas were referred into the medical system through the program. Without EPSDT many of these problems would not have been noticed until emergency and possible long-term care became necessary. Even in those cases which would not necessarily have reached emergency states, such as vision or hearing problems, correction in the early years is important since it increases the probability ofsuccess in school and allows a child to lead a productive and fulfilling life. 
There are many children in families living below the poverty line who are not eligible for this program and who in all probability have untreated medical problems comparable in number and type to those who are eligible for the program. Of the approximately 81,000 children in 
Table 120  
11tle XIX Medical Propam: Total FJiglble, Screened and Referred  
County  Eligible  Screened  %  Refernd  %  
Aransas Atascosa Bandera Bee Bexar  211 769 59 698 34,811  99 206 36 334 16,304  46 25 61 48 46  20 30 4 77 5,514  20 14 11 23 34  
Brooks Cameron Comal Dimmit Duval  448 7 ,116 315 510 592  168 3,019 122 200 404  37 42 38 39 68  38 459 7 44 78  22 15 6 22 19  
"  Edwards Frio Guadalupe Gillespie Hildago  71 709 827 78 10,174  21 482 240 38 S,803  29 67 40 48 57  9 89 27 s 594  42 18 11 13 10  
i I· I.. I:­ Jim Hogg Jim Wells Karnes Kendall Kerr  143 1,386 558 66 283  98 737 244 17 175  68 53 43 25 61  8 170 54 3 20  8 23 22 17 11  
[. t 1· ' [' E  Kinney Kleberg La Salle Live Oak Mavrick Medina Nueces Real Refugio San Patricio  104 991 325 102 322 307 8,537 55 227 1,757  56 444 166 20 883 156 3,888 18 129 823  53 44 51 19 • 51 45 32 56 46  6 94 34 4 289 27 1,313 6 27 212  10 6 20 20 17 33 33 13 25  
Starr Uvalde Val Verde Webb Willacy  950 644 800 3,275 763  398 395 398 1,767 331  41 61 49 53 43  42 79 74 470 54  10 20 18 26 16  
Wilson Zapata Zavala  489 189 727  156 85 385  31 44 52  22 4 BS  14 4 22  
Not Listing Kenedy McMullen  

*Includes some out of county screening. Source: Texas Department of Public Welfare. 
Government Financing 165 

Table 121 
Title XIX Medical EPSDT Program: Medical Summary 
STATE  GSTCB  
ITEM  REFERRED  %  REFERRED  %  
TEMPERATURE  184  .15  48  .12  
HEIGHT  166  .14  66  .16  
WEIGHT  1002  .83  353  .80  
BLOOD PRESSURE  384  .32  152  .37  
MENTAL HEALTH  605  .50  105  . 26  
VISION SCREEN  7595  6.30  2274  5.68  
HEARING SCREEN  1789  1.48  571  1.42  
DEVELOP. PROGRESS  942  .78  405  1.01  
MUSCULOSKELET AL  1388  l.15  343  .85  
EVTREMITIES  1382  1.15  356  .88  
LYMPHATICS  487  .40  83  .20  
SKIN  3103  2.57  115  2.78  
HEAD  178  .15  67  .16  
HAIR  419  .35.  313  .78  
SCALP  279  .23  85  .21  
EYES  2116  1.75  620  1.50  
EARS  2561  2.12  739  1.84  
NOSE  676  .56  173  .43  
MOUTH  274  .23  92  .29  
THROAT  1429  1.18  549  1.39  
NECK  122  .10  22  .05  
LUNGS  ·  703"  .58  168  .41  
BREAST  329  .27  55  .13  
HEART  3667  3.04  921  2.30  
ABDOMEN  909  .75  222  .55  
HERNIA  1050  .87  125  .31  
GENITALIA  2603  2.16  749  1.87  
REFLEXES  62  .OS  38  .09  
ENDOCRINOPATHIES  124  .10  
TEETH  13  .01  
URINE SUGAR  177  .Is  62  .Is  
URINE ALBUMIN  958  .79  158  .39  
URINE BILIR UBIN  38  .03  
URINE BLOOD  421  .35  112  .27  
HEMOGLOBIN  3783  3.14  1081  2.70  
HEMOGLOBINOPATHY  
(INCL SICKLE CELL)  893  .74  72  .17  
RPR  51  .04  
LEAD  620  .51  250  .62  
PKU  3  .01  

Percentages referred are based on total screened 
STATE (120,615) GSTCB (40,026) 
Source : Texas Department of Public Welfare. 



Map 22 
EPSDT Rate Screened to Total Eligible Population 
Greater South Tens Cultural Basin 

CJ Less than 30% 




ITI1II. 30-59% 

60% and over 
Government Financing 167 

Map23 
EPSDT Rate Referred to Total Screened 
Greater South Texas Cultural Basin 



30% and over 

the eligible population for EPSDT services in South Texas in FY 1976, 40,026 were screened and 10,227 were referred for suspected morbidity. The characteristics of both the screened population and the eligible but un­screened populations were the same. They both were poor and from AFDC families. 
If the referral rates for the screened population are extrapolated to the eligible but unscreened population, a perhaps overly stark picture of unmet need in the eligible population emerges (see Table 124). Through this analy­sis, a total of l0,282 children in South Texas are shown to 

'i need diagnosis and treatment of health problems. This estimate is in addition to those already screened and referred.20 A major problem with EPSDT as it is administered in Texas, then, is the very restrictive eligibility criteria. The poverty population in South Texas is almost identical 
Table 122 
Referral Rates for Ten Highest Problems 
Problem State Project Area 
Vision 6.30% 5.68% Hearing 1.48% 1.42% Skin ·2.57% 2.78% Eyes 1.75% 1.50% Ears 2 .72% 1.84% Throat 1.18% 1.39% Heart 3.04% 2.30% Genitalia 2.16% 1.87% Hemoglobin 3.14% 2.70% Lead Poisoning 2.93% .62% 
Source: Texas Department of Public Welfare. 
with respect to both income and education to those on welfare. There is no reason to believe that the health status of those children under the poverty guidelines but ineligible for Medicaid is any different from that popula­tion of children presently eligible for EPSDT. 
Ifthe assumption is valid, then extrapolation ofscreen­ing results from the screened population to the popula­tion of children under the poverty level would function as a reasonably accurate indicator of the level of need unmet by the EPSDT system. The estimates used for the popula­tion below the poverty level are substantially understated for several reasons. First, neither the state nor DHEW has population projections for 1976 cohorts under the poverty level. The only figures available are based on 1970 census data, and the population has grown since 1970. Also, the census data only allow identification of children under eighteen years of age living in poverty, whereas eligibility under the EPSDT program is extended until age twenty-one in some cases. 
The population estimate used here is 273,385 children under the poverty level within the project area. Extrapo­lating the EPSDT referral rates derived from the 40,000 children actually screened yields the figures shown in Table 124. The nine most common problems anct their ­specific referral rates are shown in Table 125. 
The cost effectiveness of a preventative health system lies in the fact that some have estimated that it costs less to provide a child an adequate program of preventative health for sixteen years than it would cost to keep the child in a hospital for two weeks.21 A poor child will have enough problems trying to break the web of poverty without being burdened with anemia, lead poisoning, or bad vision-to list a few of the problems one in four children living in the study area is suspected of having. 
To a large extent, these and other problems may be 
PROBLEM 
Vision Hearing Skin Eyes Ears Throat Heart Genitalia Hemoglobin Lead Poisoning 

Table 123 
Total Number Screened for Ten Highest Problems 

STATE 

Number of  
Rate  Children Refe"ed  Rate  
6.30%  7,595  5.68%  
1.48  1,789  1.42  
2~ 57  3,101  2.78  
1.75  2,116  1.50  
2.72  2 ,561  1.84  
1.18  1,429  1.39  
3.04  3,667  2.30  
2.16  2.603  1.87  
3.14  3,783  2.70  
2.93  3,539  .62  

PROJECT AREA 
Number of Children Refe"ed 
2,274 571 
1,115 620 739 549 921 749 
1,081 250 
Source: Texas Department of Public Welfare. 
. Government Financing 169 

Table 124 
Trtle XIX Medical EPSDI' Program Projections of Screening Referrals in the Greater South Texas Cultural Bain 
Item  Actual  Eligible•  Below Poverty  125% ofPoverty  
Temperature  48  49  355  721  
Height  66  63  248  502  
Weight  353  294  1,834  2,491  
Blood Pressure  152  147  859  1,163  
Mental Health  105  105  605  819  
Vision Screen  2,274  2,326  13,254  17,924  
Hearing Screen  571  578  3,311  4,478  
Develop Progress  405  412  2,356  3,186  
Musculoskeletal  343  345  1,980  2,679  
Extremities  356  356  2,049  2,773  
Lymphatics  83  78  463  628  
Skin  1,115  1,136  6,485  8,770  
Head  67  62  370  501  
Hair  313  318  1,819  2,460  
Scalp  85  85  489  661  
Eyes  620  594  3,484  4,714  
Ears  739  751  4,291  5,804  
Nose  173  138  1,002  1,356  
Mouth  92  142  700  939  
Throat  549  576  3,251  4,393  
Neck  22  18  114  155  
Lungs  168  164  952  1,289  
Breast  55  50  300  407  
Heart  921  941  5,366  7,257  
Abdomen  222  223  1,281  1,733  
Hernia  125  126  722  977  
Genitalia  749  765  4,363  5,900  
Reflexes  38  34  208  282  
Endocrinopathies  
Teeth  
Urine Sugar  62  59  348  471  
Urine Albumin  158  157  908  1,228  
Urine Blood  112  106  417  848  
Hemoglobin  1,081  1,105  6,300  8,520  
Hemoglobinopathy  72  65  392  532  
(incl. Sickle Cell)  
Lead Pois0ning  250  252  1,444  1,954  
Eligible Population  40,026  80,982  273,385  355,603  
Total Problem Referral/  
Problem per Child ( 1.231)  12,592  12 ,661 1  72,320  98,515  
Total Children Referred  10,227  10,282  58,734  80,009  

*This column and both the 100 and 125 percent do not include actual figures. 
1 Seeming incongruities in columns one and two are caused by rounding percent rates in determining the referral rate. Svurce : T PY"" Deoart me nt of Public Welfare. 
Table 125 
Estimates of Referral Rates for Nine Main Problems in Below-Poverty Population in Project Area 

Rate Actual 
Vision 5.68 2,274 Hearing 1.42 571 Skin 2.78 1,11 5 Eyes I.SO 620 Throat 1.39 549 Heart 2.30 921 Genitalia 1.87 749 Hemoglobin 2.70 1,081 Ears 1.84 739 
Source: Texas Department of Public Welfare. 
alleviated with the anticipated passage ofthe Child Health Assurance Act (HR 13611), which failed adoption in the 95th Congress but which will be reintroduced in 1979. Among the more significant aspects of the Child Health Assurance· Program·(€HAP)-are-that· it:.. · 
-extends coverage under Medicaid to all financially eligible children under the age of eighteen, regard­less of family structure; states have the option of covering either all or particular groups of finan­cially eligible children under the age oftwenty-one; 
...., 	establishes a minimum CHAP income standard of $4,200, which is substantially above that of many states; 
-makes it easier for qualified providers to be certi­fied and reimbursed for providing CHAP services; 
-increases the federal matching rate for assessments and all "non-inpatient" services provided for as­sessed children to the lesser of(a) 90 percent, or (b) the federal Medicaid rate plus 25 percent; 
· -provides for a 75 percent federal matching rate for 
the cost of outreach and followup; 

-establishes a new penalty provision which would decrease by 20 percent the federal matching rate for Medicaid's administrative costs, if states fail to meet the specific CHAP requirements; and 
-establishes a "Maintenance of Effort Require­ment" for states.22 
Texas Department of Health 
The programs of the Texas Department of Health (TOH), although extensive and in many cases well fun­ded, do not comprise a comprehensive set of services for the indigent in Texas. Rather, TOH operates a wide variety of programs to enhance the capacity of local health departments and programs in the delivery of some 
Below Poverty Total (not including actual) 
13,254 15,528 3,311 3,882 6,485 7,600 3,484 4,104 3,251 3,800 5,366 6,287 4,363 4,812 6,300 7,381 4,291 5,030 

services; it serves a regulatory function in a number of areas; and, for certain diseases or problems, it runs statewide programs to assure that all citizens will be appropriately treated. 
Ofthe-254 counties irfTexas, 178 do nothave organized .. local health departments. TDH has divided the state into ten regions to provide some public health services to these counties and to coordinate activities in counties with local health departments. Regional staffs play their tradi­tional roles of consultation and assistance, and they coordinate activities between program directors in the central office and the local unit. They may supplement programs operated by the local unit at the unit's request. In addition, local health departments routinely receive significant portions of their budgets from state and federal funds, which are routinely channeled through TOH. In. counties which do not have organized health depart­ments, the regional staffs cooperate with city and county health officers and other local officials in delivering health services. Mobile teams are used in some regions in addition to satellite offices.23 
A number of the programs which are administered on a statewide basis are funded in full or in part by Title V of the Social Security Act. Crippled Children's Services is a statewide program which purchases restorative services for crippled children from private treatment sources. For a child to be eligible for the program, the county judge in the county where the parents reside must certify that the parents are unable to pay for the needed care and treat­ment. Decisions are made by TOH on an individual basis, taking into account income, asets, family size, and the nature of the problem and required treatment. 
Family planning services are generally made available to urban and some rural low-income neighborhoods on the assumption that residents of other areas can afford to use the private sector for these services. In 1974 twenty­nine local health departments and two public health 
Government Financing 171 

Table 126 
32 Selected Direct Health Service De6very Programs 

Expenditures Per  
Total  Median  Low/High  Per Capita  Poverty Level  
Program  Expenditures  Expenditures  Expenditures  Expenditures  Person  
Core  $ 448,886  $ 9,993  $912  I  35,832  $ .22  .78  
EPSDT-Adm.  95 ,503  721  22  I  38,644  .05  .16  
EPSDT-Med.  943,741  4,767  40  I  423,977  .46  1.63  
EPSDT-Dental  3,257 ,558  18,565  818 / 1,374,839  1.59  5.63  
Crippled Children  2,397,127  21,965  o I  800,972  1.17  4.14  
Congenital Heart  843,592  4,397  o I  282,942  .41  1.46  
Cystic Fibrosis  92,592  3  o I  37,580  .05  .16  
Mother and Child  821,708  .4  o I  711,682  .40  1.42  
Speech and Hearing  38,383  86  o I  15,448  .02  .07  
Cervical Cancer Ser.  9,372  19  0  I  2,478  .005  .02  
Prenatal Well Child Clinic  28 ,943  11  0  I  15,147  .01  .05  
MR/PKU Ser.  4,807  IO  0  I  1,865  .002  .008  
Statewide F arnily Planning  782,339  91  0  I  312,686  .38  1.35  
WIC  16,220,000  85,798  0  I 3,634,621  7.93  28.01  
Cancer and Heart  71,403  453  143  I  35,835  .03  .12  
Kidney Health Care  569,582  2,503  0  I  272,291  .28  .98  
Chronic, Disease.  147,889  547  0  I  30,315  .07  .26  
Dental Health  59,591  32  0  I  14,787  .03  .IO  
LAB  476,044  1,926  27  I  157,684  .23  .82  
Local Health  77,033  376  3  I  20,1 IO  .04  .13  
Public Health Nurse  40,252  283  0  I  15,582  .02  .07  
Communicable Disease  22,745  38  I  I  12,602  .01  .04  
Immunization  216,746  1,144  34  I  118,450  .11  .37  
VD Control  78,420  868  18  I  29,426  .04  .14  
TB  1,205 ,224  7,582  92  I  418,733  .59  2.08  
Home Health Svc.  17,569  36  0  I  11,118  .01  .03  
Nursing and Convalescent  465,155  2,520  0  I  188,366  .23  .80  
Emergency Medical Services  193,546  1,007  28  I  92,972  .09  .33  
Zcionosis Control  37 ,596  336  40  I  6,021  .02  .06  
Dangerous and Synthetic  
Narcotic Drugs  32,069  12  0  18,026  .02  .06  
Migrant Labor Camp  25,926  207  55  6,092  .01  .04  
Special Mother and  
Child Projects  2,652  4  0  1,270  .001  .005  
40 County Total  
(excludes TRAVIS)  $29,720,000  $14.53  $51.33  

Source: Texas Department of Health expenditures worksheets. 
regions organized maternity clinics, while well-child clin­the chronic disease screening program, the latter being ics were held in forty-one local health departments and in primarily a program for the detection of diabetes.2s one region. Nutritional education and counseling services are currently provided to patients in the maternity and 
Local Procrams 
child health clinics and in some family planning clinics. 24 
In addition, statewide programs in vision and hearing Local programs for health care for the indigent tend to testing, speech and hearing testing and treatment, and be extremely variable. They represent a patchwork ap­phenylketonuria screening and treatment are run at a proach to care, and in most cases they are not adequately statewide level, as are the kidney health care program and funded. 
Medicaid* Selected Programst Commwnity MHMR t Expenditures per Expenditures (DPW) (TDHR) (TDMHMR) Total Poverty Level Person per Capita 
Table 127 
State Expenditures for Direct Health Care Progrum and Services, FY 1975 


Aransas  $ 68,447  $ 319,728  $  -0­ $ 388,175  $157  s 33  
Atascosa  567,209  538,847  26,085  1,132,141  182  61  
Bandera  86,331  58,288  6,345  150,964  163  34  
Bee  383,597  355,448  34,565  773,610  125  35  
Bexar  15,808,497  7,642,505  1,216,689  24,667,691  149  29  
Brooks  218,744  294,914  14,260  527,918  128  57  
Cameron  2,449,691  3,314,356  191,478  5,955,525  96  44  
Comal  485,736  97,781  36,096  619,613  149  24  
Dimmitt  243,973  57,416  -0­ 301,389  55  33  
Duval  336,919  308,229  19,685  664,833  107  52  
Edwards  23,099  28,879  -0­ 51,978  50  23  
Frio  305,650  80,747  18,471  404,868  71  31  
Gillespie  350,061  40,434  14,382  404,877  303  40  
Guadalupe  630,771  205,808  47,658  884,237  118  26  
Hidalgo  3,244,562  3,485,961  247,596  6,978,119  80  40  
Jim Hogg  85,188  796,515  -0­ 881 ,703  340  170  
Jim Wells  994,732  664,771  51 ,925  1,711,428  163  51  
Karnes  453,853  266,222  19,740  739,815  136  53  
Kendall·  172,703'  33,508•'  9,870  216,081  183  31  
Kenedy  2,403  141,206  1,085  144,694  424  207  
Kerr  351 ,439  96,951  28,482  476,872  149  24  
Kinney  27,595  47,940  -0­ 75,535  65  40  
Kleberg  343 ,774  416,156  53,940  813,870  87  23  
LaSalle  129,596  242,608  -0­ 372,204  121  64  
Live Oak  111,766  89,776  9,920  211,462  102  33  
McMullen  4,558  74,849  1,395  80,802  300  90  
Maverick  311,461  319,467  -0­ 630,928  62  31  
Medina  374,510  107,915  32,007  514,432  74  23  
Nueces  5,169,189  5,328,048  396,955  10,894,192  201  43  
Real  18,991  8,608  -0­ 27,599  38  14  
Refugio  151,077  140,054  14,162  305,293  124  31  
San Patricio  779,545  932,995  73,625  1,786,165  116  38  
Starr  327,748  312,704  -0­ 640,452  60  33  
Uvalde  323 ,816  134,818  -0­ 458,634  65  23  
Val Verde  395,055  200,075  -0­ 595,130  67  20  
Webb  l,546,160  l,494,644  -0­ 3,040,804  75  33  
Willacy  236,999  626,942  20,445  884,386  107  61  
Wilson  325,004  152,628  18, 189  495,821  129  38  
Zapata  76,356  143,404  -0­ 219,760  72  41  
Zavala  190,929  118,183  -0­ 309,112  46  22  
South Texas$  38,107,736  $29,720,000  $ 2,605,050  $70,432,786  $122  $34  
Texas  182,129,061  16,122,187  
*Actual expenditures for services by county of service.  
t See Appendix  for list of services and expenditure by service for South Texas.  

tGrants from TDMHMR are made to regional centers serving several counties. Funds in this column were allocated by 
population to the counties served by each center as an arbitrary device for disaggregating funds by county. 
Figures may not add to totals due to rounding. 
Sources: Medicaid expenditures from Table 117, THHR and TDMHMR expenditures from agency worksheets. 

Government Financing 173 
Table 128 

Prevalence of TDH Recommended Services in Local Health Departments in 1974 
Number of 
Local Units 

Which Offer Health Care Service the Service 
Family Planning 30 
Maternity Care 29 
Child Health Care 41 
Dental Care 22 
EPSDT-Medical Screening 15 
Hypertension Screening N.A. 
Chronic Disease (Diabetes) Screening 68 
Venereal Disease Screening and Treatment 68 
Tuberculosis Screening and Treatment 68 
Immunizations 68 
Source: Texas Department of Health Resources. 
Virtually from the beginning of the state's history, localities in Texas have been responsible for providing services for poor residents. In 1875 the Texas Legislature provided that "if there is a regular established public hospital in the county, the commissioners court shall provide for sending the indigent sick ofthe county to such hospitaJ.26 Similarly, in 1876, Article 443 empowered the commissioners courts of counties and the municipal authorities of towns and cities within the counties to cooperate in the construction of and payment for im­provements deemed necessary for the public health. This law became the basis for the organization of many local health departments. 
Public Health Departments 
Although public health departments receive funding from local, state, and federal sources, their operations in most cases are primarily supported by local funds. Since they have no dedicated tax base, their funding comes locally from the budgets of cities or counties. TDH generally provides some contribution to departmental budgets in the form of staff salaries, ranging from 5 percent in the urban counties to 71 percent in the rural counties, with the average in 1974 being 38 percent. Each local health department determines what services it will pirvide, though TDH encourages local health depart­ments to offer certain personal health care services. A list of these recommended services and their prevalence in 1974 in the sixty-eight departments accredited by TDH is provided by Table 128. 
To some extent there are different eligibility criteria for different services. Some services are limited to specific age or sex groups or to particular diseases and disabili­ties. In addition, financial eligibility is determined by local departments. Some departments offer service with­out regard to ability to pay, but most restrict service to low-income groups, either by formal application of a means test or by exclusive placement of facilities in low­income neighborhoods. 
Public Hospitals 
The primary source of direct health care for the indi­gent who do not fall into any category is through local hospitals-in most cases through local public hospitals. In Texas, local public hospitals can be organized as hospital districts with their own taxing authority, as authorities dependent upon the local county or munici­pality for support, or as city hospitals which are in the city budgets and treated as city operating departments for budgetary purposes. In any case, Texas, because of the rather limited eligibility for Medicaid, places much of the burden of indigent care on the local public hospitals. 
Many public hospitals and hospital districts in the state have established sliding scales of eligibility and payment for indigents. They also generally attempt to restrict hospital services to indigents from their own counties or districts; exceptions are made through arrangements with the county judge of the neighboring county of which the person seeking admittance is resident. The principle prob­lem in enforcing these regulations comes from the fact that the public hospital often has the only open emergency room in several counties and cannot refuse to treat genuine emergencies. If the physician in the emergency room finds that the problem caused by this emergency is sufficient to require immediate hospitalization, few hos­pitals refuse to hospitalize. In many cases, as soon as the indigent person is stabilized, the hospital will send the patient to John Seeley Hospital in Galveston, which is maintained by the State of Texas for the medically needy. 
The net cost of maintaining care through these public hospitals is substantial; but at least a minimum level of services is provided. In addition, of course, many private voluntary and proprietary hospitals in the state provide free or reduced-cost care to the indigent either inten­tionally or unintentionally, through bad debt. 
In 1977 the six largest hospital districts in Texas levied property taxes amounting to $139 million (see Table 129), while private hospitals, physicians, and city-county hos­pitals proferred at least that much, ifnot more, in free and part-paid care. These losses would be reduced somewhat if the Medicaid program were extended to cover finan­
Table 129 
Property Tax Revmue in Six Lariest Hospital Distlit1s in Teus 

Auessed  Percent of  
Value  Assessment  Tax Rate  Revenue  
Bexar  3,075,343,646  42  .73  22,450,009  
Dallas  5,760,793,270  35  .69  39,749,474  
El Paso*  819,108,528  35  .75  6,143,612  
Harris  10,965,185,730  32  .53  56,620,034  
Nueces*  1,035,497,709  41.4  .52  5,389,788  
Tarrant*  2,678,958,184  30  .65  9,579,401  

*1976 data; 1977 data used for all other districts 
Source : Emmette Grief, 	M.D., "Medically Needy Issues in Texas," Speech presented to the Committee on Tax Supported Health Programs, Texas Medical Association, Austin, Texas, September 23, 1978. 
cially eligible children under age twenty-one and AFDC unemployed fathers, and if the state entered the federal "Medically Needy .. program. 
Federal Financing Programs 
The federal Medicare program is by far the largest g~vernment health care program in South Texas. It spent more than S103 million in South Texas in FY 1975. Since the MeXican-American age distribution is younger than the Anglo distribution, only 5.5 percent of Mexican­Americans were over sixty-five years of age in 1970, compared with 11.6 percent of Anglos-Mexican-Amer­icans likely receive less from this program. Furthermore, since deductables, coinsurance, and many physicians' fees are not fully covered by Medicare, many Mexican­American elderly are not able to buy their way into a comprehensive medical care system to the extent that Anglos do. 
Under Medicaid also, which spent $64 million in FY 1975 in South Texas, expenditures are also skewed toward the aged. In Texas as a whole, 54.9 percent of total Medicaid expenditures were for the aged and only 20.8 percent were for the AFDC category. In any case, most Mexican-American poverty-level families are not eligible for Medicaid because I) even when unemployed and having no income, two parents are usually at home with the children; and 2) even if the single parent requirement were waived, Texas welfare payments are currently so low that a family of four would not be eligible if its income exceeded $191.66 a month. 
One solution would be to raise welfare payments and therefore financial eligibility for Medicaid while relaxing the one-parent requirement for medical indigcocy. Ac­cording to estimates by the Texas Department of Human Resources, iffinancial eligibility were lifted to two-thirds of the federal poverty level, the total number of eligibles statewide would increase by 780,570 and the total cost would increse by more than $550 million annually. About 40 percent of this increased cost would have to be borne by the Texas State government. This increase might be offset somewhat by decreases in local expenditures in health departments and hospital districts and payment for physicians who currently provide some of these ser­vices free orata reduced rate. Improved health statusand some benefits from more federal funds in the state might also be realized. On the other side of this issue is the problem that in most states with such Medicaid programs, the funds have somehow gone into increased hospital and physician costs without providing comprehemivc medi­cal care for the poor. 
Lacking a comprehensive financing program, all levels of government have put together a patchwork of direct delivery programs. The federal government has devel­oped migrant health centers which have been effective in some areas in targeting health resources. The state and federal government together have developed the EPSDT program which, at least for eligible children, does seem to have uncovered and treated a number of medical prob­lems. And, the state health departments and localities have a large number of specific programs for specif1e groups. 
Government Financing 175 
Table 130 

Combined City-County Expenditures for Direct Health Care in South Texas: 
Fiscal Year 1975 

COMBINED CITY-COUNTY EXPENDITURES FOR DIRECT HEALTH CARE IN SOUTH TEXAS: FISCAL YEAR 1975 
City-County 

Htalth Exp•nditures  Exp•ndltures  
FY JP75 G•neral  Health Care  as a Percent of Total  Per Capita Htalth  Percent Pop.  Percent Pop.  P•r Povtrty  
County  Fund R~vtnue1•  Expendituresf  Gtneral Fund Rtvenuts  Cart Expenditur•s  Mex.-Amtr.  B•low Povtrty L•w:I  Level Rtsldtnt  
Aransas  271,238  1,400  Cl.5%  $0. 12  26.6  21.1  .56  
Atascosa  1,149,618  1,392  less than 0.1 %  0.08  51.4  33.7  .22  
Bandera  299,606  1,886  0.6  0.42  9.2  20.6  2.03  
Bee  844,706  53,009  6.3  2.38  39.1  27.8  8.55  
Bexar  140,543 ,049  3,089,565  2.2  3.58  45.3  19.2  18.60  
Brooks  552,550  27,349  4.9  2.97  79.9  44.7  6.65  
Cameron  15 ,214,531  866,617  5.7  6.38  76.2  45.6  
Comal  2,721,773  138,176  5.1  5.40  29.0  16. 2  33.30  
Dimmitt  302,377  6,200  2.1  0.69  81.7  61.1  1.13  
Duval  628 ,877  65,481  10.4  5.16  84.5  49.0  10.52  
Edwards  246,550  16,025  6.5  6.97  43.8  45.3  15.38  
Frio  814,986  9,269  I.I  0.71  69.1  43.3  1.63  
Gillespie  952,887  35 ,378  3.7  3.47  9.8  13.1  26.47  
Guadalupet  1,587,817  121 ,531  7.7  3.60  27. 1  22. 1  16.27  
Hidal,go  17,204,061  787,95 I  4.6  4.49  79. I  49.5  9.06  
Jim Hogg  260,665  3,077  r.2  0.59 ··  91.9 ·  49.8  I.I&  
Jim Wells  2,494,279  126,187  5.1  3.77  64.0  31.3  12.03  
Karnes  452,800  22,053  4.9  1.58  41.0  38.9  4.04  
Kendall  291,623  10,901  3.7  1.56  20.3  16.9  9.21  
Kenedy  354,289  -0·  ·0­ --0­ 78.5  48.7  
Kerr  2,174,163  49,727  2.3  2.46  13.3  15.8  
Kinney  168,633  --0­ ·O·  ·0­ 72.2  61.3  
Kleberg  4,233 ,016  114,484  2.7  3.29  43.6  26.8  12.28  
LaSalle§  280,969  19,73 2  7.0  3.40  78.4  53.0  1.07  
Live Oak  388 ,937  22,894  5.9  3.58  40.3  32.4  11.04  
McMullen  245 ,189  3,199  1.3  3.55  58.6  29.9  11.89  
Maverick  3,574,621  46,043  1.3  2.28  90.3  50.7  4.50  
Medina  842,233  22,057  2.6  0.97  48.5  30.5  
Nueces  33,2 17,092  949,138  2.9  3.71  43.6  21.2  
Real  80,575  890  I.I  0.45  23.6  36.2  
Refugio  1,418,890  2,655  0.2  0.27  38.0  25.3  
San Patricio  3,770,027  177,145  4.7  3.73  49. 1  32.4  
Starr  539,070  2,160  0.4  0. 11  97.9  54.9  
Uvalde  660,979  22,733  3.4  l.!4  50.7  35.4  
Val Verde  2,231,384  44,220  2.0  1.45  56.6  29.2  
Webb  6,190,471  448,252  7.2  4.84  85.6  43.9  
Willacy  1,131 ,866  11,600  1.0  0.80  75.1  56.9  
Wilson  220,557  1,000  0.5  0.08  41.5  29.8  
Zapata  344,870  888  0.3  0.17  91.S  57.8  
Zavala  702,212  25,043  3.6  1.80  81.S  48.3  

Total 249,604,036 7,347,307 2.9 $3 .59 53.5% 30.3% 
SMSA Counties 220,448,821 6,578,375 3.0 4.04 53.0 33.3% 
Non-SMSA 
Counties 29,155,215 768,932 2.6 1.85 55.4 29.5% 

Sources: 

Mexican American and poverty level figures: U.S. Census, 1970. 
City and county General Fund llefenues and Health Care Expenditures: individual city and county budget documents. 

Notes: 

•combined county and city expenditures. Cities included are only those with a population of S,000 or more. In most cases revenue and expenditure figures are actual amounts. Where actual amounts were not available e1timaud actual or bud,eted figures for fiscal year J97 S were used. 
tExpenditures for direct health care services only. Since each city and county had unique budget categories, distinpiishing between direct and indirect 
health care expenditures was difficult. In aeneral, vital statistics for rodent control, inspections, autopsies, and similar activities were not included. 
t $50,941 paid by county on hospital bonds for city-county hospital in FY J97 5. § $2,200 paid on hospital bonds in FY 1975. 

176 Mexican-American Health Care in South Texas 
Total Total Expenditures 

Table 131 
Local State and Federal Expenditures for Penom.I Heallh Services in South Taas 


City-County  State  Federal  Total  Expenditures  Per Po11erty Le11el  
County  Expenditures  Expenditures  Expenditures  Expenditures  Per Capita  Resident  
Aransas  $ 1,400  $ 388,175  s  784,297  s  1,173,872  Sl00.12  s 475.56  
Atascosa  1,392  1,132,141  2,596,485  3,730,018  201.08  598.22  
Bandera  1,886  150,964  656,143  808,993  180.42  873.03  
Bee  53,009  773,610  1,922,199  2,748,818  123.38  443.55  
Bexar  3,089,565  24,667,691  11 ;154,362  98,911,618  114.58  596.60  
Brooks  27,349  527,918  859,390  1,414,657  152.97  134.65  
Cameron  866,617  595,552  13,138,658  14,600,827  147.38  326.00  
Comal  138,176  619,613  2,824,716  3,582,505  139.40  863.30  
Dimmitt  6,200  301,389  931 ,896  1,239,485  137.69  225.13  
Duval  65,481  664,833  1,410,124  2,507,308  168.16  344.52  
Edwards  16,025  51,978  216,723  284,726  123.97  273.38  
Frio  9,269  404,868  1,303,338  1,717,475  31.71  30263  
Gillespie  35,378  404,877  1,994,713  2,434,968  239.47  1,822.47  
Guadalupe  121,531  884,237  3,337,973  4,343,741  128.60  581.27  
Hidalgo  787,951  6,978,119  16,156,526  23,922,596  136.49  275.06  
Jim Hogg  3,077  881,703  482,944  1,367,724  263.59  527.18  
Jim Wells­ 126,187- 1,711,428  3,343;856  5;181,471 - 153.77  494,03­ 
Karnes  22,053  739,815  2,106,078  2,867,946  204.58  527.04  
Kendall  10,901  216,081  1,138,280  1,365,262  195.56  1,154.21  
Kenedy  144,694  44,338  189,032  270.00  554.00  
Kerr  49,727  476,872  3,373,450  3,900,049  193.46  1,221.58  
Kinney  75,535  192,116  267,651  141.00  230.00  
Kleberg  114,484  813,870  1,811,672  2,740,026  78.29  293.28  
LaSalle  19,732  372,204  700,134  1,092,070  188.40  350.07  
Live Oak  22,894  211,462  721 ,722  956,078  149.58  461.04  
Mci~ullen  3,199  80,802  93,954  177,955  197.55  415.89  
Maverick  46,043  630,928  1,643,945  2,320,916  114.28  147.50  
Medina  22,057  514,432  2,161,487  2,697,976  118.97  389.19  
Nueces  949,138  10,894,192  21,024,522  32,867,852  128.71  379.48  
Real  890  27,599  227,869  256,358  128.45  354.23  
Refugio  2,655  305,293  882,568  1,190,516  122.27  398.27  
San Patricio  177,145  1,786,165  3,665,813  5,629,123  118. 73  565.50  
Starr  2,160  640,452  2,116,705  2,759,317  141.11  257.20  
Uvalde  22,733  458,634  1,920,468  2,401,835  121.14  341.23  
Val Verde  44,220  595,130  1,860,612  2,499,962  82.45  618.97  
Webb  448,252  3,040,804  7,550,141  11,039,197  118.84  272.01  
Willacy  11 ,600  884,386  1,347,262  2,243,248  154.80  271.41  
Wilson  1,000  495,021  1,645 ,716  727,127  166.08  129.26  
Zapata  880  219,760  506,367  727,007  137.17  239.29  
Zavala  25,043  309,112  1,634,538  1,634,538  141.80  292.73  
Total  $7,347,307  $70,432,786  $181,484,100  $259,264,193  

SI 26. 77 Average Expenditure Per Capita 

Average Expenditure Per Poverty Level Resident s 418.00 
Nevertheless, the vast majority of poor Mexican­Americans in South Texas do not have access to compre­hensive health care. Also, for a great many, basic educa­tion in health practices and nutrition, access to clean water and sewerage systems, adequate physical checkups for their children and basic immuniutions, and the possibility of childbirth attended by a competent profes­sional in sterile surroundings, remain unfulfilled expecta­tions. 
Conclusion 
The picture which emerges from an examination of government programs for the delivery and financing of health care in South Texas is far from what a reasonable person would identify as a well-organized and rationalized program to take care of the most pressing health needs of poor Texans. In fact, it is far from a rational arrangement even if the only concern were to ensure maximum future productivity and reduce future dependency in the popu­lation. This is true of both the federal and state financing programs and the state and local delivery programs which-have been patched together to fill the gaps left by· the financing program. 
References 

1Special Analysis L, "Health," 1979 U.S. Budget, p. 243. Data are from chart entitled "Public and Private Health Expen­ditures." 
2/bid., p. 245. 
3/bid. 
4/bid. 
5/bid. 
6Aileen Whitfill, "The Impact of the Medicaid Program on Rural Areas in Texas," IRP 1978, p. 45. 
7Vernon's Annotated Civil Statutes of Texas, Art. 695 j-1, Sec. 3(2). 
KWhitfill, "Impact," pp. 45-46. 
9 Ibid., p. 58. 
10/bid., p. 73. 
11 /bid., pp. 105-06, citing Texas State Board of Medical Examiners, Rules and Regulations on Physician Assistants, IQ77. Secs. I & II. 
Government Financing 177 

12vernon's, Art. 4518(6). 
13Children between eighteen and twenty-one years ofage must be students in order to qualify for EPSDT. 
l•Texas Department of Public Welfare, Texas Medicaid Re­ports, 1976. 
Ufbid. 
J6U.S., Congress, House, "Short Changing Children," Report by the Subcommittee on Oversight and Investigations of the Interstate and Foreign Commerce Committee, 93rd Congress, 1st sess., 1976, p. 8. 
178ased on information on FY 1976 from files at the Texas Department of Human Resources, 1977, 
JK"Short Changing Children," p. 6. 
198ased on an interview in Brownsville on April 15, 1977. 
20 1f, in fact, most children are screened every other year, there is no overwhelming problem. If half are screened every year and half are never screened, these estimates may .. be.approximately . correct. If the worst-off families with the worst-off children rarely initiate a screen, the figures may understate the situation. 
2J"Short Changing Children," p. 4. 
22National Rural Center, Rural Health Newsletter 2, no. 4 (August 25, 1978), pp. 4-7. 
2JU.S., Congress, House and Senate Sµbcommittee on Public Health, "Health Care for the Medically Indigent in Texas" (mimeo.), 94th Cong., Ist sess., 1977. 
24/bid. 
2s Ibid., pp. 88-91. 
2~Texas Constitution, Article 4436. 

. APPENDICES 



Appendix A 
Folk Medicine in South Texas 

As the treatment of illness differs among cultures, so too do the definitions, the ascnbed causes, and, in many cases, the symptoms of illness vary. A discussion of folk medicine is too narrowly focused if it centers exclusively on the question of whether certain healing practices are effective. Equally significant, cultural norms concerning health and illness, and the pertinence of these norms to the subjective well-being of individuals, must be con­sidered. 
Of course, Mexican-Americans in South Texas do not all share the same beliefs about health and illness, and different persons may seek treatment from differing so.urces~both, "traditional'' and--"scientific,-" Nor: does curanderismo, the practice of folk medicine, necessarily conflict with scientific medicine. Curanderos (healers) recognize most of the illnesses catalogued by science, and additionally identify some illnesses having no parallel in Anglo culture. 
Most folk medicine practices in themselves are harm­less, although adherence to these practices can create problems by allowing a disease to be left untreated. Additionally, treatment by family members or a curan­dero can benefit individual mental health. Given the extreme poverty of the majority of Mexican-Americans in South Texas, health services provided by family, friends, or local healers often may be the only available health care. Many persons, lacking financial resources, may seek treatment from these alternative sources, even if the patient feels physician treatment is needed . In such situations, delay in seeking medical services can result in an increase in the severity of the illness. 
Healing in South Texas 
In a study of one small city in the Lower Rio Grande Valley, Rubel identified four groups that provide treat­ment within the community-family members, neigh­bors, curanderos, and physicians.1 
Home treatments for many scientific and folk diseases are common among many Mexican-American families of the Southwest. A number of illnesses are treated by family members, using herbal, medicinal, and religious methods. For example, a re de manzanilla (chamomile tea) might be prepared to settle an upset stomach. Also, immediate relatives often provide referral to more know­ledgeable persons. 
Neighborhood healers can be a major part of a com­munity's medical system. Frequently elderly, these people have learned much of the culture's traditional medical lore, and treat many illnesses that immediate relatives of patients cannot handle. In Mexiquito ("little Mexicoj, the Mexican-American neighborhood studied by Rubel, neighborhood healers were important as parteras (mid­wives). In 1966 the Hidalgo County Health Unit recog­nized seven practicing midwives in Mexiquito-these parteras performed a substantial if indeterminate num­ber of deliveries. 
Curanderos, who may be either male or -female, are considered. to heal by virtue of.a, gift (don)-from-God;­through dreams, unusual traits, or magical experiences, an individual acquires healing ability. The number of healers in an area, their methods, and fees, vary widely. Some famous curanderos, such as Don Pedro Jaramillo and Nino Fidencio, had enormous followings in the Southwest while they were active, and have since become folk heroes. Today, many curanderos practice in their names. 
A curandero's treatments are usually a blend ofseveral elements; he or she may call on herbal lore, superstition, magic, psychology, and modem medicine. Religion is particularly important to treatment. In this respect, cur­anderismo represents a culturally distinct belief structure resulting from the imposition of Catholicism by the Spaniards on natives of what is now northern Mexico and the southwestern United States. Acurandero's office usually contains a number of religious items; some cur­anderos dress in white robes. 
Curanderismo is not practiced solely in rural areas. A number of curanderos practice in San Antonio, and at least one practices in Austin. 
There are a number of reasons why an individual might seek the services of a curandero instead of a medical doctor. First, as mentioned earlier, many Mexican­Americans in South Texas cannot afford medical treat­ment. Second, even where subsidized services are availa­ble, the individual may be unaware of them. Third, transportation to medical services may be unavailable, especially in rural areas. Fourth, the local healer is usually readily available, while a physician's schedule, divided among clinic, hospital, and private practice, may preclude ready access to services. Finally, the attitudes of the service providers are significant in the patient's choice. 
182 Mexican-American Health Care in South Texas 
Often, patients perceive differences between the attitudes of curanderos and physicians. Patients in clinics and hospitals might feel slighted by doctors who, for what­ever reason, devote little time to their patients. Medical doctors are sometimes viewed as enriching themselves at the expense of the sick. 
Curanderos, by contrast, accept gratuities rather than set specific fees for services, and are consequently seen as caring more for the liaileiit -ttian 70rpaymenCATso-fn contrast to a physician's emphasis on treating a specific ailment, a curandero is felt to be more interested in the "complete" person. The curandero's office is a comforting blend of familiar religious and cultural objects, and the healer usually makes an effort to know the person as an individual. Thus, while m_any of the curandero's treat­ments might be of dubious physical value, the patient may feel more secure in his or her care. 
Theories of Disease 
In recent years, numerous surveys and case studies have sought to determine what Mexican-American cul­ture considers a "disease." While generalizations obscure iildi'Viduar variations ill belief; the following summary statements may be useful. 
Mexican-Americans in South Texas believe in the existence of most or all diseases recognized by modern medicine. At the same time, many people believe in and treat illnesses which have no parallels in modem medi­cine (see Table 1). Six classes of illness in Mexican­American culture may be broadly defined: 
1. 
diseases of "hot and cold" imbalance; 

2. 
diseases of dislocation of internal organs 

3. 
diseases of magical origin 

4. 
diseases of emotional origin 

5. 
other folk-defined diseases 

6. 
standard scientific diseases.2 


Many diseases fit more than one of these categories. 

First among these groups are illnesses through to be caused, at least partly, by an imbalance between "hot" and "cold" body characteristics. Not directly related to temperature, these "hot" and "cold" traits resemble the Hippocratic humoral theory, which suggested that health results from a correct balance of four bodily "humors"­phlegm, blood, black bile, and yellow bile.J Some humors were thought to be "cold" and others "hot." Much folk · medical theory can be traced to these humoral postulates. 
Table 132  
Illnesses and Treatments Specific to Mexican-American Culture  
Illness  Most Susceptible  Cause  Symptoms  Cure  
Caida de la fontanel (fallen frontanel, i.e., skull depression)  Very young children  Fall  Diarrhea, skull depression, restlessness, high tempera­ture, blocked throat  Prayers, thumb pressure against upper palate, egg applied to skull depression  
Empacho  All  Often caused by stress of forced eating  Sharp pain, due to food being blocked from entering the intestinal tract  Spinal massage, plus herbs given to restore the patient's balance of "hot" and "cold" quali­ties (related to the humoral theory of medicine)  
Mal Ojo (evil eye)  Women and Children ; others susceptible to lesser degree  Strong glances, covetous expression, excessive attention  Headache, inconsolable weeping (children only), fretfulness, high tempera­ture  Egg rub; egg-water mixture placed under patient's bed. Both drain the stronger individual's power away  

Susto  All  Sudden fright,  Loss of appetite, listless- Prayers, sweeping of  
(spirit loss)  buildup of everyday  ness, due to one's  the body with herb  
life's vexations  "espiritu" (spirit, soul)  branches, plus a talk  
having left the body  about the patient's  
personal life  

Foods in particular are often viewed as beingeither"hot" or "cold" (again, temperature is not a factor), and indi­gestion, sore throat, diarrhea, and other minor ailments are thought to result from eating too much ofeither type of food. Treatment usually centers around herbal reme­dies or dietary adjustments. 
The second group.Qf illnesses are those resulting froll}a dislocation of internal organs, which is thought to result from a major disturbance of the fontanel (top of the skull).5 These illnesses are usually restricted to the very young. Symptoms include diarrhea, fontanel depression (resulting from a fall), high temperature, or blocked throat. Death can result if untreated. The treatment, usually performed by a local curandero, involves prayer, thumb pressure against the palate, and / or application of raw egg to the affected area.6 
Third in this grouping are illnesses of magical origin. A 

minority of Mexican-Americans believe in brujeria, witch­
craft, as a cause of disease or misfortune. Consultation 
with a local brujo (sorcerer) is occasionally sought. More 
common is belief in ma/ ojo (evil eye), which 
may be inflicted by a person who possesses ''strong vision." Such persons are conceived to have a strong power over weaker indi\iduals. and the seat of this power is his visual apparatus. Covetous glances or excessive attention paid one person by another exposes the individuals involved to the dangers of an unnatural bond in which the weaker is drained of his will to act and the power of the stronger enters his body . . Symptoms may consist of severe headaches, fretfulness. high temperature. and, in the case of children. inconsolabie weeping. Because the power of the stronger individual is beyond his control. he is considered guiltless unless he reiuses to break the bond. He may do this by simply passing a hand o'er the victim's forehead. or patting the victim about the temples. • 

For more advanced stages of such illnesses. a curandero must be consulted. Treatment involves prayer and body rubs with raw egg to draw out the evil force and sickness. 
Fourth are illnesses of emotional origin. Susto (fright or spirit-loss) is one of the most common folk illnesses. Caused by a sudden fright, susto is believed by some folk healers to result in the departure of one's soul from the body. Other healers suggest less dramatic effects, but all agree that children are the most susceptible to this illness. Symptoms (headaches, poor appetite, depression, or list­iessness) may persist for many months if left untreated. Folk healers treat the illness in several ways; the most common treatment is a brushing of the body with herbal branches. 
The fifth classification of diseases includes such folk­defined illnesses as la1ido and empacho. Latido (palpita­tions) is thought to be caused by going without food for several days. Weakness and chest pains can occur, and the patient is unable to eat even if he or she wants to. Thin people are especially prone to latido._8 Empacho is caused by poor digestion. resulting from mgesuon of certain foods or from eating when one doesn't really want to. The Folk Medicine 183 
stress from such eating conditions is believed to build a ball of food in the stomach, blocking normal digestion.'> Herbal remedies, purges, and spinal massage are some of the treatments. 
Finally, most scientifically defined illnesses are also recognized by folk healers. Among these are measles, pneumonia, whooping cough, asthma, tuberculosis, can­cer, appendicitis, and others. 1c In some cases, however, the scientific and folk explanations for the causes of these illnesses differ. 
Curanderismo as Folk Psychiatry 
The mental health aspects of folk medical practice cannot be ignored. A study in San Antonio suggests that folk psychiatry is practiced on a significant scale, not only because of economic and other difficulties in accessing mental health services, but also "because it works. "11 While broadly based, specific data are not available, curanderismo is thought to have both intentional and unintentional psychological benefits. 
Unintentional effects are numerous. According to Kiev (1968), in poorer Mexican-American communities a sig­nificant emphasis is placed upon sharing; one person's joys and sorrows, including illness, are symbolically shared by everyone else. Modern medical care, by con­trast, concentrates on a patient's physical illness, and · often excludes family and friends from the healing pro­cess.12 The curandero often uses religious metaphor to encourage the patient to accept sufferng as a necessary share of the world's burden of suffering. The curandero represents the belief that disease may have religious or social causes (God's punishment, the malevolence of others) and deals with the patient from that perspective. 
The curandero can be a comforting influence, repre­senting familiar traditions which can be useful in treating both physical and psychological problems. Modern medi­cal personnel usually have little knowledge of or respect for such traditions, and arc unable or unwilling to incor­porate these concepts into health care delivery. 
In addition to the physical illnesses mentioned pre­viously, numerous phychological ailments are recognized by curanderos. As in treatment of physical problems. a curandero's psychological treatment methods may be of dubious value. However, there is no evidence that such treatment is not helpful or that it causes direct harm. Some psychological disorders and causes recognized by curandcrismo include the following: 
-Disorders of the instincts result in difficulty in 
restraining the emotions, particularly rage (choque 
nervios). 

-Excessive activity is thought to be a cause of 
emotional illness. Overwork and overstudy may 
be criticized as evidencing greed and replacement 
of group concern with self-concern. 

-Excessive use of special heaing or harming powers may cause the possessor of these powers to become insane. 
-Inhibition of emotions may cause depression or sud­den outbursts. (Some mainstream psychotherapists have expressed similar opinions.) 
-Excess or lack of sexual activity may cause insanity 
(furor) . -Melarchio (depression) may follow the death of a loved one or the loss of a spouse. -Mal ojo (evil eye) and envidia (envy) are emotional ailments that can result in physical disorders. 
Successful treatment of these illnesses stems both from use of effective folk methods and from the curanderos' often astute ideas about why people become emotionally distressed. Perhaps the most effective treatment results from the curandero's ability to understand the patient's culture, and from his or her willingness to listen. The healer's presence can provide a sense of security, protec­tion, wish gratification, and even religious absolution. Professional counseling may or may not be preferable, but in any case it is only available to a limited degree. In its ·place-, ·folk· psychiatry··has· useful featm:es,-.As-one· healer put it: 
With faith, which is a quality of the healthy mind, man can accomplish miracles . .. . The greatest power in the uni­verse is the power of suggestion. It is the real cause of mental healing and is influential thrnugh the subconscious mind, the seat of the soul, and the emotions. Faith is the second greatest force in the world. tJ 


References 
'Arihur J . Rubel, "Concepts of Disease in Mexican-American Culture," American Anthropologist 62, no. 9 (October 1970): 795-814. 
'Margaret Clark, Health in the Mexican-American Culture !Berkeley: University of California Press, 1970), p. 164. 
JBrussell. Charles B., Disadvantaged Mexican-American Children and Early Educational Experience(Austin: Southwest Educational Development Laboratories Corporation, 1968), p. 
36. 
•Clark. Health. pp. 164-70. 
~Brussell. Disadvantaged, p. 36. 
'Rubel, "Concepts of Disease," p. 795. 
7Burssell, Disadvantaged, p. 36. 
sc1ark, Health, p. 178. 
9 Arthur J. Rubel, Across the Tracks: Mexican-Americans in 

a Texas City (Austin: University of Texas Press, 1966). 10c1ark, Health, p. 180. 11 Ari Kiev, Curandismo: Mexican-American Folk Psychiatry 
(New York: Free Press, 1968), p. 148. t2Kiev, Curandismo, p. 34. IJ/bid., p. 146. 


Appendix B 

CAUSE-OF-DEATH CATEGORIES AND CORRESPONDING THREE-DIGIT 
ICDA CLASSIFICATIONS USED IN 1975 SOUTH TEXAS RESEARCH 

Cause of Death 
INFECTIVE AND PARASITIC DISEASE* Bacillary Dysentery and Amebiasis · Enterities and Other Diarrheal Diseases Tuberculosis, All Forms Septicemia Syphilis and its Sequelae Other Infective and Parasitic Diseases 
NEOPLASMS, TOTAL Malignant Neoplasms, including lymphatic and hematopoietic tissues Malignant neoplasms of buccal cavity and pharynx Malignant neoplasms of digestive organs and peritoneum Malignant neoplasms of respiratory system Malignant neoplasms of breasts Malignant neoplasms of genital organs Malignant neoplasms of urinary organs Malignant neoplasms of all other and unspecified sites Leukemia Other neoplasms of lymphatic and hematopoietic tissues Benign neoplasms and neoplasms of unspecified nature 
DIABETES MELLITUS 
AVITAMINOSES AND OTHER NUTRITIONAL DEFICIENCIES 
ANEMIAS 
MENINGITIS 
. MAJOR CARDIOVASCULAR DISEASES Diseases of Heart Ischemic Heart Disease All other heart diseases•• Hypertension Cerebrovascular diseases Diseases of arteries, arterioles and capillaries• 
ACUTE BRONCHITIS AND BROCHIOLITIS 
INFLUENZA AND PNEUMONIA 
BRONCITIES, EMPHYSEMA AND ASTHMA 
PEPTIC ULCER 
ICDA Code 
000-136 
004,006 
008,009 
010--019 
038 
090-097 Remainder of 000-136 
140-239 140-209 140-149 150-159 160-163 174 180-187 188, 189 170-173, 190-199 204-207 200-203, 208, 209 210-239 
250 
260-269 
280-285 
320 
390-448 390-398, 402, 404, 410-429 410-413 390-398, 402, 404 400, 401, 403 430-438 411-448 
466 
470-474, 480-488 
490-493 
531-533 186 Mexican-American Health Care in South Texas 
APPENDICITIS 

HERNIA AND INTESTINAL OBSTRUCTION 
CIRRHOSIS OF LIVER 

CHOLELITHIASIS, CHOLECYSTITIS AND CHOLANGITIS 
NEPHRITIS AND NEPHROSIS 
INFECTIONS OF KIDNEY HYPERPLASIA OF PROSTATE 
COMPLICATIONS OF PREGNANCY 

CONGENITAL ANOMALIES CERTAIN CAUSES OF MORTALITY IN EARLY INFANCY 
Birth inj.ury 
SYMPTOMS AND ILL-DEFINED CONDITIONS 
ALL OTHER DISEASES** 
DEATH BY VIOLENCE* 
Accidents Motor Vehicle Accidents 
Suicide Homicide 
OTHER EXTERNAL CAUSES 
540-543 
550-553. 560 
571 
574, 575 
580-584 590 
600 
630-678 
740-759 
760-772, 774-778 
780-796 
Residual 
E800-E978 E800-E949 E810-E823 E950-E959 E960-E978 
E980-E999 

*These categories are not found among those prepared by the Texas Department of Health Resources. They arc used in tables and text of this report for the sake of convenience. 
**These categories are found in reports by the Texas Department of Health Resources. However, as may be seen by the ICDA codes they differ somewhat from the TDHR categories. 
Appendix C 
FONNER'S CLASSIFICATION SYSTEM 
Cause of Death Cate1ories and Correspondin& Four-Dipt 
ICDA Classifications Used in Present Research 
(U.S. National Center for Health Statistics, 1965) 

Primary Cause of Death 
INFECTIVE AND PARASITIC DISEASES, TOTAL Tuberculosis, All Forms All Other Infective and Parasitic 
NEOPLASMS, TOT AL Malignant Neoplasm of Buccal Cavity and Pharynx Malignant Neoplasm of Stomach Malignant Neoplasm of Large Intestine and Rectum Malignant Neoplasms, All Other Digestive Organs and Peritoneum 
Malignant Neoplasm of Trachea, Bronchus, and Lung Malignant Neoplasms, Other Respiratory Sites Malignant Neoplasm of Bone, Connective Tissue, Skin Malignant Neoplasm, Breast Malignant Neoplasm of Cervix Uteri Malignant Neoplasm of Ovary, Fallopian Tube, and Broad Ligament Malignant Neoplasm of Prostrate Malignant Neoplasm of Other Genitourinary Organs 
Neoplasms of Lymphatic and Hematopoietic Tissue All Other Neoplasms 
ENDOCRINE, NUTRITIONAL, AND METABOLIC DISEASES, TOTAL Diabetes Mellitus All Other Endocrine, Nutritional, and Metabolic Diseases 
DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS, TOTAL 
MENTAL DISORDERS, TOT AL 
DISEASES OF THE NERVOUS SYSTEM AND SENSE ORGANS, TOT AL 
DISEASES OF THE CIRCULATORY SYSTEM, TOT AL 
Active Rheumatic Fever Chronic Rheumatic Heart Diseases Hypertensive Disease 
Ischemic Heart Disease 
ICDA Four-Digit Code 
000.0-136.0 010.0--019.9 000.0-009.9 020.0-136.0 
140.0-239.9 140.0-149.0 151.0-151.9 153.0-154.2 150.0, 152.0-152.9, 155.0-159.0 
162.0-162.1 160.0-161.9, 163.0-163.9 170.0-173.9 
174.0 
180.0 183.0-183.9 
185.0 181.0-182.9, 184.0-184.9, 186.0-189.9 
200.0-209.0 190.0-199.1, 210.0-228.0, 230.0-239.9 
240.0-279.0 250.0-250.9 240.0-246.0, 251.0-279.0 
280.0-289.9 
290.0-315.0 
320.0-389.9 
390.0-458.9 390.0-392.9 393.0-398.0 400.0-404.0 410.0-414.9 

188 Mexican-American Health Care in South Texas. 
Prima,,y Cause of Death 
Other Forms of Heart Disease 
Cerebrovascular Disease 
Diseases of Arteries, Arterioles, and Capillaries 
All Other Circulatory Diseas.es 


DISEASES OF THE RESPIRATORY SYSTEM, TOTAL Influen7.a and Pneumonia All Other Respiratory Diseases 
DISEASES OF THE DIGESTIVE SYSTEM, TOTAL 

DISEASES OF THE GENITOURINARY SYSTEM, TOTAL 
COMPLICATIONS OF PREGNANCY, CHILDBIRTH, AND THE PUERPERIUN, TOTAL 
DISEASES OF THE SKIN AND 
SUBCUTANEOUS TISSUE, TOTAL 


DISEASES OF THE MUSCULOSK.ELETAL SYSTEM . ·'<iii~~~t'r Al~~i11r-.J:lV£ TlSSUE, TOTM. 
.. ~Tld;ANOMALIES, TQTAL 

~~l'+~·~S.Qf.PERIN'/\TA,L ~y 
. ~.:,;.,, ANJ'~MJOl;.:l"M:flTY, TOTAL :. ··:;;:?~~YM~MS.A.NDILLPDEFINED CONDITIONS ACCIDENTS, POISONINGS, AND VIOLENCE, TOTAL 
ICDA Four-Digit Code 
420.0-429.9 430.0-438.9 440.0-448.0 450.0-458.9 
4(;().0-519.9 470.0-486.0 460.0-466.0, 490.0-519.9 
520.0-577.9 
580.0-629.9 
630.o-678.0 
680.0-709.9 
710.eJ;.731~9 
740.0-759.9 
760.0-719.9 780.0-789.9 800.0-999.9 


Health-Related Publications of the LBJ School of Public Affairs 

Health Planning in Transition: Structure and Performance in Arkansas, Oklahoma, and Texas (1978), project directed by David Warner and Dennis Thomas, $4.00 
Organizing for Health Planning: Report of a Conference (1978), edited by David Warner and Dennis Thomas, $3.50 
The Impact of the Safe Drinking Water Act on Texas (1978), project directed by Gerard Rohlich and David Eaton, $4.00 
Options for Community Response to the Safe Drinking Water Act (1979), project directed by Gerard Rohlich and David Eaton, $5.00 
Toward New Human Rights (1977), edited by David Warner, $6.95 
Alternate Care for the Elderly: An Annotated Bibliography (1977), project directed by Lodis Rhodes, $3.00 
Colonias in the Lower Rio Grande Valley of South Texas 
(1977), project directed by Kingsley Haynes and Jared 
Hazleton, $3.00 

On Deployment of Health Resources in Rural Valle Del Cauca, Colombia (1979), project directed by David Eaton, $3.00 
Office of Publications Lyndon B. Johnson School of Public Affairs The University of Texas at Austin Austin, Texas 78712