United States– Mexico Border Area · The border area includes 48 U.S. counties in 4 states1 and 94 Mexican municipalities in 6 states,2 including 15 pairs of sister cities.3 In

INTRODUCTION

The United States–Mexico border region extends for

3,141 km, stretching from the Gulf of Mexico to the

Pacific Ocean. The 1983 La Paz Agreement, which

was signed between the governments of Mexico and

the United States with the goal of protecting,

improving, and conserving the environment along

the border (1), defines this area as the land within

100 km on either side of the international boundary.

United States–MexicoBorder Area

Health in the Americas, 2012 Edition: Country Volume N ’ Pan American Health Organization, 2012

The border area includes 48 U.S. counties in 4

states1 and 94 Mexican municipalities in 6 states,2

including 15 pairs of sister cities.3

In order to manage its program designed to

improve health along the border, the U.S.-Mexico

Border Health Commission (USMBHC) (2) limited

the border area to the 44 U.S. counties and 80

Mexican municipalities that have most of their

population within the 100-km limit (see Figure 1).

This constitutes a total population of approximately

14.94 million people (7.45 million males and 7.49

million females), about 7.44 million (3.68 million

males and 3.76 million females) in the U.S. (3) and

7.50 million (3.77 million males and 3.73 million

females) in Mexico (4) (see age and sex distribution

1 Arizona, California, New Mexico, and Texas.2 Baja California, Coahuila, Chihuahua, Nuevo Leon,

Sonora, and Tamaulipas.3 San Diego/Tijuana (California/Baja California),

Calexico/Mexicali (California/Baja California), Yuma/

San Luis Rıo Colorado (Arizona/Sonora), Nogales/

Nogales (Arizona/Sonora), Naco/Naco (Arizona/Sonora),

Douglas/Agua Prieta (Arizona/Sonora), Columbus/Puerto

Palomas (New Mexico/Chihuahua), El Paso/Ciudad

Juarez (Texas/Chihuahua), Presidio/Ojinaga (Texas/

Chihuahua), Del Rio/Ciudad Acuna (Texas/Coahuila),

Eagle Pass/Piedras Negras (Texas/Coahuila), Laredo/

Nuevo Laredo (Texas/Tamaulipas), McAllen/Reynosa

(Texas/Tamaulipas), Weslaco/Rıo Bravo (Texas/

Tamaulipas), and Brownsville/Matamoros (Texas/

Tamaulipas).

FIGURE 1. United States–Mexico border region.

Mexico Border StatesUnited States Border States

CountryMexico

Mexico sister cities

La Paz Agreement (100km)Latitude longitude (10 deg)

Major rivers

United States

United States sister cities

U.S.- Mexico border counties and Municipalities

Source: Elaborated by the PAHO United States-Mexico Border Office.

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of the border population in Figure 2). Between 2000

and 2010 the U.S. border population increased by

about 12% and the Mexican border population

increased by about 18%.

About 84% of the U.S.-Mexico border popula-

tion is urban. Mexico’s three largest urban munici-

palities—Ciudad Juarez in Chihuahua, and Tijuana

and Mexicali in Baja California—account for almost

half of the total Mexican border population. Over

80% of the U.S. border population is concentrated in

six counties: San Diego in California; Pima in

Arizona; and Cameron, El Paso, Hidalgo, and Webb

in Texas. San Diego alone, the wealthiest of the U.S.

border counties, represents about 40% of the U.S.

border population. About half of the U.S. border

population is Hispanic, primarily of Mexican

ancestry (5, 6).

The U.S.-Mexico border area represents a

binational geo-political system based on strong

social, economic, cultural, and environmental con-

nections governed by different policies, customs, and

laws. Important dimensions of this binational system

include commerce, tourism, sister-city familial ties,

Mexico’s assembly plants or maquiladoras (plants that

import components for processing or assembly by

Mexican labor and then export the finished pro-

ducts), ecological services, a shared heritage, social

partnerships, and immigration.

The area has experienced continuous growth

since the 1940s associated with the 1942–1947

Bracero Program (laborers contracted in Mexico to

work in the U.S. agricultural sector), the Border

Industrialization Program initiated in 1965, and the

North American Free Trade Agreement (NAFTA)

signed in 1993. Projected population growth rates in

the border region exceed anticipated national average

growth rates for each country. If current trends

continue, the border population is expected to

increase to about 20 million people by 2020 (7).

Trade has also increased significantly, particularly

since the NAFTA agreement came into force. For

example, in 2008, cross-border land trade between the

U.S. and Mexico totaled over US$ 293 billion, about

three times the amount recorded in 1995; 13,300

commercial trucks crossed the border daily, up 70%

from 1995 (8). However, the region is experiencing

several challenges, including the situation of violence

on the Mexican side of the border, the deceleration of

the maquiladora industry, and reduced northbound

illegal immigration stemming from both the slow-

down in the U.S. economy and enhanced U.S. border

immigration enforcement efforts. These factors may

slow development and affect cross-border trade and

travel. Personal legal border crossings from Mexico to

the U.S. decreased from 313.8 million in 2006 to

229.7 million in 2010 (9). In addition, the number of

FIGURE 2. Population structure, by age and sex,a United States border population in 2009 and Mexican borderpopulation in 2010.

Mexico (2010)

6.004.002.000.006.00 4.00 2.00 0.00

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

United States (2009)

FemalesMales

6.004.002.000.006.00 4.00 2.00 0.00

Percentage

FemalesMales

Percentage

Source: United States Census Bureau (2009); Mexico National Institute for Statistics and Geography, Population and Housing Census (2010)a Each age group’s percentage represents its proportion of the total for each sex.

UNITED STATES–MEXICO BORDER AREA

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apprehensions of unauthorized Mexican migrants in

the U.S. decreased from 1.17 million in 2005 to 0.45

million in 2010 (10).

The population on both sides of the border is

relatively young because of high fertility and a

continuous migratory flow (the population that

migrates north to the U.S. tends to be younger and

healthier). About 30% of the Mexican border

population and 24% of the U.S. border population

is under 15 years of age. In 2007, the total fertility

rates in the Mexican border states ranged from 2.0

children per woman in Nuevo Leon to 2.2 in the

states of Sonora, Chihuahua, and Coahuila, on a par

with Mexico’s national rate of 2.1. The total fertility

rates in the U.S. border states in 2007 ranged from 2.2

in California to 2.4 in Texas and Arizona, higher than

the U.S. national rate of 2.1. The proportion of

population over 60 years old is about 17% (55%

females) on the U.S. side of the border and 7% (51%

females) on the Mexican side (4, 11).

Life expectancy at birth for U.S. border states in

2007 ranged from 77.1 years in New Mexico (74.5 for

males and 79.7 for females) to 81.0 years in California

(78.6 for males and 83.2 for females), compared to

78.8 years for the U.S. (76.0 for males and 81.2 for

females). For the Mexican border states, life expec-

tancy at birth in 2009 ranged from 76.3 years in

Tamaulipas (74.0 for males and 78.7 for females) to

77.1 years (74.9 for males and 79.2 for females) in Baja

California, compared to 75.3 years for Mexico (72.9

for males and 77.6 for females) (12, 13, 14, 15, 16).

The native indigenous population along the

Mexican border area in 2005 totaled approximately

130,000 people, located primarily in Baja California,

Tamaulipas, Chihuahua, and Sonora (17). The

estimated Native American population during 2005–

2009 along the U.S. border area was approximately

80,000 people, located primarily in California and

Arizona (5). Five native indigenous groups have a

permanent land base that extends to both sides of the

border: the Kikapu peoples in Coahuila, known as the

Kickapoo in Texas and Arizona; the Kumiai peoples in

Baja California, known as the Kumeyaay in California;

and the Papago, Cucapa, and Yaqui peoples in Sonora,

known as the Tohono O’odham, Cocopah, and Pascua

Yaqui, respectively, in Arizona.

The African-American population along the

U.S. border area in 2005–2009 comprised approxi-

mately 3.2% of the U.S. border population (3),

located primarily in San Diego, California; Tucson,

Arizona; and El Paso, Texas.

This chapter examines health determinants and

health conditions along the border region. In

general, the issues are described at the state level,

with some specific examples given at the county/

municipality level. For several conditions, direct

comparisons between the U.S. and Mexican sides of

the border cannot be made because the available

information is not readily comparable.

HEALTH DETERMINANTS AND

INEQUALITIES

In 2009, the per capita gross domestic product

(GDP) for the Mexican border states ranged from

US$ 7,501 in Baja California to US$ 13,481 in

Nuevo Leon, compared to US$ 8,143 for Mexico as

a whole. The per capita GDP for the U.S. border

states ranged from US$ 39,123 in New Mexico to

US$ 50,871 in California, compared to US$ 45,989

for the nation. The U.S. border region includes both

one of the wealthiest and one of the poorest cities in

the U.S.: in 2009, the per capita GDP of San Diego,

California, was US$ 51,035 whereas the per capita

GDP of McAllen, Texas, was US$ 15,818 (18, 19,

20, 21).

The unemployment rate in the U.S. border

states for 2005–2009, measured as the population 16

years old or older who are in the labor force, was

6.8% in Texas, New Mexico, and Arizona, and 7.9%

in California, compared to 7.2% for the nation. At

the local level, the differences were more significant.

San Diego, California, had an unemployment rate of

6.7% whereas in McAllen, Texas, it was 9.2%. For

the Mexican border states, the unemployment rate in

2010, measured as the labor force for the population

14 years old or older, ranged from 5.9% in Baja

California to 8.7% in Chihuahua, higher than the

5.2% rate for the nation. It should be noted that in

Mexico there is a significant level of underemploy-

ment that has not been reported. Unemployment

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rates for the two nations are not readily comparable

(18, 19, 20, 21).

The education level of U.S. border residents is

lower than the national U.S. average, but there are

regional differences. For example, in 2009, in San

Diego, California, 6.8% of the population between

25 and 64 years old had an education level below the

ninth grade and 22.1% had completed a four-year

university degree. In contrast, in Brownsville, Texas,

27.6% had an education level below the ninth grade

and only 10% had a university degree. In the U.S. as

a whole, 6.4% had an education level below the ninth

grade and 17.4% had a university degree. The

education level on the Mexican side of the border

is more homogeneous. In 2010, between 25% and

30% of the border population had completed primary

school (up to sixth grade) and about 10% had a

professional degree, similar to Mexico’s national

average of 32% and 10.7%, respectively (4, 18, 20,

21).

THE ENVIRONMENT AND HUMAN

SECURITY

ACCESS TO CLEAN WATER AND SANITATION

Water is a limited resource in several parts of the

border region. Population growth along with eco-

nomic development places increasing stress on water

quantity and quality. The International Boundary and

Water Commission (IBWC) is a bi-national govern-

mental organization charged with identifying and

solving boundary and surface water issues arising along

the border between the U.S. and Mexico. In particular,

IBWC is responsible for preserving, protecting, and

delivering the waters of the Colorado and Rio Grande

rivers. The IBWC is not authorized to work on

transnational, groundwater issues.

Access to drinking water and sanitation services

has improved significantly in urban areas on the

Mexican side of the border, but it is still one of the

most significant physical environmental determi-

nants of health in the rural areas of both sides of the

border. In 2010, access to piped drinking water

services in the Mexican border cities ranged from

78% of the households in Nogales, Sonora, to over

95% of the households in Tijuana and Mexicali in

Baja California; San Luis Rıo Colorado, Naco, and

Agua Prieta in Sonora; and Acuna and Piedras

Negras in Coahuila. Access to sewer services ranged

from 84% in Reynosa and Rıo Bravo in Tamaulipas

to over 95% in Naco, Nogales, and Agua Prieta in

Sonora; Acuna and Piedras Negras in Coahuila; and

Ojinaga in Chihuahua (4). Sewer services may

represent wastewater collected but not treated prior

to discharge.

In U.S. border cities, over 98% of the house-

holds have access to piped drinking water and treated

wastewater services (3). However, access to these

services is still a challenge in rural border colonias.

Colonias are mostly unincorporated housing devel-

opments located primarily along the New Mexico

and Texas borders; they are characterized by high

poverty rates and may lack basic community infra-

structure. In 2010 in the six most populous Texas

border counties with colonias, there were 519 colonias

housing approximately 126,000 residents who lacked

some basic services and an additional 400 colonias

with approximately 50,000 residents who lacked all

basic services (22).

SOLID WASTE

Millions of scrap tires have accumulated in 46 known

tire piles throughout the border region. As the result

of a strong market for used tires, millions of tires from

the U.S. are imported to Mexico for reuse. Scrap tire

piles create breeding grounds for mosquitoes, rodents,

and other vectors of disease. In addition, tire pile fires

are difficult to extinguish and can emit noxious fumes

for months. From 2004 through 2009, almost 6.9

million scrap tires were removed from 12 areas on the

Mexican side of the border region as part of the U.S.-

Mexico Border 2012 Environmental Program. The

majority of these tires were used as fuel in cement

kilns. Pilot road paving projects and other innovative,

experimental reuse projects were also implemented

(23, 24).

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AIR POLLUTION

The most common and harmful air pollutants in the

border region include suspended particulate matter

(PM10, or particulate matter that is 10 m in diameter

or less, and PM2.5, particulate matter 2.5 m in

diameter or less) and ground-level ozone. For

example, San Diego exceeded the U.S. ozone standard

for 24 days in 2008 and Imperial Valley, California,

exceeded the standard for 15 days in 2006. In

addition, Imperial Valley exceeded the U.S. PM10

standard for 20 days in 2007, Nogales (Arizona and

Sonora) exceeded the standard for 45 days in 2006,

and Ciudad Juarez/El Paso exceeded it for 48 days in

2006. A number of measures, such as stricter

standards on motor vehicle emissions, cleaner fuels,

vehicle anti-idling programs, and road paving, have

been implemented in the border region to reduce the

sources of ozone and particulate matter (23).

PESTICIDES

California and Arizona have significant agricultural

industries in their border areas and maintain

reporting systems that track pesticide use.

According to the California Department of

Pesticide Regulation (25), the amount of pesticides

applied in California border counties dropped by

32% from 2006 through 2009, from about 3.1

million kg to 2.1 million kg. Dry winters and springs

and a shift from broad-based pesticides to newer,

more targeted products account for part of the

decline. On the other hand, the amount of pesticides

applied in Arizona border counties increased by 36%

from 2005 through 2009, from about 635,000 kg to

862,000 kg. Between 2006 and 2008, the California

border counties reported 161 definitive or probable

illness/injury incidents related to pesticide exposure,

of which only 54 incidents involved pesticides

intended for use in agricultural production. The

data suggest that most cases of pesticide exposure

occur in the household setting and primarily

involved household pesticides (26).

A major concern on both sides of the border is

the use of polvo de avion or methyl parathion as a

household pesticide. This product is licensed for

industrial agricultural application, but is illegally

packaged and sold to residents for household use. In

2007, a research group of the University of Texas

Health Science Center at Houston (School of Public

Health) reported that in a survey conducted in the

Lower Valley of El Paso County, Texas, about 90%

of participants used pesticides in their homes. Of

these, about 10% admitted using illegal products

(27).

ROAD SAFETY

Road traffic accidents constitute a major public

health concern in the border region—they are the

leading cause of death for school-aged children in

Mexico (28) and for people between the ages of 5

and 34 years in the United States (29). In 2009,

traffic-related mortality rates in Mexican border

states ranged from 8.1 deaths per 100,000 population

in Baja California to 26.2 in Sonora, compared to

14.0 for the nation. In the U.S. border states, traffic-

related mortality rates ranged from 8.3 in California

to 18.0 in New Mexico compared to 11.0 for the

nation (30). According to the U.S. National

Highway Traffic Safety Administration (31), the

U.S. border states reported a consistent decrease in

traffic-related mortality rates during 2005–2009.

Long-term declining trends in the U.S. have been

associated with behavioral and vehicle safety pro-

grams and the issuance of federal motor vehicle

safety standards, such as the Texas Teens in the

Driver’s Seat program. The declining trend since

2007 has coincided with the slowdown of the U.S.

economy (31), and areas that experienced greater

increases in unemployment rates recorded higher

decreases in fatalities.

VIOLENCE

The increase of violence in Mexico, mainly in the

northern cities, has been associated with the imple-

mentation of national policies to crack down on

organized crime and drug trafficking. In the six largest

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border cities, with an approximate population of 5.3

million inhabitants, the number of homicides related

to organized crime increased from 390 (7.3 deaths per

100,000 population) in 2007 to 3,585 (67.5) in 2010

(32). In the respective U.S. sister cities with a

population of 5.5 million inhabitants, the phenomenon

was the opposite, with a decrease in the number of total

homicides from 192 (3.5 per 100,000 population) in

2007 to 156 (2.8) in 2009. The reasons for this decline

are unclear. The most dramatic difference in the

number of homicides was between Ciudad Juarez,

Chihuahua, with a mortality rate of 167 deaths per

100,000 population, and its sister city of El Paso,

Texas, with a rate of 2 in 2009 (33, 34, 35, 36). In

response to the situation in Ciudad Juarez, the federal

government launched a violence prevention program in

2010 called ‘‘Todos Somos Juarez, Reconstruyamos la

Ciudad’’ (‘‘We Are All Juarez; Let’s Rebuild Our City’’)

with an investment of over US$ 300 million and over

160 social interventions (32).

One of the most significant phenomena of

social violence occurring on the Mexican side of the

border has been the increase in feminicide, defined

as the killing of women and girls. A study conducted

from 2006 to 2008 showed that feminicides in

Ciudad Juarez, Chihuahua, increased from 19 in

2006 to 111 in 2008. To address this phenomenon,

the Government has implemented national legisla-

tive measures such as the Law on the Right of

Women to a Life Free of Violence in Chihuahua and

the General Law of Women’s Access to a Life Free

of Violence aimed at reducing systematic female

homicides (37).

DISASTERS

The most significant natural disasters that affected

the border region during 2006–2010 were a flood, a

major hurricane, and an earthquake. The 2008

flooding in Presidio, Texas/Ojinaga, Chihuahua,

was unprecedented. Floodwaters inundated

Ojinaga’s wastewater treatment plant, sending sew-

age into the Rio Grande.

In July 2008, Hurricane Dolly hit the coast of

the Gulf of Mexico and affected the U.S. counties of

Starr, Cameron, and Hidalgo in Texas and the

Mexican municipalities of Matamoros, Valle

Hermoso, Rio Bravo, Reynosa, Dıaz Ordaz,

Camargo, and Miguel Aleman in Tamaulipas. The

hurricane caused flooding, power outages, evacuation

of about 20,000 people, two deaths on the Mexican

side of the border, and estimated losses of US$ 1.2

billion on the U.S. side (38, 39, 40).

In April 2010, the Mexicali Valley experienced

an earthquake measuring 7.2 on the Richter scale.

Mexicali in Baja California and El Centro in

California were the most affected cities. The earth-

quake was felt as far away as San Luis Rıo Colorado

in Sonora. Despite the magnitude of the event, there

were only two deaths and relatively few injuries. The

damage reported included the disruption of the

Mexicali-Tijuana highway, structural collapse of

public buildings and private homes, partial evacua-

tion of 17 hospitals on both sides of the border,

disruption of utilities, and gas leaks (41).

CLIMATE CHANGE

The U.S. Global Change Research Program (42)

reported in 2008 that the average temperature in

the southwestern region of the U.S. has increased

about 0.8 uC from a 1960–1979 baseline and

estimated further increases in average temperatures

by 2090 ranging from 3.2 uC to 5.6 uC above the

baseline. Rising temperatures decrease upstream

mountain snowpack and precipitation and increase

the evaporation rate of available water. This affects

the water sources for rivers and reservoirs in the

region and, as a consequence, the availability of

water for human consumption. Increases in

temperatures were also reported in the northern

Mexico border region. Assuming a scenario of

average economic growth for Mexico, average

temperatures would increase between 1.5 uC and

3.0 uC and precipitation would decline between

3.5% and 15% countrywide between 2010 and 2100,

with the greatest impacts being seen in the northern

border region. Water supplies in this region are

already stressed and are projected to become

increasingly scarce in the next 50 years (43).

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HEALTH CONDITIONS AND TRENDS

HEALTH PROBLEMS OF SPECIFIC POPULATION

GROUPS

Maternal and Reproductive Health

Maternal mortality rates for the U.S. border states in

2008 ranged from 8.1 maternal deaths per 100,000 live

births (8 deaths) in Arizona to 22.2 (90 deaths) in

Texas, compared to 12.7 (548 deaths) for the nation in

2007. In Arizona, the rate may not be statistically

reliable because of the low number of deaths. Texas

had the highest rate of maternal deaths consistently

from 2005 to 2008. Among African-American women

living in U.S. border states, maternal mortality was

about twice the national rate. For the Mexican border

states, maternal mortality rates in 2008 ranged from

30.1 (24 deaths) in Nuevo Leon to 62.9 (40 deaths) in

Chihuahua, compared to 59.7 (1,167 deaths) for the

nation. Chihuahua consistently recorded the highest

rate among the border states from 2005 to 2008 (12,

44, 45, 46).

Early prenatal care (percentage of live births

whose mothers received prenatal care in the first

trimester) for the U.S. border states in 2008 was 52.0%

in New Mexico, 58.4% in Texas, 79.4% in Arizona,

and 80.7% in California, compared to 71% for the

nation. A review of border counties in California

showed that early prenatal care in San Diego (2006–

2010 median household income of US$ 63,069) was

comparable to the level provided throughout the state

(82%), whereas in Imperial County (median house-

hold income of US$ 38,685) it was about 53%.

Prenatal care visits (number of visits for pregnant

women) for the Mexican border states in 2004–2009

ranged from 7.3 visits per pregnancy in Sonora to 8.5

in Baja California and Nuevo Leon. More than 95% of

infants in all six Mexican border states received at least

one prenatal care visit (47, 48, 49, 50, 51).

Teen pregnancy and childbearing is a signifi-

cant issue in the U.S.-Mexico border region (52, 53).

During 2006–2008, teen birth rates were about 50%

higher than the national average for the U.S. (42 live

births per 1,000 females age 15–19 years) in three of

the four border states: Arizona (60), Texas (63), and

New Mexico (65). For the same 2006–2008 period

in Mexico, teen birth rates were 11% higher than the

national average (70 live births per 1,000 females age

15–19 years) in three of the six border states:

Chihuahua (76), Baja California (77), and Coahuila

(77).

Child Health (0–4-year-olds, except for two U.S.

states that do not report on 1–4-year-olds, only on

1–14-year-olds)

In 2008, infant (children under 1 year of age)

mortality rates for the U.S. border states ranged from

5.1 infant deaths per 1,000 live births in California

and New Mexico to 6.3 in Arizona, lower than the

6.6 infant mortality rate for the country as a whole.

With the exception of 2002 and 2005, infant

mortality rates have remained statistically the same

or decreased significantly each successive year from

1958 through 2008. The leading causes of infant

death in U.S. border states were congenital mal-

formations, deformations, and chromosomal

abnormalities; disorders related to short gestation

and low birthweight; sudden infant death syndrome;

maternal complications of pregnancy; newborns

affected by complications of placenta, cord, and

membrane; and unintentional injuries. In all four

states the infant mortality rates for African

Americans were the highest of all racial/ethnic

groups, ranging from 6.7 in New Mexico to 17.7

in Arizona (14, 45, 54, 55).

Infant mortality rates for the Mexican border

states in 2008 were about double those of the U.S.

border states but lower than the national average for

Mexico. They ranged from 10.6 infant deaths per

1,000 live births in Nuevo Leon to 13.4 in

Chihuahua, compared to 15.2 for the nation.

These rates were about 20%–25% lower than they

were in 2000. The leading causes of infant death

were certain conditions originating in the perinatal

period; congenital malformations, deformations, and

chromosomal abnormalities; accidents; pneumonia

and influenza; intestinal infectious diseases; acute

respiratory infections; and septicemia (28, 56).

Mortality rates of children 1–4 years of age for

U.S. border states in 2008 were 21.3 deaths per

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100,000 population (23.4 for males and 19.1 for

females) in California and 36.8 (47.2 for males and

26.2 for females) in New Mexico, compared to 28.6

(31.3 for males and 25.7 for females) for the nation

in 2007. For California, this represents a decrease of

about 20%–25% from the rate in 2000. Texas and

Arizona reported data for children 1–14 years of age,

and mortality rates in 2008 were 19.7 deaths per

100,000 population of this age group (21.9 for

males and 17.5 for females) in Texas and 19.7 (22.3

for males and 17.0 for females) in Arizona. The

leading causes of death for both age groups and sexes

were unintentional injuries, malignant neoplasms,

congenital malformations, and assault (homicide)

(45, 55, 57, 58).

In 2008, deaths among male children 0–4 years

of age in the Mexican border states ranged from

4.0% of the total number of deaths in Coahuila to

6.3% in Tamaulipas, lower than the 6.6% for the

nation. Deaths among female children 0–4 years of

age ranged from 3.9% of the total number of deaths

in Coahuila to 8.4% in Baja California, compared to

6.5% for the nation. The leading causes of death for

both genders were unintentional injuries, congenital

malformations, malignant neoplasms, intestinal

infectious diseases, and septicemia (59, 60).

Indigenous Peoples

Available health data specific for indigenous groups

are limited. In 2009, a study of Native American

residents of Arizona showed that this population

ranked poorly on maternal and reproductive health

measures. On average, indigenous populations are

19.5 years younger than white non-Hispanics. They

also had high mortality from alcohol-induced causes

(62.1/100,000 population age-adjusted to 2000

standard), diabetes (54.2), influenza and pneumonia

(42.7), motor vehicle accidents (36.9), and from

other unintentional injuries (92.6). However, they

ranked better than average on mortality rates for

several chronic diseases (Alzheimer’s disease, lung

cancer, breast cancer, prostate cancer, colorectal

cancer, chronic lower respiratory diseases, and

coronary heart disease), tobacco use, and incidence

of genital herpes among women giving birth (61).

MORTALITY

In 2008, age-adjusted mortality rates in the four U.S.

border states ranged from 650.1 deaths per 100,000

(764.4 for males and 556.4 for females, 2000 U.S.

standard population) in California to 907.9 (982.7

for males and 832.7 for females) in New Mexico,

compared to 758.7 (901.0 for males and 643.7 for

females) for the nation. These rates are about 10%–

15% lower than 2002 rates. Crude mortality rates

ranged from 612.0 deaths per 100,000 population in

California to 740.4 in New Mexico, lower than the

813.3 for the nation. Mortality rates were the highest

for African Americans, ranging from 710.7 in

Arizona to 979.3 in Texas (12, 14, 55, 62).

In 2008, age-adjusted mortality rates in the six

Mexican border states ranged from 620 deaths per

100,000 (760 for males and 500 for females, World

Health Organization world standard population) in

Tamaulipas to 810 (990 for males and 620 for

females) in Chihuahua, compared to 650 (770 for

males and 530 for females) for the nation. For several

states, the rates have increased from previous years.

For example, between 2005 and 2008 age-adjusted

mortality rates in Chihuahua increased from 750 to

810. Crude mortality rates ranged from 460 deaths

per 100,000 population in Baja California to 630 in

Chihuahua, compared to 510 for the nation (63).

Table 1 describes the 10 leading causes of death for

the Mexican border states in 2008 and U.S. border

states in 2007.

MORBIDITY

Communicable Diseases

Vector-borne Diseases

In 2010, 1,021 cases of West Nile virus infection

were reported in the U.S.; 38% of these cases were in

the four U.S. border states: Arizona (167 cases and

15 deaths), California (111 cases and 6 deaths), New

Mexico (25 cases and 1 death), and Texas (89 cases

and 6 deaths). El Paso reported 30% (27 cases) of the

cases in Texas. The 28 deaths in border states

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represent nearly half (49%) of the total deaths from

West Nile virus infections reported in the U.S. in

2010. From 2006 to 2010, the number of reported

West Nile Virus cases and deaths in the U.S. border

states decreased by about half (64, 65). In the

Mexican border states only one West Nile virus case,

in Nuevo Leon in 2010, was reported. However, the

number of cases reported on the U.S. side of the

border, with markedly similar ecology, suggests that

West Nile virus may be a health concern along both

sides of the border (66).

Nuevo Leon, Sonora, and Tamaulipas are the

Mexican border states with the highest risk for

dengue fever. In 2010, Nuevo Leon reported 12,464

cases of dengue fever and 141 of dengue hemor-

rhagic fever, Sonora reported 3,588 and 191 cases,

respectively, and Tamaulipas reported 1,361 and 186

cases, respectively (66). The last reported continental

dengue activity on the U.S. side of the border was in

south Texas in 2005, when a local case of dengue

hemorrhagic fever was reported in Brownsville,

Texas. The number of cases in the U.S. may be

underreported, however (67, 68). Beginning in 2009,

all dengue infections diagnosed in the U.S. have

been reportable to the U.S. Centers for Disease

Control and Prevention. Most Mexican border states

have sizable dengue control programs, but the U.S.

has more limited and inconsistent programs to that

end.

Rocky Mountain spotted fever (RMSF), caused

by Rickettsia rickettsii, is a tick-borne disease with

epidemic potential that has been reported in U.S.-

Mexico border areas. During 2010, 1,682 cases of

RMSF were reported in the United States. Arizona

reported 41 cases during this time period (69), all

associated with tribal lands and transmission from

Rhipicephalussanguineus, the brown dog tick (70).

The disease has also been reported along the

Mexican side of the border. During 2009–2010,

over 1,000 cases of RMSF were reported in Mexicali,

Mexico. The Mexicali outbreak was also linked to

transmission by Rhipicephalussanguineus, and spread

through infected ticks by stray and free-roaming

dogs (71) Subsequent surveillance efforts have

suggested that sporadic RMSF cases, likely asso-

ciated with the brown dog tick, are widespread

throughout many Mexican border states.

Vaccine-preventable Diseases

Childhood immunization programs have been a

success in both countries and in the border area

TABLE 1. Ten leading causes of death, United States and Mexican border states, 2007 and 2008.

U.S. border states (2007) Mexican border states (2008)

Cause of death Mortality per100,000 population

Cause of death Mortality per100,000 population

1. Diseases of the heart 162.5–168.8 1. Diseases of the heart 78.0–112.2

2. Malignant neoplasms 150.5–164.4 2. Malignant neoplasm 52.9–76.5

3. Unintentional injuries 31.8–67.5 3. Diabetes mellitus 45.0–87.4

4. Cerebrovascular diseases 34.8–41.0 4. Homicides 7.6–75.2

5. Chronic lower respiratory diseases 33.9–44.9 5. Unintentional injuries 25.9–55.0

6. Diabetes mellitus 18.3–34.2 6. Cerebrovascular diseases 20.4–29.7

7. Alzheimer’s disease 16.3–32.4 7. Chronic liver disease and cirrhosis 17.6–29.8

8. Influenza and pneumonia 13.5–17.9 8. Influenza and pneumonia 8.2–15.8

9. Chronic liver disease and cirrhosis 10.6–18.9 9. Conditions originating in the perinatal period 7.4–16.3

10. Suicide 9.9–20.4 10. Chronic obstructive pulmonary diseases 9.1–16.5

Sources: United States, Centers for Disease Control and Prevention. Deaths, percent of total deaths, and death rates for the 15 leading causes of death:

United States and each state [Internet]; 2007. Available at: http://www.cdc.gov/nchs/data/dvs/LCWK9_2007.pdf. Accessed on 29 December 2011.

Mexico, Sistema Nacional de Informacion en Salud. Principales causas de mortalidad general por entidad federativa [Internet]; 2008. Available at: http://sinais.

salud.gob.mx/mortalidad. Accessed on 29 December 2011.

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itself. Immunization coverage in 2009 with a

complete vaccine series in the U.S. border states

(four doses of diphtheria, tetanus, and pertussis

[DtaP] vaccine; three of polio; one of measles,

mumps, and rubella [MMR]; three doses of

Haemophilus influenzae type b vaccine; three of

hepatitis B; and one dose of varicella vaccine by a

child’s second birthday) ranged from 84.2% in New

Mexico to 87.9% in California. It should be noted

that some border counties had significantly lower

coverage. For example, the coverage in Imperial

County, California, and Dona Ana County, New

Mexico, was 65% and 57%, respectively. The cover-

age improves to over 95% by the fifth birthday

because of compulsory vaccination laws for school

entry. Coverage of fully immunized children 1–4

years old in the six Mexican border states by the end

of the second quarter of 2009 ranged from 93.9% in

Chihuahua to 99.4% in Tamaulipas (72, 73, 74).

In 2007, the incidence of acute hepatitis A and

hepatitis B in the U.S. border states was 1.6 and 1.1

cases per 100,000 population, respectively, in

California; 2.4 and 1.3 in Arizona; 0.6 and 0.7 in

New Mexico; and 1.1 and 3.1 in Texas. For 2006–

2010, the six Mexican border states reported 13,553

cases of hepatitis A and 557 cases of hepatitis B, with

Sonora having the highest number of hepatitis A

cases (4,329 cases, 162 cases per 100,000 population)

and Tamaulipas having the highest number of

hepatitis B cases (132 cases, 4 cases per 100,000

population) (4, 75, 76).

HIV/AIDS and Other Sexually-transmitted Infections

In 2009, along the U.S. side of the border, Arizona

reported a total of 676 (587 males and 89 females)

newly reported cases of HIV/AIDS, with an

incidence rate of 10.2 cases per 100,000 population

and a death rate of 1.6 deaths per 100,000

population (77). Texas reported a total of 4,230

(3,289 males and 941 females) newly reported cases

of HIV infection, with an incidence rate of 17.1

(26.5 for males and 7.6 for females). African

Americans had the highest incidence rates of HIV

infection (62.7) in Texas. In addition, males had a

higher incidence rate of AIDS (15.6/100,000) than

females (5.0) and African Americans had the highest

rate (36.8) (78). In 2008, New Mexico reported

1,458 new cases of HIV and 4,356 new cases of

AIDS (88% males) (79). California reported 29,939

new cases of HIV and 138,013 of AIDS (89% males)

(80).

In 2007, reported new cases of HIV in the

Mexican border states ranged from 12 in Coahuila to

91 in Tamaulipas; reported new cases of that same

year ranged from 5 in Coahuila to 85 in Baja

California, with a mortality rate between 3.1 deaths

per 100,000 population in Coahuila to 9.5 in Baja

California (81).

In 2010, the incidence rates of congenital

syphilis reported in the Mexican border northern

states were among the highest in the nation. Rates

were the highest in Baja California (0.3 per 1,000

population under 1 year) and Sonora (0.21), compared

to 0.03 for the nation (82) In the U.S. border states in

2010, congenital syphilis ranged from 0.0 cases per

100,000 live births in New Mexico to 25.3 in Texas,

compared to 8.7 for the nation (83).

Tuberculosis

Tuberculosis (TB) continues to be a concern along

the border. For the U.S. border states, in 2009,

California reported the highest incidence rate in the

region (6.7 cases per 100,000 population), followed

by Texas (6.1), Arizona (3.5), and New Mexico

(2.4). California had the highest incidence rate in the

continental U.S. and the highest number of cases

(2,470) in the nation. However, the rate was about

13% lower than the 2005 state rate. The decrease has

been less among foreign-born persons, who comprise

about 60% of all reported cases (84, 85).

The six Mexican border states reported TB

incidence rates higher than the national average of

13.5 cases per 100,000 population in 2007. Baja

California reported the highest incidence rate (38.3)

and the highest number of cases (1,147) in the

border area and the nation, followed by Tamaulipas

(32.4 and 1,011), Sonora (26.1 and 644), Chihuahua

(18.4 and 612), Nuevo Leon (18.1 and 783), and

Coahuila (16.7 and 430). With the exception of

Sonora, these rates were significantly lower than the

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2002 rates. In Sonora, the incidence rate increased

about 18% between 2002 and 2007 (86).

Emerging Diseases

The first two H1N1 influenza sentinel cases in the

border area were detected and confirmed in San

Diego and Imperial Valley, California (87).

California reported 596 fatal H1N1 influenza cases

between April 2009 and August 2010. In 2009,

Mexico reported 2,074 confirmed cases in Baja

California (54.77/100,000 population), 1,142 in

Chihuahua (34.23), 398 in Coahuila (15.63), 3,902

in Nuevo Leon (90.76), 2,377 in Sonora (105.55),

and 2,281 in Tamaulipas (71.28) (66, 88).

Chronic, Noncommunicable Diseases

Cardiovascular Diseases

In 2008, the crude mortality rates due to heart

disease in the Mexican border states ranged from

78.0 deaths per 100,000 population in Baja

California to 112.2 in Sonora and Chihuahua,

compared to 86.9 for the nation. The main

contributor to heart disease mortality was mortality

from ischemic heart disease (28). For the U.S. border

states in 2007, the crude mortality rates due to heart

disease ranged from 162.5 deaths per 100,000

population in Arizona to 168.8 in California, lower

than the 204.3 for the nation. These rates were about

15% to 18% lower than the 2003 rates (89).

Malignant Neoplasms

Malignant neoplasms continue to be either the

second or third leading cause of death in all four U.S.

and all six Mexican border states. For the U.S.

border states in 2007, the age-adjusted incidence

rates for the top five cancer sites were: prostate

(120.0–151.7 cases per 100,000 population), female

breast (99.9–122.2), lung and bronchus (44.5–61.9),

colon and rectum (34.3–43.9), and corpus and uterus

(not otherwise specified) (18.7–22.4). With the

exception of the incidence rate for female breast

cancer in California (122.2 cases per 100,000

population), none of the border states surpassed

national incidence rates. The age-adjusted mortality

rates for the top five cancer sites were: lung and

bronchus (37.8–47.6 deaths per 100,000 U.S.

standard population), female breast (20.1–22.6),

prostate (19.1–24.5), colon and rectum (14.5–16.4),

and pancreas (9.4–10.4) (90, 91). For the Mexican

border states of Chihuahua and Sonora, in 2008 the

mortality rates for the top three cancer sites were:

lung and bronchus (11.1 and 13.0 deaths per 100,000

population), female breast (6.8 and 6.9), and colon

and rectum (4.9 and 5.7) (28).

Diabetes

For the Mexican border states in 2009, the rate of

new cases of type 2 diabetes mellitus ranged from

346 cases per 100,000 population in Sonora to 621 in

Coahuila, compared to 397 for the nation. Only

Sonora had an incidence rate below the national

average (76). For the U.S. border states in 2009, the

age-adjusted rate of new cases of diabetes ranged

from 860 in California and New Mexico to 1,010 in

Arizona, compared to 840 for the nation. Between

2000 and 2009, the number of adults diagnosed with

diabetes since 1994 increased 49.5% in Arizona, 43%

in Texas, 37% in New Mexico, and 32% in

California. Native Americans, African Americans,

and Hispanics have higher rates after adjusting for

population age differences. For example, the 2009

death rate from diabetes for Native Americans in

Arizona was about 245% higher than the state rate

for total population (61, 92, 93).

Nutritional Diseases

Obesity

In 2010, the age-adjusted percentage of adults who

were obese (body mass index > 30) in the U.S.

border states ranged from 24% in California to 31%

in Texas, compared to 33.8% for the nation. In 2009,

the prevalence of obesity among low-income chil-

dren aged 2 to 4 years was 10%–15% in Arizona and

New Mexico and 15%–20% in California and Texas,

compared to about 15% for the nation (94, 95).

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A survey conducted in 2006 (95) indicated that

the prevalence of abdominal obesity in adults in the

Mexican border states ranged from 76.9% in Baja

California to 82.9% in Tamaulipas (the highest of

the nation). Excessive weight gain, obesity, and

abdominal obesity have increased among adults

compared to a 2000 national study. Among the

many possible explanations cited for the increases

were factors related to urbanization, increased access

to unhealthy foods, and lack of opportunities for

physical activity.

Mental Disorders

The rate of suicide deaths has declined in the United

States–Mexico border region over the past decade,

but remains relatively high in certain states and

communities. In 2007, New Mexico had the highest

rate of suicides among U.S. border states (20.4

deaths per 100,000 population), followed by Arizona

(16.0), Texas (10.2), and California (9.9), compared

to 11.3 for the nation, rendering suicide the 10th

leading cause of death in this geographical region.

Almost four times as many males as females died by

suicide in the U.S. and it was the third leading cause

of death for young people ages 15 to 24 (89, 96). For

the Mexican border states, in 2008 Sonora had the

highest rate of suicides (7.6 deaths per 100,000

population), followed by Chihuahua (6.9), Coahuila

(5.8), Nuevo Leon (5.6), Tamaulipas (4.5), and Baja

California (4.1), compared to 4.4 for the nation,

corresponding to about 23% of the suicides for the

nation. About 80%–90% of suicides were males in

Mexican border states (63, 97).

Risk and Protection Factors

Alcoholism

In 2008, the prevalence of heavy drinking in men

(defined as having more than five drinks per occasion)

in the Mexican border states ranged from 23.6% in

Baja California to 47.5% in Nuevo Leon, compared to

39.1% for the nation. The prevalence of heavy

drinking in women (having more than four drinks

per occasion) ranged from 9.6% in Coahuila to 14.1%

in Chihuahua, compared to 15.1% for the nation (98).

For the U.S. border states, the prevalence of heavy

drinking in men (defined as consuming an average of

more than two drinks per day) ranged from 5.2% in

New Mexico to 6.9% in California, compared to 5.7%

for the nation. The prevalence of heavy drinking

consumption in women (consuming an average of

more than one drink per day) ranged from 3.5% in

New Mexico to 4.9% in California, compared to 4.2%

for the nation (99, 100, 101).

HEALTH POLICIES, THE HEALTH SYSTEM,

AND SOCIAL PROTECTION

HEALTH SYSTEMS AND SERVICES

In the United States, the health care system is

characterized by a demand model and health care is

delivered through a fee-for-service system. Health

services are provided primarily by nonprofit institu-

tions and private entities. Native Americans also

receive services through the public Indian Health

Service. In 2008–2009, private health insurance

coverage ranged from 44% in New Mexico to 53%

in California. Public health insurance such as

Medicare (for an individual over 65 years of age who

has been a U.S. citizen or permanent legal resident for

five years) covered 9%–12% of the population and

Medicaid (for low-income and disabled U.S. citizens

or permanent legal residents) covered 15%–19% of the

population. The uninsured population in the border

states was higher than for the nation as a whole, from

19% in California to 26% in Texas, compared to 17%

for the nation. The uninsured population in the three

most populous border counties of Texas was 33% (102,

103); with this high percentage of population lacking

health insurance, Texas faces a significant challenge of

uncompensated health care. In 2008, Texas hospitals

reported US$ 13.6 billion in uncompensated care

charges (104). The federal Patient Protection and

Affordable Care Act of March 2010 put in place a

comprehensive health insurance reform to expand

health insurance coverage (105).

In Mexico, health is considered a constitutional

right, but there is no universal health care coverage.

UNITED STATES–MEXICO BORDER AREA

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Public and private institutions provide health care

services. In 2009, the uninsured population in the

Mexican border states ranged from 20% in Nuevo

Leon to 28% in Baja California, lower than the 34%

for the nation. An insurance system known as

‘‘Seguro Popular’’ became available in 2002 to provide

health service coverage, through voluntary enrollment,

for persons who are not affiliated to the country’s social

security scheme (106). Between 2002 and 2009, more

than 500,000 families from border municipalities and

over 2 million families from the border states enrolled

in this system (107).

The U.S. and Mexican health care systems have

various programs and projects in place to promote

health services along the border. For example, the

Binational Health Week and Border Binational

Health Week promote public health care, outreach,

and immunization services every October, reaching

vulnerable groups along the border. The Ventanillas de

Salud (health stations) program provides on-site health

advice and outreach at Mexican Consulates in the U.S.

to low-income and Hispanic migrant families unfa-

miliar with the U.S. health system. It was launched in

San Diego and Los Angeles in 2002 and has expanded

to include all 50 consular offices in the U.S. (108).

HUMAN RESOURCES

The number of professionally active physicians per

10,000 civilian population for the U.S. border states

in 2008 ranged from 21.5 in Texas to 26.2 in

California, lower than the 27.7 for the nation. In

Texas, most border counties are federally designated

as medically underserved areas (having too few

primary health care providers). In 2007, the number

of professionally active dentists per 10,000 civilian

population ranged from 4.6 in Texas and New

Mexico to 7.6 in California, compared to 6.0 for the

nation. In 2010, the number of registered nurses per

10,000 population ranged from 64.4 in California to

70.1 in Texas, compared to 86.0 for the nation (102).

The number of physicians per 10,000 population for

the Mexican border states in 2009 ranged from 14.6

in Baja California to 20.2 in Sonora, compared to

16.9 for the nation (107).

Maintaining the health workforce in the border

region faces a number of challenges, including a lack of

medical and public health higher education institu-

tions. There are 19 schools offering medical education

and 12 schools offering graduate degrees in public

health in the U.S. border states and 19 medical schools

and 15 public health programs in the Mexican border

states. New investments in health education have been

made in the U.S. border counties since 2006. For

example, a new master in public health program was

started at the University of Texas in El Paso in 2008

and a medical school was created in El Paso, Texas in

2009 (109). It has been equally challenging to attract a

health workforce within the border region.

For the U.S. border states in 2009, the number

of hospital beds ranged from 1.9 per 1,000 population

in California (0.4 in state/local government facilities,

1.2 in nonprofit facilities, and 0.3 in for-profit

facilities) to 2.5 in Texas (0.4 in state/local govern-

ment facilities, 1.1 in nonprofit facilities, and 1.0 in

for-profit facilities), compared to 2.6 for the nation

(0.4 in state/local government facilities, 1.8 in non-

profit facilities, and 0.4 in for-profit facilities).

Hospital admissions ranged from 91 per 1,000

population in New Mexico to 107 in Arizona,

compared to 116 for the nation, and hospital

emergency room visits ranged from 286 per 1,000

population in California to 413 in New Mexico,

compared to 415 for the nation (102). In the Mexican

border states in 2009, the number of beds in facilities

of the National Health System (excluding facilities of

the Secretary of National Defense) ranged from 0.6

per 1,000 population in Baja California to 1.0 in

Sonora, compared to 0.7 for the nation (107).

KNOWLEDGE, TECHNOLOGY,

INFORMATION, AND HUMAN RESOURCE

MANAGEMENT

EVIDENCE-BASED PRACTICE AND INFORMATION

ACCESS

Since 2008, the U.S. Health Resources and Services

Administration has been working closely with

academic institutions, health sciences libraries, and

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the U.S. National Library of Medicine to assess the

need and implementation of evidence-based practice

approaches that contribute to strengthening health

systems and improving health care in the border

region (110). As a result, Frontera Collaboration

(‘‘Border Collaboration’’) was created to bring

together members of the Border Virtual Health

Library and the National Network of Libraries of

Medicine in the U.S. border states to improve the

evidence-based practice skills and information access

of health professionals working in rural clinics and

community health centers (111).

HEALTH INFORMATION TECHNOLOGY

In the U.S., substantial progress has been made

toward the establishment of the National Health

Information Infrastructure, particularly in setting

standards to harmonize information systems and

enhance interoperability. Since 2003, the U.S.

Department of Health and Human Services has

allocated over US$ 40.6 million to northern and

southern border states for this purpose. Combined

allocations for Arizona, California, New Mexico,

and Texas exceed US$ 30.5 million for the U.S.

Border State Early Warning Infectious Disease

Surveillance Project (EWIDS) (112). In the U.S.-

Mexico border area, EWIDS and the Border

Infectious Disease Surveillance Program collabora-

tion demonstrated its relevancy during the 2009

H1N1 influenza pandemic through exchange of

surveillance findings, distribution of laboratory

supplies, availability of highly trained technical staff,

and training of public health personnel.

HEALTH AND INTERNATIONAL

COOPERATION

There are several transnational agreements, alliances,

and partnerships along the U.S.-Mexico border. The

most notable are the U.S.-Mexico Border Health

Commission (86); the Binational Health Councils;

the International Boundary and Water Commission

(IBWC); the Border Environment Cooperation

Commission (BECC) and its sister institution, the

North American Development Bank (NADB) (113);

the Border 2012 Environmental Program (114); the

Border Governor’s Conference (115); the Border

Legislative Conference (116); the Coalition of

Border Mayors; and PAHO/WHO’s U.S.-Mexico

Border Office.

The U.S.-Mexico Border Health Commission

was created as a binational health commission in July

2000 and was charged with providing leadership to

optimize health and quality of life along the border.

Commission membership includes the Minister of

Health of Mexico and the U.S. Secretary of Health,

the chief health officers of the 10 border states, and

prominent health professionals from both nations.

During 2006–2010 the Commission held several

research forums (117), established expert panels,

sponsored activities each year for the National Infant

Immunization Week and Vaccination Week in the

Americas, supported a tuberculosis working group,

and established a tuberculosis consortium. Each year

the Commission has sponsored activities for the

Binational Border Health Week, including work-

shops and seminars on topics such as health

diplomacy, tobacco policy, and diabetes prevention

(86).

The Binational Health Councils (BHC) were

originally established as local chapters of the U.S.-

Mexico Border Health Association, which stopped

operations in 2010. There are 16 Councils, consist-

ing of volunteer members from local health services

and community organizations from both sides of the

border. In June 2008, the Councils defined border-

wide health priority areas for 2009–2011. Most

Councils identified TB and issues associated with

diabetes, obesity, and nutrition among their prio-

rities. At least half of the Councils identified dengue

fever; the Early Warning Infectious Disease

Surveillance program; issues relating to mental

health, substance abuse, and domestic violence; and

HIV/AIDS and other sexually-transmitted infec-

tions as issues of leading concern (118).

The Border Environment Cooperation Com-

mission and the North American Development

Bank were created as interdependent institutions

in 1993 under a side agreement to NAFTA. Both

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entities were intended to improve environmental

conditions along the U.S.-Mexico. They work

with communities and project sponsors to develop,

finance, and build sustainable projects that address

human health and environmental needs. Between

1995 and 2010 the Border Environment

Cooperation Commission certified 175 projects—93

in Mexico and 82 in the U.S.—with an estimated

total cost of US$ 3.924 billion. These projects

provided access to safe and sanitary water infra-

structure, increased wastewater management effi-

ciency, enhanced proper waste disposal, and

improved air quality related to paving to approxi-

mately 7.2 million border residents (113).

SYNTHESIS AND PROSPECTS

This chapter shows that differences in economic

development persist between both sides of the U.S.

Mexico border region and that significant differences

persist along the U.S. side of the border. Water

supplies in the area are already stressed and are

projected to become increasingly scarce in the next

50 years due to climate change. In general, health

conditions have improved since 2005. However,

since 2008, there has been an increase of violence

along the Mexican side of the border, associated

primarily with the implementation of national

policies to crack down on organized crime and drug

trafficking. In addition, the low immunization

coverage, limited access to health care services,

limited primary care providers along the U.S. side

of the border, precarious health of indigenous

populations, public health emergencies, and high

rates of certain health conditions such as childhood

obesity, diabetes, teen pregnancy, and tuberculosis

along both sides of the border continue to be of

great concern.

Increasing investments in physical infrastruc-

ture as a result of security concerns in the U.S.-

Mexico border area may benefit health and develop-

ment in the region. In addition, the health care

reform in the U.S. and the increasing investment in

the Seguro Popular system in Mexico are expected to

increase access to health care along the border.

Strategies such as Healthy Border 2012, an initiative

of the U.S.-Mexico Border Health Commission

(119) and the Border 2020 Environmental Program

(120), administered by Mexico’s Secretariat for

the Environment and Natural Resources

(SEMARNAT) and the U.S. Environmental

Protection Agency (EPA), will set important

benchmarks to improve health and quality of life

along the border. Finally, increasing investments in

health education, including the establishment of new

medical and public health schools in the area, will

provide much needed opportunities for young

professionals to stay and work in the border

region.

REFERENCES

1. United States of America and United Mexican

States. La Paz Agreement: agreement between

the United States of America and the United

Mexican States on cooperation for the protec-

tion and improvement of the environment in

the border area. La Paz, Baja California,

Mexico; 1983.

2. United States-Mexico Border Health Com-

mission. Healthy Border 2010. An agenda for

improving health on the United States-

Mexico border. El Paso, TX, and Mexico.

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