National Hispanic Medical Association 11th Annual Conference Celebrando la Diversidad U.S. Mexico Bo

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Seventh Annual Primary Care and Prevention
Conference 12th Annual HeLa Womens Health
Conference
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Eduardo Sanchez, M.D.,
M.P.H.Director, Institute for Health
PolicySeptember 14, 2007
Meeting the Health Needs of the Emerging
Majority Applying Lessons Learned from
Border Health Programs to Eliminate
Health Disparities throughout the U.S.

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Dr. Eduardo Sanchez includes no discussion of
off-label, experimental, or investigational use
of drugs or devices in the presentations, nor
does he have any relationships with relevant
commercial entities.
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• Of all the forms of inequality, injustice in
  healthcare is the most shocking and inhumane.
• - Martin Luther King

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Objectives

• Describe the demographics and epidemiology of the
  US-Mexico border region
• Describe US Latino demographic trends and health
  issues
• 3. Describe three specific Texas border city
  programs related to population health, public
  health, and diabetes

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The U.S. Mexico Border

• 10 states
• 14 sister cities united by the border
• 13 million people
• 2000 miles long

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• Mexicos three largest municipios
• Ciudad Juárez, Chihuahua
• Tijuana, Baja California
• Mexicali, Baja California
• account for slightly more than half of the total
  Mexican border population.
• Nearly two-thirds of the United States border
  population is concentrated in three counties
• San Diego, California
• Pima, Arizona
• El Paso, Texas

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2000 Population Data States Municipios/Co
unties México (80 municipios) Baja California
2,487,367 2,487,367 Chihuahua
3,052,907 1,363,959 Coahuila 2,298,070
387,922 Nuevo León 3,834,141 116,556
Sonora 2,216,969 607,508 Tamaulipas
2,753,222 1,387,549 Border States
16,642,676 6,350,861 United States (44
counties) Arizona 5,130,632 1,159,908
California 33,871,648 2,956,194 New México
1,819,046 312,200 Texas 20,851,820 2,125,
464 Border States 61,673,146 6,553,766
United States-Mexico Border Area
Totals 78,315,822 12,904,627
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Population Trends, U.S.-Mexico, 1970-2000
Population in millions
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Percent Hispanic
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Hispanic Population in Texas
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Age-adjusted Mortality Rates, Mexico and United
States, 2000 Rate per 100,000 inhabitants
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Age-adjusted death rates per 100,000 inhabitants,
Year 2000

• Mexico United States
• Cause of Death Rate Cause of Death Rate
• 1. Heart disease 109.0 1. Heart disease 151.4
• 2. Cancer 87.0 2. Cancer 138.3
• 3. Diabetes mellitus 77.6 3. Stroke 33.7
• 4. Accidents 42.2 4. COPD 24.1
• 5. Stroke 40.6 5. Accidents 30.2
• 6. Cirrhosis 42.4 6. Diabetes mellitus
  16.5
• 7. COPD 17.6 7. Pneumonia/flu 12.6
• 8. Pneumonia/flu 16.2 8. Alzheimers disease
  8.5

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Diabetes Mortality Deaths per 100,000
inhabitants
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San Antonio Heart Study

• Mexican-Americans at greater risk of all-cause,
  cardiovascular and coronary heart disease
  mortality than non-Hispanic whites
• Spanish speaking elders living longer with
  disease and disability than matched white elders
• From Hunt KJ, Resendex RG, Williams K, Haffner
  SM, Stern MP, Hazuda HP. All-cause and
  cardiovascular mortality among Mexican-American
  and non-Hispanic white older participants in the
  San Antonio Heart Study Evidence gain the
  Hispanic paradox American Journal of
  Epidemiology, 158(11), 1048-1057. 2003.

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From Bastida, Cuellar, and Villas. J. Comm
Health Nursing 2001
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Communicable disease cases and rates, Mexico and
United States Border, 2000

• Mexico Border Municipios U.S.
  Border Counties
• Disease Cases Rate Cases Rate
• Dengue 173 2.7 6 0.1
• Gonorrhea 507 8.0 3069 46.8
• Hepatitis A 1526 24.0 722 11.0
• Hepatitis B 71 1.1 410 6.3
• HIV 215 3.4 301 8.4
• AIDS 370 5.8 607 9.3
• Malaria 784 4.7 15 0.2
• Salmonellosis/
• Shigellosis 582 9.2 1880 28.7
• Tuberculosis 2124 33.4 653 10.0

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The U.S. Mexico Border Region(if it were the
51st state)

• Last in Access to Health Care
• Second in deaths due to Hepatitis
• Third in deaths related to diabetes
• Last in per capita income
• First in childhood poverty
• First in uninsured children

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Binational Health Organizations

• U.S. Mexico Border Health Commission
• U.S. Mexico Border Governors Conference Health
  Work Table
• U.S. Mexico Border Health Association
• Pan American Health Organization

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The five Cs

• Communication
• Coordination
• Collaboration
• Co-existence
• Camaraderie

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Healthy Border 2010

• Improve access to primary health care
• Reduce breast and cervical cancer mortality by
  improving screening
• Reduce tobacco use
• Reduce diabetes-related morbidity and mortality
• Improve water quality
• Reduce pesticide poisoning
• Improve mental health

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Healthy Border 2010

• Reduce HIV transmission
• Improve immunization rates
• Reduce infectious disease rates
• Reduce unintentional injuries
• Increase prenatal care
• Reduce infant mortality
• Increase dental services
• Reduce asthma morbidity

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Access Mexico

• National
• 57 of the population does not have health
  insurance
• 40.1has Social Security coverage
• 2.9 are in the unspecified category.
• Border
• 37.3 do not have health insurance
• 58.7 are covered by the Social Security system
• 4 are in the unspecified category.
• 5 of the Mexican population lacks access to
  basic health services, primarily because they
  reside in areas far from any government services.
  

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Access US

• In 2000, about one third of the U.S. border
  population resided in HPSA-designated areas
• The shortage of primary care providers was
  particularly acute in the Texas border region,
  where more than 70 percent of border residents
  resided in shortage areas.

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Insurance

• In the border region of Texas, 30 percent of the
  population does not have health insurance
• In the California border communities of San Diego
  and Imperial Counties, about 14 percent lack
  health insurance

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Border Health Insurance Study Findings

• CA, AZ, NM, TX the only states with uninsured
  rate over 18
• Uninsured rates in sample
• 57 under 50 years old were uninsured
• 30 overall
• 46 from 50-64 years old
• 2 over 65
• Bastida, Brown and Pagan, 2007

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Border Health Insurance Study Findings

• The four U.S. border states have the highest
  rates of uninsurance in the US, accounting for
  over 30 percent of the total US uninsured
  population.
• Having a regular doctor in Mexico lowers the
  demand for health insurance coverage in the US
  side of the border.
• Bastida, Brown and Pagan, 2007

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Border Health Insurance Study Findings

• 75 of uninsured and 24.4 of insured obtained
  medical care in Reynosa, Rio Bravo and Miguel
  Aleman
• Strong positive association between years in US
  and being insured
• Less than 10 years in US 84 uninsured

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U.S. Census 2000 Demographic Profile
Highlights Hispanic or Latino (of any race)

• General Characteristics Hispanic or
  Latino Total Population
• Total population 35,305,818 281,421,906
• Median age (years) 26 35
• Under 5 years 3,717,974 (10.5) 9,175,798
  (3.2)
• 65 years and over 1,733,591 (4.9) 34,991,753
  (12.4)
• Avg. household size 4 3
• Average family size 4 3

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U.S. Census 2000 Demographic Profile
Highlights Hispanic or Latino (of any race)

• Characteristics Hispanic or Latino Total
  Population
• High school graduate or higher 9,577,031
  (27) 146,496,014 (52)
• Bachelor's degree or higher 1,908,039
  (5.4) 44,462,605 (15.8)
• Civilian veterans 1,139,179 (3.2) 26,403,703
  (9.4)
• Foreign born 14,157,817 (40) 31,107,889 (11)
• Language not English at home 24,804,832
  (70) 46,951,595 (16.7)
• Economic Characteristics
• In labor force (gt16 yo) 14,835,741
  (42) 138,820,935 (49)
• Median household income 33,676 (1999 ) 41,994
• Per capita income 12,111 (1999 ) 21,587
• Individuals below poverty level 7,797,874
  (22) 33,899,812 (12)

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Texas MedicineFebruary 2007 Vol. 103 No.
2SYMPOSIUM ON BORDER HEALTH

• Tuberculosis among Mexican-American immigrants
• Border pandemic influenza planning and response
  efforts
• Estimated prevalence of hyper-insulinemia among
  Mexican American adolescents in South Texas
• Exotic disease in the migrant patient

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Reducing Health Disparities What Works

• CATCH - El Paso
• Lessons Comprehensive programs work
• Can apply to other populations
• Binational TB CARD program
• US Mexico Border Health Commission
• Lessons Cooperation
• UT Pan American/UT SPH Brownsville research
• Texas DSHS Preparedness projects
• Promotora Program
• Lessons Collaboration
•  

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Efficacy X Reach Public Health Impact!!
2000-2002
2004-2005
Obesity is gt 95th Percentile for BMI by Age/Sex
4th Grade Prevalence of Overweight by Health
Service Region, SPAN, 2000-2002 to 2004-2005
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Coordinated Approach To Child Health (CATCH)
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What Caused the Decrease in Overweight Among 4th
Graders in Regions 9 10?

• Paso del Norte Health Foundation
• CATCH initiative
• 8 years
• Resources, support
• Qué Sabrosa Vida
• Walk El Paso
• Legislation
• Senate Bills 19, 1357
• Other Policies
• Texas Public School Nutrition Policy

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Previous collaborations US-Mexico Border
Health Commission

• Binational TB Card program
• Ten Against TB

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Tuberculosis Rates
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MMWR Trends in Tuberculosis IncidenceUnited
States, 2006

• 60 of all US cases in
  (over 500 cases in each)
• California
• Florida
• Georgia
• Illinois
• New Jersey
• New York
• Texas
• MMWR. 200756245-250

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2006 Tuberculosis rates

• US-born
• 2.3/100,000
• A 7 decline since 2005
• 68.6 decline since 1993
• Foreign-born
• Number increased, rate decreased from 2005
• 21.9/100,000
• 0.5 decline since 2005
• 35.8 decline since 1993

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2006 Tuberculosis Statistics

• 2006
• 55.5 of TB cases among foreign-born from
• Mexico
• Phillipines
• Vietnam
• India
• China
• More cases among Hispanics than any other
  race/ethnicity

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Ten Against TB

• Ten US and Mexico Border States
• Arizona Baja California
• California Chihuahua
• New Mexico Coahuila
• Texas Nuevo Leon
• Sonora
• Tamaulipas

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TB and Diabetes?

• Case-control study
• 15 border counties
• Hospital discharge data
• Texas Healthcare Information Council, 1999-2001
• Diabetes patients almost twice as likely to have
  TB
• Association between tuberculosis and diabetes in
  the Mexican border and non-border regions of
  Texas.
• Adriana Perez, H. Shelton Brown III, and Blanca
  Restrepo.
• The American Journal of Tropical Medicine and
  Hygiene, 74(4)604611.

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Tuberculosis and Diabetes

• Retrospective studies suggest that
• Diabetes is the most common risk factor for TB on
  the Texas Mexico Border
• Patients with TB and Diabetes are more likely to
• Develop Multi drug resistance
• have delayed clearance of mycobacteria from
  Sputum
• Prospective studies are confirming that DM
• is the most frequent co-morbidity among Hispanic
  TB patients from the Texas-Mexico border
• Occurs in older patients without a history of
  alcohol, drug abuse or evidence of HIV infection
• Prospective studies further suggest that TB
  patients with DM may have a more acute
  progression of TB infection

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Post 9/11 Post Anthrax

• Bioterrorism Preparedness
• Additional funds for border preparedness
• Binational sister city assessment and planning
• Binational state to state assessment and planning
• Border region assessment and planning
• When Texas studied preparedness communcation, we
  learned.

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Social Networks and Communication Lessons from
Preparedness

• Daily access Spanish-language radio and TV
  programs, daily print media Karr and Alcalay
  2001
• The family is the most credible source of
  health information (Purnell Paulanka, 2003)
• Reliance on social networks is likely to be
  increased in the event of bioterrorist threats or
  events that are unfamiliar and require a fast
  response, particularly if the threat is to urban
  areas and is observable.

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Social Networks and Communication

• Children attend public schools information can
  flow through these
• Social networks (family members, neighbors,
  recognized community members, churches and church
  networks) are important avenues
• Police, firefighters, uniformed emergency
  personnel and health-care workers are considered
  reliable information sources undocumented
  immigrants may be reluctant to interact with them
  out of fear of disclosure of undocumented status

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Social Networks and Communication

• Television and radio messages should be
  culturally competent, including messages
  reflecting strong family and community
  connectedness.
• Television stations broadcast from both US and
  Mexico radio may reach more people
• Printed materials should be passed out during or
  in conjunction with face-to-face outreach.

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Social Networks and Communication Lessons from
Preparedness

• Word of mouth communication and local media
• For colonias and rural groups, notices posted in
  local general stores and restaurants
• Few have land-line phones, but cell phone usage
  is high
• Promotoras

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Texas Primary Care Office  Promotor(a) or
Community Health Worker Training and
Certification Program

• training and certification standards
• administrative rules
• SB 1051 (77th Texas Legislative Sessions)

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Social Networks and Health Status

• The Spread of Obesity in a Large SocialNetwork
  over 32 Years
• Obesity appears to spread through social ties.
• These findings have implications for clinical and
  public health interventions.

Christakis and Fowler, NEJM 7/26/200 7
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The five Cs

• Communication
• Coordination
• Collaboration
• Co-existence
• Camaraderie

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Concept
Primary-care Centered Health System
Medical Care
Public Health
Specialty/Tertiary Care
Primary Care
Tuberculosis control
Specialty Care Diagnostic Testing

• Patient Centered
• Medical Home
• (mental/dental/medical)
• Easy access
• Continuity of care
• Comprehensive care
• Coordination of all care
• (Clinical preventive services
• and disease management)

Comprehensive School Heath Education
Hospital Based Care Inpatient Care Emergency
and trauma care
Promotores
Optimal Communication (Integrated
Virtual System) Including best use of
health informational technology
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One more C

• Currency
• Health is the most valuable currency we have
  to address international issues.
• U.S. DHHS Secretary Tommy Thompson

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You are never strong enough that you don't need
help. Cesar Chavez

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• Julie Graves Moy, MD, MPH
• assisted with the production of this presentation