AAMC Reporter: September 2008

On the Borderline: Teaching Hospitals, Medical Schools Work with Immigrant Populations

Steffanie A. Strathdee, Ph.D., chief of the Division of International Health and Cross-Cultural Medicine at UCSD School of Medicine, inspects a man during mobile clinic rounds near the U.S.-Mexico border.

The Tijuana River canal cuts a fetid swath through its infamous border city namesake. Masses of waste and debris—all the runoff of Mexico's infamous urban playground—collect between the canal's sloping concrete walls, and lie scattered through a greenish ribbon of stagnating water.

Some immigrants traveling between Mexico and nearby San Diego call the canal's walls and drainpipes home. Drug abuse and diseases such as AIDS and hepatitis are rampant here, as are skin abscesses and other telltale signs of a neglected population.

Thousands of miles away, along the Rio Grande, a roofer lives with his family and about 7,000 other immigrants in Cameron Park, a skeletal living community or colonia on the outskirts of Brownsville, Texas. There is no running water to speak of. A butane tank hooked up to a hose brings gas to the shelter's furnace through a hole bored in the wall. The roofer works about 70 hours a week for $2,000 a month. He has no health insurance, but a recent screening revealed that he could have diabetes. Between 1970 and 2000, the population of the U.S.-Mexico border region—defined as the area 100 kilometers to either side of the international boundary—more than doubled, rising from 3.1 million to 6.6 million. If trends hold, the border population could approach 10 million by 2020, according to the binational United States-Mexico Border Health Commission (USMBHC).

The immigration debate recently took up residence on the front pages of American politics. Policy reforms have yet to roll down from Capitol Hill, but in the meantime, the challenges of immigration remain in force and could only grow more prominent with the swelling border population.

Chief among the challenges is how to provide health care for these millions of workers and families. For immigrants both legal and illegal, the border health system is a kind of patchwork safety net, and no small part of it comes from teaching hospitals and medical schools.

There is certainly no shortage of border health problems. According to USMBHC statistics, between 1990 and 2000 Mexico's AIDS mortality rate rose about 60 percent faster along the border than it did for the nation as a whole. Tuberculosis rates along the border significantly outpaced national averages in 2000: Mexican border cases reached 33 per 100,000 residents versus the national average of 16, and American border cases reached 10 versus about six nationally. Diabetes is the third-leading cause of death in Mexico's border region, causing nearly 4,000 fatalities there each year.

There are also financial problems. Three U.S. border counties are among the nation's 10 poorest, USMBHC figures show. Overall, about 19 percent of the U.S. border population (as opposed to 13 percent nationally) lives below the federal poverty level of $21,200 a year for a family of four. In the Texas border regions, an estimated 30 percent of the population lacks health insurance; in the California border communities of San Diego and Imperial counties, about 14 percent of people lack health insurance.

And there are access problems. About one-third of the U.S. border population in 2000 resided in a federally designated Health Professions Shortage Area, which contains more than 3,000 inhabitants for every physician. A 2005 analysis published in the American Journal of Public Health found that immigrants received an average of $1,139 of health care each year, compared to $2,564 for non-immigrants, and consumed about 8 percent of U.S. health care, despite accounting for 10 percent of its population.

Many hold the view, however, that caring for immigrants—particularly undocumented immigrants—unduly burdens the U.S. health care system. According to the Center for Immigration Studies, a Washington think tank that favors stricter immigration controls, immigrants accounted for 18 percent of the nation's uninsured care expenses. Center Research Director Steven Camarota said that, in 2002, treating uninsured immigrants cost the federal government roughly $4.7 billion—$2.5 billion in Medicaid and $2.2 billion in other expenditures. State and local governments in border regions can spend another one-third of that total on top of the federal figures, according to center data.

"If your concerns are fiscal in nature, you either need to enforce the [immigration] laws and make illegals go home, or you have to stop complaining about the cost," Camarota said.

As the national debate continues, medical students and faculty train, conduct research, and practice in border areas, while local teaching hospitals do their best to accommodate patients with little or no means of payment.

"We do take care of the health needs of those who are undocumented," said Sister Margaret McBride, vice president of mission support for St. Joseph's Hospital in Phoenix. "We're really on the firing line. As a tertiary hospital with a lot of residents, we tend to handle a larger burden."

The financial impact of treating illegal immigrants can be daunting, especially in Arizona, which lacks a Medicaid program. Nevertheless, McBride said, the hospital works to "identify early on those patients who may have a financial challenge," and provides charitable care for all those within 500 percent of the federal poverty line. She estimated that the hospital provided about $27 million in charitable care in 2006-2007. The hospital also makes a conscious effort to reach out to local immigrant populations, McBride said.

Translators are available throughout the hospital and its outpatient settings, and cultural sensitivity is a priority. St. Joseph's also deploys mobile clinics in Hispanic neighborhoods to provide free care.

Proactively working in immigrant communities, rather than waiting for immigrants to seek help for an acute problem, seems to be a common theme in border health. Six times a year, the Texas-based Frontera de Salud program allows medical and nursing students from the University of Texas Medical Branch at Galveston and the University of Texas Health Science Center at San Antonio to provide various health services in colonias around the state. According to Frontera Executive Director Kirk L. Smith, M.D., Ph.D., students are confronted by squalid living conditions and myriad untreated health problems, such as a woman who once entered a clinic carrying a 15-pound goiter.

"Every time we take a trip, there are one or two students I have to take aside, because they break down," Smith said. "A lot of the people rely on folk remedies, like healing touch. [Colonia residents] just wouldn't have access to real care if not for us."

As for the roofer in Cameron Park, he was ultimately diagnosed with diabetes.

"In 10 or 15 years, he may be looking at dialysis, losing a limb, or going blind," Smith said. "And he's one of the ones who's better off."

The clinical treatments help, but as with St. Joseph's, Smith emphasized prevention as the true key, especially in managing chronic conditions like diabetes. Smith said the work held great benefits for students as well.

"In medical education, we keep talking about moving to interdisciplinary teams," Smith said. "Here, they work in real teams out in a community. They teach prevention. They learn how to be effective advocates. They work with state legislators and agencies. They work with the media. They don't just read about it."

In California, amid such hellish backdrops as the Tijuana River canal, medical residents at the University of California, San Diego (UCSD) Medical Center are learning more about immigrant health through research.

"We work on everyone from sex workers to drug abusers to those with occupational diseases," said Steffanie A. Strathdee, Ph.D., chief of the Division of International Health and Cross-Cultural Medicine at UCSD School of Medicine. "We take residents into the underbelly of the city to work with people who are homeless or addicted, or live in the dry sewer pipes to avoid the police. Sometimes the only health care [immigrants] are receiving is through our studies."

UCSD's Proyecto El Cuete ("the needle project") tracks 1,000 injection drug users in Ciudad Juarez for tuberculosis, AIDS, and other diseases. Another recent UCSD-led study revealed that a tuberculosis strain called Mycobacterium bovis, typically associated more with cattle than humans, is spreading in San Diego and concentrated mostly in Hispanics of Mexican origin. The new Paul L. Foster School of Medicine at Texas Tech University Health Sciences Center at El Paso, Texas, located just minutes from Mexico, is tailoring its curriculum to the special health needs of the border—and the special skills doctors need to practice there.

"Our students can understand international health by working within 10 miles of the medical school campus," said Jorge Manuel de la Rosa, M.D., the school's dean. "You're not only in another country, you're in a different milieu for health care.... We give geographic preference to students who come from the border area. They know the social mores of the area, and they will be more likely to practice on the border."

Border health care is central to the school's curriculum, which among other things includes special clinical presentations and instruction covering five major public health disciplines in a border health context. A tailored M.D./M.P.H. program is on the table for the future. The school is also involved with nearby Universidad Autonoma Ciudad Juarez, which contains a medical school.

"There are," de la Rosa said, "many opportunities for discussion."

—By Scott Harris