Photo Credit: Galatea Audiovisual

One might excuse an outsider’s surprise to learn how familiar and extensive the health problems along the U.S.-Mexico border are.  For years, health professionals and policymakers along the border have known, for example, that the U.S.-Mexico border has some of the most severe health conditions in the entire United States, and the weakest health infrastructure to respond to them.  For someone familiar with the region, however, it’s hard to find an excuse for failing to respond to these urgent threats. 

In March, 2006, the International Community Foundation (ICF) convened a group of binational public health practitioners from the San Diego-Baja California region to participate in a forum in order to discuss the health priorities in the region and to begin to identify ways in which working together across the border could help.  (See Appendix B for a list of forum participants).  The forum participants, who represented several of the most successful regional health initiatives, discussed the border’s more pressing needs and began to lay out strategies that have either worked on a small scale or that would be needed to significantly improve cross-border health conditions.  Clearly evident from the discussion was a solid understanding of the border region’s health landscape.  Equally clear, however, was uncertainty and hesitancy in how to engage a regional process that would both significantly increase investment in public health and health programs in the area and bring the cross-border communities together to build a strategy for identifying priorities and mobilizing necessary political and popular support.

Disease Risks

These practitioners’ experiences echoed the health problems that have been documented both in the San Diego-Baja California region and across the U.S.-Mexico border as a whole.  The immediate realities for many of the programs in which these participants worked involve a sustained increase in the incidence of infectious diseases.  The increase is occurring on both sides of the border and is fueled by the continuing movement back and forth of visitors, families, and workers. The forum’s participants frequently cited the prevalence of tuberculosis (TB) as a clear example of the cross-border risks they face daily.  The incidence of TB at the border among all counties is twice as high as elsewhere in the United States.[1]

The disease risk that generated special concern and interests among the participants from the San Diego-Baja California region, however, was the rate of HIV infection. Tijuana is a large metropolis whose population of approximately 1.5 million people, is being increased on a daily basis by the constant influx of migrants from all over Mexico as well as people being deported by the U.S. back to Mexico. It has been well documented that Mexican migrants, the vast majority of which are young men, engage in high risk behaviors at a much greater rate compared to non-migrants. Being away from home for extended periods, exposure to several sex partners, using sex workers, sharing needles or men having sex with men all increase with migration[2]. Although the “official” rate of HIV infection along the border in Mexico  is only slightly higher than the national rate (16.1 per 100,000 persons compared to 15.2 per 100,000 persons), the rate is increasing at a much faster pace than previously estimated.[3]  Men and women aged 15 to 49 years who are infected with HIV may be as high as one in 125 persons, which would place [4] Tijuana's HIV infection rate close to three times higher than Mexico's national average.[5]

The incidence of HIV/AIDs in San Diego County is also high.  At the beginning of the decade, San Diego had the sixth highest incidence of AIDS among California counties.  Although the incidence rate was well below the target set by the Center for Disease Control (CDC) for 2000 (39/100,000), its linkages with the higher incidence of AIDS in Baja California and its disproportionate impact on specific subgroups made it one of the prominent health issues along the border.  In a 2002 study, for example, researchers examined blood samples taken from 374 gay and bisexual Hispanic male participants (18-29 years old), 125 living in San Diego and 249 in Tijuana.  The study found that 35% of the men from San Diego and 19% from Tijuana were infected with HIV and had never been tested before.[6]  HIV infection also has a special impact on women.  Pregnant women can pass the virus on to their newborns.  A 2004 study conducted by UCSD found that pregnant women receiving care at Tijuana General Hospital, whose patients are mostly poor, had a 10 times higher rate of HIV infection (1.2%, or about 48 mothers a year) than among women receiving care from a UCSD medical group.[7]

The social sensitivities and potential stigma that too frequently are associated with individuals infected with HIV also made this an important topic among community-based healthcare practitioners.  Latino-focused AIDS education programs and other prevention efforts have uncovered cultural factors that affect the spread of the disease.  Talking about one’s sexuality, for example, is taboo in the Latino community.  As such, many of the educational materials may not be as culturally sensitive and linguistically appropriate for some sectors of the Spanish-speaking population, let alone meeting the needs of  new immigrants from regions of the country that speak Mixtec other indigenous Mexican languages.[8]  Clearly, language and cultural barriers exacerbate new HIV infections and AIDS cases, and further concentrates this fatal disease within neglected portions of border communities.

Beyond the risks of tuberculosis, HIV/AIDS, and other infectious diseases complicated by the back-and-forth movement across the border, health threats associated with non-infectious disease are also on the rise.  Today, the San Diego-Baja California border region and the state of California as a whole are facing alarming rates of obesity, diabetes and mental illness that disproportionately harm Latino youth.  The risk has dire consequences for the future of the regional economy.

The binational region’s future depends, in large part, on maintaining a healthy, productive workforce.  Whether the costs of illness are born directly by employers or shared generally among the public through increased taxes, the health of children and youth, and of new immigrants into the area, will have an impact on the success of current and future economic growth.  Yet, ominous signs warn about the growing incidence of obesity and childhood diabetes among Latino youth.  In the state as a whole, 24% of adolescents ages 12 to 17 are overweight or at risk of being overweight.  African American and Latino adolescents have higher rates than both whites and Asians.

Project Concern International’s “Ventanilla e Salud” Program at the Mexican Consulate in San Diego, an initiative supported by the California Endowment. Photo Credit: Miriam Hiel.

As a leading factor in the development of diabetes, obesity can kill.[9]  In Mexican border communities, diabetes is the third leading cause of death; on the U.S. side of the border, the prevalence of diabetes is even greater.[10]  As more first and second-generation immigrants from Mexico adapt their lifestyles and diets to the American way of life, diabetes has increased substantially.  The longer an immigrant lives in a U.S. community, the more they encounter cheaper, low-quality food and poor eating habits.[11]  According to a recent study by the CDC, with time these immigrants are more likely to become obese and develop diabetes, high blood pressure and heart disease.  The CDC study found that 22% of Mexican migrants that had been in the U.S. five years or more were obese, compared to 16.1% who had been in the United States less than 5 years.  As migrants stay in this country longer, diabetes rates rise from 6.9% to 7.5% and heart disease increase from 3.5% to 7.5%.[12]  The high rates of diabetes and hypertension in Latinos are also associated with a 50% higher rate of dementia or undiagnosed Alzheimer’s disease.[13]

Access Deficit

The forum participants, however, did not place any specific disease at top of the priority list of health intervention needs.  Reflecting similar perceptions documented by researchers all along the U.S.-Mexico border, these local professionals reported that regardless of disease, the inability to gain access to healthcare was the critical unmet need that affected the entire cross-border community, including residents, migrants, rich and poor.  The counties along the U.S.-Mexico border, where residents are most vulnerable to HIV/AIDS, tuberculosis, hepatitis and other infectious and non-infectious diseases, also have very low levels of health insurance and far fewer healthcare practitioners than the rest of the United States.

In San Diego County, although information on access rates is difficult to pin down reliably, various estimates show that 27 percent of residents are uninsured, the third highest percentage of all the counties in California.  In turn, the state has the highest uninsured rate in the nation.[14]  Across San Diego County, health coverage varies not only according to income, but also according to ethnicity and citizenship or immigration status.   In San Diego County, only 73% of Hispanic children had health insurance, compared to 94% of African-American and 93.4% of white children.[15] 

Lack of access to healthcare also disproportionately affects large subgroups of the region’s workforce.  In particular, a staggering 96% of migrant workers interviewed in Vista, California, reported that they had no health insurance.  Only 2% said they used employer-provided health insurance.  Nearly half of the respondents had not seen a physician in two years or more.[16]  All of the respondents said they were from Mexico and 49% were undocumented.[17] 

Evidently, along with the region’s fast changing demographic landscape, its health care needs are also rapidly evolving.  In addition to the wealth and opportunities available throughout the region, both sides of the border also share in poverty and poor healthcare.  Not surprisingly, the prevalence of infectious disease is greatest among the poor and those least able to receive medical care.  In Tijuana’s fast growing colonias populares or shantytowns, many still lack basic public utilities, making them vulnerable to infectious and otherwise preventable water borne diseases.  San Diego County faces similar challenges in many of its migrant communities.  Migrants living in worker camps are especially threatened and vulnerable to infectious disease.[18] 

The March forum participants also highlighted occupational injuries as an often neglected source of health problems in the region.  According to Don Villarejo, a UC Davis researcher, "It's well documented that farm workers suffer high rates of fatal and nonfatal work-related injuries and illnesses, but 70 percent of laborers hired to work on perishable crops in California lack any form of medical insurance.”[19]  Not surprisingly, the mix of low wages, no insurance, little access to health facilities, and physically hard work increases the occurrence of repeated injuries.  The migrant workers in this region, spreading out from the fields of San Quintin in Baja California to Escondido in San Diego’s North County, face a wide array of workplace hazards and occupational injuries ranging for physical injury, pesticide exposure and heat stress.   

Mexican migrant workers in Carmel Vallley, San Diego with Alejandra Ricardez, board member of the Oaxacan hometown association, COCIO (right). Photo Credit: ICF

The cost of these un-insured rates and lack of access to healthcare may be hard to document with precision, especially through the indirect impact on productivity and other costs to employers.  Undoubtedly, there is a significant human toll.  The financial costs, however, result from the combination of lack of access to healthcare, lack of insurance, and low per-capita income.  In one study, migrant workers’ sprains and strains cost the agriculture industry an estimated $1.266 billion in 2005 from lower productivity and lost hours of work.[20]  This mix of circumstances also contributes to the high cost of uncompensated care about which hospitals in border areas complain.  According to one estimate, the hospitals in the border counties on the U.S. side provide $800 million dollars annually of uncompensated care.[21]  It is not clear however what portion of this amount is due to care given to legal or undocumented immigrants without health insurance.

The healthcare access deficit in the binational region, however, is not limited to these familiar conditions and migrant workers.  Cross-border health care access and availability is a growing concern for the emerging California baby-boom population that is now approaching retirement.  With insufficient personal savings to maintain a desirable lifestyle in the state, many are increasingly looking to spend their golden years south of the border in Baja California.  At least part of the attraction is the proximity to San Diego and the availability of U.S.-based health care just across the border.  Their resettlement is creating a new twist to providing access to healthcare across the border.  Difficulties in crossing the border with long traffic delays and the higher costs of seeking care north of the border are also prompting a growing demand for health care services in Mexico.

For retirees who remain in San Diego and its surrounding counties, Baja California is increasingly a place to turn for more affordable dental care and prescription drugs.  The extent of San Diego area residents now relying on medical care in Tijuana is not well documented. In Los Algodones, a small Mexican border town located across the border from eastern Imperial County, thousands of people cross the border each year to receive primary care or homeopathic services, go to a dentist or an optometrist, or purchase prescription drugs from the more than 20 local area pharmacies.[22] Current FDA regulations allow U.S. citizens to purchase and re-import a three-month supply of prescription medications with a valid Mexican or U.S. prescription. For fixed income retirees, the cost advantage is clear. Prices in discount drug stores in Tijuana can be as low as 40% or even lower than the price for the same medication in San Diego.

While the prescription drug market in Baja California is more cost-efficient than in San Diego, the quality of healthcare and specifically drugs is less certain. The industry is far less regulated in Mexico than on the U.S. side of the border and Americans purchasing services and medication have, in some cases, been victims of fraudulent practices.  By law, prescriptiondrugs sold in Mexican pharmacies require a prescription from a licensed Mexican doctor. Yet some Tijuana pharmacies accept prescriptions from the U.S. and there are reported incidences where no such prescription is required.  Though many residents on both sides of the San Diego/Tijuana border may benefit from affordable medications, without accredited medical consultation the practice can lead to serious medical consequences. Existing policy leaves it in the hands of the consumers to exercise judgment and to follow the advice of their physician or pharmacist.

For the number of Mexican citizens living in San Diego without adequate health insurance, crossing the border back home is another increasingly viable option to access healthcare.  Similarly, a growing number of San Diego residents who have become border commuters, residing in Baja California but working in San Diego, medical insurance options now include plans that provide alternative, culturally competent medical care in Mexico as well as in San Diego.  The Mexico-based options are often much more affordable than similar arrangements in the U.S.  Although slowly developing, cross-border plans such as Servicios Medicos Nacionales, S.A., Access Baja HMO (a product of Blue Shield of California), Salud con Health Net and PacifiCare now may offer new ways to organize healthcare access in a crossborder community. Mexico’s Social Security system (Seguro Social) also sells an insurance product that covers the cost of health care provided in Mexico to a person working in the U.S. or their family members back home.

Not all borders in this binational region are international.  A growing number of San Diego’s workers now live in bedroom communities not only in Baja California but also Imperial and Riverside Counties.  A sizable number of San Diego’s North County residents also regularly commute north to Orange and Los Angeles Counties.  These residential-work patterns are defining new boundaries of community and economy that also influence health needs and programs.  Health issues and programs that respond to the entire binational region need to address this broader regional context requiring providers, employers, consumers and governments to look beyond traditional jurisdictional boundaries, regardless of whether the jurisdiction is a city, county, state, or national government. 

Pandemic Health Risks

In the midst of the national attention to pandemic influenza, the March Forum obviously recognized the new but critical need to upgrade the public health infrastructure in the region.  The San Diego-Baja California cross-border region, however, adds special features to the national strategy.  Within its boundaries, the region has the busiest land port-of-entry in the world, two international airports, both commercial and military seaports, and a cross-border rail transportation system.  On both sides of the border, this infrastructure is critical to the security of the region and its economic well-being.  Pandemic flu, which could cause nearly 40 percent of a region’s workforce to remain at home and also kill hundreds of thousands, represents perhaps the most plausible, catastrophic cross-border risk.

Informal housing, Cañon Los Laureles, Tijuana. Photo Credit: ICF

San Diego-Baja California is particularly vulnerable to the spread of avian flu because of the region’s high degree of urbanization and the large number of its people living in urban slums.  According to Tijuana’s planning agency, IMPLAN, about 30-40% of residential areas in that city remains squatter housing without electricity, potable water, and sewage.[23]    Such dreadful living conditions are not just limited to Tijuana.  San Diego County’s high cost of housing forces many migrant families to double and triple up, often with 10 to 12 people living in the same apartment.  Perhaps as many as 10,000 migrant workers live in migrant worker camps in San Diego County without adequate electricity, sewers, or running water.[24]

These sub-standard living conditions are potential bird flu incubators because humans and chickens live in close proximity.  Mexican communities on both sides of the border are particularly vulnerable because many families raise chickens for domestic consumption.  Other households own caged birds and roosters for cock fights.  While widely considered an illegal activity, los Palenques, or cockfights, are quite commonplace. In the United States, the outbreak of the exotic Newcastle disease in 2002 among poultry in California, Arizona, Nevada and Texas, was attributable, according to the US Department of Agriculture, in large part to illegal cockfights.  The disease cost taxpayers about $200 million to contain.  It cost the poultry industry many millions more in lost export markets.[25]  And the fights can be deadly to humans.  In Asia, at least four children died last year due to exposure to bird flu from cockfighting activity, according to news reports.[26]

Mexican migrant workers at Camp Del Mar near the community of Carmel Valley in San Diego. Photo Credit: ICF

The recently released implementation plans for the National Strategy on Pandemic Influenza call for addressing the threat of a flu pandemic through greater cross-national cooperation.  In the San Diego-Baja California region, cooperation is a necessity, not just desirable.  Yet, homeland security strategies related to pandemic flu and other cross-border risks rely on measures that, by the federal government’s own admission, will have only partially successful effects.  Travel restrictions, quarantines and even closures of ports-of-entry are familiar containment measures, but especially in the San Diego-Baja California area, their effectiveness will be minimal.  As the immediate aftermath of the 9/11/01 attacks showed, the pressures to open the border to trade and travel as soon as possible after the tragedy were overwhelming.

Federal plans also call for more careful and extensive screening for infectious diseases and contaminated goods at the borders.  While undoubtedly a useful health measure, reliance on steps taken at the border is only a partial solution. .  Joint San Diego-Baja California efforts are needed to prevent disease throughout the entire region and to take immediate, effective mitigation action.  Although there has been some discussion and planning to share the U.S. national stockpile of vaccines across the border in case of an outbreak of communicable disease, the benefits are not well appreciated and, in the absence of education, are opposed by the general public.[27]

Preparation for pandemic influenza and other lethal infectious diseases, however, offers the binational region an opportunity to greatly expand its infrastructure and strategic thinking on cross-border health solutions to everyday communicable conditions.  For too long, health advocates and officials from both Mexico and U.S. have been caught in a dilemma.  They clearly needed to address health concerns for their residents, and disseminate information about the sources of potential health hazards and risks that threaten people everyday such as TB and HIV/AIDS, as well as the rarer epidemics.  Yet, without a fully collaborative foundation that engages both sides of the border, that information often relies on pointing across the border as the source of various problems.  In the past, for instance, Mexican health officials warned their citizens of the potential impact of bio-terrorism and the spread of SARS and West Nile Virus emanating from the U.S. side of the border.[28]  Similarly, an outbreak of hepatitis A in the United States led U.S. health officials to point to its source among harvested green onions from Baja California.[29]   The USMBHC has been quite successful in achieving one of its goals that is pertinent here, binational cooperation, trust and an openness when dealing with any cross-border health problem, potential or current. Still, a binational approach to pandemic influenza preparedness could enhance the motivation and urgency to break the stalemate in the region that prevents broader bilateral action on all health matters.