One Physician's Vision of Border Health is Now Binational Reality
Public Health Feature -- July 2001
By Laurie Stoneham
To look at him, you wouldn't know that Laurance N. Nickey, MD, is a physician warrior. But this eloquent retired pediatrician and lifelong resident of El Paso is indeed a tenacious soldier. He has been fighting to get the public health needs of the border region of Texas noticed and safeguarded for decades.
For Web sites relating to border health, see July 2001 Med Bytes.
And those years of dedication working in both private practice and in the public health sector have paid off. Some 15 years after envisioning an organization dedicated to overseeing the health needs of the citizens on both ides of the 2,000-mile order that separates the United States from its southern neighbor, Dr. Nickey's dream is fully operational.
The drive to create a binational commission to address border health issues was spurred in 1989 when the Texas Medical Association and the Texas Department of Health (TDH) hosted a Border Health Conference in El Paso. (See "Back to the Border," November 1999 Texas Medicine , pages 34-45.)
Physicians, along with local, state, national, and international government officials, and representatives from medical schools and medical associations from New Mexico, Arizona, and California, and the American Medical Association, attended. Their hope was to carry out a mission that would bring the basics of public health -- clean water, proper disposal of waste, and improved health care -- to the region. The plan was to urge Congress to establish a U.S.-Mexico Border Health Commission. That became a reality in 1994 when then-President Bill Clinton signed legislation creating the binational commission.
After a delay in appointing the commission members from Mexico, the commission held its first official meeting in November of last year. Since then, it already has begun to make substantial progress in meeting its mission: "To provide international leadership to optimize health and quality of life along the U.S.-Mexico border."
The vision is for the United States and Mexico to work together to improve the health, reduce disparities, and enhance the quality of life for all of the people living in the border regions.
And this is obviously no small feat, given the countries' vast language, cultural, economic, and social differences.
The work is of vital importance not only to the border but also to the entire state of Texas and, indeed, the United States. Recently appointed commission executive director for the U.S. section, Russell Bennett summarized the significance of the efforts: "The health of Texas is inextricably tied to the health of the border and to the health of Mexico."
More than a dividing line
The region encompasses 200 kilometers on either side of the U.S-Mexico border between Brownsville and San Diego. Six Mexican and four U.S. states butt against each other in an area with an estimated population of between 11.5 and 12 million people. The Rio Grande River defines the 1,200-mile Texas-Mexico border. Most of the population resides in seven pairs of sister cities that make up the major crossing areas between the two countries. (See " Major Border Sister Cities .")
Dr. Nickey described the region: "It's the busiest border in the world. This past year, more than 400 million legal, northbound crossings were made."
Based on current trends, the region's population is expected to double in the next 25 years. "That's 23 million people. We've got to get a handle on this!" said Dr. Nickey. "We're already behind the curve. We can't sit back and rest on the laurels of what has already been done; to do so would be preposterous. This growth is not going to stop."
U.S. Sen. Kay Bailey Hutchison (R-Texas), who has been instrumental in both the creation and funding of the border health commission, described the health, economic, and environmental status of the area. "According to the Texas comptroller, if the Texas border were a state, it would rank first in poverty and second in deaths from hepatitis. The tuberculosis rate is three times as high as the national rate. There are environmental nightmares in many of the colonias : no running water, lack of sewage disposal facilities, and inadequate drainage. It is clear that health care providers and residents face health threats unknown elsewhere in America," she said.
"We don't keep tuberculosis on one side and measles on the other. It is an enormous public health challenge," said Dr. Nickey, the recent recipient of the Texas Public Health Association's James E. Peavy Memorial Award for Distinguished Contributions to Public Health in Texas.
The border region has been undergoing tremendous population growth since the mid-1960s when the Mexican government established a Border Industrialization Program to provide jobs and stimulate economic growth in its northern states. The program encouraged foreign companies to build assembly operations, known as maquiladores , to finish their products for exportation.
The Texas State Comptroller's Office figures indicate that total maquiladores employment rose from 67,000 in 1975 to nearly 900,000 by the end of 1997. In Juarez, across from El Paso, the number of maquiladores workers increased from roughly 20,000 to 191,000 during the same period.
Population growth alone has placed enormous pressure on the public health and environmental infrastructure, says R.J. Dutton, PhD, director of the Texas Department of Health Office of Border Health. "Environmental degradation, community sanitation problems, waste water, lack of clean drinking water, and solid waste problems have contributed to concerns about infectious diseases like hepatitis A, dengue fever, and tuberculosis," he said.
An operating framework
The border health commission comprises two sections of 13 commissioners each. Dr. Nickey is one of the two commissioners from Texas appointed by the president of the United States. (See " U.S.-Mexico Border Health Commission .") The organization has five key functions.
Conduct needs assessments, investigations, and research
This is an effort to measure the same health indicators in both countries and track progress toward improvement. Based on the U.S. Healthy People 2010 initiative, the commission has begun the Healthy Border 2010 program, which identifies various indicators dealing with infectious and chronic diseases and access to health care. For example, diabetes mortality rates and case rates of tuberculosis (TB) are indicators that will be measured and tracked. "With the Healthy Border 2010 program, we're going to provide a series of objectives by which we can measure progress over time and let the communities choose themselves what they think is most important to work on," Mr. Bennett said.
To have meaningful data, the commission is working on standardizing data sets with Mexico and the U.S. states. An early disease priority is TB, and Mexico tracks it differently than the United States does. Standardizing data collection and how it is applied will allow the information to be tracked and compared in a similar fashion in the two countries.
Provide support (financial, technical, and administrative to other entities
While the commission is not designed as a funding source or policymaking body, it is dedicated to identifying and extending the efforts of other best-practices models. Speaking to the TMA Council on Public Health during TexMed 2001 in Houston in May, Mr. Bennett said two programs that hold tremendous potential to be carried to other parts of the region have been identified. One is a folic acid program in Nuevo Leon, and the other is a children's data collection effort under way in Yuma, Ariz. In addition, the commission also is pulling together a summary of all health regulations and laws in both countries.
Carry out health promotion and disease prevention
The commission will design and develop health educational material and videoconference programs to offer to interested communities. Initial topics to be covered are TB, immunizations, substance abuse, and prevention of HIV/AIDS.
A vital part of this effort, according to Mr. Bennett, will be "harmonizing information about all of these topics so the people can get the same messages from the ministry of health in Mexico and from our departments of health on the U.S. side. We think that by having common messages, we're going to have a stronger educational component."
Miguel Escobedo, MD, director for TDH Regions 9 and 10, spearheaded a binational initiative known as Project Juntos in El Paso 10 years ago. With the help of health officials in Juarez and funding from the Centers for Disease Control and Prevention (CDC), Project Juntos focuses on the screening, identification, and treatment of people with TB or at risk for contracting the disease. The program pioneered the use of a binational TB card that allows individuals to receive ongoing treatment on both sides of the border.
A binational TB card program is being developed in San Diego-Tijuana; El Paso-Juarez; and Chicago-Los Altos, Jalisco. (Chicago has a large number of TB cases because it is the destination of migrant workers from Jalisco.)
Establish a coordinated information and communication system
Working with The University of Texas-El Paso, the commission has started a pilot project to develop a geographic information system (GIS). The binational, borderwide digital maps will show the location of health facilities and other assets on both sides of the border. "As we move forward, we will be able to put the Healthy Border 2010 data on the GIS system," Mr. Bennett said.
The organization also is establishing a second Web presence. In addition to the Web site www.borderhealth.gov, www.borderhealth.net will provide free e-mail addresses to everyone involved in border health so they can communicate among themselves on a regular basis. "E-mail through borderhealth.net can give them daily contact and should help surveillance activities and promote the sharing of information across the border," Mr. Bennett said.
Collaborate with other organizations involved in public health activities
The commission will be working with and sharing resources with existing entities such as the Pan American Health Organization. "They will support us with a lot of research," Mr. Bennett said. "They have an outstanding diabetes project that's working with CDC and other projects and research, the result of which will help guide some of our actions."
The same sort of collaborative working relationship has been established with the U.S.-Mexico Border Health Association.
According to Dr. Nickey, 104 agencies located in the border region have something to do with health. Part of the commission's work will be to synthesize the efforts of these various agencies to produce measurable public health improvement results.
All is not smooth sailing, though. Communication, cultural, and technological barriers must be overcome for the commission to work efficiently on both sides of the border.
Then there are matters of communication technology. Frequently, the health offices in Mexico do not have enough telephone lines. Mr. Bennett was told that the health department in Matamoros has a staff of 300 people but only three phone lines.
The Office of Border Health in Texas is assisting these facilities to buy computers and install telephone lines for dedicated Internet connections.
Equipment shortages of all sorts are typical. "Our sister-city public health departments in Mexico have dedicated staff and a lot of field workers to go out into the community and talk about prevention of things like dengue fever. But they don't have sprayers to kill the mosquitoes," Dr. Dutton said.
"When you really get down to the nitty-gritty of things, it's not just a matter of setting policy, it's actually going and getting their facilities more telephone lines or doing whatever is necessary so we can have better surveillance activities and more cooperation between the authorities on both sides," said Mr. Bennett.
Charles E. Bell, MD, executive deputy commissioner of TDH, said, "Improving communications will help in a number of areas: addressing standard data definitions and collection methodologies, joint disease surveillance, professional and academic exchanges and training, and health promotion and education. The border health commission will be an integral part in making these goals a reality."
Hilda Davila is director for America of the General Direction for International Cooperation at the Federal Ministry of Health in Mexico City. This agency deals with international affairs and projects regarding health issues. Ms. Davila expressed Mexico's commitment to this effort. "As environmental and health problems recognize no borders, binational cooperation is key to developing a strong communication and information system along and across the border," Ms. Davila said. "We will set measurable objectives for health improvement and will advocate for the necessary resources to address health problems at the border."
Of statewide importance
"The border is really porous," Dr. Escobedo said. "People travel freely across the border, together with any infectious or chronic diseases they may have and any social problems that manifest in health problems. And people who have been exposed to these diseases, including TB and even malaria, can show up on your doorstep in Dallas or in Austin," he said.
Eduardo Sanchez, MD, chair of the TMA Council on Public Health, says some physicians may think the border health commission does not pertain to them. "There's probably not a city in the state of Texas where there is not an impact of folks who are coming across the border. This affects the entire state," he said.
"Improved health status along the border will improve the health status of Texas as a whole," said Dr. Bell, who is serving as Texas health commissioner while that position is vacant.
Long road ahead
Dr. Nickey is a sage soldier. He understands that a long road stretches ahead. "This is a golden opportunity, but I think everybody understands that for a binational commission to get going, it's going to take five to 10 more years of good, hard work. It just takes that long," he said.
While the hard work has just begun, it's ironically long overdue, Dr. Nickey believes. "We give hundreds and hundreds of millions and billions of dollars away to Pakistan and Afghanistan and every other 'stan' in the world, and yet we're just now beginning to help our neighbors who live 100 yards away from us," said Dr. Nickey. "This is incredible. These are our neighbors, our colleagues, our relatives; these are our business and medical associates.
"You have got to do it eye to eye, person to person, equal to equal. This has got to be an equal partnership," he added.
The warrior is still on the battlefront.
Major border sister cities
U.S.-Mexico Border Health Commission
TMA efforts to establish the U.S.-Mexico Border Health Commission
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