Dental screenings at La Maestra Dental Clinic, San Diego. Photo Credit: Elizabeth Santillañez

A search for new strategic thinking on binational healthcare requires a full review of public policies and how they stack up to the challenges and needs of cross-border communities.  Many current policies are counterproductive, helping only segments of the community in the name of empowering the entire community.  Others are punitive in their efforts to block community-level, cross-border transactions and movements, or to separate out those who are eligible for care from those who are not.

Current policy approaches form the following four broadly-defined models of cross-border public health strategies.

A.  Governments Go It Alone:  Block and Screen

Historically, governments routinely and unilaterally intervened to stop the movement of people across borders in an effort to reduce health risks.  In earlier times when migration did not lead to such tightly integrated, cross-border communities as they do now, governments could intervene more easily, prevent movement back and forth and reduce disease risks through immigration controls.  The near legendary practices at Ellis Island at the height of the transatlantic migrations provide clear examples.

The public health logic of such unilateral efforts remains strong.  The SARS epidemic brought officials back to these earlier techniques.  At airports and other ports-of-entry, travelers were asked if they had a dry cough, fever or nausea or contact with anyone with symptoms.  At some airports, travelers received a modern version of the Ellis Island “six second medical” – a thermometer stuck in their ear or, unbeknownst to the traveler, an invisible scan by a hidden thermo-detection device.  Current planning for pandemic influenza takes a similar path.  Expanded quarantine stations, restrictive border closures, and enhanced capabilities to screen travelers are all part of recently published plans.

Another motivation behind this approach involves the rising costs of border medical care.  The debates and political outcries about the costs of health care services for immigrants and their impact on the health infrastructure continue daily.  Many hospital officials and lawmakers say that the cost of providing uncompensated care to people from Mexico places additional stress on facilities that already face overwhelmed hospital staffs and a growing patient population. Los Angeles Supervisor Mike Antonovich once proclaimed, in reaction to the large number of immigrant patients, “Los Angeles County cannot be the HMO to the world.”[1]

One proposed solution is to physically block transnational community members from crossing borders.  Another, similar strategy attempts to deny care to certain groups.  In California and elsewhere along the U.S.-Mexico border, governments have moved to define which members of communities and families may have access to health facilities and which can not.  Even though employers in the U.S. benefit greatly from low-wage immigrant workers from Mexico, there seems to be no sense of responsibility to provide their workers with basic health coverage nor does the U.S. government feel the need to compel the employers to provide such services.  As necessary or valuable as these and related approaches are, the goal is primarily to suppress the cross-border activities that are so deeply rooted in the global economy and society, rather than focusing on the health risks themselves.  Policies work against the community, not with it.  In a sense, the approach puts its primary emphasis on physical and social dimensions of quarantine and screening.  Yet, even in emergency situations, efforts at confining the problem have proven less than adequate and often counterproductive.

B.  Government-to-Government Coordination

The limits to governments working alone to combat transnational disease risks, of course, have been acknowledged for decades.  Mexico and the United States began cooperating as early as 1927, when they responded together to emergency health conditions caused by floods along the border.  Formal U.S.-Mexico cooperation began in the late 1940's when health authorities realized that separate and isolated efforts on each side of the border to control syphilis and gonorrhea were unsuccessful because they involved shared infections among community members living along the border and crossing in both directions.  In 1942, the U.S. Public Health Service asked the forerunner of the Pan American Health Organization (PAHO) to help coordinate a border health campaign.  The meetings spawned the U.S.-Mexico Border Health Association (USMBHA), an organization of health professionals from both sides of the border that has met annually since 1943.

Although professional development and communication represent a valuable enterprise, government-to-government program coordination has unfortunately been limited to annual calls for more cooperation and not much concrete progress.  For instance, when U.S. and Mexican health officials met for their annual meeting in 2002, no one was apparently embarrassed to declare, after sixty years of coordination, that this year’s event was a “dramatic first step” toward improving binational cooperation for better border health.  The Texas Commissioner of Health at the time said, "We must build strong relationships, improve communications and work together if we are ever going to seriously improve the health of citizens on both sides of our border."  The Consul General of the Mexican Consulate in Austin repeated the familiar refrain, "As we all know, disease knows no borders. Cooperative efforts involving all sectors of society are key to outsmarting this disease (tuberculosis)".[2]

These government-to-government programs have generated far more hope and expectation than they have delivered on-the-ground assistance.  As the U.S.-Mexico Border Counties Coalition has recently documented, border communities are even less prepared today to handle rising trans-border disease risks than before.  More and more people cross the border, communities become even more integrated and interconnected, and yet the prospects for an integrated public response remain stymied.

Part of the reason is that these inter-governmental, Mexico-U.S. health programs fail to overcome the institutional mismatch represented by the border.  Their annual efforts actually reinforce it.  The proposed government programs remain separate and unequal efforts, each pursuing parallel goals on separate sides of the border, hoping that their independent pursuits will reach parallel outcomes.  They fail, however, to identify and work with the dimensions of communities that cross the border and sustain connections that share disease risks, stimulate unhealthy behavior, and divide opportunities for health care between different family and household members.  Here again, the USMBHC has made some progress in bringing the public health professionals together for research, education and treatment of various common illnesses, such as tuberculosis.

C.  Civil Society Engagement

Although governments are usually the most powerful health sector actors, their resources and authority to influence community activities weaken in cross-border affairs.  In nearly all inter-governmental programs, their comparative advantage relies on internal reforms.  For instance, in the fight against tuberculosis, the Mexican Ministry of Health has its most leverage in combating the disease within its own rural communities and through substantial reform of its own health care delivery systems.

The capacities of civil society to augment and influence health conditions and health care beyond government actions are, of course, topics of widespread, global discussion.  In the context of U.S.-Mexico relations, however, attention to the contributions of civil society organizations to improving health is relatively new.  To some extent, this is not surprising.  Civil society organizations in Mexico are on the whole in the early stages of development.  While there are effective health-related practices in Mexico, these have not generated an extensive network of providers and community-level organizations with any substantial capacity to advocate within the highly centralized, Mexican federal government for health resources and attention. One notable exception is the Mexican Red Cross. Not only has this organization taken on the role of being the primary provider of ambulance services throughout Mexico, it has recently become involved in providing health care and education to U.S. bound migrants in order to reduce the deaths of undocumented people attempting to cross the border illegally. Notwithstanding this exception, lack of civil society participation in Mexico remains a critical source of the institutional weakness along the border.

In 2002, dozens of foundations formed the Border Philanthropy Partnership (BPP) to foster civil society capacity along the U.S.-Mexico border.   Over the last four years, BPP has done much to catalyze expanded community-based philanthropy with an emphasis on addressing critical border issues including concerns over border health. For the most part, however, its focus underscores rather than overcomes the limits of most border initiatives.  The emphasis is largely limited to activities that take place on either side rather than involving a conscious effort to organize in a cross-border fashion.  At most, these and other civil society initiatives attempt to coordinate parallel actions among small associations and groups separated by the border.  Cross-border relationships remain issue-specific campaigns or information sharing activities.  Unfortunately, the result is typically to produce weak coalitions of interests rather than an integrated cross-border initiative.  Border groups’ futures remain very uncertain as they face tremendous difficulties just in maintaining day-to-day contacts across the border.  They also continuously confront the difficulties of working with allies on the other side of the border that have very different levels of financial support and organizational capacities.

The few border nonprofit organizations that have focused on cross-border health issues have concentrated primarily on information campaigns, especially involving cultural or behavioral issues.  They include media programs on preventive measures related to HIV/AIDS, unwanted pregnancies, sexually-transmitted diseases, and domestic violence.  In only a few cases, such as Project Concern International and the Bilateral Safety Corridor Coalition, have groups been able to establish parallel activities on each side of the border.  Planned Parenthood, to use another example, has established a binational network to deliver services in both San Diego and Tijuana, and several organizations that focus on substance abuse also have information campaigns and clinics on both sides of the border. See Appendix C for a list of border area and migrant-serving nonprofits in the healthcare area.

Truly, cross-border programs remained blocked by a combination of problems.  First, cross-border activities depend heavily on a small number of “bridge builders.”  These leaders, and the interests they represent, rest on the margins of the primary organizations and their main strategies.  Second, financial support directed specifically at cross-border activities is rare.  Leaders of these fledgling organizations often believe they have better opportunities for funding with their own national governments, and, to a large extent, they have accurately diagnosed their financial environment.  Third, groups along the border often define their organizational interests and identities, if not their issue areas, strictly in national terms.  It is not rare, for example, to have community-based organizational leaders in Mexico advocate for a Mexican approach to the border and the time and resources to mobilize “on their own” before joining forces into a cross-border singular entity.

Finally, many leaders of community-based organizations along each side of the border believe it is too difficult and perhaps “premature”, as one program director in Tijuana explained, to take on cross-border issues that will run afoul of either Mexican or U.S. government policies on border affairs.  Immigration policy tends to be the most frequently cited problem, but the costs to health care systems in the United States and the inflexibility of health care resources in Mexico also top the list.

When governments become partners with these civil society organizations, their activities of course can grow.  U.S. and Mexican officials, for instance, have included a role for community organizations in their binational tuberculosis campaign.  Through the USMBHC, they are also are working together to establish internet communications among various workplace treatment and education programs as well as the establishment of confidential links among health professionals sharing research and treatment information to improve the efficiency of their work.  Unfortunately, the record provides little evidence that these activities or relationships have sunk deep roots into border communities because these innovations are costly and time-consuming to create.  Improvements in the capacities of community-based organizations in Mexico especially have stalled but at least communication between Mexican and U.S. leaders is strong and this area is fertile ground for the investment of the private and nonprofit sector resources because the benefits accrue to the whole of both countries.

In the last few years, the Mexican government has reached out to civil society organizations to forge a public-private partnership on health issues related to the Mexican community in the United States.  The move represents a valuable innovation in attempting to overcome the institutional mismatches common at the border.  In a real sense, the Mexican government has decided that its jurisdiction extends beyond its borders to reach members of transnational communities who reside in the United States. An example of such a collaboration is the California-Mexico Migrant Health Initiative with active participation from the highest levels of both the Mexican government, the State of California and the University of California.

Although these programs have received broad public recognition, they remain small scale and tenuous. Mexican government involvement with its citizens living in the U.S. has at times been criticized by media and some politicians as meddling in U.S. affairs. Without support of the U.S. government, the  Mexican government’s authority in the transnational community remains weak.  The lack of a history of cooperation between government and civil society in Mexico has also reinforced skepticism among Mexican community members in the United States for any government-led initiative.  Others have also worried that the Mexican government’s focus on the part of these transnational communities residing in the United States has served to weaken its resolve to respond to the needs of the origin communities inside Mexico.

D.  Cross-Border Projects

The search for a sustainable cross-border healthcare strategy differs from the above policies because its primary focus is on the way in which people organize their community life across borders, rather than the limits and needs of the institutions that work on either side of the border.  The goal of such a project is to create and sustain a “virtuous cycle” that matches the circulation and connections of movements back and forth across the border, between  the ways in which the health-related risks may occur.  These cross-border strategies would seek improvement of conditions at home in Mexico and in the linked U.S. communities.  Although specific project interventions may occur at various locations in Mexico or the United States, they must have linked connections to complementary efforts throughout the binational region.  Few examples of such projects exist from which to compile a list of positive and negative attributes or practices or from which to develop a comprehensive binational and regional strategy.  Innovative financial arrangements would also be needed to provide incentives throughout the community to maintain participation and commitment.

However, the ICF forum of healthcare practitioners supported several key principles from which to begin a strategic design.  First, the strongest resistance to working in a way that reaches throughout a cross-border community is the uneven distribution of finances.  Without a process of project development that allows people or representatives on both sides of the border to participate, whoever controls the project money becomes a dominant leader.  This de facto designation of a leader can generate opposition or, in most cases, a simple refusal to participate in the initiative from the outset.  A common fund, rather than separate budgets, could respond to and help overcome this concern.

Second, the difficulties of simply getting people from each side of the border to cross and work together day-to-day must be overcome.  Like other developing community-based organizations, direct interpersonal connections are important.  So too is an expectation that the outcomes of a project will be considered successful only if there are improvements throughout the community – in this case, on both sides of the border.  Joint project development, including clear performance measures that require reciprocal gains, could provide the discipline to reinforce working together as opposed to separately.   This is another goal of the USMBHC but which progresses slowly for obvious reasons.

Third, sharing information, supporting common positions, and solidarity campaigns are not enough to generate and sustain the community connections in a cross-border environment.  In a sense, projects need to be transnational in their design, addressing a problem that is truly a cross-border issue.  Health care infrastructure provides a good example.  A project could target the inequality between the two sides of the border in health care expertise and facilities by designing and developing ways to share diagnostic and treatment assets through new long-distance technologies.  Improvements in health care in Tijuana could be matched with reductions in emergency health care costs in San Diego but these benefits go beyond the border for the border is a gateway to both countries.   As such, solving health problems when they are relatively containable at the border can prevent the cost in lives and other resources that the spread of a pandemic could bring to the interior of both countries.

Fourth, several existing institutions may have greater potential and capacity for working across borders than what can be achieved by building new programs from the ground up.  For example, unions, churches and service  service clubs (Rotary, Lions, Shriners, etc.)  have a history of members working on small projects across the U.S.-Mexico border.  They have often met resistance from the governments, but as a model for organizing activities that reflect how their members live, these two offer strong clues.  The union agreement in San Diego that allows workers to select the Mexican government’s health insurance coverage as part of their benefits package is a good example of how, by working with community members’ own interests and practices, existing institutions could be reshaped into a binational, regional program.

Photo Credit: ICF

These principles may help form the foundation of the design of cross-border projects.  By themselves, however, they need to be incorporated into a more comprehensive planning process and mobilization campaign.  They could be instrumental in forming a leadership team that, as seen earlier, is instrumental in scaling up healthcare efforts.  These principles, and an organized leadership team, could be a first step in creating a strategic vision that is rooted entirely in innovation, of reaching for a scale that perhaps few in the region have yet to realize is needed, and to overcome the barriers to healthcare institution building that are deeply rooted in existing, but alterable, jurisdictional preferences.  Leadership must come from the border where the experiences that will bring health and healthcare abide and must then reach out to the leaders of both countries since any health threat to the border previews threats to the whole country or countries.