Nurses With Borders

More than 9 million people live along the U.S.-Mexican border, a figure so staggering that economists and health care workers view this region as a quasi-country onto itself–neither American nor Mexican, but rather Amexican, as it was recently referred to in a Time magazine cover story.

This huge population–which includes both undocumented U.S. immigrants and legal residents–faces a variety of serious health risks, creating an urgent need for culturally and linguistically competent preventive education and nursing care. Yet with today’s severe shortage of nurses–particularly Hispanic nurses, who currently make up only about 2% of the nation’s RN workforce–the health care situation on the southwest border is in a near-crisis state. All sorts of undesirable health records are being broken at the border, including highest teen pregnancy rate, highest obesity rate, highest diabetes rate and highest rate of car crash injuries caused by not wearing seatbelts.

To complicate matters even further, more than 800,000 people cross the 2,000-mile-long border every day. As a result, says the Southwest Center for Environmental Research and Policy, the Borderlands population is expected to escalate to an unmanageable 24 million by the year 2020.

First Stop in America: The ER

Rudy Valenzuela, RN, MSN, FNP-C, is a family nurse practitioner with Southwest Emergency Physicians at the Yuma Regional Medical Center in Yuma, Arizona. “Last year our hospital received 14 patients who died crossing the desert [to enter the U.S.],” he says. “The increased security on the border has narrowed the cross points to only the most dangerous areas. [Undocumented] immigrants are forced to cross the driest, hottest part of the desert at night, and that’s how they die. Containing the border won’t stop them. The economic disparity between Mexico and America is so great, people will do anything to get here.

“As nurses, we see their health problems every day,” Valenzuela continues. “Heat exhaustion, hypothermia and poisoning. They get so thirsty crossing the desert that they’ll drink anything, including antifreeze. If they make it to the ER, we send them to dialysis.”

When illegal immigrants or undocumented workers show up for emergency treatment, nurses can find themselves caught in an unfortunate political bind. They want to treat the patients, but all too often they can’t, because no one can cover the expenses. Emergency nurses are trained to save lives, no matter what. Yet unless undocumented patients are literally at the brink of death, the hospital must turn them away.

“If patients are diagnosed in Mexico with a terminal illness, they try to come here because they think we can save their lives,” explains Jacqueline Crespo Perry, RN, BSN, president of the Houston Chapter of the National Association of Hispanic Nurses (NAHN) and an ER nurse at the Lyndon B. Johnson Hospital in Houston. “Unfortunately, we can’t do much for them. Some of them have cancer, but we can’t treat them long-term with chemotherapy if they’re undocumented and uninsured. It breaks our heart, but it’s the law.”

In 1985, to ensure that emergency care was available to anyone who needed it, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA). This law mandates that all patients who present themselves to the emergency department must be given a medical screening examination and be stabilized (if their condition warrants it), regardless of whether or not they have insurance coverage. Once they are screened, however, and are deemed to be in a stable condition, the patient must be released.

“We have patients who come here with end-stage renal failure,” says Perry. “Because they’re undocumented, we can’t put them on regular dialysis, which would be a three-times-a-week schedule. They can only come to the ER when they’re very sick, which is about every seven or eight days. If their potassium level is not low enough, we have to send them away until they get sicker.”

Torn Between Two Cultures

While the plight of undocumented immigrants is the most acute, legal residents living on either side of the border also have their share of health problems. For example, Yuma, a town on the Arizona/Mexican border, has the highest teen pregnancy rate in the state.

Valenzuela, who is president of NAHN’s Yuma chapter, attributes this to the fact that young people in the Borderlands are caught between two cultures. He explains that the parents come from a strict Mexican culture that doesn’t allow for abortion or adoption, yet the children grow up in a more liberal American environment, where teens are likely to be sexually active regardless of whether or not birth control is available.

But the most serious problem of all is that many, if not most, border residents lack access to preventive health care services. “Most of them do not have health insurance benefits, so they have to pay cash for their clinic visits. As a result, preventive care becomes a luxury,” says Maria Salinas, RN, who works at a family practice clinic in Houston.

“The biggest challenge for nurses is trying to educate these patients about why prevention is so important and what will happen if they don’t take care of themselves,” she adds. “For example, we explain over and over again that they need to do something about their high cholesterol or high blood pressure, but they don’t understand it, because they don’t feel sick.”

Furthermore, of the 9 million people living in the 48 border counties, 3.4 million fall below 200% of the poverty level, according to the Health Resources and Services Administration (HRSA)’s U.S./Mexico Border Health Task Force. This means that 38% of the border population is trapped in substandard living conditions and needs special assistance. Specifically, the task force has identified six major health priority areas for this region:

• Environmental health

• Health promotion/disease prevention

• Maternal and child care

• Occupational health (such as protecting migrant farm workers from pesticide exposure)

• Primary health care

• Substance abuse.

“This is all related to the poverty syndrome,” Valenzuela emphasizes. “The worst disease at the border is poverty. It results in unemployment, teen pregnancy, lack of quality housing, domestic violence, diabetes, cancer and more.”

Partnerships in El Paso

Fortunately, Hispanic nurses aren’t the only ones who are deeply concerned about the serious health disparities affecting border populations. In recent years, a variety of organizations–including hospitals, medical and nursing schools, government agencies, and non-profit foundations–have been teaming up in collaborative efforts to close the Borderlands’ health care gaps.

One particularly outstanding cooperative venture was created in El Paso as a partnership between the University of Texas at El Paso (UTEP), the Texas University Medical School in Brownsville, the W.K. Kellogg Foundation and the U.S. Department of Health and Human Services (HHS).

El Paso shares a border with Juarez in Mexico, and the two cities have a combined population of 2 million. The only thing that separates them is a dried-up Rio Grande, which at this point is no bigger than a family-size swimming pool, says John Conway, MPH, PhD, dean of the College of Health Sciences, Nursing and Allied Health at UTEP, where about 70% of the students are Hispanic.

In 1991, the college received a grant from the Kellogg Foundation to build four clinics dedicated to providing health care and medical services to the border population. The school then formed a partnership with the Texas University Medical School to run the clinics jointly. The Brownsville school supplies the doctors, while UTEP provides nurse practitioners.

HHS awarded UTEP’s Family Nurse Practitioner Program an $800,000 grant to prepare culturally and linguistically competent FNPs to work at the border clinics. The students are required to take two semesters of Spanish, says Jane Poss, PhD, DNSc, ANP, C-FNP, director of the program. About 12 nurse practitioner students, half of whom are bilingual, are enrolled in the program each year.

“They learn how to take a health history in Spanish, how to converse about medical issues with their patients and how to provide health care education,” Poss explains. “It’s practically impossible to provide good care to patients if you don’t speak their language.”

The clinics, which are directed by Leticia Paez, BS, MA, MPA, and managed by nurse practitioners, are located about 25 miles outside of El Paso in the Texas towns of Socorro, Montana Vista, Sabens and San Elizario. These are colonias or shantytowns, some without water and most with only dirt roads. Families with typically three children or more buy a piece of land for $200 and build one room as their home–living conditions that foster infections, domestic violence and squalor. The clinics themselves are based in school district buildings which were donated.

“We are training our health professionals to work in the colonias because these communities are terribly underserved medically and the people are extremely financially challenged,” says Paez. “Patients come to us with serious complications, things that could have been managed had they been caught at an earlier stage. They’ve had to go through years of [lacking access to even the most basic health care services] until they got to us.”

Poss notes that border populations have an especially high risk of diabetes, partly because of their diet, which is high in fat, carbohydrates and sugar. There is also a prevalence of obesity, asthma, tuberculosis, hepatitis A and lead poisoning in the colonias, she adds.

Robert Amador, RN, BSN, is a staff nurse at the clinic in Socorro, which sees about 500 patients a month, and he loves the work. “It’s different from working in a hospital, where you only see a patient for one or two shifts,” he says. “Here, you get to know how the people live and what kind of resources they have. You get to meet their families, and to understand the patient as a person.”

He remembers one patient who refused to take Celebrex to alleviate her rheumatism pain because she was seeing a curandero (folk healer) who had already prescribed herbs. Amador spent time talking to this patient, convincing her that his medicine was plant-based as well. Finally, she consented to try the Celebrex and soon felt relief from her pain.

The nurses quickly learn that many patients are being treated herbally for susto or fear (e.g., fear of dying from cancer), which the curanderos consider a symptom or even a separate disease. Several different herbs are prescribed for susto, depending on the curandero, so the nurses must keep up with the latest folk remedies and be mindful of adverse reactions that can occur when the American drugs interact with the Mexican ones.

Each of the four clinics also has promotoros (promoters), community outreach workers who visit the patients in their homes or other places in the community to educate them on the importance of visiting the clinic. Although the clinics do charge for their services, the cost is relatively low.

Guadalupe Ramos has been a promotora for the clinic in Sabens for 10 years, and she has seen and heard many stories. “A lot of people don’t believe in mental illness or depression,” she says. “They think it’s something they can control, rather than a disease that needs to be treated. I’ve learned a great deal about humanity in this job. The people I work with keep me grounded. Every day, I see life, death and resurrection.”

Many other health professionals who work with border populations are similarly passionate about what they do and have seen their efforts make an immediate impact in the lives of their patients. They feel gratified to be helping people who are so desperately in need, and they only wish that more could be done.

As Paez puts it, “The patients are so appreciative of our services. Nobody helps them but us and God. As Hispanic health professionals, we have a cultural understanding and sensitivity to these patients’ needs. The border is an exciting place with great opportunities to work with wonderful and courageous people who have tenacity and pride.”

What Can You Do to Help?

If you’re a nurse who wants to get involved in serving the urgent health care needs of Hispanic populations on the U.S.-Mexican border, here are three organizations that are worth looking into. They are involved in a variety of Borderlands outreach programs that can provide rewarding career opportunities for nurses.

US/Mexico Border Health Association

Institute for Border Community Health Education
http://chs.utep.edu/KelloggProject/index.htm

HRSA Border Health Program
http://bphc.hrsa.gov/programs/BorderProgramInfo.htm

New Initiatives to Improve Health in the Borderlands

Factors such as lack of health insurance, a shortage of culturally competent Spanish-speaking nurses and limited opportunities to receive preventive care and screening have all been identified as factors contributing to unequal health outcomes between Hispanic border populations and the Caucasian majority. Here’s a look at several innovative new Borderlands initiatives in California that are making strides in addressing these issues.

To close the insurance gap, Blanca Ramirez Brown, RN, CQI, CCM, cross border medical management manager at Blue Shield in San Diego, has designed the first HMO for the cross-border population in California. This program, which lets patients choose health care providers from Mexico or the United States, currently has 1,300 enrollees, many of whom still cross the Tijuana/San Diego border every day, although they are legal U.S. residents. They work for American companies who are willing to pay their health insurance premiums.

“Many patients have difficulty understanding the plan,” Brown reports. “I tell them to make an appointment with the doctor for preventive care, but they’re only used to walking into a doctor’s office when they’re sick.”

To recruit more Hispanic nurses into Borderlands health programs, Pablo Valez, RN, MSH, chief nursing officer at Chula Vista Hospital in San Diego, is working with the University Iberoamericana in Mexico to help nurses studying there become eligible for licensing in America. “Preparing these nurses to pass the U.S. licensing exam will be a long process,” he says, “but our goal is to recruit more Hispanic nurses from Mexico because there’s such a big shortage on this side of the border.”

Another U.S.-Mexican collaborative initiative, hosted by San Diego members of the National Association of Hispanic Nurses, is a binational health fair, now in its second year. The fair is held in April in Tijuana, Mexico. Nurses from Tijuana and San Diego participate in the event, performing physical exams (including measurements of weight, blood pressure, sugar, hearing and vision) and providing preventive education about diabetes management and diet control.

“The people in the community were so hungry for information about the management of difficult disease processes,” recalls Valez, who participated in last year’s fair. “It was a rewarding experience, because I know I really made a difference in the lives of many patients.”