1. Public Health Challenges at the U.S. - Mexican Border: Lessons for Europe? Armin Fidler (World Bank) Alfonso Ruiz (PAHO/WHO) Nuria Homedes (University of Texas)

2. U.S. – Mexico Border Population 25 US Counties 34 Mexican Municipalities 24 Native American Nations 12 Million people Ten States, 70 Million People Border length 3140 km

3. U.S. - Mexico Border Population Demographics  55% of the population lives on the U.S. side in 4 states  45% of the population lives on the Mexican side in 6 states  70% of the U.S. border population is of Hispanic origin  47% of the border population is under 20 years of age

4. Population Dynamics  Population growth rate (4.3% for Mexico and 1.8% for U.S) higher than national rates ( 1.9%) Mexico, (0.9%) U.S.  Large minority population in the U.S. border (average Hispanic population 70%)  Three largest Mexican border cities (Juarez, Tijuana, Mexicali) comprise 50% of Mexican Border population Estimated Border Population 1990-2020 Population estimate: de Cosio, G. (in Millions)

5. U.S. - Mexico Border: Socio-Economic Indicators  Mexico exports to U.S. =  $90 billion p/a  40% exports from 6 Mexican border states Inequities 6 Poorest U.S. counties Lower poverty rates in Mexican border states than the nation 2,878 Maquila plants: 1.8 million employees Maquiladora sites

6. Maquiladores: A Mixed Blessing? + Generate work for 1 M Mexicans + Generate US$ 60 B in exports + US$ 400 M in corporate taxes (2.5% of government revenues + US$ 1.3 B in social security taxes - highly increased environmental pollution - increased south-north migration - evidence that low skill, low wage business is resettling elsewhere (India, China) - increased disease incidence due to pollution (smog related air-borne, water-borne pollutants)

7. A Normal Day at the Border ….. 400 million legal crossing/year South to North 3.8 million commercial truck crossings/year South to North

8. Health Divide Hepatitis A: US side 3 times national rate, Mexican side twice national rate (Study El Paso/Cd. Juarez 76% and 96% of pregnant women) Mexican border: Salmonella incidence 26% higher than in rest of country High prevalence of TB (9% MTR-TB), dengue, leprosy, rabies Concerns about increasing injury rates (accidents, violence).

9. Health Services US citizens come to Mexico for purchasing drugs and to seek medical and dental care: 18% of patients in Mexican border cities are from US (mostly uninsured) Mexicans seek treatment in the US for high complexity treatments BUT: differences in organization, financing and insurance mechanisms (including malpractice) results in little collaboration or referrals. Some US insurers offer now insurance benefits in Mexico

10. History of Border Health 1902 Foundation of PAHO (Pan-American Sanitary Bureau) 1906 Food and Drug Act, regulating pharmaceuticals 1919 Passports required for border crossing 1927 Flood victims support across border 1940 bi-national cooperation to combat infectious and venereal diseases at border 1942 PAHO establishes Field Office in El Paso, Texas 1943 USMBHA founded 1994 NAFTA signed, Border Health Commission established

11. Cross-border Initiatives US-Mexican Border Health Association (USMBHA) 60 year history: Annual Meetings – technical cooperation “ Enlaces ” – capacity building in HIV/AIDS prevention Migrant Partnership Program against substance abuse “ Cara a Cara ” Project – Latino MSM HIV prevention program Disparities Elimination Project – substance abuse and mental health program Farm workers Health Program

12. USMBHA Mission and Objectives Contribute to Public Health and promote health and living conditions at border Bring together institutions and professionals with interest in border health Learn about health needs of populations (Sister Cities, Bi-National Health Councils) Promote public health and environmental health Serve as mechanisms for communication and collaboration of local health authorities Carry out and support specific health programs (public and private sectors)

13. The North American Free Trade Agreement (NAFTA) 1994 Exponential increase of cross-border transactions of goods and services and capital flows between the US, Mexico and Canada. But: Globalization may not have promoted increased bi-national health policy cooperation Barriers for health cooperation continue to exist. Informal work has become more difficult, with policy decisions having been centralized Political, social and cultural interdependence must be equally understood as international trade is being promoted.

14. Barriers: By law, US institutions are not allowed to spend resources in Mexico – channels through PAHO PAHO: “….there are many meetings but few resources ” US seems only concerned about containing problems spreading north Border Health Commission approved by Congress in 1994, funded in 1998, first meeting in 2000! Allegations of red tape, harassment in particular after September 11, 2001 ( “ federal intrusion ” ) Cultural Barriers: distrust, lack of respect, racism, corruption

15. EU Relevance? Must understand border as a special area with special needs Migration may pose health and environmental threats for both sides Trade agreements may cause deterioration of local working, environmental and public health conditions Formal and informal mechanisms of exchange and collaboration can make a difference Targeted funding for cross-border public health interventions is essential