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| Health Care: Crisis at the Border May 5, 2002 HARLINGEN -- It is a contradiction as stark as the contrast of gleaming office developments and dusty, dilapidated colonias that line the Texas-Mexico border. In a region of 2 million people where a rate of growth -- in jobs and population -- continues to outpace that of the nation, a pervasive lack of health care has mortgaged the border's future with a profound and often deadly liability. Border residents fall ill and die from disease at rates significantly higher than those of not only the United States as a whole but also the rest of Texas. An appalling example is women in the lower Rio Grande Valley and other places along the border who are dying at twice the national rate of cervical cancer, even though the disease is curable if caught in time. And rates of tuberculosis and liver disease are twice as high on the border as in other parts of the state. "What we have is a full-blown health crisis in these border counties," warns state Sen. Eliot Shapleigh, D-El Paso. "What others in Texas need to know is soon this will affect them -- the infectious TB not treated in Laredo soon ends up at Parkland (Hospital) in Dallas." Diabetes, which strikes Mexican-Americans more frequently than the statistical average, kills at a much higher rate along the border because of the large concentrations of Hispanics who live there. In Harris County, the death rate for diabetes is just below the Texas average of 17.8 deaths per 100,000 residents; the death rate is 24.9 in El Paso, 26.4 in the McAllen area and nearly 33 in Laredo. If that were not enough, the border region is a porous frontier where diseases more prevalent in the Third World are increasingly appearing. Outbreaks of mosquito-borne dengue fever, a plague of deadly birth defects, drug-resistant strains of tuberculosis, rabies, leprosy, high rates of children with hepatitis A, and even cholera are crowding the plates of border health workers. "We've got our hands full trying to build up our public health infrastructure on the border," acknowledged R.J. Dutton, director of the Border Health Office of the Texas Health Department in Austin. "It's definitely a unique part of the state." The incidences of disease combined with high levels of poverty and high numbers of people without insurance make "some pretty scary equations," said Dr. Sue Fisher-Hoch, of the University of Texas' newly opened School of Public Health in Brownsville. "There really are massive problems down here, mainly because the area is very economically disadvantaged," said Fisher-Hoch, whose office is only blocks from the Rio Grande. "There is a lot of disease, but the average income in the Rio Grande Valley is half that of the rest of the United States whereas the health costs are the same. "So we've got half the money to pay for the same thing that everybody else does." It is hardly surprising that a health crisis has evolved in a remote region of the state, where huge numbers of people are desperately poor -- 27 percent live below the poverty line, and per capita income is the lowest in the nation. Most can't afford private health insurance or qualify for government health benefits. And there are simply not enough health professionals to take care of them -- 31 of 32 border counties in 2000 were designated as medically underserved. "We have poor people living on the border, and if going to the doctor costs the same in McAllen as Dallas, you're getting your butt kicked," said Dutton. "There's also a case to be made that there's not enough health professionals on the border -- that is doctors, nurses, dentists, allied health workers," Dutton said. In some areas of the border, medical care can be miles and hours away. "We have a Payless Shoe store but no doctor," laments Cynthia Clarke, the city secretary in tiny Presidio. One day a week, a doctor shows up at the rural health clinic in that border town of 5,500 people, an outpost on the Rio Grande some 250 miles downriver from El Paso. If a medical emergency arises when the doctor is out of town, people can choose between a trip across the river to Mexico or an ambulance ride to the hospital in Alpine, 90 miles away. "Trauma care? Forget it. And God forbid if the ambulance is already taking some woman in labor to the hospital," said Clarke. Presidio might get its first full-time doctor in September, Clarke said. Predictably, border emergency rooms and hospital beds are swamped with uninsured patients, a cost to federal taxpayers who repaid border hospitals $108 million in 1998 for the care of uninsured patients. The border is in a Catch-22 when it comes to the all-important reimbursement rates for health services paid for by Medicaid and other federally funded programs. The rates are based on the usual fees charged in an area and the number of procedures performed. The border has meager medical facilities and a shortage of doctors. Consequently, fewer procedures are performed and the average cost of each procedure is less than in other parts of the state. The lower reimbursements make it difficult for border counties to attract more doctors or improve their medical facilities, experts say. A little more than a year ago, a trio of senators from the border -- Shapleigh, Eddie Lucio Jr., D-Brownsville, and Judith Zaffirini, D-Laredo -- asked the state Health and Human Services Commission to examine the reimbursement disparity. The agency recommended boosting Medicaid rates 16 percent, offering 10 percent bonuses to attract and retain doctors on the border and making it easier for children to get state health coverage. The changes, depending on the number of border counties included, would cost taxpayers between $150 million and $260 million. No action has been taken on the agency's recommendations. Last year, the state-mandated indigent health care programs, designed to be a safety net for the poorest of the poor, simply ran out of money in Hidalgo and Cameron counties, South Texas' two largest. Last May, Hidalgo County's indigent care program closed after spending all of its local tax money and going through $4.6 million in state aid. The closure sent Hidalgo County residents to emergency rooms for primary medical care. In neighboring Cameron County, the $2.3 million indigent health program had to cut services and manage costs by hiring three local doctors to screen health care claims. The millions these counties are spending do not come close to covering the actual costs of providing medical care to the uninsured in the Valley. The seven largest private hospitals in both counties were reimbursed by the federal government $44 million for a portion of the free services they provided to residents who could not pay. The 494-bed Providence Hospital in El Paso provided $10 million to $11 million in free health care last year, said Chief Operating Officer Irene Chavez. The hospital was reimbursed for $3 million, Chavez said. "It just drives the cost of health care up," Chavez said. "It's complicated, but part of the solution is economic development for these areas (on the border) so folks can get jobs with insurance coverage." Experts agree that the lack of health insurance is contributing to the border health problem. In border counties, 25 percent to 35 percent of people have no coverage of any kind. In many cases, the uninsured work in jobs that don't offer health insurance or the benefit is too expensive to accept, yet they earn too much money to qualify for Medicaid or other benefits. Sister Mary Nicholas, a Catholic nun who is director of community public health at the state Health Department's regional office in Harlingen, said lack of insurance is by far the biggest health problem. "When you have people who don't have access to health care, you're preventing them from getting things they need and you end up with real sick people," said Nicholas, a registered nurse who spent 32 years in public health. "You end up spending a lot on sick people to get them well." Nicholas said the state has a dismal record on immunizations. "We used to have a saying: `Thank God for Mississippi or we'd be dead last.' We're better in some things, but we're last in immunizations," she said. A lack of health insurance is more acute in the hundreds of border colonias, where nearly 400,000 people live in unincorporated subdivisions, many still without sewage service or garbage pickup. A recent survey by the Border Health Office indicated that in the border's colonias, nearly 64 percent of the people did not have health insurance. The survey found that colonia residents not only face health risks from bacterial contamination and disease borne by rodents and insects but noted most colonias are in rural areas close to agricultural fields that are regularly dusted with pesticides. Health Department workers found large numbers of children living in colonias tested positive for antibodies that develop after exposure to hepatitis A, an illness linked to untreated sewage. Colonias surrounding Laredo had the highest percentage, with 43 percent of children under 12 testing positive. As a result, the Health Department now requires children in the 32 border counties to receive a hepatitis A vaccine before entering school. An El Paso community group has estimated that 35 percent of El Paso County's 679,622 residents are uninsured, and another 33 percent have some form of federally funded health benefits. Only 32 percent of county residents have private insurance, which pays doctors more than a break-even rate. The group estimates the insurance mix in Austin is nearly opposite: 69 percent of the residents have private insurance, while only 13 percent rely on federal benefits and only 18 percent have no insurance of any kind. "That tells the story -- two-thirds of the population (in El Paso) has no commercial private pay insurance, and today the Texas border counties have the least developed medical infrastructure in America," said Shapleigh, a member of the state Senate committee on health and human services. Because of the border's low reimbursement rates in all the various federally funded health programs, Shapleigh said border doctors take on more patients "to try and make up for a rate that doesn't produce profits." "The bottom line is they work on more patients, work longer hours, for less money. When you add malpractice premiums that are skyrocketing, and the emergence of exotic diseases, doctors make the practical decision to move to Plano," he said. Shapleigh advocates raising the reimbursement rates for doctors and having the state indemnify them in malpractice suits and cap the amount of damage claims. In addition to illness caused by the pervasive poverty, doctors and health workers along the border continue to confront tragic and baffling birth defects. The most notorious was a cluster of birth defects called anencephaly, in which a baby is born without a brain. In 1990 and 1991, after horrified doctors and nurses raised the alarm, state and federal researchers tracked down 33 cases of anencephaly and other related neural tube defects in Cameron County, a rate triple the national average. Communities in the Rio Grande Valley wondered if the booming maquiladora factories across the border in Mexico were contaminating the air and water with solvents and other chemical waste. Health researchers launched investigations and prevention projects, trying to find what may have caused the defects and prevent affected women from having another child with a defect. Women with a previous neural tube defect pregnancy are 30 to 50 times more likely to have another, they note. A decade later, there is still no answer. "It's very rare that a cluster investigation is going to come up with a smoking gun or a cause," explains Peter Langlois, the senior epidemiologist with the Texas Birth Defects Monitoring Division. Researchers have added to the study a new cluster of seven anencephaly cases in Laredo in late 2000 and early 2001, which translates to an incidence rate of 26.7 cases per 10,000 births. It is the highest rate seen on the border since 1993. Currently, state researchers are investigating whether fumonisins, a toxin produced by a fungus that grows on corn, may be a contributing factor, Langlois said. Corn tortillas are a staple in many border households. Anencephaly is hardly the only birth defect that occurs at a higher rate along the border. Langlois said six other serious birth defects -- spina bifida (spine), hydrocephaly (brain), craniosynostisis (skull), ventricular septal defect (heart), patent ductus arteriosus (blood vessel) and pyloric stenosis (stomach) -- occurred on the border in 1998 and 1999 at nearly twice the Texas rate. Health researchers are not sure if economic barriers or other factors are responsible for cervical cancer killing women on the border at nearly twice the rate as in other parts of the state, with the highest death rates in the four counties of the lower Rio Grande Valley. "Women here are not getting pap smears as they should," said Maureen Sanderson, a cancer epidemiologist at the University of Texas school of public health in Brownsville. "Once they are identified with an abnormal lesion, they don't come in for a follow-up." Other researchers report that Hispanic women would much prefer a pelvic exam to be administered by a doctor who is both Hispanic and a woman. "The number of Hispanic female doctors is abysmally small," Sanderson said. Sanderson agrees with Sister Nicholas, who is convinced the cancer deaths occur because border women can't afford to see doctors. "I would hate to say how many people I've worked with right here (at the Health Department) whose mothers never had a pap screen until the Health Department allowed them to come in and do it for free," Nicholas said. "We really need to understand why women aren't being seen and are falling through the cracks," Sanderson said. Veteran health professionals are hardly optimistic about the future. "While there have been great strides made, and wonderful success stories, the reality is we're probably further behind now than 30 years ago," said Dr. Antonio Zavaleta, vice president for external affairs for UT-Brownsville and a medical anthropologist who has worked on Valley health issues for three decades. "The reason is the sheer weight of the population. ... The increase in the size of the population far outstrips funding, and there is no end in sight." Zavaleta, who organized the first health outreach program for colonia residents, said the problem is simple: Health funding isn't keeping up. "Let's say in the last 30 years we've increased the level of health-care funding on the border and in the Valley from $1 to $10 -- that's a tenfold increase," he said. "But over the same time, the population has increased by a magnitude of 50. So you're behind the curve, and always falling behind. "It's very frustrating. I continue to work in all areas in health care in the Valley, but we're not winning the game." |
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