Mutual Assault : U.S., Mexico Join Hands and Funds to Fight the Spread of Tuberculosis

For the past five years, a San Ysidro health clinic and the Mexican government have used joint funds to operate a unique binational program that attempts to limit the spread of tuberculosis into the United States by treating patients in Baja California.

The effort involves the Baja California branch of the Mexican Secretariat of Health and the San Ysidro Health Center, a publicly funded, nonprofit clinic that operates out of the San Diego community of San Ysidro, just across the border from Tijuana. The center, bolstered with up to $200,000 annually in U.S. tuberculosis-control funds, provides the Mexican health agency with supplies and expertise.

While the incidence of tuberculosis--once a scourge of mankind, known alternately as consumption and the “great white plague”--has been reduced considerably in the United States and other Western nations, the far-reaching disease remains a serious problem in the developed world and a crucial health one in Mexico and much of the Third World.

Since 1984, the center and Mexican officials have quietly operated the joint program in an effort to thwart the spread of the contagious illness across the border, which is annually traversed by tens of millions of people, both legally and illegally.

The U.S. Department of Health and Human Services began funding the program after the San Ysidro clinic documented that area patients--many of whom maintain close family and social ties in Mexico--suffered from a higher incidence of TB than was evident elsewhere in the United States.

“Disease does not recognize frontiers,” said Dr. Jesus Ontiveros, chief of the federal health department branch in Tijuana, a city of up to 1.5 million people.

“We have to work together, respecting the laws of each other’s nations, in order to combat these problems,” said Ontiveros, who has overall responsibility for the entire government tuberculosis treatment program here.

The international cooperation may seem natural and logical, but health experts say it is by far the largest such formal initiative involving direct treatment of patients with contagious diseases along the U.S.-Mexico border, which stretches for almost 2,000 miles and is a mecca for economic and political refugees from around the world.

Conflicting laws and guidelines, plus nationalistic sensitivities, often hamper coordination--facts that have led officials to be deliberately low-key about the TB effort. Health officials along the border have traditionally exchanged information about contagious diseases in both nations, but the TB initiative here is one-of-a-kind, officials said.

Joint treatment programs “are a politically sensitive issue, particularly for (officials) in Mexico City and Washington, D.C.,” said Gabriel Arce, chief executive officer of San Ysidro Health Center.

Yet the need is clear. While ailments such as tuberculosis and Hansen’s disease (leprosy) are more prevalent in Mexico, other problems--notably AIDS--have migrated south from the United States.

There is a hope that the TB program, which has attracted widespread attention in the border health community, could serve as a model for similar initiatives aimed at further combating the spread of TB and other infectious ailments along the border.

“If our goal is to wipe out TB, then it’s essential that we do something like this,” said Dr. Laurance Nickey, director of the El Paso City-County Health District in Texas, across the Rio Grande from Ciudad Juarez, Mexico. “There is a lack of understanding among the people who give out the money. . . . They assume that public health problems belong in one jurisdiction, whereas in our case, it’s 1.8 million people (in two nations) who live in a valley where they share the same air, water and diseases.”

Whether similar initiatives will evolve remains an open question.

“You don’t often get a foreign government allowing you to march around treating their citizens,” said Arleigh Sawyer, chief of primary care programs for the U.S. Department of Health and Human Services in San Francisco, which has allocated $200,000 to the joint program during the current fiscal year. “This program is unique.”

In Baja, the program, which complements Mexico’s own broad anti-TB effort, has been credited with considerable success in helping reduce TB rates and in cutting down on the mortality of patients. The disease has long been treatable with a variety of drugs.

Tuberculosis is a particular problem in Tijuana, which is a melting pot of every region of Mexico. Many people arrive from poor regions in which TB rates are particularly high, and they settle into shantytowns that are breeding grounds for disease. Researchers have long noticed a correlation between the disease and socioeconomic factors since populations whose resistance is weakened by poor nutrition are more vulnerable. With Mexico’s protracted economic crisis, once-middle-class families have joined the legions of the working poor, surviving on the margins and increasingly exposing themselves to the illnesses of underdevelopment.

Tijuana’s rate of new TB cases, according to medical experts on both sides of the border, has also been exacerbated by the growing presence of AIDS, which reduces resistance to all diseases, including tuberculosis. AIDS also produced a slight increase in overall tuberculosis cases in the United States in 1986, officials say, reversing a general three-decade decline in its incidence north of the border.

The border TB program, according to Benjamin Sanchez, a Mexican physician who works for the San Ysidro clinic and is its TB coordinator, has cut mortality rates in half among treated patients. The program assists in screening, diagnosis and treatment, all of which are provided free of charge.

To date, Sanchez said, 1,034 patients have been treated during the program’s five-year life; doctors identify more than 200 new TB cases annually, many of them family members of existing patients. Of those treated, Sanchez said, slightly more than half have been cured, 29 died and 73 transferred to other programs (usually at area hospitals). Another 153 are under treatment.

In addition, 242, or almost one-quarter, abandoned the program--a serious problem, physicians say, since many patients assume wrongly they are cured once their symptoms are alleviated. Relapses are frequent.

“Most of the patients are poor, and often they cannot afford to be away from work,” said Sanchez, who himself came from a campesino background in Mexico’s Jalisco state. “

Surveys reveal that almost one-third of the patients in the program have jobs that involve handling food, peddling goods and working in stores that put them in direct contact with the public, including tourists. Almost one in five work in the United States, some of them in restaurants--a practice discouraged by doctors but which many feel they must pursue in order to have steady work.

Tuberculosis, which is caused by the tubercle bacillus, or bacteria, is most often caught from other victims, typically via the inhaling of microscopic particles. (Patients are urged to cover their mouths when they cough.) The disease most frequently attacks the lungs, although it is also found in the skin, spine and other parts of the body.

Each morning, TB patients--some gaunt, some appearing outwardly normal, all poor--line up at a downtown Tijuana clinic. Most leave clutching copper-colored vials filled with pills. Others receive further consultation or X-rays.

Convincing TB sufferers to come forward can be difficult. The disease still has a strong stigma, and many people do not want to admit--or hear--that they have the illness. Among those treated in Tijuana, doctors say, are a number of U.S. residents who do not want anyone to know they have the disease.

“Some people reject you when they hear you have it,” said Andres Carrillo Arreola, a 22-year-old former grocery store cashier who has been in treatment since November.

Carrillo, a soft-spoken man who says he would like to study communications at a university someday, said he began feeling weak last winter and eventually went to a doctor, who referred him to the clinic. He said he has received considerable support from his family, including his parents, natives of the Mexican state of Durango who migrated to Tijuana. He is feeling better, and doctors say there is every reason to believe he will recover fully.

Others are not so lucky. Many are so far gone by the time they reach the clinic that they must be immediately hospitalized. The program provides largely for initial care, with the hope that patients will be found in the early stages.

In Tijuana, the U.S. funds are used for a variety of purposes, principally the purchase of drugs--some of which are not widely available in Mexico--as well as sundry supplies, such as film and chemicals for X-ray machines, syringes and containers.

Sanchez, who oversees the joint program, works closely with Mexican health professionals at more than a dozen clinics in Tijuana and neighboring Tecate. Baja health officers working with the program also visit city neighborhoods, urging TB carriers to come forward. Officials in both the United States and Mexico say that sufficient guidelines exist to demonstrate that the funds have been well-used and the purchased anti-tuberculosis drugs strictly accounted for.

Although health officials caution that it can be difficult to compare disease rates in the United States and Mexico--reporting procedures vary greatly--existing figures do demonstrate the disparity between the incidence of TB in the two nations. Overall numbers are generally on the decline in both nations, officials say.

For 1986, the most recent year for which comparable figures are available, the reported rate of TB was 9.5 cases per 100,000 people in the United States, according to the Pan American Health Organization, a United Nations-affiliated health-monitoring group. In Mexico, the reported rate was 14.0 per 100,000.

In San Diego County, incidence rates have roughly paralleled those reported nationwide. The county reported 149 new TB cases in 1985, 158 cases in 1986, 244 in 1987 and 207 in 1988.

According to Mexican government officials, 6,721 people died from tuberculosis in 1981, the most recent year for which solid figures could be obtained; of those, 513, or 7.6 %, were younger than 15. Mexican health officials acknowledge that most of the deaths could have been prevented with proper treatment.

But treatment is costly. And Mexico is mired in an economic crisis. While health officers know that “prevention is a hell of a lot cheaper than treatment . . . traditionally the first thing to go in (a budget crunch) is prevention,” said Herbert Ortega, director of the Pan American Health Organization’s El Paso field office. “That’s true whether it’s Mexico or Washington.”

For many TB patients in Tijuana, the joint effort has provided the only avenue for effective diagnosis and treatment. Many would have likely gone without medicine until they were hospitalized, officials say. By then it might have been too late.

“I don’t know how I would have gotten better without this program,” said Andres Carrillo Arreola, now that he appears to be on the road to recovery. “My family could never have afforded to pay.”

TUBERCULOSIS MORBIDITY RATES

Baja BORDER STATES Year Mexico USA Calif. Calif. Mexican U.S. 1981 18.2 11.9 32.4 18.7 29.5 16.2 1982 11.6 11.0 16.5 14.5 15.0 13.7 1983 15.2 10.2 18.9 13.7 26.9 12.7 1984 16.0 9.4 31.1 8.7 26.8 9.4 1985 14.3 9.3 29.0 13.2 25.9 12.0 1986 14.0 9.5 7.1 13.0 22.8 8.4

Rates given are per 100,000 inhabitants.

Mexican border states are Baja California, Sonora, Chihuahua, Coahuila, Nuevo Leon and Tamaulipas.

U.S. border states are California, Arizona, New Mexico and Texas.

Sources: Mexican Ministry of Health, U.S. and state Departments of Health Services.