The Southern Exodus

Is Seeking Health Care South of the Border a Healthy Practice?

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Public Health Feature -- December 2000

By Laurie Stoneham
Contributing Editor

No antibiotic known to man can stop the resistant strain of Pseudomonas aeruginosa that has begun appearing in South Texas. It eats away at human flesh. "It's an excruciatingly slow and gruesome way to go," said Michael Jelinek, MD, an infectious disease specialist in McAllen. He's watched three patients die this year -- one man from Mexico lapsed into a coma as his leg slowly rotted away.

All of these patients had, over the years, taken antibiotics obtained in Mexico, with and without medical supervision. This self-medication and unsupervised use of antibiotics is contributing to a drug resistance problem "that's more serious than people realize," Dr Jelinek said.

But pharmaceuticals are cheap and easy to come by south of the border. So are walk-in medical, dental, and optometry care.

When 20-year-old Irma Rodriguez wanted contact lenses, she went to Matamoros. There, the eye exam and contacts cost about $90. At home in Brownsville, those same services would have cost double that.

Money was also the reason 21-year-old Isai Ramirez traveled to Matamoros to have all four wisdom teeth removed. There weren't any x-rays or fancy anesthetics used to stave off the pain. But the fee -- only $170 -- wasn't painful either. A few miles north, he would have paid a dentist roughly $700 and an oral surgeon perhaps as much as $1,000.

Just makes sense

"The border is an amazingly different place," said Laurance Nickey, MD, a retired pediatrician in El Paso. "There's no place else like it in the world. Here you have essentially a Third World country adjoining the most advanced, industrialized nation in the world."

Why people do what they do can be traced to economics, language, cultural comfort, and just plain convenience. Physicians and dentists treat walk-in patients, have evening hours, and are open on the weekends. Street-side pharmacies are open until late into the night.

Dollars and cents drive a lot of the decisions. Take El Paso, for example. With a population of some 750,000, it's not only the nation's largest city along the US-Mexico border, but it also has the largest population of uninsured persons in the country. The region's chronic unemployment rate hovers at close to 10%, and somewhere between a third and a half of the city's residents live at or below the poverty level, depending on who's counting.

A recent University of California at Los Angeles study showed that 37% of the people in El Paso County are either uninsured or underinsured. The rigors of applying for public assistance programs, including Medicaid, Medicare, and the Children's Health Insurance Program, are not worth the effort for many would-be applicants. The result is "underenrollment, underfunding, and underutilization" of the safety net designed to capture the indigent and working poor, says Jose Moreno, executive director of Community Voices, an organization dedicated to helping the medically underserved in El Paso.

So it makes sense for people who have no insurance and no other resources to go to a country where their native tongue is spoken, prices are cheaper, and care is easier to obtain. Dr Nickey said, "It's often a choice of whether to buy medicine or put food on the table." This is the reality of life on the border.

No picnic for physicians

Border communities have fewer doctors than other areas of Texas because practice conditions are tough. Salaries are lower, overhead is high, and staff is hard to recruit, train, and retain. Liability insurance is increasingly difficult to obtain and what's available is more expensive than in other parts of the state.

"Insurance companies don't want to insure physicians in this area because we treat poorer people who may be getting treated in Mexico, who may not be compliant with treatment regimens, and who are getting bombarded by lawyers seeking to make a living off malpractice suits," said Elaine Barron, MD, an El Paso internist. "It's no wonder physicians are leaving border towns for greener pastures in Texas and other parts of the country."

It's not uncommon for Dr Barron to compete with cultural belief in the power of the curanderos , faith healers who offer herbal preparations and old wives' tales as cures for most anything that ails a person. She says she respects the legacy of these native medicine people and does not intervene unless the remedies threaten to interfere with the clinical outcome. "It takes enormous amounts of time to educate patients and to teach them why, for example, they should take the prescribed medication for their rheumatoid arthritis, instead of Cat's Claw, a popular herb. And we don't get reimbursed for that time."

Easy to access

Mr Moreno believes access is the key dilemma. His organization, Community Voices, an initiative underwritten by the W.K. Kellogg Foundation, is dedicated to improving access to care and the quality of health care provided to the people of El Paso. In one of its successful strategies, Community Voices has enrolled 6,500 people in the El Paso First Network, a primary care plan. "This gives people a medical home," said Mr Moreno.

The El Paso Hospital District provides matching funds to pay for the services, and it's hoped that as many as 10,000 will be enrolled in the near future. Though valiant, this effort is only a drop in the bucket. Mr Moreno estimates 120,000 people need to be able to access health care services and affordable medications. And they do, in Mexico.

But Mr Moreno and Miguel A. Escobedo, MD, MPH, regional director for the Texas Department of Health, point out that a lack of continuity of care and complications in case management are among the major concerns with seeking treatment in Mexico. While a licensed Mexican physician's qualifications, skills, and certifications are similar to those of US physicians, according to Dr Escobedo, communication is difficult. Trans-border case management is complicated not only by language but also by the differences in forms, procedures, and systems used in the two countries.

More comfortable

Fernando Cespedes, MD, is a cardiologist in Matamoros. He says 25% to 30% of his patients come from the United States. "Most of my patients tell me they have a name here, but they are just a number over there," he said. He adds that his patients tell him they feel more comfortable asking questions about their illnesses and "they like that the doctor spends more time with them."

Despite these realities, Dr Cespedes, who estimates his services cost as much as 60% less than charges for the same services in Texas, says he has good relations with physicians in Brownsville. They refer patients back and forth across the border.

Another kind of drug trade

Irma Rodriguez is a waitress at a popular Brownsville eatery. She says winter Texans are always asking about the famed Garcia's -- the gift shop/restaurant/bar that's also a pharmacy -- on "The Strip" in Matamoros, across the border from Brownsville. US residents from all over the country stock up on medications for themselves and their neighbors at Garcia's and dozens of other drugstores that now dot the Mexico-Texas border and cater to American visitors.

El Paso pharmacist Barry Coleman, who owns pharmacies throughout El Paso, says the price differentials between the United States and Mexico can be startling. "I bought a 1-month supply of a national-brand birth control pill for $1.79 in Juarez. My cost for the same medication is $24."

Marvin Shepherd, PhD, director of the Center for Pharmacoeconomic Studies at The University of Texas College of Pharmacy, says the primary reason prices are dramatically cheaper below the border is that all major pharmaceutical companies have manufacturing facilities in Mexico. Labor is cheaper and the regulatory environment is different. "They don't have the FDA looking at everything they do. And while I'm sure the products are comparable in quality, I wonder what shortcuts they take in the manufacturing process."

Whatever the reasons, price differences can and do cause huge resentments. Mr Coleman recalls an incident when an older gentleman butted ahead of other people in line and demanded to know the price for a medication. Mr Coleman told him the price was roughly $85, which represented $5 above his cost. "At that point, he threw a crumpled piece of paper at me and said in a very loud voice that I was one of the worst, lousiest thieves he's ever come in contact with. He could get it in Mexico for $24. I felt awful, but there is nothing I can do about the situation."

Bringing home the drugs

A US resident is permitted to bring into the country a 90-day supply of pharmaceutical products for personal use. "You can bring in these quantities of 15 different drugs, go back an hour later, and bring in another batch," Dr Shepherd explained. "There are basically no limits. They sell amoxycillin like we sell Hershey bars."

For a product that's considered a "controlled" substance in this country, a prescription from an American physician is required, but US Customs officials do not check for that kind of documentation. There's no time. The US Customs Service documented 21.3 million pedestrian crossings and another 47.9 million cars and buses entering through the state's 13 land border points of entry in 1999. Another 3 million commercial trucks were northbound. By the way, Laredo is the state's busiest port of entry, with 6.5 million pedestrian, 1.45 million truck, and 6.9 million car crossings.

Beyond prices

Most experts contend the quality of pharmaceutical products in Mexico is probably comparable to US standards. However, Dr Shepherd points out the vast majority are not FDA approved, and there may be a difference in the excipients used, which could affect bioavailability.

He doesn't recommend that anyone switch back and forth between US and Mexican products for a variety of reasons, eg, there's no assurance of the product's safety, the dosage and strength may vary, and there is a proliferation of counterfeit drugs. The selling of placebo pharmaceutical products in look-alike packaging is a $3 billion to $4 billion industry worldwide, according to Dr Shepherd, and recent studies estimate that between 5% and 25% of that trade takes place in Mexico.

In addition to manufacturing issues, Dr Shepherd notes that record-keeping is minimal, written information about the drug or drug interactions is not provided, and, often, the drugs are not identified with labels. "It's a pharmaceutical mill down there," he said.

Growing resistance

Easy access to antibiotics is causing a widespread increase in drug resistance within border communities. This includes resistance to common bacteria and to a lesser extent to tuberculosis (TB), according to Dr Escobedo. He says resistant strains of TB are not tied so much to indiscriminant use of antibiotics as they are to the inconsistent use of the drugs used to treat the disease.

There is one exception, however. Rifampin, a high-powered antibiotic used to treat TB, is available in Mexico in combination with the drug trimetroprin. This mixture is sometimes used to treat urinary tract infections (UTIs), and abuse of this drug can lead to rifampin resistance. Dr Escobedo notes the problem is not widespread because it's not a well-known medication among the lay public and it's relatively expensive, as are most TB drugs.

When interviewed by Texas Medicine , Dr Jelinek was caring for a hospitalized patient who had treated herself for a UTI with penicillin from Mexico. The E coli bacteria spread into her bloodstream, and the 38-year-old woman went into cardiac respiratory arrest before falling into a coma induced by anoxic encephalopathy. If she survives at all, she will live in a vegetative state. "She thought she was doing herself a favor and saving some money. This is an extreme example, obviously, but it's the sort of thing that happens when people try to self-treat and self-medicate," Dr Jelinek said.

He says it's also common to see a youngster hospitalized for a ruptured appendix with a nonresistant, but still virile, strain of Pseudomonas aeruginosa . "The child has to be hospitalized for 7 to 10 days following surgery and be pumped with IV antibiotics to get rid of the bacteria."

Surviving the competition

How does an independent pharmacy stay in business in a border community with such stiff competition just a few miles away? It's not easy.

Mr Coleman owns seven stores in El Paso. All five of his children work in the business he's been in since 1960. They make it, he says, by having convenient locations in medical buildings, working very closely with physicians and laboratories, providing counseling services for diabetics and asthmatics, and offering services through Medicare and Medicaid insurance and welfare businesses that aren't available in Mexico.

The stores all have lower volumes, Mr Coleman admits. Some barely make a profit from year to year, and some don't make a profit at all. "My wife and I work here in the office, and we work cheap." Some years, he says, he makes less than the pharmacists who work for him, "but I love it."

Solutions

"Instead of pointing fingers, we need to communicate," Dr Escobedo said. "Physicians and health care officials in both countries need to work together."

Dr Barron believes that investments in the medical systems of border communities are needed. "We need to beef up the infrastructure for our physicians, county hospitals, and other facilities to provide greater access and higher quality care." She also thinks that enrollment procedures in public assistance programs need to be simplified to improve funding for and use of existing resources.

In addition to the local efforts of Community Voices in El Paso, the US-Mexico Border Health Association has established binational collaborations and reciprocal technical cooperation to disseminate information on border health issues and create effective network resources. The organization is part of the Pan American Health Organization, also headquartered in El Paso, which serves as a regional site for the World Health Organization.

Dr Nickey, who has lived in El Paso for 70 years, remains philosophical. "Texans have been going to Mexico for decades. I don't expect the practice to change. We just have to work within the system to give quality care on both sides of the border."

SIDEBAR

Mexican Pharmaceutical Laws

Many pharmaceuticals requiring a prescription in this country are dispensed as over-the-counter products in Mexico, including antibiotics, cardiac medications, antihistamines, antihypertensives, anti-inflammatory agents, antiulcer medications, and products containing estrogen.

Three classes of drugs in Mexico require prescriptions, which can be written by veterinarians, midwives, nurses, social services professionals, homeopathic doctors, dentists, and medical physicians. These regulated products include:

  • Group I: injectable narcotic analgesics.
  • Group II: benzodiazepines, antidepressants, sedative/hypnotics, amphetamines, and tranquilizers.
  • Group III: antidepressants, tranquilizers, and anabolic steroid products.

And while a prescription is legally required for these classes of drugs, obtaining them without one is not impossible or even particularly difficult.

Source: "US vs Mexican pharmacies: competition at the US-Mexico border," US Pharmacist , 1997, Marvin D. Shepherd, PhD, RPh, The University of Texas College of Pharmacy.  

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December 2000 Texas Medicine Contents
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