Binational Health Policy: Border Health Commission Comes Online

BHC Mexican Section(5) 263-9211
BHC U.S. Section
(915) 532-1006
“Community Health in the Borderlands”
borderlines vol. 6 no. 4
Web Resources:
PAHO El Paso Field Office
Sonia Contreras
(619) 692- 8625
Dr. Jeffery Brandon(505) 646-7303

Anticipating the need to work binationally to address borderlands health issues, health advocates and physicians in Texas first proposed creating a binational border health commission in 1988. They were soon joined by medical professionals in other states, and in 1994 scored a major victory when the U.S. Congress approved a bill calling for the creation of a just such an entity.

Public Law (PL) 103-400, sponsored by Senator Jeff Bingaman (D-NM) and
co-sponsored by Senators Kay Bailey Hutchison (R-TX) and John McCain (R-AZ),
authorized and encouraged the president to conclude an agreement with
Mexico to establish a binational commission to address health issues in
communities along the border. The organization’s primary goals, according
to an early concept paper, would be to “institutionalize a domestic
focus on border health which can transcend political changes and to create
an effective venue for binational discussion to address public health
issues and problems.”

President Clinton signed the legislation in October 1994, and in a letter
two years later reaffirmed his support for the commission and announced
that he’d begun informal discussions with the Mexican government
on the topic. In 1997, Congress approved funding—channeled through
the Office of International and Refugee Health, U.S. Department of Health
and Human Services—to assist in the creation of the BHC’s U.S.
section and for direct support to the four U.S. border states. Appropriations
for the U.S. section have included $800,000 in 1997, $1 million in fiscal
years 1998 and 1999, and $1.5 million in fiscal year 2000. Funding for
2001 is approximately $2 million dollars. Mexico will also provide a proportionate
percentage of its annual budget to fund the commission.

In July 2000 the Border Health Commission was officially created via
a binational cooperative agreement signed by former Mexican Minister of
Health José Antonio González and then-U.S. Health and Human
Services Secretary Donna Shalala. The BHC’s inaugural meeting occurred
last November, and in March BHC commissioners from both countries agreed
on a strategic plan for the institution. “Now we have a binational
agreement on our strategic plan. We have a framework, our operating goals
and objectives are in place, and we’re ready to move forward,”
says Sonia Contreras, outreach officer and coordinator for the BHC’s
California section.

The BHC does not provide medical care, nor does it set policy, pass
laws, or have any enforcement authority. Its official mission is to “provide
international leadership to optimize health and quality of life along
the U.S.-Mexico border,” according to its March 2001 Strategic Framework.
In support of its mission, under the July 2001 agreement which created
it, the BHC is authorized to:

  • Conduct or support health promotion and disease prevention in the
    border area;
  • Conduct or support the establishment of a coordinated system which
    uses advanced technologies to gather health-related data and monitor
    health problems in the border area;
  • Conduct public health needs assessments in the border area and conduct
    or support investigations, research, or studies designed to identify
    and monitor health problems on the border; and
  • Provide financial, technical, or administrative support to assist
    the efforts of public and private nonprofit entities to prevent and
    resolve health problems.

Additional goals and activities identified for the commission via binational
consensus include: collaborating with nongovernmental organizations and
other entities involved in public health activities; conducting public
outreach to draw attention to border health needs; establishing mechanisms
for the movement of funds, equipment, and laboratory supplies and samples
between both countries; improving communications between health professionals
across the border; policy advocacy and attracting new resources to the
border; and serving as a venue for broad participation by health professionals
and others interested in improving border health. Once year, the commission
must submit a report to both governments regarding its activities.

The U.S.-Mexico Border Health Commission is made up of 26 members, 13
from each country, with Mexico’s Secretary of Health of Mexico and
the U.S. Secretary of Health and Human Services acting as commissioners.
The BHC’s U.S. membership also includes the chief health officers
of California, New Mexico, Arizona and Texas as well as two border residents
from each of those states who have demonstrated interest and expertise
in regional health issues and who have ties to community-based health
organizations. Those commission members are nominated by the state governor
and appointed by the president. Mexican membership in the commission includes
the secretaries of health of each of the six Mexican border states as
well as one commissioner from each of those states appointed by the Mexican
government. Commission decisions are made by majority vote.

The BHC has headquarters in El Paso, Texas, and Mexico City. The U.S.
section has opened outreach offices in San Diego, California, Las Cruces,
New Mexico, and Tucson, Arizona. The Mexican Section has offices in each
of its six border states.

The commission’s creators were convinced that the BHC would require
significant support from federal and state representatives in both countries
and knew that one of their first challenges would be to make the commission’s
effort’s truly binational. Russell Bennett, executive director of
the BHC’s U.S. Section, points to the July 2000 binational agreement
that establishes the commission: “It really is a well-written agreement
that allows us to do a lot of things together to improve health on both
sides of the border,” he says. “And it’s clear that both
countries are very committed to it.”

That binational commitment, some observers say, will be critical if
the commission is to successfully meet the dramatic challenges in improving
health along the border. The border zone, typically defined as a strip
100 kilometers wide on either side of the U.S.-Mexico dividing line, is
home to nearly 12 million people, most living in the 14 pairs of sister
cities that straddle the international boundary. The health problems that
those residents face are numerous and extreme. Tuberculosis (TB), an infectious
and chronic disease associated with poverty and limited access to health
care, is particularly worrisome. The rate of TB along the border is more
than three times the U.S. national average. And there are fears that due
to the inconsistent, sporadic treatment that many migrants with TB receive,
a drug-resistant strain of the contagious disease could develop.

Other chronic illnesses are rampant along the border as well. Cancer
rates are higher there than the national averages. Incidents of diabetes
in the region are three times higher than the rest of the United States.
Hepatitis A, B, and C, measles, and mumps also occur more frequently along
the border than in many other regions in both countries. HIV/AIDS is on
the rise in Mexico and of growing concern for border communities on both
sides of the line.

Rampant poverty in the region is one major culprit in the multitude
of serious health problems that border residents endure. Counties along
the U.S.-Mexico border are among the poorest the United States. At least
one-third of U.S. border families live at or below the poverty line—the
national average is about 11%. An estimated 400,000 border residents on
the U.S. side live in colonias with limited access to public drinking
water or public sewage systems. Unemployment in the U.S. border area is
roughly three times higher than in other parts of the United States.

Complicating the situation, say health care advocates in the region,
are years of neglect by both the U.S. and Mexican governments. “The
root causes of many of the health problems are poverty and years of a
hands-off attitude toward the border from governments on both sides—thinking
that the border was the furthest thing from their capitals,” says
Bennett, who adds that as a result of the BHC’s creation and other
developments, things are changing. “Now [the border] is being looked
at as a gateway into the neighboring country.”

A Binational Approach

The fact that the border is a gateway rather than a barrier adds complexity
to health issues there—diseases don’t recognize borders. “We
had last year along the U.S.-Mexico border in excess of 400 million northbound
and legal crossings. And a like number go back down south. We have to
remember, it’s a two-way street. That’s very important,”
explains Dr. Laurance Nickey, a BHC commission member from Texas. “It’s
an enormous interplay of people. And in a situation like that, you don’t
keep measles on one side and chicken pox on the other.”

Nickey points out that without direct binational action the problems
are not going to get better. The current border population of nearly 12
million is expected to double in the next 22-25 years. “These health
issues are absolutely exploding. We cannot wait and deal with problems
in two-to-four year increments. We’ve got to be thinking 20-25 years
out. Both countries certainly understand that,” he says. “It’s
a very complex issue that needs people of good faith, people who have
great interest along our shared space to come to agreement on ways to
help both populations.”

Mr. Fernando Sepulveda, executive director of the BHC’s Mexican
section agrees. He says the 2000 census shows the U.S.-Mexico border region
as one of the fastest growing regions in both countries, generating unique
and serious problems for area residents. “There are many magnets
that bring newcomers to the area—migrant work, the maquiladoras.
If you consider the population increase and the lack of adequate medical
services in border communities, we have a very bad combination,”
Sepulveda explains. “From Mexico’s point of view, we are placing
[border health] as an issue of the highest importance. You cannot do something
on one side only. If you don’t have the cooperation and collaboration
of the other side, you are just dealing with part of the problem.”

Observers say that an emphasis on a binational approach in addressing
borderlands health issues has been evident in the BHC’s first actions
as a new player in the border region. One of the commission’s first
steps, for example, was to investigate the health needs of border communities,
coupling a formal needs-assessment process with public forums involving
key players on both the north and south sides of the line.

On the U.S. side, commission members used a framework for assessing
community health issues and setting target goals for improvement that
has been in place for more than 20 years—the Healthy People Program
administered by the U.S. Surgeon General’s office. Using that health
needs evaluation process, the U.S. commissioners came up with 25 prioritized
goals for a border health agenda, termed the “Healthy Gente”
program. They then met and compared notes with their Mexican counterparts,
who had recently completed a similar assessment through the Mexican National
Health Indicators Program. Commission members from both countries found
common ground in 11 topic areas, and in March those priorities were integrated
into the BHC’s agenda for promoting health and preventing disease
on both sides of the border.

The agenda, titled “Healthy Border/Frontera Saludable 2010,”
is a harmonizing of both country’s goals and areas of focus for improving
individual and community health along the border, including reducing rates
of diabetes, TB, cancer, HIV/AIDS, respiratory disease, and infant mortality.
Other goals include enhancing border residents’ access to health
and dental care, increasing immunization levels, preventing injuries,
strengthening mental health initiatives, improving environmental health
by broadening access to sewage disposal, and providing treatment for acute
pesticide poisoning. After establishing the agenda, BHC members from both
sides of the border then agreed on four areas of immediate focus during
the next 10 years: TB, immunizations, HIV/AIDS, and substance abuse.

Community-Based Solutions

According to its stated health objectives, the commission’s work
will take into account differences between the two countries’ health
care systems as well as the unique characteristics of individual border
communities. Specific strategies for meeting those goals will be both
country- and community-specific. This focus on facilitating community-based
solutions to health problems, say observers, will be crucial to the BHC’s

As a first step towards at promoting trickle-up solutions, the commission
facilitated a series of public forums in California and New Mexico on
the issue. Participants included BHC members, government officials, and
community organizations working to address health issues along the border.
Those attending the forums discussed border community health problems
and the strategies being used to address by groups working on the front

“There is a real advantage in working with the very active binational
community groups. Many have existed for years, and it’s incredible
the work they do. Many are volunteers, many are activists, and they really
want to address health issues that people are suffering from on the border,”
says California BHC outreach officer Sonia Contreras. “So I think
we’re definitely putting resources and attention toward their needs,
so we can strengthen their efforts. They are the pioneers of a lot of
the binational work, and we have a lot to learn from them.”

To that end, the BHC is designing its Best Practices Program, which
will identify criteria the commission can use to determine what community-created
models have been most successful in preventing illness and promoting health
along the border. Once those criteria have been established, community
health organizations will be able to submit proposals to the commission
and, if they meet established requirements, receive help in teaching other
communities how to replicate their efforts. The BHC will also publicize
such successful programs through educational materials and media outreach
efforts to encourage their implementation in other appropriate border

“We want to identify model projects and programs, then disseminate
them along the border. There are some wonderful things already being done
in the border states. In Yuma there’s Nuestros Niños, which
goes house-to house to identify whether children have been vaccinated
and whether they have or qualify for health coverage. There’s a program
in the state of Nuevo León where they’ve reduced neural tube
birth defects by providing folic acid to women of child-bearing age. In
three years they’ve cut the incidence of those birth defects in half.
These are model programs, ” explains Bennett. “But you ask the
state next door in Mexico, or the state across the border, and they’re
not aware of the programs. And you ask the people in Mexico City, and
they’re not aware of the program, and in Washington, even less so.
So we want to say, ‘Look, here’s a successful project that’s
happening in Monterrey, or in Yuma. These are people we can learn from.’”

That approach is not lost on Dr. Fernando Gonzales of the binational
TB program Project Juntos, who says that he’s been impressed by the
level of interest and solidarity shown by BHC members. According to Gonzales,
the new, high-level entity is welcome on the border. “I’ve already
gotten a lot of support from the commissioners. They’ve visited us
and talked with us about our projects and our strategies. I think it’s
a way for us to have the ears of not only the local and regional [commission
members], but the federal authorities in the U.S. and Mexico as well,”
Gonzales says. “I feel their presence along the border creating opportunities.
I really feel they’re paying attention.”

Other binational and international health organizations, such as the
Pan American Health Organization (PAHO) and the U.S.-Mexico Border Health
Association (USMBHA), have also been working closely with border communities
to address the multitude of serious health issues on the border. Some
observers have wondered if the BHC will be that much different than existing
organizations—and if its efforts will be any more successful.

Dan Reyna, is in a good position to address those questions, since he
stands on both sides of that fence. He is a member of the nonprofit USMBHA
and, as director of New Mexico’s Border Health Office, was a member
of the U.S. BHC design team that prepared the commission’s comprehensive
assessment on border health needs.

“The commission’s goal of creating a venue for binational discussion
is key, because we have not had an effective venue to date. The [USMBHA]
has the limitations of being private, and nonprofit. PAHO is an international
health organization with a field office in El Paso, but it’s not
accountable to any one community, or state, or any one government,”
Reyna says. “Those organizations have been helpful and supportive
of many efforts throughout the years, but there’s nothing that reaches
the level of the BHC, which has federal legislation behind it and presidential
appointments. I think that lends a level of accountability and involvement
that a private nonprofit operating on the border can’t come close

Federal involvement in the BHC is critical, Reyna says. “No other
group to date has had that leverage. Commissioners will be reporting to
their [respective] presidents. They will have the ability to bring people
to the table. With the strength of the BHC, they can call the Centers
for Disease Control, or the secretary of health, and they’ll be listened
to,” he notes. “There’s no other organization that can
manage that type of leverage.”

Although the federal component of the BHC is critical for impacting
policies and implementing strategies, the participation of border residents
on the commission is potentially another big advantage for the organization.
In addition to being familiar with the specific health issues unique to
their own border communities, governor-appointed, commission members from
border areas will be in a position to act as representatives of and advocates
for their communities, a dynamic that could bring a sense of responsibility
and accountability to the commission’s work.

“I grew up in Tijuana. I’m from the border. People there are
very hardworking, and they deserve a lot of attention, something they
haven’t gotten in the past,” says the BHC’s Contreras.
“We are a new element…that hasn’t been available in the
past. Before, locals had to work hard to get to the federal level. Now
this commission will be able to link them directly. Now, finally, there
is a lot of opportunity to address their needs. For me, that is a big



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