7 DESARROLLO DE LA METODOLOGÍA
7.4 METODOLOGÍA DE ANALISIS DE LA PRUEBA MINIFRAC
In 2003, many headlines reminded the residents of the San Diego-Tijuana region that sharing the border meant sharing many health issues. In March, the Centers for Disease Control and Prevention (CDC) released findings that showed that foreign-born population accounted for 51% of tuberculosis (TB) cases in the United States. Of these cases, Mexicans accounted for 23%. While these figures are startling, equally, if not more, powerful was the response of John L. Kirkwood, President and CEO of the American Lung Association: “We share a border, we share the TB problem and we share the responsibility for helping the people involved.”220
Reflecting this cooperative spirit, a pilot program is underway in the US-Mexico border region to improve treatment completion by TB patients who cross the border.221 San Diego and
Tijuana are one of the two groups of sister cities to take part in this innovative and much- needed program.222
Although it is evident that cross-national cooperation is critical in addressing many health issues along the U.S.-Mexico border, health advocates and officials from both Mexico and US are often caught in a dilemma. They need to address health concerns for their citizens, and disseminate information about the sources of potential health hazards and risks. But they also need to maintain a cordial and cooperative relationship with their partners on the other side of the border. The difficulty of balancing these needs is evident from other headlines on health issues from 2003: Mexican health officials warned Mexicans of the impact of possible bioterrorism and the spread of SARS and West Nile Virus from US to Mexico,223 while the outbreak of hepatitis
A created a controversy between US and Mexican officials, as US health officials believed the source was green onions harvested in Baja California.224
This chapter will demonstrate how the San Diego and Tijuana health and human service issues and infrastructures are tied together. Infectious diseases, such as TB, hepatitis, dengue, and HIV/AIDS, cross borders freely. While medical facilities in San Diego may offer specialized services unavailable in Tijuana, Tijuana may offer culturally competent services unavailable in San Diego. If we can realize how inter-connected our health issues are, as well as how interdependent we already are for culturally-competent health care, prescription drugs, and affordable medical services, we can leverage this knowledge to improve cross-border cooperation and strengthen the linkages that benefit all of us. The closer we (governments,
220 American Lung Association press release on March 27, 2003, available at http://www.lungusa.org/press/lung_dis/dis_032703.html (last accessed 1/13/04)
221 As detailed later, the focus on border crossers stems from the concern that this population tends to develop
drug-resistant TB due to incomplete treatment.
222 The other group is El Paso, Texas, Las Cruces, New Mexico, and Ciudad Juarez, Chihuahua. 223 See, for example, Frontera Norte Sur (online publication), June 18, 2003.
224 See, for example, Diane Lindquist and Sandra Dibble,“Clues, but no smoking guns,” San Diego Union Tribune,
public and private partnerships) work together, the more effectively our binational region will function to provide the best healthcare at the least cost for all its residents.
Another aspect of border health issues that requires more attention is the fact that, within borders of each country, there are pockets of neglected, or under-served communities. As alluded to in Chapter 1 and 2, some parts of San Diego have very high indices of poverty, a fact that contradicts, and too often is masked by, the overall image of San Diego as a prosperous city. Tijuana, too, is considered one of the richer cities in Mexico, and yet many colonias populares lack basic services, making them vulnerable to infectious or preventable diseases. This chapter will highlight non-profit groups and initiatives that seek to meet the medical needs of the particularly underserved communities in the San Diego-Tijuana region.
Healthcare in the Border Region
San Diego’s healthcare system includes an estimated 7,000 licensed physicians, nurses and nurse practitioners, 27 hospitals, 59 community clinics, 6 trauma centers, for-profit urgent care centers, various ambulance services, paramedics, and nearly 7,000 hospital beds tied together by an award-winning county-operated Emergency Medical Services system.225 In rough
estimates, over $1.3 billion is spent annually on healthcare in San Diego County, or alternatively, on average, each San Diegan spends $3,759.226 Although health care spending is
comparatively high in San Diego, still 21% of the non-elderly (ages 0-64) population had only partial or no health insurance during year 2001.227 Whereas in Tijuana, the 2000 census data
show that 47.9% of residents have health insurance coverage, and the vast majority (over 90%) of the coverage is through a public healthcare program.228
In the state of California, with a population of roughly 35 million, 6.3 million residents had no health insurance for all or part of year 2001.229 3.3 million people had been uninsured for more
than a year.230 Lower income Californians are more likely to be uninsured for a long time.
Although an average of 86% of children (ages 0-17) have health insurance, this figure is much lower for children in poorer households. Among children in poverty, i.e., in families earning below 100% of Federal Poverty Level (FPL), a shocking 14.4% had no insurance at all, and another 10.4% was covered only part of the year.231 In other words, about one in four of
California’s children in poverty was lacking continuous health insurance coverage. Children in poor or near poor (below 200% of FPL) households accounted for 80% of children without any health insurance.232 Health insurance coverage was even lower for the adult (ages 18-64)
population: just over 50% of adults in poverty had insurance all year, compared to 88% of those households earning 300% of more of FPL.233
225 San Diego Book of Facts - 2001 226 Health Affairs (July/August 2002) 227 Brown, et.al. (2003), p. 23. 228 Lomelí (2001), p. 2. 229 Brown, et.al (2003), p. 11. 230 Ibid, p. 12. 231 Ibid, p. 15. 232 Ibid, p. 17. 233 Ibid., p. 16.
Health coverage varies not only according to income, but also according to ethnicity and citizenship/immigration status. More than one in four (28%) Latinos ages 0-64 are uninsured, compared to only 9% of whites.234 Latino children were five times more likely to have no
health insurance than white or African American children: over 90% of white, African- American, and Asian American/Pacific Islander children were insured all year, compared to only 76% of Latino children.235 Adult Latinos under age 65 had an even higher rate of uninsured:
28.5% had no insurance all year during 2001, and another 15% had it only part of the year. It is the non-citizens, however, that lack health insurance most: a staggering 44% of adults, and 34% of children, had no health insurance at all.236 The ethnic disparities are even more pronounced
in San Diego County. In San Diego, only 73% of Hispanic children had health insurance, compared to 94% of African-American and 93.4% of white children.237
Health services delivery in the border region is characterized by a three-tiered system of care: residents with private insurance and/or discretionary income, public insurance, and the uninsured. In San Diego, consumers without insurance either obtain free (uncompensated) care or pay out of their own pocket on a sliding fee scale at community clinics and other safety net health providers. Medi-Cal and Medicare public insurance programs are available to strictly defined segments of the population, and are often unavailable for many Mexican workers in San Diego. As a result, many migrant workers and residents either do not qualify for health care assistance, or frequently have no access to even basic medical services. The alternative they often turn to is medical care in Mexico, which is much more affordable than in San Diego. Some also turn to emergency rooms in San Diego medical facilities, although patients who cannot pay for their medical care account for less than 5% of emergency room visits in San Diego County.238
The uninsured are not all poor: many middle class workers cannot afford insurance. Spiraling health care premiums make it prohibitive for small and medium-sized companies to offer health insurance as an employment benefit. Likewise, many poor would like to have health insurance, but cannot afford it. The Academy for International Health Studies (AIHS) found that 73% of Mexican nationals working in the US earned $25,000 or less per year,239 which means,
according to the AIHS study, that the monthly premium would have to be $60 or less.240 The
study found that an overwhelming majority of Mexican nationals working in the US had a strong interest in an affordable, comprehensive cross-border health insurance – a policy that works on both sides of the border.241
234 Aguayo, et.al (2003), p. 1. 235 Brown et.al., p. 18. 236 Ibid., pp. 19-20.
237 San Diego County Child and Family Health and Well-Being Report Card 2002, p. 27.
238 Insure the Uninsured Project, Orange & San Diego Regional Workgroup 2002 Charts, available (as of 3/8/04)
from http://www.work-and-health.org/regionalWG/OrangeSDCounty/OrangeandSD.html
239 Grantmakers in Health Bulletin, July 24, 2000, p.3.
240 Managed Care Magazine 2000, available (last accessed on 3/8/04) at
http://www.managedcaremag.com/archives/0008/0008.news_intlplan.html