Brief Description of Diabetes Along the Border

Information describing the health status of the Spanish-speaking population is extremely scarce (Ramirez A, et al, 1981). Several studies about the Hispanic population have documented that programs should be designed for less acculturated individuals and they should use informal and interactive educational methods that incorporate skill-enhancing and empowering techniques (Mishra SI, et al, 1998). There are very few studies that have documented the diabetes burden in the Hispanic population. Nevertheless, these studies are almost 10 years old. However, based on this information, it has been found that on both sides of the U.S.-Mexico border there are considerable variations in the prevalence estimates for diabetes and high-risk behaviors^5,6. These variations are due to the use of various methodologies, and therefore, they provide an incomplete picture. Even more, it is less known about their health care access patterns because many U.S. residents use both systems of health care. It is imperative to obtain accurate data to detect the prevalence of diabetes, extent of high risk behavior and health care access patterns for the U.S.-Mexico border if we are to reduce the health disparities in this population. Although the scarcity of information, there are indications that the risk factors for Hispanic in the U.S. are higher than those shown at the national level. Of interest is the fact that Mexican-Americans have higher rates of diabetes, obesity, physical inactivity, with a limited access to health care than any other Hispanic group (Stern, 1994, NCHS, 2000, NHAINES, 1984).

The border area includes a large Hispanic population that suffers from many health disparities including a higher prevalence of diabetes than the general population. Our proposal is consistent with the approach of elimination of disparities. Through this project, it will be possible to strengthen the delivery of diabetes health services, and to reduce the burden of diabetes and related risk factors for Hispanics along the border. This project provides an opportunity for Diabetes Translation Division of the Centers for Disease Control and Prevention to proactively engage in a bilingual/bicultural demonstration program to decrease the health disparities for Hispanics on both sides of the Border. The project will also serve as a model for future binational approaches to other chronic diseases.

It has been documented elsewhere that the main barriers that the Hispanic community faces are related to lack of knowledge of how to access health services; cultural and linguistic barriers; cost of coverage; training and distribution of health care providers; denial to health care to undocumented individuals; availability of services, and transportation means and distance (Moya and de Cosio, 1999). It is not unusual that U.S. residents cross the border in search of health care services because they are provided at a lower cost. This is the case of Presidio, Texas, where the closed health care facility with medical and paramedical personnel is almost 90 miles away. Therefore, it is more convenient to cross the border to obtain services.

B. Socio-demographics and economic profile

A conventional description of the border includes the area extending 100 km (60 miles) on each side of the 3400 km (2040 mile) international boundary between the US and Mexico⁷ (Figure 1). The border area includes the southern portions of four US states (Arizona, California, New Mexico, and Texas) and the northern portions of six states of Mexico (Baja California, Chihuahua, Coahuila, Nuevo Leon, Sonora, and Tamaulipas) with an estimated population of 9,089,508 (57% in the U.S. and 43% in Mexico).

The U.S. border area contains a mix of Hispanic and non-Hispanic cultures, including the Native Americans. According to the 2000 population census, about 70 percent of all Hispanics living in the U.S. are concentrated in the four U.S. border states. For some U.S. States, the Hispanic influence reaches far from the actual border region and encompasses practically the entire state (e.g., New Mexico). Most cities along the US side of the border are heavily influenced culturally, economically, and socially by the populations that live on the Mexican side. The Mexican border population is predominantly Hispanic. Hispanic growth is even higher. For instance, the overall population growth rate for this border region is higher than the national figures (2.4%). In other words, this means that the region will double its U.S. general population in 29 years and the U.S. Hispanic population will do it in 23 years (similar to the Mexican border population doubling time), if the current conditions remain the same.

On the Border poverty rates are very high . According to several reports the US border area has at least five of the poorest counties in the United States, one of them is El Paso¹⁰. These three counties have higher percentages of populations living under the poverty level- e.g., El Paso 32% (Escobedo – de Cosio, 1997). Colonias¹¹ (human settlements lacking basic sanitation services) are common on both sides of the border and can best be described as third world in nature (non potable water, open sewage, unsanitary living conditions and disproportionate health disparities). It has been estimated that along the Texas-Mexico border there are more 1,800 colonias with more than 500,000 people living there, 98 percent of whom are Hispanic (Ramos I, 2001).

These social-economic conditions bring high unemployment rates with an estimated 33% of the Hispanic population without health insurance. Due to these conditions, the Federal Government of the United States has designated all border counties in the Rio Grande area "medically under-served areas". Therefore, they qualified for special public health funding⁶.

Due to the lack of health insurance for a large number of the US population, several studies have documented that approximately 30% of this population crosses the border to the Mexican side to receive health care, and 60% for dental care services. Approximately 60% of the Hispanic population purchases medications on the Mexican side since they are 40-50% cheaper than in the US side¹².

3. Diabetes Epidemiological Profile Overview

Among Hispanic persons in the US, the Third Health and Nutrition Examination Survey (NHANES III) estimated that type 2 diabetes (diagnosed and undiagnosed) is present in 2.3% of persons aged 20-39 years, 13.2% of persons aged 40 to 49 years, 26.0% of persons aged 50 to 59 years, 29.3% of persons aged 60 to 74 years, and 29.7% of persons aged 75 years and greater¹³. There is a clear ethnic disparity in the burden of diabetes given that both the incidence and prevalence of type 2 diabetes are 2-3 times greater in Mexican Americans than in non-Hispanics⁴. Type 2 diabetes is associated with a host of other risk factors, including hypertension, obesity, unhealthy diet, and physical inactivity. Previous investigations found that Mexican Americans exhibit a greater prevalence of certain type 2 diabetes-associated conditions, including obesity and hypercholesterole-mia, and higher rates of some adverse complications⁵ (renal failure⁶, amputations, peripheral vascular disease), and type 2 diabetes-associated mortality, than non-Hispanic white persons with diabetes⁷.

The 1993 National Chronic Disease Survey (Encuesta Nacional de Enfermedades Crónicas) conducted in Mexico by the National Epidemiology Office (Direccion General de Epidemiologia) assessed the prevalence of diabetes and related risk factors. The survey estimated that 7.2% of the population between 20 and 69 years of age had diabetes. However, in the 60 to 69 year-old-group, the prevalence of diabetes was more than 20%. Among individuals 60 years of age and older with diabetes, 75% reported being diagnosed with the disease before the survey⁸.

In Mexico, the 1996 National Mortality Report revealed that 77% of deaths were due to non-communicable diseases. Of these 32% were due to diabetes, high blood pressure, cerebrovascular and cardiovascular disease combined⁸. In addition, the diabetes mortality rates increased in all Mexican border states from 1993 to 1996, ranging from 5.2% in Baja California and Coahuila to 13.1% in Chihuahua. In 1997, data from the Mexican hospital surveillance network (Red Hospitalaria de Vigilancia Epidemiológica) that compiles hospital discharge data from 67 hospitals with more than 100 beds nationwide, showed that hypertension and diabetes ranked 3^rd and 4^th respectively among the 20 most common discharge diagnoses⁹. The data reflect the significant impact that chronic diseases in general, and diabetes specifically, have had on total mortality rates of Mexico.

The following table shows the cumulative mortality rates along the U.S.-Mexico border states and its counties/municipalities. As can be seen, these rates for many of the border region are higher than the national figures¹⁰. Also, it is important to point out that based on the table’s data, mortality shows an increasing trend.