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Chronic Conditions

Health conditions on the Texas-Mexico border are among the worst in the U.S., so distressful at times that reports on health conditions suggest a remote country in need of medical missionaries, not a part of Texas. Cases of hepatitis A, a gastrointestinal virus borne by contaminated food and water, are four times as common in the Rio Grande Valley as in the rest of Texas.1 The diabetes-related death rate in the Border region is nearly 25 percent greater than the state rate.2

Nor is it a secret that the region's health care delivery system is unable to serve all residents who need care. All but two of the 43 Border counties--including every county on the Rio Grande--are federally designated "medically underserved areas."3

Why is the Border's health care system so fragmented? With so many people, and so much sickness, why aren't there enough providers to treat everyone?

One answer, of course, is money, or lack of it. Too often in addressing the Border's health needs, Texas has made a common mistake of modern medicine--treating the symptom, rather than the underlying condition. The Border's underlying condition is poverty, which has hindered development of the region's health sector.

In the Border region and beyond, the health sector consists of three systems: the public health system, which tries to prevent disease; the health care delivery system, which treats people when they get sick; and the health care finance system, which pays for prevention and medical care.

Ideally, local health care finance systems draw upon a balanced mix of private, public, and non-profit support. In the ideal scenario, most residents have health insurance paid by their employer, their own wages, or a combination of both. And public insurance programs cover other groups--low-income populations, the elderly, and government employees. Publicly funded facilities serve local populations, and charities help fill gaps by funding facilities and specific services.

In contrast, the Border region's health care finance system is out of balance, missing a stable base of private insurance to complement public and charity programs. Only 40 percent of Texans living in Border cities had private insurance by one 1994 estimate, compared to almost 60 percent of non-Border city residents. The study found that the Border economy, with its predominance of small employers and low-wage jobs, appeared to be a breeding ground for an epidemic of "uninsurance."4

Lack of insurance has been compounded by a lack of infrastructure--especially potable water--necessary for disease prevention. Lack of infrastructure is also the result of poverty, that of communities and of individuals.

Even if poverty were not an issue, the Border region would face significant and unusual health challenges. The flow of people back and forth between Mexico and the U.S. creates opportunities for diseases to spread across a border invisible to germs. Such routine comings and goings naturally spotlight the different focuses of the U.S. and Mexican health care systems. The former system emphasizes private insurance and public health infrastructure, while the latter revolves around a publicly owned delivery system. Differences between the systems can be addressed and overcome on a case-by-case basis. But the long-term efforts of health care providers in both countries to coordinate two public health care systems and two health care delivery systems can hardly meet health needs without sufficient financial glue to hold them together.

Just as the root of poor health along the border is financial, so too are many outcomes. A health care system that functions less than optimally has a draining effect on an area's economy. Individuals with poor health, especially chronic, untreated conditions, lose the capacity to work, and families are unable to remain self-sufficient. This, in turn, costs state and local taxpayers, who pay the tab for indigent health care. A fragmented health care delivery system can be an impediment to economic development.

Finally, health care amounts to a significant economic sector in its own right--one typically providing a large number of living-wage jobs. Improving the Border's health care delivery system would contribute to economic development by generating jobs that offer workers and their families the insurance coverage they need.

Money Alone No Solution

It would be simple to recommend a rapid infusion of health care dollars to remedy the widespread gaps in the Border region--simple, perhaps, but misguided.

To be sure, the Border's health care system needs money. But it doesn't need "quick fix" public spending that further fragments the delivery system by setting up more special programs covering specific illnesses or serving individuals who meet special guidelines. Instead, the region may need a health care finance system based more on private payments and less on public contributions. To win support from all, and to benefit many, the system must be based on the shared responsibility of families, businesses, and public programs. In short, Border residents should "own" their health care system, rather than lie at its mercy.

A Different Kind of Melting Pot

From a public health perspective, the Border is a unique epidemiological melting pot of diseases such as tuberculosis, leprosy, dengue fever, typhoid, and hepatitis A, and conditions such as diabetes and hypertension.5 Diseases pass freely via shared water resources, contaminated foods, and sometimes uncontrolled pharmaceuticals and consumer products, generally because of human and animal migration (see A Tale of La Crema de Belleza).

A Tale of La Crema de Belleza

Beyond its economic implications, poor health along the border ripples through both nations that share the boundary. The massive, daily movement of people and goods through the region--often to places far beyond--comprises an entirely too efficient disease transportation system.

In general, public health officials rank specific diseases and conditions based on prevalence, the potential for widespread outbreaks, and severity. As of early 1998, Texas state officials listed tuberculosis, hepatitis A, and shigellosis, a gastrointestinal ailment, as communicable disease priorities in the Border region (see Table 8.1 and Figure 8.1).6

Health officials refer separately to the threat of "emerging" diseases, defined as those with low incidence along the border and elsewhere in modern times, yet once again ripe for outbreaks because of inadequate sanitation. In the 1990s, Texas Border communities experienced outbreaks of dengue fever and rabies. Communities on the Mexican side of the border confronted cholera, a deadly gastrointestinal illness extremely rare in the U.S.7

Unlike contagious diseases, chronic diseases are less the results of infrastructure deficiencies and more the products of lifestyle and genetics. In the Border region, public health officials have focused on health problems prevalent in the predominant Hispanic population, such as diabetes, cervical cancer, and breast cancer.8 Birth defects have also drawn attention, including a cluster of Cameron County infants born in 1991 with anencephaly, a fatal neural tube defect.

While many health conditions are worse in the region than elsewhere, residents are better off than the state average in at least two ways. Border mortality rates for exposure to HIV, the virus that causes AIDS, were 9.4 per 100,000 population in 1995, compared to 14.8 statewide. And the generally healthy habits of Hispanic women and a cultural commitment to family and children were reflected in better birth outcomes than the state average.9

As Goes Mexico...

Public health strategies that work well in other parts of Texas often fail to address the Border's unique needs. For instance, to function optimally in Texas Border communities, government disease prevention programs must collaborate with Mexico in attacking shared problems and root causes.

Concerns are not limited to the Texas side of the border. Mexico, for instance, fears the spread of afflictions such as HIV/AIDS to its population, which has reported infection rates much lower than the U.S. Mexico also must contend with increasing rates of diseases from U.S. conditions such as drug abuse, diabetes, heart disease, and hypertension.

The two nations take different tacks to track diseases and other health indicators. Unfortunately, the differences sometimes impede collaborative efforts to prevent and control outbreaks. In the U.S., for instance, health officials record both new cases of tuberculosis (TB) and TB-related deaths. In Mexico, TB-related deaths are recorded, but not all areas of the country report new cases. Since TB is a highly treatable disease, focusing only on deaths may minimize TB's true prevalence.

Such reporting differences are due largely to a lack of resources for tracking diseases and conditions, commonly called surveillance. Scarce funds are spent on direct treatment and basic health education. In many cases, a local health department on the Mexican border may have only one computer, if any, to share among many users. In other cases, staff might have to rely on a single shared manual or electric typewriter.

Inadequate Health Care Access

Just as the public health system along the border struggles to promote health, the health care delivery system labors to provide care to those who need it. By common measures, many Border residents have inadequate access to health care. Without access, they miss school and work while spending hours waiting for scarce services, or they do without care until their conditions are severe, when they may travel to other cities for care, often at considerable cost to Texas taxpayers.

Visiting la Farmacia

Quantifying an individual's or community's access to health care is an imperfect science. Common indicators of deficiency in the health care delivery system are HPSA and Medically Underserved Area (MUA) designations, which the federal government gives to areas that meet certain criteria. Another indicator is the amount of indigent care provided by local hospitals. A high level of indigent care indicates that many local residents cannot afford to pay for services. Most lack health insurance.

The U.S. Department of Health and Human Services assigns a Health Professional Shortage Area (HPSA) designation to U.S. counties based on their ability to provide health services to local residents. Counties with less than one physician for every 3,500 residents are designated a federal HPSA if physicians are not accessible within a reasonable distance. The designations may apply to primary medical care, dental services, or mental health services.10

While less than half of the state's 254 counties had HPSA designations in 1998, 27 of 43 counties (63 percent) in the Border region had HPSA designations for primary medical care. For dental services, 44 percent of the region's counties had a HPSA designation, compared to 20 percent of non-Border counties. Some 95 percent of the Border counties were designated HPSAs for mental health care, compared to 72 percent for the rest of the state. Only Nueces and Bexar counties lacked this designation.

Counties with a HPSA designation become eligible to have health care providers placed with them from the National Health Service Corps. This program pays to train health care professionals if participants agree to serve a "tour of duty" in an area lacking adequate health care services. Primary care physicians practicing in HPSAs also may qualify for federal repayment of their medical school loans.

Counties may also be designated as MUAs, based on a shortage of personal health services for local residents. The federal government determines a county's qualification for such a designation by comparing its percentage of aged residents, poverty rate, infant mortality rate, and ratio of primary care physicians per 1,000 residents to national averages. If the resulting Index of Medical Underservice score falls below the national average, the county is considered underserved.

Of the 43 Texas Border counties, 31 were designated as MUAs in 1998. Ten other counties, including urban Bexar, El Paso, Webb, Hidalgo, Nueces, and Cameron counties, received partial MUA designations. In total, 95 percent of Border counties were judged MUAs in whole or in part, compared to 85 percent statewide. Importantly, even the region's most urban counties, with greater medical resources, still were considered at least partly underserved.

Local Health Centers

By law, hospitals cannot turn away patients in need of emergency care, regardless of their ability to pay. But what resources are available for preventive care, primary care, and the treatment of chronic conditions such as diabetes, cancer, or heart disease? In the Border region and statewide, community and migrant health centers, public health clinics, and public hospitals shoulder much of the burden. In 1997, 22 community health centers in the Border region served 203,027 medical and dental clients in more than 700,000 visits. A single community health center in the Rio Grande Valley served more than 22,000 patients; its five pediatricians treated an average of 138 children a day.

Community and migrant health centers have a variety of medical personnel on staff such as family practice physicians, obstetricians, gynecologists, pediatricians, internists, dentists, nurse practitioners, physician's assistants, certified nurse midwives, and other specialists. For treatment of conditions ranging from allergies to HIV/AIDS, clinics maintain referral agreements with nearby subspecialists, who are paid up to 50 percent of their regular rates.

If a specialist refuses to accept less than full reimbursement, patients may be left without care. They also could be referred to public hospitals with specialists available to provide indigent care, which would be welcome if the referrals led to accessible care, but that is not the case. Indigent patients in the Rio Grande Valley faced with conditions such as kidney disease or cancer may be referred to the closest medical facility for indigent care--the University of Texas Medical Branch in Galveston nearly 400 miles away. For older residents, 40-hour-per week workers, or people without reliable transportation, such a referral is daunting at least, probably impractical, and even potentially life-threatening.

In West Texas along the border, the city of Presidio offers no full-time physician, no hospital, nor even a pharmacy. The nearest emergency care facility on the U.S. side of the river is 90 miles away in Alpine--a $200 trip by ambulance. Presidio's clinic staff, without a pharmacy, wait two to three days to receive medicine delivered from Alpine. The Texas Department of Health's nearest regional office is in El Paso, more than five hours away.

There is an immediate border solution. Presidio residents simply cross the river to obtain health care services and medicine in Ojinaga; some also may depend upon folk medicine to treat routine ills (see Folk Medicine).

Folk Medicine

Women in Presidio are not as likely to receive prenatal care and are more likely to deliver their babies at home. This isolation also makes disease tracking and record-keeping nearly impossible. Incomplete tracking can lead to misleading conclusions, limiting the effectiveness of public health care. For example, Presidio reported low rates of hepatitis A from 1992 through 1997. But the low rates did not necessarily mean a lower rate of infection; state health officials suspect many infected individuals sought care in Ojinaga and weren't noted in Texas.

Community health advisors have long helped public health advocates serve communities. In the Border region, such workers--known as promotoras de salud, health promoters, or simply promotoras--provide a bilingual liaison between health care providers and the public.11 As members of the community, promotoras are uniquely positioned to work within communities, bridging cultural gaps and gaining the trust of residents. Some promotoras are paid while others volunteer.

Within a health center, promotoras may assist in daily clinical activities such as case conferences, patient education, referrals to other health and social services, and volunteer coordination. In the community, promotoras may conduct needs assessments, distribute surveys to identify barriers to health care delivery, and make home visits for patient education or with a health professions student for patient follow-up. In addition, promotoras help families talk to their health care providers.

By 1998, at least 30 promotora projects operated in the Texas Border region. The level of training received by promotoras varied based on each program and the responsibilities of the individual involved. In a project funded by the Kellogg Foundation, for instance, El Paso promotoras received 60 hours of training in the agencies they served. A cadre of volunteers, known as Volunteer Community Health Advocates, receives 55 hours of training through El Paso Community College.

Texas has no uniform training curriculum or certification program for promotoras. Anyone can call themselves a promotora without training. Furthermore, promotoras may receive different degrees of training, ranging from lay workers who provide basic health education materials to community health workers who provide clinical services such as blood pressure monitoring. Having a uniform training and certification program would enable clinics, hospitals, and patients to know exactly what type of training promotoras have received.

Experts agree that a key element to the success of any promotora project is the close ties promotoras have to their communities. Any training or certification program should preserve this vital linkage. Furthermore, training or certification should remain an option for promotoras, not a requirement. Just as some promotoras maintain that they do not want to be paid for their work, not every promotora wishes to attain additional training or certification. Basic theory behind community health workers validates the need for promotoras representing a broad spectrum of abilities and skills.12 Certification, however, should be available for those that want it, and for health care providers who wish to hire promotoras with known medical and other job skills.

A pilot project under the Health Education Training Centers Alliance of Texas (HETCAT) has been developing a uniform curriculum for training and educating promotoras along the Texas-Mexico border, along with a plan to establish a certification process to enable employment.

Given the shortage of health care providers, cultural considerations, and transportation issues, expanding the use of paid and volunteer promotoras in the Border region could be one way of maximizing resources while having the greatest impact on the community. To achieve uniformity, the state could invest in developing a training curriculum and certification program.

To date, promotoras have worked in public health services and community/rural clinics. If the program were to be standardized through training and certification, promotora services could be an integral part of public health coverage for Border residents.

For rural areas, difficult-to-reach populations, and MUAs, a delicate balance must frequently be struck between bringing services to residents and bringing residents to services. Promotoras seem to merit support as a popular, low-cost way of making sure residents get the health services they need. They also seem to be a model for making sure medical personnel hear precisely what patients desire.

Health Care Finance: A System Out of Balance

In general, residents of the Border region are much less likely to have health insurance than are other Texans. In a 1994 analysis, 28 percent of residents in a sample of the Border population were uninsured, compared to 20 percent of other urban Texans. The analysis indicated that the prevalence of insurance along the border was on the decline.

The Border's high uninsured rate is due to the low incidence of private coverage. Because private coverage rates are so low, the federal, state, and local tax burdens of public programs are much higher in Border cities and counties than in other parts of Texas.

The Border's low rate of private insurance stems largely from the region's employment profile. A greater portion of Border residents work for small employers than do non-Border residents. Small employers--those with 75 employees or fewer--are less likely than larger employers to pay for employee insurance.13 More than 50 percent of Border workers worked in small firms in the early 1990s, compared to 43 percent of workers in other Texas cities. Border workers also are more likely to work in low-wage jobs than non-Border workers, and low-wage jobs typically do not include insurance coverage.14

The Texas Insurance Purchasing Alliance (TIPA), established by state lawmakers in 1995, has served as an avenue for small businesses to offer employees affordable health insurance. TIPA has expanded the pool of Texans with private, employer-sponsored insurance. More than 50 percent of the employers who joined TIPA were previously uninsured, compared to only 17 percent of all the small businesses who purchased coverage in 1997.15

Despite this success, however, TIPA has not eliminated wide variations in insurance. According to preliminary TIPA estimates, more than 200,000 Texas small businesses did not offer employee insurance as of 1998. This figure reflected more than 60 percent of all small businesses in Texas.16

To obtain employee coverage through TIPA or any other program, small employers must guarantee that 75 percent of their workers will enroll in the insurance plan they are offered, to avoid the actuarial problem of self-selection. But many small businesses cannot convince enough employees to participate--unless the employer is willing to pay for most or all of the cost of coverage.

According to TIPA staff, small business coverage has been even more uncommon in the Border region. At least part of the difficulty stems from problems insurers have had in contracting with providers to care for their enrollees because the managed care system is newer in the region.

While the Border's private insurance rate has been substantially lower than the rest of Texas, public health insurance coverage consistently reaches more residents. In 1994, more than 32 percent of sampled Border city residents were covered under Medicare, Medicaid, or CHAMPUS, the military's health program, compared to 21 percent of non-Border Texans.

Medicare and CHAMPUS are federal programs, but Medicaid is funded by a mix of state and federal dollars.

The Medicaid coverage rate in Border cities is nearly twice that of non-Border cities--11.4 percent compared to 6.3 percent. If the Border's Medicaid profile were consistent with the rest of Texas, the state's Medicaid program would cost state and federal taxpayers $1 billion a year less. In 1996, the Border region accounted for 22 percent of Texas' population, but more than 30 percent of Texas' Medicaid clients.17

The pervasive lack of private insurance along the border results in public and non-profit funding stepping in to fill the gap. Border hospitals provided more than $600 million in uncompensated care in 1997, amounting to about 8 percent of gross patient revenues for the providing hospitals.

Public hospitals are less common in the Border region than in the rest of Texas. The region has four county hospitals, two city-county hospitals, and 13 hospital districts. Two state-owned hospitals--South Texas Hospital in Harlingen and the Texas Center for Infectious Disease in San Antonio--are almost entirely devoted to indigent care.

Health care experts say that most Border counties make substantial efforts to fund health care, given their limited local tax bases.18 By state law, counties are responsible for funding indigent care for residents not served by a hospital district. The Texas Indigent Health Care and Treatment Act of 1989 provides state matching funds for counties that spend more than 10 percent of their gross revenue tax levies on qualified indigent care. In 1997, Border counties accounted for six of 16 counties qualifying for state matching funds. Four Border counties were among the state's five leaders in the share of gross tax levies devoted to indigent care. Border counties spent $8.8 million of the $14.6 million spent by the 16 qualifying counties. Hidalgo County alone spent $6.5 million.19

Imbalance in the Border's health care finance system has kept the health care delivery system from developing the capacity to serve residents adequately. Health care experts have said that continuing gaps in the finance system could put the area's entire health care safety net in jeopardy as managed care requirements cause for-profit providers to shift more and more indigent patients to public facilities.

Even more than the traditional "fee for service" system, managed care derives its profit by assuming that most people are insured. Dr. David Smith, head of the Texas Tech University Health Science Center in Lubbock and former head of TDH, told the Comptroller's review team that insuring segments of the Border region's uninsured population would bring much relief to the region's health care delivery system.20

Children's Health Insurance Program

The federal Children's Health Insurance Program (CHIP) could be an important tool for increasing the level of private insurance along the border. CHIP, created by Congress in 1997, subsidizes insurance for children with family incomes below 200 percent of the federal poverty level. Unlike many programs, CHIP is intended only to purchase insurance, as opposed to providing direct services. More flexible than traditional Medicaid, CHIP emphasizes family and employer contributions and is designed to promote shared responsibility and private contributions.

In Texas and other states, debate continues over the appropriate strategy to expand children's insurance. For example, CHIP could be used to fund additional insurance through a new, state-sponsored plan, through Medicaid, through private employer-sponsored plans, or a combination of any of the approaches. Lacking data on the success rates and costs of various options, most states have been slow to implement CHIP-funded programs.

CHIP was designed in part to encourage innovative ideas such as premium "credits," which parents could use to purchase children's insurance in the market. Federal officials stressed that states were free to test a variety of approaches with CHIP funds to see what strategies worked best for their populations.21 Pilot programs would help a state insure children immediately, without locking states into long-term commitments to programs that may not serve particular state needs.

Mexican Health Care: A Constitutional Right

The Mexican Constitution deems health care a fundamental right.22 The federal government owns and operates most of the country's health care infrastructure, including hospitals and primary care facilities.

Mexico's health care system can be described as "quasi-socialized," since it is funded with employer-paid premiums as well as taxes. Mexican employers are required to cover their employees under the Instituto Mexicano del Seguro Social, which covers private-sector employees, retirees, and their families. Federal employees are covered under the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, and state and local governments operate their own employee insurance systems.

All of Mexico's compulsory insurance programs cover care through the government's network of providers and facilities. Employers may also purchase private insurance, covering care by private providers, but this is in addition to the compulsory government program.

The Mexican government also operates the health care system for the uninsured, called the "open population." The open system includes both primary care and hospitals, including Mexico's major health institutions.23

Approximately 30 percent of Mexicans, generally middle- and upper-class individuals, opt for private health care, often in addition to their guaranteed public benefits. Some 70 percent of private providers offer basic care only--most of Mexico's advanced medical facilities are government-owned.24

Private health insurance is a new but growing industry in Mexico. The industry more than doubled the number of policies sold between 1987 and 1989, from 242,000 to 533,000.25 As the number of policyholders grows, the market should become more sophisticated, profitable, and desirable to foreign investors.

Binational Cooperation

Joint public health efforts teaming Texas experts with their Mexican counterparts can make a lasting difference, saving dollars, time, and lives. Unfortunately, most "technical assistance" of this sort relies on shoestring budgets, surplus equipment, and, all too often, the generosity of staff to provide lodging and meals to foreign visitors.

All the same, U.S. personnel gain a greater understanding of cooperative mechanisms for disease surveillance and treatment by experiencing first-hand the Mexican health care system and its strategies of health care delivery. Mexican personnel receive laboratory and computer training as well as exposure to U.S.-style managed care.

As Mexico boosts its ability to diagnose and treat diseases, the U.S. health care system could see fewer patients with intractable health problems, especially in the Border region. Furthermore, improvements in detection and disease surveillance in Mexico help U.S. health officials by yielding early warnings of disease outbreaks.

For more than four decades, Mexican and U.S. health officials have collaborated to various degrees. In 1942, the U.S. government asked the Pan American Health Organization (PAHO) to help coordinate venereal disease controls on the U.S.-Mexico border. This effort started the PAHO field office in El Paso, serving the 10 U.S. and Mexican border states by conducting workshops, seminars, and an ongoing epidemiological surveillance program along the border. Another group, the U.S.-Mexico Border Health Association, created in 1943 as an arm of PAHO, encourages communication among border health care providers, in part through an annual international meeting.

Another collaborative effort, the Border XXI program, is a "binational interagency program aimed at protecting the environment and environmental health while fostering sustainable development in the U.S.-Mexico border area."26 Objectives include decentralization of border decision-making, public involvement, and increased U.S.-Mexico cooperation. In 1992, environmental officials for both countries released the Integrated Environmental Plan for the Mexican-U.S. Border Area. In 1996, the second stage of the plan, Border XXI, included environmental health and natural resource issues.

The U.S.-Mexico Binational Commission (BNC), a forum established by the two countries in 1977, allows for regular exchanges between cabinet-level officials and their staffs on a range of issues critical to U.S.-Mexico relations. The health secretaries of both countries participated in the BNC for the first time in 1996. Begun by U.S. President Jimmy Carter and Mexican President Jose Lopez Portillo, it was formalized by Presidents Ronald Reagan and Lopez Portillo in 1981. Its original focus was on trade and international relations, but it has since expanded to include 14 working groups such as environmental cooperation, agriculture, business development, fisheries and tourism, health, labor, and trade and investment. The health working group has four subgroups: smoking cessation, women's health, migrant health, and HIV/AIDS.

Sometimes, an emergency underscores the importance of smoothly teaming U.S. and Mexican resources. In fall 1996, the Texas coast fell victim to a "red tide," a large bloom of the Gymnodinium breve, which gets its name from the red tinge it casts on water.27 This naturally occurring algae can kill fish, poison shellfish, and cause respiratory, eye, nose, and throat irritation for humans. Human consumption of shellfish contaminated by red tide can lead to neurotoxic shellfish poisoning. Although infected waters can be visible, layers of clear water can cover the red tide. The Texas seafood and oyster industries suffer substantial losses when waters are closed due to red tide contamination.

When Texas health officials contacted their counterparts in the Mexican Gulf Coast state of Tamaulipas to warn them about the red tide, Mexican officials said that they could not confirm its presence because they lacked equipment to perform the diagnostic tests. TDH staff needed to know the extent of the bloom to gauge how long it might last, so they headed to Mexico the next day. They worked alongside local and state health professionals from Tamaulipas and showed them how to administer the test. When they departed, the Texas staff left behind extra test kits so that their Tamaulipas colleagues could conduct the test when needed, improving the ability to monitor red tide along the Gulf Coast.

In 1996, the Migrant Health Subgroup formed a Binational Health Professional Exchange between U.S. and Mexican health care professionals.28 Participants hope to extend funding past 1999 and increase the number of sites participating in the exchange. In fall 1997, six Mexican delegates, three from Jalisco and three from Coahuila, joined staff at migrant health clinics in Colorado and Washington State for a two-week exchange. The U.S. delegation went to work with health care providers in Jalisco, Puebla, Michoacan, Guanajuato, and Coahuila. Members of the U.S. delegation said they gained a greater understanding of the health care that Mexican migrant farm workers receive at home, and a better understanding of the cultures from which they come. They were also impressed by the efficiency of the Mexican public health system, especially by how much it does with little money. From a clinical perspective, learning first-hand the types of medicines used to treat various diseases in Mexico allowed the U.S. providers to enhance the continuity of care for farm workers returning to the U.S.

Since 1995, TDH has led a successful binational attempt to control TB in the Border region and to create new mechanisms for binational disease control and prevention called Ten Against TB (TATB), a partnership of state and federal government as well as private-sector participants. Some Border counties' rates are more than four times as high as the 1997 statewide TB case rate of 10.3 per 100,000 residents.29 Central to the success of the initiative is the creation of lasting relationships among the states to foster the trust necessary to share information and to learn from differing treatment regimens and programs.

This must come from a true desire among public health professionals, policy-makers, and the private sector to address a problem of common concern and to attain real solutions. As part of its initiatives to unify surveillance and diagnostic capabilities in both countries, one of TATB's priorities is to lend computer and laboratory equipment to local and state health departments in Mexican border cities and states to increase their ability to diagnose, treat, and record TB cases.

A 1997 TATB survey found that many Mexican local health departments lacked such basic equipment as computers, microscopes, and safety hoods.30

TATB's related attempts to provide surplus U.S. equipment to Mexican health departments were slowed by side issues such as determining maintenance responsibility and insuring equipment, as well as questions on how to transport items across the border safely. In addition, the stewardship of state and federal funds for the equipment came into play.

Due to a general lack of equipment, Mexico has historically relied upon a "smear test" to diagnose TB. This test, while diagnosing the presence of TB, does not diagnose any strains that are resistant to antibiotics. Each diagnosed Mexican patient, in turn, receives a protocol of four antibiotics, an approach that can be more harmful than no treatment at all because strains of TB can develop antibiotic resistance merely from exposure to the drug.

The cluster of infants born with brain defects in Cameron County in the early 1990s spawned a number of surveillance and monitoring activities. The projects, housed within TDH's Texas Birth Defects Research Division, include cooperative endeavors with Mexican sister cities to collect and share data and information. The key to this process is to ensure that data collection and surveillance systems in both countries are compatible in how they record information.

Some policy-makers contend that state and federal funds used in Mexico can have a greater impact on health in the U.S. than certain funds spent domestically. Others disagree, saying that U.S. funding should be spent solely on U.S. soil.

While the basic premise of spending state funds in Texas is sound, reaching the root of many public health problems requires the direct involvement of Mexico. Furthermore, in some cases, allocating certain funds to help Mexico address the root causes could be more cost-effective than using the funds to treat the symptoms of the problem as they are manifested in Texas. For a mosquito-borne disease such as dengue fever, spending funds to eliminate the source of mosquito breeding grounds in Mexican states could keep the disease from spreading north.

Exchanges benefit health outcomes in both countries. Increased efforts to remove barriers and to expand and institutionalize programs contribute greatly toward improved health in the Border region.

Trends in Binational Health Care

Some U.S. companies along the U.S.-Mexico border have begun to cover health care services received in Mexico. While looking for lower cost health care, the companies also want to control costs and ensure quality care.

For nearly two decades, the Western Growers Association, an agricultural trade group, has provided benefits in Mexico and even operated its own managed care network in Mexico. More than 14 percent of the 70,000 people covered by the association seek care in Mexico. Of those, 80 percent are U.S. residents, and the rest are dependents residing in Mexico. The plan offers a financial incentive for members to receive care in Mexico: patients must pay 20 percent of their cost of care for services provided in the U.S., while care provided in Mexico requires a $2.50 copay per visit.

Individual companies also provide health coverage. In one survey, some 30 of 39 companies in Brownsville, El Paso, McAllen, and San Diego, Calif., reported covering employee health care services received in Mexico. Three plans allowed only for emergency care, and others had restrictions on the type of care received or the facility used.31

A survey of medical care providers in 16 Texas counties on the Mexico border looked into the use of U.S. primary care physicians, specialists, and dentists by Mexican nationals residing in the Texas Border region.32 Of the providers responding, 85 percent reported seeing Mexican nationals as patients. Of those who did not see Mexican patients, most were public providers who were prohibited from using state or federal funds to treat Mexican nationals. Among physicians who treated Mexican nationals, 72 percent said they were fully or partly paid in cash. Of Mexican nationals seeking health care in the 16-county region, more than 78 percent lived in cities on the Mexican side of the border.

Mexican residents who purchase private insurance can obtain benefit packages that cover services provided in the U.S. In some cases, the package may cover care only at specific U.S. facilities.33

In 1997, the Mexican government began offering Mexican nationals and those of Mexican descent residing in the U.S. the opportunity to buy health insurance through the Mexican social security system.34 A family qualifies for hospital and maternity care, doctor visits, lab work, and medicines for $300 a year. But services must be delivered in Mexico. U.S. workers with uninsured family members in Mexico benefit most, but others targeted by the effort include legal Mexican immigrants in the U.S. who find it difficult to obtain health coverage. The program also has been opened to people of Mexican origin who are not Mexican nationals.

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