In the debate concerning health care in the United States, the voices of some segments of the population often go unheard.

America's poor, its indigent and migrant populations, are among the fastest growing in the nation. For these people, outcries over rising co-pays, freedom to select their primary care physician, or premium increases are concepts that can be as overwhelming as speaking a foreign language.

They have no insurance, no primary care provider. They are poor. Their options are limited.

When sick or injured, they often rely on home remedies, other alternative forms of care, or turn for help to one of the nation's 2500 community or migrant health centers.

A team of researchers at the UT College of Pharmacy is examining the role of pharmacists in community and migrant health centers to determine the types and levels of services provided. While the role of the pharmacist has been firmly established within all aspects of the health care delivery system, the contributions of these pharmacists is uniquely important. Since the pharmacist is often the last health care provider the patient sees during a visit to the clinic, that same pharmacist may well be the last health care provider the patient will see for some time. This appears to be particularly true if the patient is involved in migrant work and therefore moves often.

Drs. Marvin Shepherd, Jamie Barner and Carolyn Brown, all faculty members within the College's Division of Pharmacy Practice and Administration, lead the UT team which has set out to survey at least half of the centers to determine what services pharmacists provide to these individuals.

The research team is quick to point out that the 2500 centers are located throughout the United States, not just in border states. In addition, the centers are found in rural and urban settings alike.

"Poor people are found in all of our states and many migrant workers are not illegal immigrants," Dr. Shepherd said. "Also migrant workers, by the very nature of their work, move from city to city, state to state."

Nationally, the 10.3 million individuals served by these centers are predominantly low-income children and women who are of ethnic minority descent and are classified as the working poor. Estimates set more than 4 million of those served by these centers as being uninsured.

In Texas alone, it is estimated that 500,000 persons receive their primary health care through one or more of the state's 163 community health center sites. More than 75 percent of the population served by Texas health centers are women of childbearing age and children below the age of 19. Community health centers in Texas serve 4.3 percent of all ethnic minorities in the state, making up 86 percent of their client base.

"The surveys are designed to give us a picture of the services offered by pharmacists in these environments," Dr. Shepherd explained. "We want to know if the services are very traditional in nature or if they go beyond traditional to more in-depth provision of pharmaceutical care."

"Drug-related morbidity and mortality costs are estimated at $76.6 billion annually. Such high costs associated with the use of medications only highlight the crucial role that pharmacists can and should play in the delivery of quality health care," Dr. Barner explained.

"The hallmark of pharmaceutical care is in identifying, resolving, and preventing drug-related problems," Dr. Barner continued. "In the instance of patients within community and migrant health care centers, where a patient may well not see another health care provider for some time, the role of the pharmacist becomes even more critical."

"It would be easy to assume, therefore," she continued. "that pharmacists in these environments perform in capacities beyond the traditional dispensing and counseling roles, that they play a key role in improving drug-therapy outcomes of patients. The survey is designed to help us determine if these assumptions are accurate."

She continued by pointing out that prior research studies have documented the significant contribution that high level pharmaceutical care has made in assuring positive therapeutic outcomes of patients and in reducing overall health care costs.

In the case of community and migrant centers, where federal dollars are the major financial contributor, the government has taken an increased interest in assessing all avenues which might improve patient outcomes, especially those that also prove to be cost reducing, Dr. Shepherd explained.

The team's study is funded by a grant from the U.S. Bureau of Primary Care under the supervision of the American Association of Colleges of Pharmacy. In addition to assessing the role and nature of pharmaceutical care services in these facilities, the research also attempts to examine the relationship between these centers and colleges and schools of pharmacy.

"It would appear that the relationships between community/migrant health centers and colleges/schools of pharmacy are mutually beneficial," Dr. Brown said. "Students and practitioners provide services to the clinic, while the clinic serves as a rich environment for learning and experience. Among other goals, this survey is designed to determine whether or not this is true, and if it is, to what extent it is so."

During the summer, the team refined its survey instrument, sending it to several pharmacists within these centers to gain feedback concerning their perceptions of the survey document and the value of the research.

"Pharmacists within these centers have a strong commitment to their patients and are very interested in determining how to better serve these patients," Dr. Brown said.

By summer's end, the final surveys will be mailed to a random sample of 1250 centers. Once they are returned, the researchers will begin the work of determining the pharmacists' role within these centers and making recommendations for improving the impact of pharmacy in community and migrant health care centers.