Symposium on Border Health - February 2007
By Ken Ortolon
It was once described as a "slowly ticking time bomb."
In the late 1980s, a combination of high poverty rates, rapid in-migration from Mexico, high rates of communicable diseases virtually unknown in other parts of the United States, and the proliferation of substandard housing projects called colonias that lacked adequate water and wastewater facilities was transforming the United States-Mexico border region into a public health crisis ready to explode.
Then in 1988, at the urging of county medical societies along the Texas border and the Texas Medical Association Council on Public Health, led by Laurance N. Nickey, MD, of El Paso, TMA launched a campaign to take border public health concerns to elected officials in Austin and Washington, D.C. Within six years, TMA had organized a series of multistate conferences that looked at the health problems afflicting the entire United States-Mexico border and successfully lobbied Congress to create a binational border health commission to begin addressing those issues.
It would take another six years to get the United States-Mexico Border Health Commission organized and into operation, and many of the conditions that existed in the 1980s still plague the border region. But public health leaders say TMA's efforts have had a dramatic impact in raising awareness of border health concerns among the medical communities, public health agencies, and elected officials on both sides of the border.
"TMA has played a crucial role in shining a light on the U.S.-Mexico border area and, in particular, the Texas-Mexico border area," said Eduardo Sanchez, MD, MPH, former commissioner of the Texas Department of State Health Services (DSHS).
Perhaps most important, says Dr. Nickey, a former director of the El Paso City-County Health District, is that TMA recognized that cooperation among the two nations, the six Mexican border states, and four U.S. border states was essential "to have a safe and healthy border."
Facing the Challenge
TMA's active involvement in border health concerns began in 1988 when the TMA Council on Public Health determined that the association was in a unique position to address border health problems. At the council's urging, TMA in August 1989 joined with the state health department to host the first in a series of border health conferences. Those conferences brought together practicing physicians, state medical associations, government officials, national and international health organizations, medical schools, and the American Medical Association to begin to examine the causes of and potential solutions to the unique health problems facing the border.
Following two more conferences - one hosted by the California Medical Association in San Diego in 1990 and another again hosted by TMA in the Lower Rio Grande Valley in 1991 - participants began working to create a binational commission that could pull together the expertise and resources of both the United States and Mexico to address border health issues.
With the aid of AMA and the California, Arizona, and New Mexico state medical associations, TMA was instrumental in passing legislation authorizing President Bill Clinton to conclude an agreement with Mexico to create the commission. It was charged with assessing the public health problems on the border, coordinating responses and educational efforts recommended by the assessment, researching health issues along the border, and providing financial, technical, and administrative assistance to public or private entities to address the problems.
But the legislation was only the first step. It would take six years of lobbying in Washington and diplomatic efforts with the Mexican government before the commission would become a reality. In July 2000, the U.S. Secretary of Health and Human Services and Mexican Secretary of Health finally signed an international agreement formally creating the commission.
Since then, the commission has focused funding and other resources on several projects to improve health along the U.S.-Mexico border. They included a $5.4 million grant to the commission from the U.S. Department of Health and Human Services to enhance early infectious disease surveillance capabilities in the six Mexican border states. The commission also was instrumental in developing a binational tuberculosis (TB) referral and case management program to make sure TB patients traveling between the two countries receive necessary care.
Dr. Nickey says the commission's most important accomplishment may simply be to facilitate communication across the border.
"Getting people involved in public health and prevention to talk to each other, to visit with each other, to accomplish things that hadn't been done before in a binational way" has been critical, he said.
Dr. Sanchez, who sat on the commission in his capacity as Texas health commissioner, agrees. The commission has created a "forum for discussion" around some traditional public health issues, such as TB, but also has facilitated responses to emergency concerns, such as bioterrorism preparedness, he says.
Uniting Border Doctors
While TMA's early efforts to tackle border health issues focused on public health, border physicians also recognized that access to care was a major problem. To address access issues, TMA helped create the Border Health Caucus - a coalition of physicians along the 1,000-mile Texas border - in 2001 to tackle a wide range of issues impacting health care access.
El Paso nephrologist Manny Alvarez, MD, caucus chair, says the impetus for creating the group was a realization that physician payment issues under government programs such as Medicare and Medicaid were hurting the border area's ability to attract and retain needed specialists.
The group's first foray into the political arena resulted in increased funding under Medicaid for pediatricians doing newborn wellness care. In 2003, the caucus played a major role in passing medical liability reforms that capped noneconomic damages in liability cases. The group enlisted physicians throughout the border region and South Texas to participate in a Day of Awareness that called attention to the high medical liability premiums paid by border area physicians and the rising number of frivolous lawsuits against them.
The caucus also has been active on the federal level, playing a vital role in staving off projected cuts in Medicare physician payments that could have had a devastating impact on border area physicians and their patients.
Dr. Alvarez says the group will turn its attention in 2007 toward further improving access to care. "Every Texan should have a primary care physician, in other words, a medical home," he said.
To accomplish that, the caucus wants state lawmakers to boost Medicaid and Children's Health Insurance Program physician fees to encourage more doctors to accept patients under those programs. Also, Dr. Alvarez says it is important to find innovative ways to provide coverage for the uninsured, which make up a large percentage of the patient population on the border.
One idea the caucus is looking at is so-called three-share programs that split the cost of coverage among individuals, their employers, and the state or federal government. States such as Massachusetts and Oregon already are pioneering such programs, he says.
"I want to find a formula that works and push it so that every Texan has medical coverage," Dr. Alvarez said.
Eyeing the Future
More than 18 years after TMA's border initiatives began, Drs. Nickey and Sanchez say much has been accomplished. Disease rates, particularly those communicable diseases prevented through vaccination, are going down, Dr. Nickey says.
"We very seldom see diphtheria. We once in a while will see a little outbreak of whooping cough," he said. "Tetanus is something that has all but disappeared except in rare circumstances."
But TMA and public health advocates have to remain vigilant, Dr. Nickey adds. "TMA's efforts have been very positive and very forward thinking, and it needs to continue. It can't stop, because every election you get a whole new set of people who have to understand the problems. They have to understand that this is an extraordinarily fluid border, and infectious diseases don't stop on one side or the other."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or email Ken Ortolon.
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