Downtown San Diego Skyline. Photo Credit Winklopedia, 2006.

The core strategic question facing the binational, San Diego-Baja California region is straightforward:  “What can be achieved together that can not be done alone?”  Obviously, difficulties working together across borders should not be underestimated.  Years of dedicated labor have generated only a small number of success stories.  Still, cross-border community health is a challenge whose time has come.  Its origins, problems and future are linked fundamentally to the processes of globalization and cross-border regionalization that have only begun to take shape.  It is the way that people are experiencing their health risks both as they move across borders at ever increasing rates and as community members exposed to these changes.

The geographical scale of the issue is not, however, the primary policy challenge, although any time communities become stretched over long distance many problems arise.  Rather, the core policy issue involves fundamental questions of democracy and representation – to which government jurisdiction and to which health institutions can a person living in a cross-border community expect to have access?  The answers certainly require program and service innovations, but they also require a willingness and ability of political leaders to work across non-traditional lines of program authorities, to reach across borders, and to engage constituencies in new ways.  A cross-jurisdictional approach to community health pays off in the end with improved health for an entire community, greater economic productivity, and lower fiscal burdens.

Although some may think otherwise, regional political leaders can not succeed working alone.  They need to increase the level of community participation as effective partners in the policymaking process.  Whether situated in San Diego or Baja California, leaders from all sectors need to engage around community health issues that educate and mobilize the region’s residents.  Civic engagement is key to successful health solutions.  Unfortunately, educational outreach programs are often too small and ineffective on both sides of the border.  Political leadership at the elite and grassroots levels need to build health campaigns that both alert and educate the entire region to seek appropriate solutions. 

Photo Credit: Galatea Audiovisual

The financing of regional health programs can also not be done alone.  Local initiatives are unlikely to be sufficient to support the scale of required activities.  Communities, governments, and institutions in both San Diego and Baja California can become advocates for new financial mechanisms, investments, and innovative programs design that will generate more resources, expand access, and improve the health of entire communities so the costs for individuals declines.  Pooling resources and programs can be much more effective than duplicating or dividing costs.

Political leaders on both sides of the border also need to work together to attract the attention and resources of higher levels of government.  Currently, regional leadership remains encumbered by persistent, traditional financing approaches that seek reimbursement for health costs from federal governments.  Throwing the health care costs of the binational region at the foot of overly pressed federal governments does not work.  Similar federal reimbursement programs for criminal justice costs, for instance, have been riddled with problems.  In the end, when federal dollars are no longer available, the absence of local, binational engagement means that little has been done to change the health conditions and behaviors that continue to generate the costs. 

The time for innovation and large-scale reforms, then, has come, and they will not be achieved by working alone.  Even the best health programs today are structurally limited and often organized for failure.  By leaving entire sections of the continuum of care unattended, even good program interventions in selected areas will be overwhelmed by repeated exposure to risks and recurring ill health.  Most innovative programs are also simply unable to “go to scale,” relying on annual fundraising campaigns or piecemeal program budgets designed around “pilot tests” rather than systemic intervention.

The binational region needs a new start, a new strategic vision that is as encompassing and bold as the problems it seeks to solve.  The region needs a call to action that excites the enormous innovative spirit of the region and mobilizes the considerable assets and talents of residents on both sides of the border.  One way to begin is to call leaders throughout the region together for a Health Summit.  It would only be a start, but it is long overdue.  Building an agenda for the Health Summit would begin a deliberation, carried on throughout the region, that ends up with a list of objectives and solutions around which the best of the binational community could be mobilized.

The following section provides four categories of exemplary issues that could be pursued in the Summit and the healthcare campaign that hopefully would follow.  These examples are included here only to help stimulate discussion.  The intent is to focus the debate on large-scale reforms and initiatives that would reach levels of a strategic vision that encompasses the widespread and unmet needs of the entire region.

1. Getting Started

Recent declarations from the mayors of San Diego and Tijuana expressing interest in revitalizing a cooperative relationship on cross-border issues could help jumpstart increased attention to the binational character of health issues.  Beyond what the mayors would choose to take on, what are some immediate policy issues that should be addressed?  The following provides a few suggestions.

• Support the Border Health Security Act and revised implementation.

U.S. federal legislation that seeks to improve the infrastructure, access, and delivery of health care services to residents along the U.S. should be strongly supported.  The Act historically has provided substantial resources to border communities in ways that allowed flexible decisions about local priorities and use.  It has also funded USMBHC. .

Implementation of the Act, however, could be significantly altered.  While local engagement is a key to successful action, local communities need to focus on building comprehensive strategies, especially including cross-border initiatives and designs.  USMBHC could play a more aggressive role in going beyond identifying lists of priority diseases and work with communities to overcome the barriers to cross-border programs.   The USMBHC has a prominent role as catalyst in education policymakers at all levels of the community and government.

• Reinvigorate the San Diego-Tijuana Binational Health Council.

Once active in convening border area health practitioners, the San Diego-Tijuana Binational Health Council, a chapter of the USMBHA, now lays organizationally dormant.  The need for such a network is now more important than ever before.  Health-focused nonprofit organizations in both San Diego and Tijuana are working virtually independently and isolated and with limited coordination to increase opportunities for synergy and economies of scale.  A revitalized Council could also ensure representation of all segments of the region at the local level, providing a mechanism for dialogue and coordination across the border and between various social and professional groups and community based organizations among the nonprofit sector, academia and business.  It has received grants from the USMBHC to develop an administration and communications network but more sustained resources are needed.

• Support Expanded Cross-Border Health Research

A key finding of forum participants and the NLRC study was the importance of on-going research on cross-border health issues.   Without hard data and local health indicators it is difficult to make the case that additional support is needed.   Here, the San Diego-Baja California region is blessed with leading academic institutions (UCSD Medical School, SDSU School of Public Health, USD School of Nursing, UABC Medical School) that are in many cases already undertaking work on a wide range of border health issues but expanded funding is necessary as well as greater collaboration with border area nonprofits with established ties to the communities most in need of attention.  Without a doubt, there is a unique opportunity for expanded research that could positively benefit people and communities far beyond our region.

• Leverage Technology

Telemedicine-based projects exist between San Diego and Tijuana that hold considerable promise for leveraging the enormous human capital and technology potential in San Diego to improve the health care situation in Baja California.  These small projects should be reviewed to see what it would take to scale them up to a level that would have a meaningful impact on the health care status of Baja generally.  If the promise could be realized, public and private efforts should be made to enlarge them. Another way in which technology can assist binational collaboration is the routine use of video-conferencing equipment for binational meetings. Many participants in our March forum stated that, because of the long border delays, it is very hard to attract equal participation from Mexico if a binational meeting is held in San Diego and same is true for U.S. participation for a meeting held in Tijuana. Using video-conferencing equipment now available in many locations on both sides of the border would increase participation and guarantee true binational input.  

• Expand Emergency Health Services

With an expansion of the number of people living, working and retiring south of the border, the region needs to expand and modernize its delivery of emergency health services.  Opportunities exist for expanded for-profit, cross-border transportation of sick or injured US residents from Mexico to this countrya service that is currently solely provided by the Binational Emergency Medical Care Committee, a volunteer led non-profit organization with a good track record but with on-going challenges to respond to future demands.  Part of the modernization and expansion challenge is to find ways to improve the efficiency of getting across the international border.  Federal inspection authorities in Mexico and the United States obviously have legitimate reasons for regulating the movement of emergency ambulatory vehicles.  With modern technology and new security procedures – such as SENTRI – a plan to facilitate cross-border transport can feasibly be accomplished with the help of the US consulate in Tijuana and the Mexican consulate in San Diego Local and federal border authorities must be engaged in the plans to facilitate health related people and equipment crossing bi-directionally.

• Formalize Cross-border Anti-Human Trafficking Protection Teams

The Baja California – California binational region suffers from the health consequences of human trafficking, informally indentured work, and abuse.  Some of these problems are due to formal, organized smuggling.  Others arise from the household dissolution that occurs in labor markets in which members of a family are separated by long periods of time and are often completely dependent on wages generated by another member.  A promising binational regional initiative currently is working effectively on a small scale with police and other authorities on both sides of the border.  More effort in building and expanding capacity could create a model of taskforce cooperation between community and police that works directly on cross-border activities.

• Re-design Disease Specific Programs

Many diseases, from tuberculosis to HIV/AIDS, thrive on the circulation of people back and forth between U.S. and Mexican towns.  Even when treatment is offered on one side of the border, continued care is uncertain as the person continues to move around the region.  Current attempts to monitor and share information on tuberculosis patients,such as the CureTB program of the San Diego County Health Department, provide important examples of what can be done.  The USMBHC has created a health card with the cooperation of more than 40 entities working in tuberculosis care that enables patients to keep treatment going as they traverse the border back and forth.  The USMBHC also supports a Directly Observant Therapy Program in Tijuana to ensure patients take their medications every day.   Continuing basis and less costly drug therapy saves $150,000 every time a patient is treated without the highly expensive multi-drug resistant regimen.   

With tuberculosis as with many other common border illnesses, there is the ongoing struggle with reduced funding and overly complicated administrative requirements.  The binational region as a whole has a strong self-interest in making these programs successful.  Efforts to raise their visibility and expand them could be taken on at all levels of government and in institutions throughout the region.   This would save lives and resources for both countries.

• Provide Healthcare for Contract Cross-border Workers

Recent national attention to the contributions of migrant labor systems to both the U.S. and Mexican economy continues to have a fatal flaw.  The health of these workers and their families is fundamental to their successful contributions.  Yet, the health dimensions of the migratory flow are largely ignored in proposed legislation.  The San Diego-Baja California region has a substantial stake in both the labor and health conditions of its workers, on both sides of the border.  It is in the local interest, therefore, to ensure that a guest worker program or its equivalent has provisions to serve migrant workers and protect the regional community from health risks. 

What can state and county level organizations do?  Private sector leadership, public incentives, and community support should encourage companies that employ migrant workers to provide health coverage, including encouragement to the workers to enroll in one of several cross-border health plans now available (e.g. BlueShield, HealthNet, PacifiCare).  These plans are often thirty percent less expensive than traditional health plans and, if the workers gain legal status, they will be more likely to participate because they can move freely back and forth between their worksite and where they will get the care.

• Moving Beyond Crisis to Prevention

All too often public compassion and attention to border health issues tends to swing towards  the  most recent headline grabbing crisis—Tijuana’s alarming increase in HIV/AIDS or the city’s flood victims----but little attention is focused on prevention and preparedness.     As Melissa Berman, CEO of Rockefeller Philanthropy Advisors notes, “conditions don’t make the news. Crises make news.”[1]    The experience of most border health oriented nonprofits participating in ICF’s recent forum observed that it is easier to raise money in response to a crisis than for health care & disaster prevention yet the cost savings and societal benefits could be substantial if there were greater focus on prevention and preparedness.

Moving beyond crisis to prevention will require leadership.  Recognizing that many of the border’s emerging health crises can be more effectively managed and, in some cases, prevented with a more involved and engaged public,  communications is critical.  Media coverage is critical and yet more often than not, critical border health related news stories, particularly those directly impacting Tijuana, are seldom covered through San Diego news outlets until there is a crisis.  Here, border area nonprofits must do a better job of communicating critical cross-border health needs to the media on both sides of the border.    After all, if the media, especially TV, does not cover an issue, few border residents will know of its importance.

2. Financing Cross-border Health

With the possible exception of the legal issues related to border crossing, the primary problem for the region is how to finance cross-border health initiatives.  As described earlier, the persistent inequality in assets nearly dooms cross-border efforts.  The key to the financial challenge is to find creative new ways to generate resources that come from the activities of the regional economy and insure that local border communities have theauthority to control and determine the use of those resources  Some ideas for generating new revenues include:

• Border Crossing Fee

The idea of a border crossing fee, of course, has been around for years and received mixed support.  It has failed for many reasons, including disagreements over how the revenue will be distributed, the amount of the fee, and competing uses of the collected money.  The time may be right, however, for a plan that used a border crossing fee to generate funds for binational health programs.  The fees would be placed under the authority of an independent regionally focused health commission, and a cross-border leadership team, to be spent on health priorities throughout the region.  Other potential resource generating opportunities for health programs may be found in the private sector.  Improved health is a direct investment in the cross-border economy that will produce a return benefiting local small and large businesses alike.

• Catalyze Private Sector Solutions

The private sector is well positioned to dramatically expand the level of cross-border health coverage available to both U.S. and Mexican residents.  Already an estimated 150,000 California based employees have cross-border coverage through one of three existing plans:  Blue Shield of California's Access Baja plan, HealthNet and SIMNSA.  With the growing number of U.S. residents now retiring or moving to Baja California, new opportunities exist for expanded telemedicine health diagnostic screening permitting patients to receive basic care in Mexico as well as improved private sector health care options for this growing market segment.  As more people from each side of the border move to the other, opportunities to improve and equalize quality healthcare options throughout the region will increase.  Tijuana’s new Hospital Angeles has positioned itself to service this growing demand for private-pay consumers from the U.S. and Mexico and other providers are sure to follow.  

• Pilot Test U.S. Medicare Eligibility across the Border

Nearly a decade ago, the idea was proposed to create a pilot project to permit otherwise eligible U.S. residents now living in Baja California to obtain health care in Mexico that would be reimbursable by the Medicare program.[2]  Now, with funding for Medicare even more in crisis than before, the time is ripe to test the value of making Medicare portable for the growing number of U.S. senior citizens who are now living in Baja California due, in part, to their inability to afford the cost of a comfortable retirement in their own country.  The pilot is a natural opportunity for a research and demonstration project waiver from the federal Health Care Finance Administration (HCFA), but could also be supported through direct legislation.  The potential cost value of such a program would have immense financial implications along both the U.S.-Mexico and the U.S.-Canadian borders. A similar demonstration project can be developed to test the feasibility of the Medicaid program also covering the cost of services by certified  providers in Mexico.

3.    Cross-border Health-Oriented Security Program

The recent decision by the federal Department of Homeland Security (DHS) to drop San Diego from its list of metropolitan areas qualifying for its Urban Areas Security Initiative (UASI) funding demonstrated the weakness in the region’s ability to build a comprehensive approach and to advocate as a united binational mega-metropolis for the sake of its own economic well-being and security.  DHS’ decision included not only an assessment of the risk the region faced, but it’s need and plans to meet those needs.  Cross-border public health preparedness offers San Diego an innovative and vital strategic target for homeland security preparedness.  The potential risks are undoubtedly high.  Given the lack of health infrastructure on both sides of the border, the need is certainly great.  The challenge for San Diego is to craft a strategy that effectively prepares the binational region to meet these health-based security risks.  From medical surgical capacities to alternatives to border closures, San Diego could lead the way in designing an approach that would meet its own needs and offer critical lessons for other border communities.   There is currently a cooperative taskforce involving federal, state and county public health workers to design a strategy for border security and training.  This plan would not only serve in time of crisis but would boost the sadly lacking public health infrastructure needed for every day health problems.  This would be an efficient and rewarding system for today’s and tomorrow’s needs

• Craft a Cross-border Health Surveillance Initiative

Using health-related funds for homeland security, the binational region could greatly expand the CDC-funded “Binational Infectious Disease Surveillance” (BIDS) program in order to complement existing local program initiatives and volunteer cooperation with Mexico and other foreign governments.  As the SARS and Avian flu cases demonstrate, early detection and coordinated response will save lives. Thorough surveillance will direct fair and timely allocations of national and global health resources and strengthen government accountability in responding effectively. 

With these goals, surveillance systems should at least be partially independent of the governments which fund them.  Reluctance to report and to thoroughly analyze symptoms and evidence costs lives.  A binational health surveillance system, built around community involvement in reporting could provide a sustained awareness of persistent and emergency health problems throughout the cross-border region regardless of jurisdiction. Inter-agency cooperation within Mexico needs to be improved as well as binational communications protocols developed and tested to assure they will work in an emergency.

• Foster Dual-Use Programs

Health-related homeland security requires not only special projects but a sustainable approach to building comprehensive infrastructure and capabilities to achieve a desirable state of preparedness.  Much of that infrastructure and many of the capabilities have multiple uses.  While they must be able to surge at times of threat, preparedness also means that the community increases the quality and quantity of its available assets for every day uses.  The binational region should use this opportunity and the imperatives of security for the entire San Diego-Baja California area to establish the cross-border framework and rules to make healthcare programs effective.  For example, the region needs facilities to adequately test suspicious substances, diagnosis disease, and respond in both preventive and mitigation modes.  Those facilities and the network of scientists, physicians, and emergency responders should be organized in a cross-border plan that does not require complicated negotiations or competitive demands for future funding.  This may also be an opportunity to move to accredit and credential health officials on both sides of the border under similar rules, which would greatly enhance programs designed to allow professionals to contract their services to needy communities on both sides of the border.  The beginning of planning such an elaborate cooperative is currently underway but in need of more support and resources.

4.    Cross-border Private Sector, Civil Society Capabilities Initiative

The needs in the San Diego-Baja California border region are great and most active health oriented nonprofits are ill prepared to sustain their current activities without additional support.   Due to budgetary downsizing, traditional sources of funding are being cut so many area nonprofits face growing demand for services with a corresponding decrease in available funding.  Although numerous specific programs could be supported, a comprehensive initiative could begin with the following types of activities.   

• Create a Cross-Border Health Fund

San Diego grantmakers need to come together to establish a regionally focused cross-border health fund to catalyze philanthropic resources to tackle emerging issues.  Funders need to be far more pro-active on border health issues.  The Fun could help tackle the more difficult issues, often involving policy changes and overcoming the systemic barriers mentioned earlier that governments would be less able or willing to pursue.  A Cross-Border Health Fund could also support the leadership, resource team that could help bring the region through the strategic, scaling up process.

• Innovation

The San Diego-Baja California region has long been known for its innovativeness.  Now is the time to focus that capability on health care.  From technological ideas to community-based mobilizations, the region has an untapped capacity to create new, more effective ways of overcoming seemingly intractable problems.  The region also frequently serves as a test market for new products, reflecting outsiders’ expectations of the uniqueness and openness of the area’s population to improvement.  The economic development and innovation centers that currently exist throughout the region should turn their attention to the healthcare issues.

• Private Sector Leadership

From the ownership of 85 percent of infrastructure critical to homeland security to the recognition of leaders of community organizations, the private sector holds the key to change throughout the cross-border region.  Organizations, such as the San Diego Regional Chamber of Commerce and Tijuana’s Centro Coordinador Empresarial de Tijuana (CCE), have the potential to coordinate San Diego and Baja California area businesses.  Individual businesses also have clear incentives to invest in the area to enhance their own performance.  Yet, specific leadership engagement is still absent.  Private businesses need to identify or craft appropriate and acceptable channels of participation in areas where, although their role may be critical, how they can be successful remains unclear.