Traffic snarls on the northbound lanes of the wide, arching bridge. The strains of mariachi music on a distant radio blend with a classical melody or country tune emanating from the cars inching past vendors hawking backscratchers and soda before coming to a stop at the United States Customs booth at an El Paso port of entry. Drivers roll down their windows, respond to the inquiry about citizenship, and most continue their commute. So common is this scenario that El Paso officials put the number of legal crossings from Mexico's Juárez into the United States at about 61 million a year.
The sprawling 2,000-mile U.S.-Mexican border runs through 10 states; six in Mexico and four in the U.S. Around midway sits the triangle of El Paso, nearby New Mexico, and Juárez, with a combined population of just under 2 million. Some 18,000 residents from Juárez make the daily commute to El Paso for work, and about 3,000 people from El Paso head south to Juárez, mostly for jobs in the maquiladoras, U.S.-owned factories set up over the past 20 years. Hundreds of others cross the bridges spanning the Rio Grande River on foot. Still others make the trip clandestinely, in the dark of night.
The area, known simply as La Frontera, or The Border, has its own flavor, sometimes called the Third Culture. It is a culture as fluid as the river that separates the two nations, with overwhelmingly Mexican overtones. Along a typical downtown street, a store sign advertises honey butter biscuits, while another sells tacos. Conversations usually blend English and Spanish, creating a new language innately understood by all who live there.
"From a public health perspective, we may have the sovereignty of two countries and 10 states, but the fact is you have one huge population that interplays on itself day after day, year after year, sharing the same air, the same pollution, and the same diseases on an immediate basis," said Laurance Nickey, a lifelong El Paso pediatrician and president of the Paso del Norte Health Foundation. "For the purposes of public health, it's one community."
Seen from El Paso, Texas, which sits in the hardscrabble golden desert at the southernmost tip of the Rocky Mountains, Juárez is a sprawling Mexican city with dusty hills covered with cinder block homes set against a backdrop of the Sierra Juárez mountain range. Behind, sits an expanding shantytown of houses fashioned out of wood or cardboard, lacking in water and sewage. From the Juárez side, the view across the Rio Grande shows a wire fence, a pale green U.S. Border Patrol car, billboards advertising health care, and the peaks of a handful of high-rise buildings that make up the downtown.
Juárez also has mansions, as does El Paso. And many other parts of the Rio Grande along this section of the border are indistinguishable: tall river grass lining the narrow and shallow border line.
According to health statistics, the border area poses special problems. Rapid migration over the years has outpaced the ability of basic public health services to keep up with demand. The tuberculosis case rate in El Paso is about 50% higher than the incidence for other large U.S. cities. Hepatitis A is about five times the U.S. average. Dengue periodically is reported along the border. And AIDS--unknown in the border communities a decade ago--is on the rise.
"It is apparent that the Rio Grande divides two amazingly different economies, but yet has the blending of two cultures," Nickey said in an interview at his office, where the walls are covered with art and plaques attesting to his years of public service. He believes the border region serves as a model for debates supporting the need for international public health work.
"We can do all we want right here, but unless we work together we can't cure anything," said Nickey, who is a past president of the U.S.-Mexico Border Health Association (USMBHA), a group of health workers set up in 1943 to coordinate border health strategies and programs among the 10 states and two federal governments. Today the group, operating out of the El Paso Field Office of the Pan American Health Organization (PAHO), works with communities on both sides of the border, mostly training trainers and peer educators and cooperating on projects dealing with maternal and child health.
The USMBHA/PAHO team has worked on a series of "Sister Cities Projects" that link cities from Mexico with their U.S. counterparts, resulting in innovative partnerships, such as a vaccination project called Nuestros Niños (Our Children) and a tuberculosis program called Juntos (Together). The PAHO field office, which opened in 1942, serves as a focal point for these activities. By serving as the secretariat of the USMBHA, collecting and disseminating vital health statistics, and following the progress of transborder community efforts, the El Paso office is in an ideal position to gauge the impact of health interventions on the overall well-being of the citizens of this area.
In addition, it publishes the Border Health newsletter and the Border Epidemiological Bulletin, which enable health professionals to keep abreast of new trends and to stay in constant contact with one another. "Communication--good dialogue--has been one of the defining characteristics of the success of all health projects, and especially along the border, where there are so many different voices yet the same health problems," says Xavier Leus, Chief of the El Paso Field Office.
A New Life
Irma Medina, 29, sits at the lace-covered dining room table of her small cinder block house along a dirt road in Juárez. Her dark eyes sparkle, her fingers toy with the beading on her purple blouse, and she smiles often. She tells her story as if speaking of another person, another life.
Medina is one of 17 children. Just a handful of years ago, she was an abused wife, a mother at 14. Abandoned by her husband and left alone in a one-room house with no water or electricity and two young children, she turned to drugs, alcohol, and prostitution. Later, she settled down with a new partner but that didn't change her lifestyle: he used drugs, too. She felt that her life had bottomed out when she heard about a program organized by PAHO and the USMBHA to deal with drug rehabilitation and HIV/AIDS.
Scared, Medina asked her sister to accompany her to downtown Juárez, where the Compañeros project is based in what had once been a private residence. Compañeros, which means partners, provides AIDS testing, counsels patients, maintains a medicine bank, and provides food for shut-ins.
María Elena Ramos, a social worker for the past nine years with Compañeros, describes Medina as "a special person, someone who has had a big impact on her friends, her children."
Medina continues her story: "I went for talks about drugs and AIDS. They said I was at risk. So I began to take care of myself and wanted my partner to take care of himself, too." Then, after a particularly violent fight, she offered him an ultimatum: get help with Compañeros, or she was leaving.
"He went to rehabilitation, but he went back to drugs after about two months. I felt like it was the end of the world. I was so upset, but they told me at the project to take it easy, that it takes time."
And that's what it took. Ms. Medina says her partner--now her husband--has been off drugs for more than a year and a half. He built the house they are living in and there are plans for an addition. She smiles and says he's doing quite well.
Reflecting on the story she has just related, Ms. Medina lowers her voice and says: "I used drugs. I drank. No one helped me. I thought I could just stop, but I couldn't. Compañeros really helped."
Today, Ms. Medina is repaying a debt. She works with Compañeros as a health promotion worker and speaks with her neighbors and special groups about ways to prevent AIDS. She offers free condoms and answers questions posed by curious adolescents who stop by for a chat. With the help of USMBHA/PAHO, she has taken special courses for outreach workers, known as promotores, and is certified by the El Paso Red Cross. Her daughter, now 14, and her son, 12, attend Compañeros classes for teens and they speak to their classmates about the dangers of high-risk behavior.
"They go with me to Compañeros. In fact, they worry that if I don't stay with the program that I'll go back to my old ways," Ms. Medina says, nudging her daughter standing next to her to tell her friends about a fund-raiser for the project.
Her daughter, Lizania, shifts her weight from foot to foot, tugging the string on her blue sweatshirt as she speaks to her classmates about the event. Her mother, beaming, leans over and whispers with pride: "She wants to be a model."
Teens Make a Difference
Rebeca Ramos, director of the USMBHA's Training and Technical Assistance project, says that the idea of using outreach workers, whether they're young people or adults, to help promote prevention and healthy lifestyles is what she called "a reimportation of technology." In much of Latin America, these promotores are the first line in the medical chain in small communities. People naturally turn to those they know and trust for information and advice on how they can make their lives better. They share what works with others. The idea has been gaining popularity in the United States, often taking root first in Latino communities.
In a small rural New Mexico town, a stone's throw from the El Paso and Juárez border, a group of student presenters at the Santa Teresa High School prepare to share some very sensitive topics with their classmates. Using field manuals provided by USMBHA/PAHO to a community-based organization called Families and Youth Incorporated (FYI), the six teens stand nervously at the front of a ninth-grade English class.
Speaking in Spanish, the language most of the 22 students are more comfortable with, one of the students, Verónica Falcón, poses a question: "Do you know how you spread HIV/AIDS?" The students do not hesitate in their response. Cries of "Sex," "Blood," "Needles," spring from every corner of the room. One of the presenters draws a list on the blackboard. Another holds a poster.
"How can you prevent it?" Verónica asks. "No drugs," shouts one. "Precaution," says another. The girls in the class giggle; the boys snicker. Almost all are Mexican-born, the children of migrant workers who plant and pick cotton, peppers, and melons.
Having gained the class's trust, the next of the presenters, Luis Santos, steps up. He gulps, then blushes, and begins to explain how to use a condom. Dead silence descends on the classroom. He takes a deep breath, then continues his demonstration on a model penis. A round of applause by his friends follows. The next time, it will get easier.
María Chaparro, who works with the FYI group, says she is creating a network of teens in the region who can work with their friends. "This is really important. HIV actually is very low, but the behaviors are there," she says. "They are having unprotected sex and there is a high teen pregnancy rate. There's a lot of drugs around here. This is a high-risk group."
Chaparro explains that this type of peer education works because there is a strong element of trust involved. She has spoken with all the parents of the presenters, so that they are aware that their son or daughter is speaking to others about the dangers of sexually transmitted diseases. "One man told me he was relieved I was telling his daughter something he'd be too embarrassed to discuss."
"It's another world down here," Ms. Chaparro says, adding that people along the border often "feel forgotten" by the two big governments. "So we work together."
Bryna Brennan is the Chief of PAHO's Office of Public Information.
