US-Mexico Border Health
Anand Bhat tells us more about the inequalities in his own state, Texas, and also describes his experiences in the US-Mexican border
Until the immigration debate caught fire last year, the US-Mexico border was only known for Tejano music, stolen Senate elections by future presidents, and sleepy towns waking up to the new realities of NAFTA (North American Free Trade Agreement) and the War on Drugs. Little attention, however, is paid to the inhabitants of the border compared to those who illegally cross it.
The United States is known for being the only industrialized country without guaranteed, comprehensive universal health care. But perhaps less known is that my home state of Texas has the highest percentage of adults and children uninsured (1). And perhaps not known at all to the outside world is that the lack of health insurance is worst in the counties along the Mexican border. (To see a map of the area, go here)
When people in Texas refer to ‘the Valley’, they are referring to the Rio Grande Valley at the southernmost tip of Texas and the United States. These four counties are among the poorest in America, and Starr County is the third poorest overall (first in non-Native American counties) in the nation. The two largest towns in the area are Brownsville and McAllen.
The Table below shows the ethnic diversity of the state of Texas and also how Texas and the Rio Grande Valley significantly differ from the United States as a whole.
Table 1: Profile of Nation versus Texas versus Rio Grande Valley (2, 3)
| Place | Per capita income | Poverty rate | Percent Anglo | Percent Black | Percent Hispanic | Percentage Uninsured |
| United States | $21,587 | 12.7% | 66.9 | 12.8 | 14.4 | 15.8 |
| Texas | $19,617 | 16.2% | 49.2 | 11.7 | 35.1 | 24.5 |
| Cameron County(Brownsville) | $10,960 | 29.4% | 12.9 | 0.8 | 86.0 | 32.6 |
| Hidalgo County(McAllen) | $9,899 | 30.5% | 9.4 | 0.9 | 89.4 | 33.8 |
| Starr County | $7,069 | 34.8% | 2.1 | 0.5 | 97.6 | 30.5 |
| Willacy County | $9,421 | 29.6% | 11.1 | 0.7 | 86.6 | 29.4 |
The first thing to notice is that Texas, like California, is a majority-minority state with non-Hispanic whites (Anglos) making up less than 50% of the population. While the proportion of (black) African-Americans in Texas is similar to the national average, the proportion slides to almost non-existence in South Texas. Hispanics (in Texas, mostly Mexican-Americans) are more than twice as common in Texas than in the United States as a whole while in the Valley they are the overwhelming majority.
Also of note is that despite the Texan image as a rich oil exporting state, the average state income is lower than the national average while the poverty rate is higher. Poverty rates in the Valley lie at around 30% while the percentage uninsured for these counties is generally twice the national average as well.
In short, Texas today represents the diversity of the United States tomorrow. How Texas fares with the health and education of its diverse and growing population will soon test all of America.
Frontera de Salud
In 1998, medical students from my university, the University of Texas Medical Branch (UTMB) at Galveston, founded the NGO Frontera de Salud (4) (Spanish for ‘frontier of health’). It started when a medical student witnessed the denial of health care for the working poor people during his rotation in Brownsville.
I volunteered with Frontera the weekend of December 7-9th, 2007. We began our Saturday at the Brownsville Community Health Center (BCHC), a county health clinic for indigent care. We (medical students, nursing students, nurses, and physicians) were scheduled to perform over thirty well-woman check ups in just a few hours. Frontera emphasises prevention, and the emphasis on well-woman exams came from the observation that UTMB was seeing many patients with advanced cervical cancer from the Valley who had never had a pap smear.
It is difficult to attract doctors to the Valley. Texas already has a lower number of doctors per 100,000 residents than most states (5). Getting them to move to a high poverty area far from major cities is a tough sell. Even if they come to the Valley, there is no guarantee that they will continue to work at a community clinic like the BCHC. The morning we came, we noticed that two of the three obstetrician-gynecologists had quit that week, making our work that much more important.
Cameron Park, Texas
That afternoon we made house calls in Cameron Park, a community outside the city limits of Brownsville. Cameron Park is a colonia: an unincorporated community on the Texas-Mexico border that lacks essential services like sewage, clean water, electricity, paved roads, sidewalks, and safe and sanitary housing (6). Cameron Park is the poorest community in the United States with a per capita income of $4,103. (7,8)
The local Catholic Church, Iglesia San Felipe, arranged house calls for us via their community health workers. The church [featured in a deleted scene in Michael Moore’s Sicko (9) ]is a key local partner for Frontera’s outreach efforts.
Promoters identify homes where patients need screening and referral. For us, the house visits open our eyes to a forgotten people in a forgotten part of the United States. The house calls focus on getting people into the health care system and informing them of what resources are available.
On Sunday morning, we screened for diabetes and hypertension after Masses at Iglesia San Felipe. Diabetes mellitus type 2 has a high prevalence in Mexican-Americans (10, 11). By screening we can treat people early and refer them to the community healthy cooking program and community exercise program that Frontera started. The community health workers are an essential part of this, as they are locals and can better understand and communicate to their neighbours than we gringos could possibly do.
What has been accomplished?
In ten years, Frontera has shown how model community and preventive health programs can be implemented in underserved areas in the United States. Here we have all the predictors of poor health outcomes: poverty, low education, and minority status. If such a program can be done in the poorest community in the United States, why cannot and why should it not be expanded across Texas, America and the world?
Perhaps the biggest accomplishment, though, had nothing to do with modern medicine. The voter registration drive undertaken by Iglesia San Felipe registered 2,000 new voters. New voters demanded that Cameron County pave roads and sidewalks and bring essential services to Cameron Park. The city of Brownsville had to annex part of Cameron Park (forcing it to deliver city services like sewage and water and dog catchers) during a recent expansion. In a few years, Cameron Park will lose its census designation as a colonia, a victory in and of itself. (12)
Ten years ago, access to care was limited to one nurse-nun working in a broom closet in a church. When Frontera de Salud started, students making house calls needed sticks to fight off stray dogs roaming the dirt roads. Now Cameron Park residents have paved roads and sidewalks, a walking track, a cooking program, and access to house calls, screenings, referrals, and follow up in a region that has seen many feel-good efforts come and go, never making a permanent or sustained impact. And certainly not permanently altering the health or power relations of those served.
Delivering plumbing and clean water to people has saved far more lives than most medical innovations in the last fifty years. That Frontera de Salud could help empower Cameron Park residents to fight for their own health is its biggest sign of success. (13)
Anand Bhat
Second year Medical Student
University of Texas Medical Branch
akbhat@utmb.edu
More Information
Senior Family or Internal Medicine residents in any ACGME accredited program are eligible for 4-6 week elective rotations in Integrated Community Health with Frontera de Salud. Housing accommodations are provided, and out of state residents will be provided a rental car during their stay. For more information visit the Frontera elective webpage.
(1) Dallas Morning News - “Texas tops nation in percentage of uninsured residents”
(2) Texas State Data Center - “Uninsured in Texas by County” PDF
(3) U.S. Census Bureau - “U.S. Census map of Texas by County”
(5) U.S. Census Bureau - “State Rankings- Doctors per 100,000 Resident Population”
(6) Attorney General of Texas - “What is a Colonia?”
(7) Wikipedia - “List of Poorest Places in the United States”
(8) U.S. Census Bureau - “Cameron Park, Texas”
(9) Sicko DVD scene of Cameron Park http://www.youtube.com/watch?v=1yV2zNOqF4Q
(10) American Journal of Epidemiology - “Diabetes among Mexican Americans in Starr County, Texas”
(11) Texas Diabetes Council - “Diabetes Data”
(12) Federal Reserve Bank of Dallas - “Texas Colonias: A thumbnail sketch”
(13) Frontera de Salud - “Summary of Evaluation Methods”
https://webspace.utexas.edu/xythoswfs/webui/_xy-23437218_docstore1