Photo Credit: ICF

The National Strategy for Pandemic Influenza, released this May, confirms an understanding of health and borders long appreciated, but too often ignored, in the San Diego-Baja California binational region.  Controlling borders only slows the spread of health problems, it does not prevent them.[1]  Effective strategies and actions require participation of governments, communities, and programs working comprehensively together across borders.

Of course, the San Diego-Baja binational region needs no alarm over the possibilities of pandemic influenza to appreciate the challenge of cross-border health risks.  The Region’s realities are sufficient.  Yet, it faces a political and strategic stalemate in development of cross-border efforts to prevent and respond to ever mounting health risks.  From accelerating rates of infectious disease transmission to fears of bio terrorism, continued failure to act together across borders threatens to ravage the well-being of the binational San Diego-Baja economy and community.

Sounding the alarm and calling on leaders to participate in a binational strategy may appear too difficult in the present political and economic context.  Perhaps those who warned New Orleans about category 5 hurricanes for two decades before Katrina understand the frustration.  Today, the impact on the economy of ignoring health risks is already profound:  Rising health care costs for small and large businesses, lower worker productivity, and burgeoning fiscal burdens on strained public coffers.  Under the gleam of an otherwise prosperous region, disease risks are also widening beyond traditional at-risk groups, crossing the artificial barriers of social divisions and residential separation. Tomorrow, the acceleration of risks will have an even greater impact. 

The economies of the border region are simply too inter-dependent, too intertwined to have an issue such as infectious disease cast under the rug because it perceived to be too difficult or too large for effective action. Instead what is needed is co-operated binational action.

With a need so clear and even urgent, why is there so little concerted effort among the region’s leaders?  The answer is not that the problems remain hidden.  Numerous studies document a disturbingly wide array of health risks and challenges.   The U.S.-Mexico Border Health Commission (USMBHC)’s Healthy Border 2010 Program, for example, describes twenty or so health problems that represent preventable threats to border health and well being.[2]   The region’s lack of institutional capacity in healthcare programs is also well-documented.  The Border Counties Coalition recently concluded that, if the border region as a whole was considered a 51st state, it would possess the lowest level of health and well-being in the United States.[3] 

The missing ingredient in this collective understanding of binational health risks is the persistent failure of political and institutional leadership to move from knowledge to action.   Broad political and fiscal problems in the cities and counties on both sides of the border may be easily blamed.  Institutional impediments on either side of the border also preclude concrete steps to address priority needs, especially when resources must be committed on the other side of the international line.  So a stalemate persists.

Yet, perhaps the most evident barrier to action is a self-reinforcing one.  Health programs and services suffer from fragmentation of effort into discrete, small activities that focus exclusively on one disease, treatment, or subgroup.  Fragmentation reproduces limited capacity, even when a program is successful within its own objectives.  Facing what appears to be a wide array of intractable problems and insurmountable needs, financial supporters turn to favorites – the targeted disease that is politically visible at the time, a particular institution that does good work, a group that has effectively mobilized, or a medical approach that fits with the interests of the supporting agency or group.  While each effort in itself is laudable, the result is a stalemate of too many investment choices, missed opportunities to obtain advantages from a comprehensive effort, and lack of a vision of public and private leadership that could bring significantly greater health resources to the binational region.

Fragmentation of programs and institutions also make it much more difficult to mobilize and sustain policy leadership in the large health risks and healthcare challenges in the region.  Small, relatively weak border health programs and institutions make it much more difficult to “go to scale,” generating sufficient support and financial resources to reach a level of operation that could begin to improve health conditions at a community-wide level rather than only for a small number of individuals.

Delay in challenging and overcoming the political and economic stalemate on a comprehensive health care agenda for the binational region is no longer reasonable.  Reliance on programs as they exist is also no longer acceptable.  The answer is not necessarily to find new money to expand existing programs, nor is to wait for federal action on health care from Washington, D.C., or Mexico City. The need to promote local planning and action is essential.  Throughout the region, health care providers and community leaders understand and recognize that concerted and collective action is needed in support of a broad-based, bold policy agenda, requiring innovation and strong political leadership on both sides of the border.  They recognize that the public sector, in addition to playing a critical role in supporting the agenda, will need the private sector and the philanthropic sector to play a leading role because they have the capacity to work across the border, forming and supporting programs and initiatives that actually stretch across the borders to work with communities and institutions that also work across borders.

Community of Cañón Los Laureles. Photo credit: ICF

The binational region urgently needs a Cross-border Health Summit.  The Summit should give voice to the urgency of the call for leadership on health issues to move beyond documentation of problems and near heroic annual struggles to keep benefactors willing to support specific programs.  The call for leadership in a region renown for its entrepreneurship and innovation should focus on the private sector, including business, philanthropy, and community-based as well as  service organizations (Rotary, Lions, Shriners, etc).  They need to join the public health sector and contribute their skills and capacities to shape a comprehensive, integrated approach.  Private businesses and philanthropies have systemic opportunities and obligations within this area, not just to run parallel to government efforts but to carve out new mechanisms of system delivery that governments are ill-equipped to even attempt.  Community-based organizations need to help design comprehensive approaches to healthcare delivery that transcends their own initiatives that remain disease and subgroup-specific. 

Public sector leadership should help this innovative campaign to expand the scale of health innovations, striving to reach a level of self-sustaining impact on the entire region.  Public leadership, however, will have to overcome its own limitations.   Strategies to prevent and mitigate health risks in a cross-border region must overcome a systemic problem – a fundamental institutional mismatch between the way in which people live their lives (in communities that cross the borders) and the jurisdiction, authority and financial support for most health programs that rests with separate government entities.

In a binational region where no single place – a city, county, or country -- encompasses the normal routine of the people who live in local communities, the primary challenge to building an effective public health system and generating political support is to generate innovative organizational approaches.  Too much reliance on federal governments in Washington, D.C., and Mexico City or state authorities in Sacramento and Mexicali  only reinforces the leadership stalemate, in effect vetoing innovations that could stretch across borders to reach communities that share a common destiny.

The time is right, the risk is urgent.  Throughout the region, healthcare is in such disarray, and health conditions so dismal for so many, that even a willingness to spend more money on health would be counterproductive unless the cross-border community engages in an examination of common priorities and strategies.  A successful summit would call upon the region’s health, financial, and political leaders to identify the binational region’s health priorities, not just a list of needs.  It would search for and find innovative solutions to problems arising from the institutional mismatch of cross-border authorities.  And, it would lay out a roadmap to scale-up the array of energetic, small projects into a coordinated campaign that pushes the binational community to dramatically reduce its health risks on both sides of the border. Of course, cross-border collaboration will be a key to the success of such an endeavor.

This Report is a call to action and an invitation.  It lays out the groundwork to begin a binational region-wide dialogue on a comprehensive health strategy.  It also invites leaders throughout the region to step forward, to identify partners, to initiate action.