Life, Death, and In-Between on the U.S.-Mexico Border: Asi es la vida

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Life, Death, and In-Between on the U.S-Mexico Border

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Life, Death, and In-Between on the U.S.-Mexico Border Asi es la vida

Edited by

Martha Oehmke Loustaunau and Mary Sanchez-Bane Foreword by Xavier Leus

BERGIN & GARVEY Westport, Connecticut • London

Library of Congress Cataloging-in-Publication Data Life, death, and in-between on the U.S.-Mexico border : asi es la vida I edited by Martha Oehmke Loustaunau, Mary Sanchez-Bane ; foreword by Xavier Leus. p. cm. Includes bibliographical references and index. ISBN 0-89789-568-1 (alk. paper).—ISBN 0-89789-569-X (pbk. : alk. paper) 1. Public health—Mexican-American Border Region. 2. MexicanAmerican Border Region—Social conditions—20th century. I. Loustaunau, Martha O., 1938- . II. Bane, Mary Jo. RA446.5.M49L54 1999 362.1'0972'1—dc21 99-14380 British Library Cataloguing in Publication Data is available. Copyright © 1999 by Martha Oehmke Loustaunau and the Estate of Mary Sanchez-Bane All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 99-14380 ISBN: 0-89789-568-1 0-89789-569-X (pbk.) First published in 1999 Bergin & Garvey, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. www.greenwood.com Printed in the United States of America The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48-1984). 10

9 8 7 6 5 4 3 2 1

With greatest love and respect, this volume is dedicated to my friend and colleague, Mary Sanchez-Bane, whose untiring efforts, passion, and deep caring for her culture, for the borderlands, and for all her fellow creatures—humans and animals—made the world a better place and is an inspiration to all of us. We will all miss you, Mary, more than you can know. Asi es la vida.

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Contents

Tables

ix

Foreword Xavier Leus

xi

Abbreviations

xiii

Introduction

xv

1.

2.

3.

4.

5.

Demographic Factors Affecting the U.S.-Mexico Border Health Status Federico Gerardo de Cosio and Andres Boadella The Border Colonias and the Problem of Communication: Applying Anthropology for Outreach Duncan Earle Life Histories of Four Chicano Heroin Injecting Drug Users in Laredo, Texas Avelardo Valdez and Alberto G. Mata Jr. Dangerous Relationships: Effects of Early Exposure to Violence in Women's Lives on the Border Joao B. Eerreira-R into, Rebeca L. Ramos, and Alberto G. Mata Jr. The Difference a Line Makes: Women's Lives in Douglas, Arizona, and Agua Prieta, Sonora Ellen R. Hansen

1

23

39

61

77

viii

6.

7.

8.

9.

•

Contents

Creating a Future for Hispanic Mothers and Daughters on the U.S.-Mexico Border Josefina Villamil Tinajero and Dee Ann Spencer Living with HIV/AIDS in a Rural Border County: Women's Service Delivery Needs Donna Castaneda Community-Based Health Promotion and Community Health Advisors: Prevention Works When They Do It Mary Sanchez-Bane and Eva M. Moya Guzman Rural Health on the Border and New Mexico's Models for Care, Community Empowerment, and Cooperation Martha Oehmke Loustaunau

The Medical Care Systems in Mexico and the United States: Convergence or Deterioration? The View from the Border David C. Warner 11. The Sunland Park/Camino Real Partnership: Landfill Politics in a Border Community Ellen Rosell 12. Community-University Partnerships Addressing Environmental Issues along the U.S.-Mexico Border James VanDerslice, Amy K. Liebman, and Theresa L. Byrd Afterword Internet Border Sources Index About the Editors and Contributors

95

113

131

155

10.

177

191

209

221 223 225 231

Tables 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 4.1 5.1

U.S.-Mexico Border Definitionhs Percentage of People below Poverty Level along the U.S. Border, the United States, and Mexico Unemployment Rates in the United States, Texas, and on the Texas-Mexico Border U.S.-Mexico Border Population by Year, Population Growth, and Doubling Time U.S. and Mexico Border Counties and Municipalities: Mortality and Fertility Rates, 1992 United States and Mexico Health Priorities Project Consenso Binational Health Priorities, 1991 Life Expectancy for the U.S.-Mexico Border States, 1990 U.S.-Mexico Border: Leading Causes of Death, 1992-1994

2 4 5 6 8 11 13 14 15

Acute Respiratory Disease Rates along the U.S.-Mexico Border, 1992-1994

16

Barriers that Affect Access to Health Care along the U.S. Southern Border

18

Comparison of Cycle of Violence and Intergenerational Transmission of Violence Theories Crossing the Border

63 84

x

• Tables 5. 2

Cross-Border Destinations

87

6. 1

Dropout Rates for Students in the United States, by Ethnicity, 1975 to 1995

98

6. 2

6. 3

Percent below the Poverty Level: Total in All Families and Families with Female Householder (No Husband Present), by Ethnicity, 1975 and 1995 Average Earnings for Year-Round Full-Time Workers, by Gender and Ethnicity

101 102

7.1

Reported Cases of AIDS in Imperial County by Year, Age, Gender, and Ethnicity/Race, 1984-1997

116

9. 1

La Clinica de Familia Partnerships and Networking

165

Foreword

Health is created where people live, love, play, and work. That is the way health promotion professionals see the challenge before them. It is also how they promote empowerment, with a basic understanding that to a large degree people are in charge of their own health. But such concepts as empowerment, not to say health promotion, are very much determined themselves by where people live and work. They are also very much culturally determined, particularly in their application. In the world there are few places like the U.S.-Mexico border. With close to 200 countries and self-governing territories, there are many borders in the world, and there are longer borders. There are older borders, and on the different continents there are many examples of internal border lines and processes. Even when, formally speaking, there is no border as such, many of those are zones of conflict, while, as we all know, peace is the first prerequisite for health. The U.S.-Mexico border remains very much a border, even if one dividing two of the largest and most complex countries in the world. It derives its specificity from its history, its demography, its economics, its political and social processes. B. M. Jones in Health Seekers in the Southwest (Norman: University of Oklahoma Press, 1967) describes, for example, how individuals in the past century fled disease-infested urban developments in the East to look for a healthier environment on the U.S.-Mexico border. Tuberculosis was just one such prevalent condition for which the border and its arid, dry highlands were thought to provide respite, if not cure.

xii

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Foreword

For children of the border, and to live in borderlands, the human experience is colored in manifold ways. Life is about taking and blending from each of the homelands and backgrounds. That involves good things, but not only good things; life on the border can be cruel, as it is elsewhere, and the nature of the border does not always make for a simpler or better life. To understand health, we need to understand how people live and love, unfortunately also how they sometimes hate. People are complex in their ways, and so are we on the U.S.-Mexico border. This book intends to shed some light on conditions along the U.S.-Mexico border and illustrate how they link to health. By providing a better understanding of the human condition on the border, it should also contribute to a better border. While nonborderlanders sometimes see it as a dividing line, a threat to be managed, the reality of the U.S.-Mexico border is a series of distinct communities building a better life for themselves and their families. Xavier Leus Chief Field Office, U.S.-Mexico border, Pan American Health Organization Executive Director, U.S.-Mexico Border Health Association

Abbreviations

AFDC

Aid to Families with Dependent Children

AFTER

Analysis of Free Text for Enthographic Research

AHCCCS

Arizona Health Care Cost Containment System

AYUDA

Adults and Youth United Development Association

BVF

Border Vision Fronteriza

CBOs

community-based organizations

CHA CHR

community health advisor community health representative

CHW

community health worker

HELP

Home Education and Livelihood Program

HMO

health maintenance organization

HMSA

Health manpower shortage area

HRSA

Health Resources and Services Administration

HUD

Housing and Urban Development

HURA

Health Underserved Rural Area program

IDU

injecting drug user

IHS

Indian Health Services

IMSS

Mexican Institute of Social Security

IPV

intimate partner violence

ISSSTE

State Workers' Social Security and Services Institute

MCS

Medical Compliance Service

xiv

•

Abbreviations

MSA

metropolitan statistical area

MUA

medically underserved area

NAFTA

North American Free Trade Agreement

NIDA

National Institute of Drug Abuse

NMEID

New Mexico Environmental Improvement Division

OPI

Organizacion Popular Independiente

PAHO

Pan-American Health Organization

PCCM

primary care case management

PRI

Revolutionary Institutional Party

PPO

Preferred Provider Organization

RECD

Rural Economic and Community Development

RHI

Rural Health Initiative

SMSA

Standard Metropolitan Statistical Area

TANF

Temporary Assistance for Needy Families

TDHCA

Texas Department of Housing and Community Affairs

UTEP

University of Texas at El Paso

SAMHSA

Substance Abuse and Mental Health Services Administration

WHO

World Health Organization

Introduction

"Asi es la vida" says Mary's mother and other Hispanics raised in the U.S.-Mexico borderlands. Things go wrong, and what can you do about it! "That's life," says Martha's mother, and other midwesterners raised in the heartland of central Illinois, which means exactly the same thing. Life is tough, so you do the best you can. But life must be something else as well. Is there always nothing one can do about it? Very few people really know what life is like on the U.S.-Mexico border. There are many perspectives, but life in the borderlands is too often mythologized according to political and economic agendas, with no real feeling or sense of the people who live there, their experiences, hopes, triumphs, and tragedies. This volume hopefully adds to the growing literature that sheds a bit of light, offering insights on the questions of life on the border, the real issues, the problems, and their meaning for the border area as well as the two nations on each side. The border between the United States and Mexico divides two contiguous countries, covering over 2,000 miles from Texas to California. It encompasses six states in Mexico and four in the United States, including forty-eight counties in which more than a third of U.S. border families live at or below the poverty line. It often consists of desert landscape, hot and dry in summer and barren and open in winter. Other areas are filled with hills, canyons, scrub, and pine. The border has been the scene of countless legal crossings and countless illegal ones as well. Drug traffic is brisk, and the broad expanse of territory has seemed to encourage the traffic in both illegal substances and human beings.

xvi

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Introduction

The border itself is a line, demarcated by ports of entry, both large, as in El Paso/Juarez and San Diego/Tijuana, and small, as in Columbus/Palomas or Douglas/Piedras Negras. But it extends some 60 miles (some say more, even up to 120 miles) into the countries on both sides with a growth in trade and population that is explosive. The area is also home to approximately 350,000 people who are concentrated in colonias, which are mostly semirural, unzoned, and unregulated "communities" with no access to safe drinking water, sewage systems, or public services such as police and fire protection or medical/dental care. Unemployment is 250 to 300 percent higher than in the United States in general. But what is the real significance of the "border," this line between two countries, two cultures, two peoples tied inextricably together through mixtures of blood and heritage, trade and tourism, hopes and desires for a better life and the tenacity for seeking opportunity? Despite the talk of building walls, wire mesh fences, and increasing "militarization," the border sees a huge exchange of human resources. Daily crossings consist of workers, laborers, visitors, tourists, families, tradespeople, students, and shoppers—the lines of cars and people at the international bridges may often be hours long. An estimated 18,000 people from Cuidad Juarez, Mexico, 1 alone make the daily commute to El Paso for work, and about 3,000 people from El Paso head south to Juarez for work, not to mention the mutual attractions of services and tourism. The "line" cannot prevent the mixing of human beings or of cultures. The borderland has become "the land of the third culture" as noted by the Pan American Health Organization in El Paso, Texas. This third culture has a wide mixture of Anglo, Mexican, and indigenous cultures that can be seen by the blending of English, Spanish, and Indian words, creating a new language innately understood by most who live there, but seldom by outsiders. The mix of Spanish and English may be referred to as "Spanglish," and it can also be mixed with border slang and "gringoismos." Other cultural elements also reflect the heady mixture in food, clothing, and custom. Borderland music reflecting dual cultural influences of "TexMex" was widely popularized by the singer Selena. Various dishes have combined the textures and flavors of corn, chile, spices, and meats to create a delectable border cuisine, with regional variations on enchiladas, chiles rellenos, tacos, and countless other popular foods. Artistic expression also reflects the influences of multiple cultures. El Paso, Texas, for example, boasts numerous murals painted on building walls that call to mind the popular Mexican muralists, such as Diego Rivera, yet blend into a distinctly borderland style. The borderlands, however, face many problems created by poverty and overcrowding, rapid growth and development, threats to health and safety, economic activity, and the struggles to survive of those seeking what others have always sought: a better life and opportunity for the generations to

Introduction

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xvii

come. In examining the real problems of the rapidly expanding border population, the third culture must be counted in, not only in identifying, understanding, and analyzing the problems, but in finding solutions. Like most cultures at the crossroads of vibrant activity and change, the third culture is in flux, with roots in older, established cultures, but constantly re-forming and changing. This presents a challenge and a need for constant adaptation and acculturation for newcomers, as well as for those who live there. From the exigencies of providing for the basic needs of the population to the creativity of combining music and the arts to develop new and exciting culturally diverse forms and styles, the border is the home of a truly "American" culture in the full sense of the word. The difficulties of life on the border are heavily rooted in the politics and economics of the area and the problems posed by poverty, the competition for resources, the drug trade, and rapid growth. In addition to political agendas, we believe that it is primarily because of the lack of understanding, and the myths and stereotypes surrounding the border area, that attempts at solutions have failed or have been so slow in developing. Our title Life, Death, and In-Between on the U.S.-Mexico Border: Asi es la vida comes from our wish to provide insights on the difficulties of beginning life on the border, the constant threat of death from poverty, pollution, violence, and disease, and the "in-between," which not only reflects the border itself, but the time and place between birth and death that pose so many dangers and miseries. The in-between, however, may also offer challenge and opportunity to do something about making life better. We also note that no matter what the problems may be, they all relate in one way or another to health and the delivery of health care in the broadest terms, including the need for safe drinking water, police protection, employment, education, positive family dynamics, nutrition and sanitation, and disease prevention. And since disease and misery are not constrained by borders, the issues discussed in this volume must be addressed if children are to survive and grow healthy and strong, if death is to be held at bay until life has been lived, and if the in-between is to enable the borderlanders to fulfill their tremendous potential and provide a chance for the happiness and opportunities that we all seek. We also recognize and focus on the role of women in efforts to improve the quality of life on the border. Women are traditionally the care-takers, the educators, the providers of health care, and the child raisers. They are now becoming activists, organizers, and bread-winners, venturing into the community and changing their traditional roles and relationships, educating their men, and finding their own empowerment to save their families and themselves. We feel that this empowerment constitutes a major hope for the future. Realistically, the line that divides the U.S.-Mexico borderland, the "third culture," represents a national/cultural division between two worlds and

xviii

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Introduction

two world-views and has real consequences for both sides. A distinct line does not, however, separate or segregate the people, businesses, trade, problems, diseases and poverty, or anything else as completely distinct entities. We must get beyond the "wall mentality" because the wall simply does not exist; it is far too late for walls. The third culture does exist, and must be understood in its own right and in relation to national interests on both sides. Only then can we develop rational policies and programs to solve real problems and take advantage of what the border offers—a bridge between nations and not a line dividing them. These chapters are hopefully a part of that bridge. THE SELECTIONS Federico Gerardo de Cosio and Andres Boadella open the volume with a demographic profile of the border area and its relationship to health, giving an excellent overview of the area and the inhabitants. They also point out some of the myths believed about the borderand and its population, and they set the stage for a more informed exploration of the issues to follow. Duncan Earle writes of the colonias, their conditions, and the difficulties of communication between outsiders and colonia dwellers, as well as among the colonia dwellers themselves. He shows how both trust and communication are vital in changing lives and improving the colonia environment. Avelardo Valdez and Alberto G. Mata Jr. show a different perspective on the origins of the drug problems so prevalent on the border, in the broader context of the border environment. Focusing on demand rather than supply, they examine life histories of four heroin addicts with distinct differences, but also similarities in their entrapment into addiction. They then discuss the implications of these histories for addressing the border drug problems. Joao B. Ferreira-Pinto, Rebeca L. Ramos, and Alberto G. Mata Jr. tackle the problem of domestic violence, showing how traditional roles and early exposure to violence lead to female acceptance of abusive male partners including husbands, boyfriends, and male gang members. They stress the need to consider cultural and environmental background and point out the futility of confrontation in solving the problem. They suggest the need for early intervention with children, teaching women new ways to deal with anger and frustration, and new ways for men to channel aggressive tendencies. Ellen R. Hansen finds women's lives to be very different on each side of the border. Her research in Douglas, Arizona, and Agua Prieta, Sonora, explores those differences and perceptions, as well as the patterns of border

Introduction

• xix

crossings, which are different for women than for men. Women who cross for domestic and economic reasons could become the bridge across cultures as well as the link between them, with improved education and new work opportunities. Josefina Villamil Tinajero and Dee Ann Spencer discuss their MotherDaughter program in El Paso, Texas, as a growing means of empowering two generations of females through education. Each generation serves as a support and encouragement for the other. Such education changes lives and futures. Donna Castaneda writes of the problem of living with HIV/AIDS on the U.S.-Mexico border, concentrating on women's needs for services. Cultural ideas, shame, denial, and fear all play a part in the existing lack of services and in getting women to use available services. Although her work is preliminary, it suggests a need to address a growing problem that is threatening in many ways and lends insight not only to provision of services but to ultimate AIDS prevention for both men and women. Mary Sanchez-Bane and Eva M. Moya Guzman describe another group of women on the border who have become empowered and who are in the front lines to provide health care. These community health advisors also provide numerous related services including education, going where others cannot go, and succeeding due to their knowledge of language, culture, and people. These women (and some men) are the hope of the borderlands, and like pebbles dropped in a stream, their work and dedication radiates out into the population in ever-widening circles. The authors offer recommendations for strengthening and utilizing a valuable and vital resource. Martha Oehmke Loustaunau discusses the rural aspects of the border population in southern New Mexico in relation to the need for and delivery of health care. She then discusses in some detail two rural community health centers in the area that have become models for responding to the broad needs of rural populations through networking, cooperation, coordination, and participation of the client population. They face the challenge of making the most of limited resources to address rapidly growing healthrelated needs and concerns and a changing health care system. David C. Warner describes the health systems on each side of the border in relation to their own cultural contexts and development. He then shows what happens when they meet, or collide, at the border and describes the challenge of providing care to a multicultural population and addressing public health concerns that transcend national borders. Ellen Rosell describes the complexities involved when a community seeks solutions to their problems of solid waste disposal by contracting with an independent entity. The contingencies, lack of communication, misinterpretations, financial considerations, and problems of control and opera-

xx

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Introduction

tions can generate hostility, fear, and legal tangles that were totally unforeseen and unanticipated. Rosell suggests ways in which to recognize and prevent or deal with these issues. James VanDerslice, Amy K. Liebman, and Theresa L. Byrd present a series of case studies that examine the ways in which community organizations have addressed environmental issues along the U.S.-Mexico border. The chapter highlights the partnerships that have been established between community-based organizations and local universities in the Ciudad Juarez/ El Paso area. NOTE 1. Throughout this volume, Juarez, Mexico, may be referred to as simply Juarez, Cuidad Juarez, or Cd. Juarez.

1 Demographic Factors Affecting the U.S.-Mexico Border Health Status Federico Gerardo de Cosfo and Andres Boadella

INTRODUCTION Borders can be viewed as communities that share the same geographical region and physical resources. They have an important social, economic, and cultural interdependence in which the successes and concerns of one side become the successes and concerns of the other side. Although borders are interdependent, they are at the same time independent. This means that the policies, norms, and regulations of one side are not applicable to the other. For some people, borders are periphery communities leading to inequitable access to resources and services (Kamel and Leus 1998). This is the case of the U.S.-Mexico border, in which the developed and developing worlds merge. They mix to combine sometimes the best and the worst of both worlds. The U.S.-Mexico border stretches 2,000 miles and is composed of ten border states (six on the Mexican side and four on the U.S. side), twentythree U.S. counties and thirty-nine Mexican municipalities. This U.S.-Mexico border region presents a rapid population growth characterized by important migration movements, growing job opportunities on the Mexican side of the border, and the dream to cross the border in search of better living opportunities in the United States. The U.S.-Mexico border is also characterized by an uneven economic development with a high economic interdependency. This means that an economic crisis on the Mexican side of the border will severely influence the U.S. side with important losses in employment opportunities. In spite of this interdependence, each side of the border is also independent with

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Table 1.1 U.S.-Mexico Border Definitions The border region is the area lying 100 km or 62.5 miles to the north and south of the U.S.-Mexico boundary

1983 La Paz Agreement

23 U.S. border counties and 39 municipalities that touch the line

U.S.-Mexico Border Health Association

60 miles south/north of the imaginary line

North American Development Bank/SAMHA/CONADIC

300 miles north of the boundary

U.S. Public health Services / Area Health Education Center (HETC)

Area within 26 km south of the boundary line

Mexican Customs.

Source: K. Driessen and G. de Cosio, Future Directions: Substance Abuse in the U.S.-Mexico Border Region. Final Report, 1995. Presented to the Center for Substance Abuse Prevention

its own legal, economic, and social systems, which may or may not be applicable on the other side. Also, the border is characterized by sharing many health problems such as tuberculosis, sexually transmitted diseases, violence, and substance abuse, to mention a few examples. One of the most basic elements of collaboration when developing binational health programs along the U.S.-Mexico border is the recognition that "disease knows no borders," a comment made by many health officials in the region. It is important to accept that, although the problems and possible solutions to prevent and/or control them are similar, the approaches that each country may take to these problems are completely different. This is primarily due to the differences in resources and perceptions in socioeconomic and cultural values.

BORDER DEFINITION Perhaps there is one legal border definition, which is the "imaginary line" that divides Mexico and the United States (Driessen and de Cosio 1995). This "imaginary line" or la linea, sets the political and legal framework that delineates the independence and sovereignty of each country. However, there are many operational definitions of the border. Each definition responds to the specific needs of the defining organization. Any consensus is unlikely as to what is meant by the border region (Driessen and de Cosio 1995). Most definitions are geographic (see Table 1.1). In addition, for some observers, the border should also include other metropolitan areas that are far beyond the boundary because either they

Demographic Factors and Health Status

•

3

are influenced by the border or they influence the border. San Antonio, Texas, and Monterrey, Nuevo Leon, Mexico, are classic examples since these two cities consider themselves the gateway to the United States or to Mexico. The border region is also a binational region (Warner 1991) because of a number of communities that share the same land, water, and air. There are at least twelve pairs of cities that all together account for a population of more than 9.5 million people living on both sides of the border. In addition, if San Diego County is excluded, by the U.S. definition of rural populations (fifty inhabitants per square mile), a major part of the border is "rural" (Driessen and de Cosio 1995). However, a vast majority of the population is concentrated in border cities. For the purpose of this health status description, and to facilitate the description of the border, we will limit the discussion to the U.S. counties and Mexican municipalities that touch the international boundary. Economic Interdependence It is important to point out that the border is characterized by economic interdependence between the United States and Mexico. For example, it has been estimated that the Mexican city of Juarez generates 20 percent of all jobs and 60 to 90 percent of downtown retail trade in El Paso, Texas (Escobedo and de Cosio 1997). National economic issues, lack of infrastructure and lack of funding, uneven economic development, and the effects of the North American Free Trade Agreement (NAFTA) are economic issues that affect the border (Ellis 1997). These major topics are usually taken into consideration when Mexico and the United States develop their economic policies for the border. Interestingly, the U.S. side of the border possesses the three poorest counties in the United States: El Paso, Laredo, and Brownsville, all in Texas (Sharp 1998; Escobedo and de Cosio 1997). Information on poverty levels on the Mexican border are not easily available; however, a report from the Pan American Health Organization-World Health Organization (PAHOWHO) mentions that the population living below the poverty level in Mexico is 38.6 percent of the total population (PAHO-WHO 1997). This Mexican poverty level doubles the U.S. national figure (1996). When the U.S. border is compared to the national average, the percentage of population living below the poverty level along the border is higher (Escobedo and de Cosio 1997). In addition, the U.S. border poverty level is similar to the Mexican level (see Table 1.2). On the Mexican side, however, economic opportunities are considered to be among the best in certain border states, with low unemployment rates. Although the Mexican border area is better off economically than the rest of Mexico, it is still worse off economically than on the U.S. side. Of note is the fact that the poverty level in El Paso, Texas, grew from

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Life, Death, and In-Between

Table 1.2 Percentage of People below Poverty Level along the U.S. Border, the United States, and Mexico

SITE Texas Brownsvillle McAllen Laredo Eagle Pass El Paso Arizona Nogales California Calexico San Diego U.S. National Mexico National

PERCENTAGE 18 44 33 37 46 32 16 31 13 32 13 13.8 38.6

Source: PAHO/WHO, Basic Indicators: Situation in the Americas. 1997. 21.7 percent in 1980 to 32.3 percent in 1990. In 1995 Mexico experienced its worst economic crisis since 1929 (Schmidt 1995). Inflation rates jumped from less than 7.4 percent in 1994 to more than 52 percent in 1995, a 7.02 percent increase. This rapid inflation growth and consequent devaluation of its currency resulted in difficulty for Mexico to pay its national and international debt. The lack of trust in government and an increase in unemployment has resulted in violence, suicide, substance abuse, and alcohol abuse (Escobedo and de Cosio 1997). Estimates from the federal government of Mexico suggest that between the months of January and March 1995 more than 750,000 people lost their jobs. However, the Mexican Workers Commission has estimated that in the same period 2 million jobs were lost (Schmidt 1995). These figures do not even consider underemployed people such as street vendors, windshield cleaners, and beggars. The unemployment rates on the U.S. side of the border have always been higher when compared to the rest of the country (see Table 1.3). Although NAFTA implies increased trade and human interaction, little mention is made regarding health issues in the agreement. And when health issues are mentioned, they usually are related to licencing and certification of products and services (Academia Nacional de Medicina 1994; Gomez, Frenk, and Cruz 1997). The immediate effects of NAFTA have been to accelerate the maquiladora phenomenon (assembly plants, usually foreign owned, free of taxes if products are returned to the country of origin) (Ellis

Demographic Factors and Health Status • 5 Table 1.3 Unemployment Rates in the United States, Texas, and on the Texas-Mexico Border

United States Texas Brownsville El Paso Laredo McAllen

5.3 5.8 12.2 11.8 14.0 19.1

Source: M. Escobedo and F. de Cosio, Tuberculosis and the U.S.-Mexico Border. Journal of Border Health, 1997. 1997; Hayes-Bautista 1997). This means an increase in migration as Mexican citizens seek work in maquiladoras, which at the same time is stimulating a high population growth that overwhelms the current available infrastructure, including access to health care (Escobedo and de Cosio 1997). Therefore, this economic development leads to greater pressure on both sides of the border with a clear impact on the social, health, and environmental status of the border. The maquiladora phenomenon is associated with large amounts of toxic wastes that are not disposed of safely.

Population According to the 1990 Mexican and U.S. population census, there were 7,803,306 people living along the border (USMBHA 1995). However, the El Paso Field Office of the Pan American Health Organization has estimated that in 1994 the border population was 9,515,534 (PAHO 1997). According to the data obtained from the census, 59 percent of the population was living on the U.S. side of the border, whereas the remaining 41 percent lives on the Mexican side. The U.S. census estimated that of all those living in the border region, 57 percent are of Hispanic origin. However, there are counties such as Hidalgo and Webb, in Texas, in which Hispanics represent 95 percent of the total population (Ortega 1995). It is interesting to point out that although the border is 2,000 miles long, 69.9 percent of the population is concentrated in two areas: California/Baja California and El Paso, Texas/Ciudad Juarez, Chihuahua. In 1900, the border population as a whole was estimated to be less than 100,000. By 1980, the population grew up to 5,900,612 (Warner 1991; Ham-Chande and Weeks 1992). Between 1980 and 1990 the population increased 1.32 times, or 25 percent. In other words, the current estimated population is 9,515,534 inhabitants. However, it has been estimated that

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Table 1.4

U.S.-Mexico Border Population by Year, Population Growth, and Doubling Time

1990 Population 1994 Population All Ethnic population groups growth Hispanic population growth Population doubling time* Population doubling time for country*

U.S. BORDER

MEXICAN BORDER

5,186,090 5,636,983 2.4 2.8 29 years 140 years for US

3,382,669 3,878,551 3.1 N/A 23 years 37 years for Mexico

Source: PAHO, Sister Communities Mortality Profiles, 1989-1994, 1997. * Author estimates based on census population and population growth.

between 1990 and 1994, the border population grew by 1,712,228 people. If the current growth continues, the U.S. and Mexican border populations will double in twenty-nine years and twenty-three years, respectively (see Table 1.4). The border population is young, since 47 percent of the total population is less than 20 years of age. This age distribution represents a major challenge not only for the provision of health care services but also for the development of employment opportunities. The rapid population growth is increasing the number of people living in colonias, or unincorporated rural settlements situated along the U.S.Mexico border. Most colonias are located in New Mexico and Texas. However, there are reports that are beginning to document the existence of colonias in Arizona and California. Colonias lack safe drinking water supplies, sewer, wastewater drainage systems, and lack adequate roads or garbage disposal services and electricity (Texas Attorney General 1996; EPA 1997). It has been estimated that there are more than 1,400 colonias scattered along the Texas border, with a total population of more than 340,000 people (Texas Attorney General 1996; EPA 1997). Migration Immigration is another major factor that is contributing to the population growth along the U.S.-Mexico border. It has been estimated by the U.S. Immigration and Naturalization Services that almost 307 million legal border crossings occur each year (El Paso Community Foundation 1996). In addition to the legal crossings, in 1995 the Border Patrol arrested 3 million people crossing the border illegally. Most of these immigrants come from Southern Mexico in search of better opportunities in the United States. When they cannot cross the border, an unknown number of these people settle in the Mexican community that is next to the border. For example, the Mexican border city of Ciudad Juarez estimates that each year more than 35,000 new immigrants come to the city. This huge

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number of immigrants pressures the city with challenges that are difficult to respond to, such as development of health care infrastructure, roads, housing, schools, electricity, and sewage, to mention only a few. These immigrants, once in the city, in most of the cases, invade private property, creating illegal settlements called zonas marginadas (inner cities or marginated areas) that are similar to colonias. Most of these new settlers will not pay property taxes, will steal electricity, and will dig wells without sanitary controls. Farmworkers are another type of immigrant to the border. In 1994 the Texas Department of Health estimated that in Texas there were approximately 500,000 farmworkers. These farmworkers are seasonal people that move from one place to another during the crop season. Border communities may actually double their population for a few weeks during the harvest season. This high number of new arrivals for a short period of time forces these communities to provide primary health care services to all farmworkers. Denial of access to health care for these workers would be a mistake because people travel with diseases and if not treated they may infect others, including community residents. Fertility The study of fertility in a given population is important because it helps to understand the capacity to reproduce. It consists mainly of two components, the biological and the social (Weeks 1992). The biological component refers to the physical capacity to reproduce, which usually includes the age group of 15 to 44. The U.S.-Mexico border has an estimated female population of fertile age of 2,522,177, of which 51.5 percent (1,299,170) lives on the U.S. side of the border and the remaining 48.5 percent (1,223,0070) lives on the Mexican side. As can be seen in Table 1.5, the Mexican fertile population represents 52 percent of the total female population. That is 7 percent higher than the U.S. female border population. The migration movements most probably influence this higher percentage on the Mexican side; however, studies should be carried out to understand this phenomenon. The social components are associated with the social environment of the population. Factors such as the level of education, income, level of socioeconomic development of the community, opportunities for professional growth, and other factors may influence child-bearing. In general, it can be said that the more educated the population, the higher the income, the more developed the community, the lower the unemployment rate, and the lower the fertility rate. The opposite is true for a high fertility rate. As can be seen in Tables 1.3 and 1.5, however, the U.S. side of the border shows the required conditions for a high fertility rate. On the other hand, the Mexican border, in spite of a high fertility rate, is characterized by: (1) the lowest

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Table 1.5 U.S. and Mexico Border Counties and Municipalities: Mortality and Fertility Rates, 1992 NATION Crude Mortality Rate Infant Mortality Rate Maternal Mortality Rate Population Growth Fertility Rates Female popuation 15-44 Proportion of population 15-44 Illiterate Population Percentage Rate: 100,000

MEXICO BORDER

465.39 1773.0 47.7 1.9 133.6 21,876,760 48%

484.82 1911.0 19.8 3.1 109.2 1,223,007 52%

12.4

4.2

UNITED STATES NATION BORDER 875.38 830.5 7.9 1.2 67.7 21,876,760 48%

679.6 613.0 5.5 2.4 89.8 1,299,170 45%

Source: PAHO, Sister Communities Mortality Profiles, 1989-1994, 1997.

unemployment rates of Mexico, (2) the most wealthy cities of Mexico, and (3) a population with the highest educational percentages. Therefore, the question may be, what impact do migrants have along the Mexican border? The U.S.-Mexico border is also characterized by high fertility rates with low mortality rates. As can be seen in Table 1.5, the U.S. border shows higher fertility rates than the nation as a whole, whereas the Mexican border fertility rates are lower than the national figures. However, when the Mexican and U.S. border fertility rates are compared, it can be seen that the rate on the Mexican border is 18 percent higher. Also, as can be seen in the Table 1.5, the United States as a country is experiencing low mortality and low fertility, which leads to a slow population growth. Mexico is characterized by low mortality, high fertility, and rapid population growth. The U.S. border area presents a profile similar to Mexico (low mortality/high fertility). This situation is important on both sides of the border due to the fact that there is a large population under 20 years of age; there is thus a large economically dependent population as a consequence (under 16 and above 65 year of age). Also as a result, the labor force will be under great pressure to create more jobs to satisfy the demand. Failure to do so will create the conditions for development of more social and economic problems. Finally, there are studies that have shown that the more educated a woman is, the fewer children she wants to have (Weeks 1992). This is mainly due to the fact that with education there are wider opportunities for personal and professional growth. This seems to be the case with the Mexican border population since, as can be seen in Table 1.5, the illiterate percentage of this population is 4.2; that is more than three times lower than the national Mexican figure. The educational level also relates to the

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use and delivery of health care services, including pre- and postnatal care. Therefore, greater efforts should be made to improve the educational status of the female population. HEALTH CARE IN MEXICO AND THE UNITED STATES There are major differences in the way that the United States and Mexico deliver health care services. For instance, it has been said that while in the United States the health care system is characterized by a demand model, the Mexican model focuses on supply (Flores-Escarzaga 1997). In Mexico, health care is considered a fundamental right, with a health expenditure of 1.1 percent of the total GNP. In the U.S. system, care seems more of a privilege and has a health expenditure of 15 percent of the total GNP (PAHO-WHO 1997). The Mexican health care system is centralized and fragmented with a recent tendency to decentralization. The advantage is that it makes the system more cohesive, consistent, and uniform. However, its main disadvantage is related to lack of flexibility when the pre-set norms and guidelines dictated by the federal government need to be adapted to the particular conditions of each geographic region (Hopewell 1998). The U.S. health care system is diverse, with different ways of delivering health services ranging from insured population to uninsured population. Even though total expenditures are close to 15 percent of the total GNP, it is estimated that around 17.4 percent of the total nonelderly population (40.3 million individuals) is not covered by health insurance. It has also been estimated that approximately 33.8 percent of the total Hispanic population living in the United States does not have health insurance. Both health care systems are different, and what is available in one may not be available in the other. For example, in the United States, protease inhibitors for the treatment of HIV are available to people with AIDS; however, across the border in Mexico, they are barely available. In some instances, diagnosis of certain diseases such as tuberculosis is based on different methods. While in the United States, a positive culture is needed to diagnose tuberculosis, in Mexico, an AFB smear will be enough for diagnosis. This is because of economic factors, number of cases to treat, and prevalence of disease that makes the use of one approach more cost effective than the other. In general it can be said that alternative medicine is more widely available on the Mexican side than in the United States. Binational Health Priorities One of the most basic elements of collaboration when developing binational health programs along the U.S.-Mexico border is the recognition that "disease knows no borders." It is important to keep in mind that both

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sides of the border have different perceptions on how to deal with diseases and patients. For example, in the United States physicians generally inform patients of their diagnosis first and then family members are told. On the Mexican side, family members are usually informed of the condition of the patient first, and then, once action plans have been developed in collaboration with the family, the patient is informed. The identification and establishment of binational health problems along the border is not an easy task. There are many factors that influence the selection of priorities for the border since the national programs, in addition to the specific health concerns of each border (United States or Mexico), should be considered. Therefore, it can be said that the border usually first addresses national, then border and binational, issues. The federal governments of each country define national health priorities. These priorities will respond to the perceived or real needs of each country. The national health goals of the United States are based on the Health and Human Service Department Strategic Plan (see Table 1.6). The national Mexican priorities are based on the Primary Programs for the Nation. These are ten generic programs with subprograms. As can be seen in Table 1.6, focus is placed on the control and prevention of specific diseases. The strategic plan to carry out the Primary Programs is based on health promotion and health services research. The Secretariat of Health has proposed two supporting mechanisms to achieve proposed goals: (1) epidemiological surveillance and (2) statistical information and information development. In order to accomplish the goals of the national programs, both countries have placed emphasis on prevention of diseases and increased access to health services. However, each country uses different economic, human, and technological resources. Most of the goals and/or programs outlined in Table 1.6 are applicable to the border region. Major priorities for both countries emphasize prevention of diseases and increased access to health services. However, there are health problems that are more prevalent on one side of the border than on the other side. It can thus be observed that some border priorities are based on problems that are relevant to one side of the border but not to the other side. For example, the prevalence of high rates of diarrheal disease on the Mexican side is one of the major concerns of the Mexican communities because of associated problems of high mortality among children under 5 years of age, malnutrition, and potential complications for the development of other more severe diseases with life threatening consequences. On the other hand, the U.S. side is more concerned with suicides (see Table 1.9) than is the Mexican side. Furthermore, common problems such as influenza and pneumonia may have different focuses. For instance, the 65 and above age group is the target group for the U.S. program, while the Mexican major concern is the age group of children under 5 years of age.

Table 1.6 United States and Mexico Health Priorities UNITED STATES HEALTH PRIORITIES

MEXICAN HEALTH PRIORITIES

Reduce the major threats to the health and productivity of all Americans.

Family Planning Perinatal Health

Reduce tabacco use especially in youth Women's Health Reduce the number and impact of injuries Child Health Care Improve the diet and the level of physical activity Immunizations Curb alcohol abuse Diarrheal Diseases Reduce the illicit use of drugs Acute Respiratory Diseases Reduce unsafe sexual behaviors Nutrition Improve the economic and social well-being of individuals, families and communities in the United States

Oral Health

Increase the economic independence of families on welfare

Adult and Aging Health Care

Increase the financial and emotional resources available to children from the non-custodial parents

Diabetes Millitus Hypertension

Improve the healthy development and learning readiness of pre-school children.

Hepatic Cirrhosis

Improve the safety and security of children and youth

Neoplasm

Improve opportunities for seniors to have an active and healthy aging experience

Immunizations

Expand access to consumer directed home and communitybased long-term care and health services. Improve the economic and social development of distressed communities

Transmissible Diseases by Vector Malaria, Dengue and other arbovirus diseases Chagas Disease Leshmaniosis

Improve access to health services and ensure the integrity of the nations health entitlement and safety net programs Increase the percentage of nations children and adults who have health insurance coverage.

Oncocercosis Scopions Ricketsiosis

Increase the availability of primary health care services Zoonosis Improve the access to and the effectiveness of health care services for persons with specific needs.

Rabies

Protect and improve beneficiary health and satisfaction in Medicare and Medicaid. Enhance the fiscal integrity of HCFA programs and ensure the best value for health care beneficiaries. Source: USDHHS Strategic Plan Web-Page (www.dhhs.gov)

Source: Secretary de Salud Web-Page (www.ssa.gob.mx)

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Finally, binational health problems are those that are identified by both sides as a priority in which it is accepted that very little will be accomplished if no collaborative efforts are developed. There have been many attempts to reach an agreement as to what are the most important binational health priorities. Perhaps the most successful effort was Project CONSENSO, a project carried out by the U.S.-Mexico Border Health Association (USMBHA 1991; de Cosio, Apodaca, and Olaiz 1992) in which more than 600 people participated in the development of the identification of binational health priorities by consensus. Participants identified the six binational health priorities with specific issues to be addressed (see Table 1.7). The six outlined goals in Table 1.7 are broad concepts which require specific objectives and actions. Goals one and two are aimed at enhancement of the health and well-being of individuals and families; goals three and four are focused on the provision of effective health and human services; and goals five and six address the fostering of sustained advances in the systems and sciences underlying medicine and public health. The accomplishment of each goal requires the participation of other government departments that will promote the development of incentives in order to generate commitment and responsiveness. Life Expectancy Life expectancy is an important indicator to measure the chances that a person has to survive a given number of years from his/her birth if the conditions remain the same. Overall life expectancy in the U.S. border states is 75.8 years, and in the Mexican border states it is 71.6 years (see Table 1.8). This means that the U.S. border population lives at least 4.2 years longer than the Mexican population. However, when life expectancy with the national figures of both countries is compared, it is possible to observe that the border populations have a better opportunity to live longer. There are indications that life expectancy along the border has increased at least three to five years (USMBHA 1995). This gain in longevity is mainly due to advancements in medicine and public health that have contributed as landmarks to increased life expectancy. However, this does not necessarily mean quality of life, which is associated with health expectancy. In other words, it refers to the number of years lived in good health and/or favorable health status free of complications of chronic and/or infectious diseases. Athough the border population has achieved an increase in longevity, the 1997 World Report has pointed out that "increased longevity without quality of life is an empty price," (i.e., health expectancy is more important than life expectancy). Therefore, we should double efforts to improve our

Table 1.7 Project Consenso Binational Health Priorities, 1991 SPECIFIC AREAS

BINATIONAL HEALTH PRIORITY Environmental Health

Water, soil, and air pollution Hazardous waste Education Legislation

Health Promotion and Disease Prevention

Healthy lifestyles

Community Health Education (English/Spanish) Legislation Maternal and Child Health

Prenatal care Family planning Adolescent pregnancy

Occupational Health

Injury control Toxic waste Maquila Industry Health education Legislation

Primary Health Care

Health care delivery to the indigent population Access to health care services Increase efforts to improve health education Community participation

Substance Abuse

Alcoholism and tobacco Health education with emphasis in the elderly Legislation

Source: USMBHA, Final Report Project CONSENSO, 1991.

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Table 1.8 Life Expectancy for the U.S.-Mexico Border States, 1990

National Border States

TOTAL

MEXICO MALE

FEMALE

TOTAL

69.9 71.6

66.5 68.8

73.1 74.3

75.4 75.8

UNITED STATES MALE FEMALE 71.8 72.3

78.8 79.9

Source: USMBHA, Sister Communities Health Profiles, 1989-1991,1995.

lifestyles (i.e., free of tobacco, better diets, reduced stress levels, and improved quality of our environment, to mention a few).

Mortality The world is living in an "epidemiological transition"—the changing patterns of health in which poor countries inherit the problems of the rich, including not merely illness but also the harmful effects of our lifestyles such as nutrition, tobacco, alcohol, and drug abuse (WHO 1997). It is important to keep in mind that although through the epidemiological transition developing countries (areas) present higher percentages of infectious diseases, the developed countries (areas) are more characterized by a higher percentage of chronic diseases. This is the case of the United States (70 percent of deaths are related to chronic diseases) and Mexico (an estimated 49 percent of deaths associated with chronic diseases). However, along the U.S.-Mexico border the pattern is different. The U.S. side of the border, even though the United States is a developed country, behaves as a developing area in which chronic diseases are responsible for 49.5 percent of all deaths. On the other hand, the Mexican side (even though Mexico is a developing country) shows characteristics of more developed areas. Chronic diseases account for 52 percent of all deaths. The crude mortality rates of the U.S. (all races) and Mexican border are lower than those found in the United States or Mexico (see Table 1.5). These low rates are a reflection of a young population and rapid population growth, which is associated with high fertility rates (Weeks 1992) and important migration movements toward the border. The leading causes of death along the border are a mix of chronic and infectious diseases (see Table 1.9). The most important infectious diseases are acute respiratory diseases. The chronic diseases are cancer with emphasis in colon, lung, cervical, and breast, circulatory diseases (ischemic heart disease and cerebrovascular disease), perinatal deaths, accidents (motor vehicle, homicides, and suicides), diabetes, cirrhosis, and obstructive pulmonary diseases. Both sides of the border present similar causes of death, perhaps with different positions when listed in order of importance. How-

Demographic Factors and Health Status • 15 Table 1.9 U.S.-Mexico Border: Leading Causes of Death, 1992-1994

Acute Respiratory Disease Cancer: Colon Pulmonary Cervical Breast Prostate Isquemic Heart Disease Cerebrovascular Disease Perinatal Deaths Accidents Motor Vehicle Homicides Suicides Diabetes Cirrhosis Obstructived Pulmonary Disease Other Tuberculosis AIDS

NATION 23.6 52.8 5.2 6.4 11.2 6.0 6.2 38.5 24.8 23.9 66.7 16.1 18.3 2.7 33.3 22.8 17.0 5.6 3.5

MEXICO BORDER 17.8 60.2 2.9 9.5 12.8 7.6 5.8 56.7 25.1 25.7 78.9 15.6 17.3 3.7 43.8 17.5 14.2

UNITED STATES NATION BORDER 31.4 26.1 207.8 159.1 22.1 14.9 57.5 41.1 8.1 7.2 32.9 26.0 27.6 21.6 187.7 128.6 57.8 43.8 5.9 5.2 57.8 53.9 16.2 15.5 9.9 8.8 12.0 12.8 20.8 17.3 9.8 11.9 38.1 33.7

8.2 4.4

0.6 14.5

0.9 14.1

Rate: 100,000 Source: PAHO, Sister Communities Mortality Profiles, 1989-1994,1997.

ever, it should be noted that chronic diseases on the U.S. side of the border double or triple the Mexican rates. Also, when comparing both sides of the border, a review of Table 1.9 shows that cancer presentation varies on each side of the border. For instance, while in the United States breast cancer presents a higher rate than cervical cancer, on the Mexican side it is exactly the opposite. In addition, the Mexican side presents higher rates for homicides and lower rates for suicides than the U.S. side. Regarding diabetes, it can be mentioned that the Mexican rate is more than double when compared to the U.S. border. Diabetes is one of the silent diseases, which in many cases when diagnosed, serious irreversible complications and/or disabilities may have already occurred. It is expected that diabetes will rise 45 percent in developed countries and 200 percent in developing countries (WHO 1997). The U.S.-Mexico border is characterized as a developing area; thus, diabetes should be considered as one of the most important priorities. Although the border population is mainly Hispanic, the available data on their health status is limited. The Hispanic population of the border

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Table 1.10

Acute Respiratory Disease Rates along the U.S.-Mexico Border, 1992-1994 AGE GROUP Less than 1 1-4 65 and more

MEXICO 104.4 17.8 NA

UNITED STATES 17.2 NA 219.7

Source: PAHO, Sister Communities Mortality Profiles, 1989-1994, 1997.

states presents lower crude mortality rates than the overall population of the United States. In general terms, the Hispanic border states' population shows lower mortality rates than for any other ethnic group in the United States (Hayes-Bautista 1997; Ortega 1995). This may be an indication that Hispanics are better off than any other group (even though many Hispanics do not have access to health services) or that Hispanics do not have access to health care services. Data is limited. In addition, it is well known through anecdotal data that there is a tendency for Hispanics to seek care on the Mexican side of the border; therefore, this information is not reported in the United States. Besides the leading causes of death, it is important to point out that at much lower rates tuberculosis and AIDS are leading morbidity causes (Escobedo and de Cosio 1997; Redlinger et al. 1998; Redlinger, O'Rourke, and VanDerslice 1997). These two health problems are considered very important for the border to the point that a number of binational health initiatives addressing these issues have been implemented, such as the Binational Tuberculosis Projects, which are scattered along the border. The purpose of these projects is to contribute to the control of tuberculosis and to decrease the threat that tuberculosis poses for the U.S. side of the border. This threat includes the high percentage of multidrug resistance and HIV on the Mexican side (Escobedo and de Cosio 1997). The study of infectious diseases also shows important differences. For example, mortality from acute respiratory diseases on the Mexican border are mainly seen in children under 5 years of age; on the U.S. border, these deaths are more prevalent in persons older than 65 years of age (see Table 1.10). Substance Abuse One of the major health problems linked to mental health issues is substance abuse. Substance abuse represents one of the major health, legal, social, and economic problems of the border that is associated with accidents, violence, suicide, and homicide. Reports of substance abuse along the border have indicated that the Mexican border has a higher percentage of individuals who have ever used drugs than the nation as a whole, but

Demographic Factors and Health Status • 17 lower percentages than the U.S. side. Yet the U.S. border area shows lower percentages of lifetime drug use than the United States as a whole. For both sides of the border, it can be said that marijuana and alcohol are the most widely used drugs. However, the Border Epidemiology Work Group during its meeting in Tijuana, Baja California, reported that heroin use and abuse is increasing at a dramatic pace. Also, cities such as Tijuana, Baja California, and Yuma, Arizona, are reporting the presence of methamphetamine (crystal). Crystal is a drug that is preferred by young people because it is cheaper than cocaine and its effect may last for more than thirty hours. To address substance abuse, it is important to keep in mind a number of factors such as important migration movements of young people toward the border in search of better opportunities, poverty levels, and the limited number of services (treatment and prevention) to the Hispanic population that are culturally accessible. Finally, the development of substance abuse programs should take a comprehensive approach in which substance abuse prevention and treatment programs, mental health, law enforcement, and health care programs are incorporated in order to reduce the economic cost and have a positive social impact on the border communities (de Cosio, Ramos, and Leus 1998). Binational collaborative efforts are required to address this problem if an impact is expected. Access to Health Care Access to health care along the U.S.-Mexico border is considered to be one of the major problems. The U.S. border is largely Hispanic, with at least 33.8 percent of its population (1,510,148 people) uninsured (DHHS 1998; El Paso Community Foundation 1996). Many of these people in the United States may rely on Medicaid in order to satisfy their health care needs. In the 1998 Report of the Texas Comptroller of Public Accountants, it is noted that all border counties on the Rio Grande are federally designated medically underserved areas (MUAs) (Sharp 1998). The report also mentions that the Texas border region accounts for 30 percent of the Texas Medicaid clients. In 1995, the Rural Health Office of the University of Arizona conducted a Delphi Study among health providers, administrators, and community services in order to identify associated barriers that affect access to health care services along the U.S.-Mexico border. Seven issues were identified by the study (Table 1.11). It was found that there are several cultural barriers such as language, lower education attainment, and existence of few programs that are culturally and community-based, which prevent people from using the health care systems more promptly. Because of the high percentage of people living on the U.S. side of the

Table 1.11 Barriers that Affect Access to Health Care along the U.S. Southern Border BARRIERS, PROBLEMS, ISSUES

POSSIBLE SOLUTIONS

Lack of knowledge on how to access services

* Develop and enhance community-based outreach models * Develop health promotion and disease prevention programs/projects * Develop social marketing strategies to outreach underserved communities.

Language and cultural barriers

* Promote the role of community health advisors, volunteers, and promotores * Develop bilingual and bicumiral health programs. * Develop culturally competent and sensitive training programs for professionals and paraprofessionals.

Cost of Care

* Enhance true collaborative partnerships between the private and public health care sectors. * Use confiscated monies to subsidize border health care needs. * Encourage the use of sliding fee scale for services. * Promote preceptorship training in medically underserved areas.

Need for training and distribution of health care providers.

* Enhance paraprofessional and mid-level provider education. * Promote community health education efforts. * Create binational agreements to finance health care for undocumented people.

Denial of access to services for undocumented (illegal status) individuals.

* Remove threat of recrimination for providers who serve undocumented persons. * Defeat anti-immigration laws * Develop health care services that are communitybased and planned

Availability of services

* Promote the use of community and migrant health centers and primary health care services facilities. * Encourage the use of alternative health care services.

Transportation

T a k e services to communities through the use of mobile units, outreach, and satellite clinics. * Create community-based transportation models or initiatives. * Decentralize health care services from urban to rural underserved areas.

Source: E. Moya, F. de Cosio, G. de Zapien, A. Nichols, and X. Leus, ElAcceso a la Salud en la Frontera Mexicano-estadounidense, Medico Interamericano, 1999.

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border who are below the poverty level, access to health care becomes prohibitive to a large number of people. Therefore, it is not unusual that public hospital emergency rooms are crowded with patients without a "medical emergency" since this is probably the only option available to them. By the time the providers find that the case was not a "real emergency," it no longer matters as the services have been provided. In addition, by law, hospitals cannot deny emergency services regardless of patient's ability to pay (Sharp 1998). Then the question becomes, who ultimately does pay and more or less how much? Finally, the Delphi Study identified other issues associated with access to health care. For example, an undetermined number of Mexican nationals cross the U.S. border to seek health care services on the U.S. side and/or vice versa. Public transportation on the U.S. side of the border is also deficient and makes health services difficult to access. In some instances people on the U.S. side of the border are forced to cross to the Mexican side in order to find a more efficient transportation system that allows them to travel to downtown El Paso! An example of this situation was related to Dr. Marilyn Gaston, director of the Primary Health Care Bureau, Health Resources and Services Administration (HRSA) during an El Paso site visit in 1995. When she asked a woman housekeeper in one of El Paso's colonias, "How do you go to the El Paso Health Center?" Maria answered, "Whenever I have to go to the clinic in downtown El Paso, I simply cross the river [the Rio Grande] illegally to the Mexican side and take a bus to Cd. Juarez, Chihuahua, Mexico. Once I am in downtown Juarez, I cross to El Paso, and then I go to the clinic. On my way back home, I follow the same procedure, but I cross the river illegally. This is the easiest and fastest way, otherwise, it could take me at least three hours before I get to downtown El Paso." There are cases in which the U.S. population (mainly Hispanics) cross the border to seek health care or purchase their medications on the Mexican side at a fraction of the U.S. cost. Although there is limited research and information on this issue, there are some studies that have documented this fact (Parietti, Ferreira-Pinto, and Byrd 1998). Several health care providers (Sharp 1998) have created specific services for this population. Besides, private Mexican hospitals have established special offices to accept U.S. health insurance claims. There are other rural communities such as Presidio, Texas, in which there is a small clinic where medical and primary health care services are provided once a week. The closest medical facility on the U.S. side is in Alpine, Texas, 90 miles away. Then the option becomes the bordering Mexican city, Ojinaga, which is a larger community with the necessary health care facilities to provide services to the U.S. population.

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CONCLUSIONS It is important to recognize that although the problems and possible solutions to prevent and/or control the problems are similar on both sides of the U.S.-Mexico border, the approaches that each country use may be completely different, simply because of the differences in resources and perceptions in socioeconomic and cultural values. It must also be kept in mind that many barriers such as language and economic differences must be surmounted (Wallace and Fullerton 1996). In order to succeed in establishing binational collaboration, it is suggested that all efforts to address these problems be built on the principles of: (1) the good neighbor principle, (2) a comprehensive vision, (3) emphasis on cooperation, and (4) internal coordination of each side of the border for the development of binational collaboration (Department of State 1998). It must also be remembered that the U.S.-Mexico border is characterized by migration. Many people consider the U.S.-Mexico border as a place for better opportunities. However, as a result, this migration causes a high population growth that is associated with the lack of access to health care services, increase in violence, environmental pollution, and conflicting ways to deliver health services because the border is both rural and urban. The U.S.-Mexico border is a port of entry for a wide range of communicable diseases and thus generates a demand for health services that cannot be quantified due to the lack of reliable information. We know that binational collaboration is not easy; it requires commitment, trust, respect, and a real understanding of the system that characterizes the border cities on the other side. Finally, in order to achieve real binational cooperation, Mendoza and Leus (1998) have described four basic principles: We must have an interest in a common objective; respect, trust, and decision-making by consensus among the parties involved; fair allocation of resources; and the equitable distribution of the results or gains among the cooperating parties. REFERENCES Academia Nacional de Medicina. 1994. The North American Free Trade Agreement and Medical Services, 11-55. Mexico, DF: Academia Nacional de Medicina. de Cosio, F., B. Apodaca, and G. Olaiz. 1992. "Reaching Health Priorities through a Consensus Process." Border EPI Bulletin 3 (March-April): 1-10. de Cosio, F., R. Ramos, and X. Leus. 1998. "The U.S.-Mexico Border and Substance Abuse." Pipeline (January-February): 119-38. Department of State. 1998. Progress Report to the Presidents on the Initiative to Implement a New Border Vision. Washington, DC: U.S. Department of State. DHHS. 1998. Strategic Plan. U.S. Department of Health and Human Services at: http://www.dhhs.gov.

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Driessen K., and G. de Cosio. 1995. Future Directions: Substance Abuse in the U.S.-Mexico Border Region, 1-68. Final Report submitted to the Center for Substance Abuse Prevention, Arizona-Mexico Border Health Foundation/ U.S.-Mexico Border Health Association. Ellis, M. 1997. "Community and Economic Development in Health Care: The U.S.Mexico Border Case." Journal of Border Health 2(4) (October-NovemberDecember): 5-11. El Paso Community Foundation. 1996. The Border/La Frontera: The United States/ Mexico International Boundary. El Paso, TX: EPCF. EPA-U.S.-Mexico Border XXI Program. 1997. United States-Mexico Border: Environmental Indicators—1997, 4-6. Washington, DC: United States Environmental Protection Agency. Escobedo, M., and F. de Cosio. 1997. "Tuberculosis and the United States-Mexico Border." Journal of Border Health 2(1) (January-February-March): 40-48. Flores-Escarzaga, E. 1997. "The Health Systems of the United States, Canada, and Mexico Before the New Links of Transnational Health: A Comparative Analysis." Journal of Border Health 2(2) (April-May-June): 10-26. Gomez, D., J. Frenk, and C. Cruz. 1997. "Commerce in Health Services in North America within the Context of the North American Free Trade Agreement." Revista Panamericana Salud Publica 1(6) (June): 460-65. Ham-Chande, R., and J. Weeks. 1992. "A Demographic Perspective of the U.S.Mexico Border." In The Demographic Dynamics of the U.S.-Mexico Border, edited by J. Weeks and R. Ham-Chande, 1-28. El Paso: Texas Western University Press. Hayes-Bautista, D. 1997. "Issues and Options in the Border States." Journal of Border Health 2(4) (October-November-December): 12-21. Hopewell, J. 1998. "Cross-Border Cooperation: A Case Study of Binational Tuberculosis Control." In U.S.-Mexico Border Health: Issues for Regional and Migrant Populations, edited by J. Power and T. Byrd, 89-102. Thousand Oaks, CA: Sage Publications. Kamel, W., and X. Leus. 1998. "Health Dilemmas of Disadvantaged Communities in Border Areas: Global Challenges and Lessons Learned." Presentation made at the 25th Annual Meeting of the National Council for International Health, Arlington, Va., June 25-27. Martinez, O. 1996. History of the U.S./Mexico Borderlands in The Border/La Frontera. El Paso, TX: El Paso Community Foundation. Mendoza, G , and X. Leus. 1998. Bi-Border Cooperation in Public Health U.S.Mexico Border. U.S.-Mexico Border Field Office, Pan American Health Organization Internal Document for Discussion. Moya, E., F. de Cosio, G. de Zapien, A. Nichols, and X. Leus. 1999. "El Acceso a la Salud en la Frontera Mexicano-estadounidense." Medico Interamericano 18(1): 24-28. NIDA. 1997. "Key Findings." In Border Epidemiology Work Group Proceedings, ix-xv. Rockville, MD: National Institute on Drug Abuse. Ortega, H. 1995. "United States-Mexico Border: Vital Statistics Review." The Interamerica Institute for Border Health and Environment (January): 7-60. PAHO. 1997. Sister Communities Mortality Profiles, 1989-1994. El Paso, TX: Pan American Health Organization.

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PAHO-WHO. 1997. Basic Indicators: Situation in the Americas. El Paso, TX: Pan American Health Organization/World Health Organization. Parietti, E., J. Ferreira-Pinto, and T. Byrd. 1998. "Easy Access to Contraceptives Among Female Adolescents in a U.S.-Mexico Border City." In U.S.-Mexico Border Health: Issues for Regional and Migrant Populations, edited by J. Power and T. Byrd, 119-38. Thousand Oaks, CA: Sage Publications. Redlinger, T., K. O'Rourke, and J. VanDerslice. 1997. "Hepatitis Among Schoolchildren in a US-Mexico Border Community." American Journal of Public Health 87(10) (October): 1715-17. Redlinger, T. et al. 1998. "Elevated Hepatitis A and E Seroprevalence Rates in a Texas/Mexico Border Community." Texas Medicine 94(5) (May): 68-71. Schmidt, S. 1995. "Planning a U.S.-Mexican Bi-National Metropolis: El Paso, Texas-Cuidad Juarez, Chihuahua." In The North American Cities and the Global Economy: Challenges and Opportunities, edited by P. Kresl and G Gappert, 187-219. Thousand Oaks, CA: Sage Publications. Sharp, J. 1998. "Health Chronic Conditions." In Bordering the Future: Challenge and Opportunity in the Texas Border Region, 105-22. Austin: Texas Comptroller of Public Accountants. SSA. 1998. Programs Primarios de Salud. Secretaria de Salud. El Paso: Texas Department of Health at: www.ssa.gov.mx. TDH. 1994. Tuberculosis in Texas: Annual Statistical Report 1994. Bureau of Communicable Diseases. El Paso: Texas Department of Health. Texas Attorney General. 1996. Forgotten Americans: Life in Texas Colonias, 1-6. El Paso, TX: U.S.-Mexico Border Health Association. USMBHA. 1991. Final Report Project CONSENSO. El Paso, TX: U.S.-Mexico Border Health Association. . 1995. Sister Communities Health Profiles, 1989-1991. El Paso, TX: U.S.Mexico Border Health Association. Wallace, H., and J. Fullerton. 1996. "Maternity Care for Hispanic Women Who Cross the United States Side of the Border." Journal of Tropical Pediatrics 42(6): 335-38. Warner, D. 1991. "Health Issues at the US-Mexico Border." Journal of the American Medical Association 265(2) (January 9): 242-47. Weeks, J. 1992. "Population Processes." In Population: An Introduction to Concepts and Issues, 87-224. 5th ed. Belmont, CA: Wadsworth. WHO. 1997. "The State of the World." In The World Health Report 1997: Conquering Suffering, and Enriching Humanity, 1-72. Washington, DC: World Health Organization.

2 The Border Colonias and the Problem of Communication: Applying Anthropology for Outreach Duncan Earle

INTRODUCTION: THE REALITIES OF BORDER COLONIAS A housing and community crisis of huge proportions and serious national impact is brewing on the U.S. border with Mexico. Over a third and perhaps more than a half million poor people, mostly of Mexican and Mexican American descent currently reside in impoverished border area settlements called colonias. Living conditions in colonias rival the worst in the nation, characterized in the press and in congressional reports as similar to those in Third World settlements. Housing is for the most part substandard, basic services are absent or inadequate, health problems are ubiquitous and frequently debilitating, economic and social problems abound, and by whatever measure used, quality of life levels are generally lower than for noncolonia residents, and far worse than for most of the U.S. population. In some respects they are even worse than colonias across the border in Mexico. While close to the border, these shanty subdivisions are removed and isolated from urban areas, following the vagaries of developer initiatives on low value real estate, often far from the places where people must go to seek employment and such social services as they are eligible for. Isolation is a serious problem, both physical and social, and the inability to effectively communicate with colonia households serves as a barrier to their improvement. Texas has nearly 1,500 documented colonias, and several hundred more are located in the rest of the southwest border region, mostly in Dona Ana

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County in New Mexico. Their rate of growth has been as much as 10 percent per year in the last decade, and with the current financial and political problems in Mexico, the lack of affordable housing in much of the border region, and comparatively high birth rates, they show no signs of slowing, despite legislative efforts to restrict colonia development since 1989. Colonias promise to be one of the next century's most difficult challenges, in an area of the nation historically troubled and currently near crisis. The health problems are striking. The incidence of Hepatitis A, associated with contaminated water and food, was found in El Paso County to be five times the national average, and some colonias test 90 percent exposure for the virus by age 30. It has more TB cases than the totals for nineteen other states (Lamporte 1992). Because so many residents use Mexican medical facilities, which are as little as a tenth the cost, good statistics on the true depth of the health crisis is difficult to gather from health institutions. Many residents are chronically ill and do not seek medical assistance. To this, one must add exposure to risk, for many of these settlements are a long way from any medical facility and lack an ambulance service. Substance abuse is also a rising problem, as are gangs in some colonias. Many colonias are situated on polluted or periodically flooded ground. The economic picture is not pretty either. Median monthly salary in one well-surveyed colonia was $600 per month in 1989 (Towers 1991). Other more recent data put average income to be in the $700 to $1,200 range, with a considerable range of variation. It should be noted that these figures do not represent the true degree of unemployment, because the survey only covers the land-purchasing households (only one household and one residence is supposed to be on each lot). An unknown percentage of the colonia population sublets space from lot contract purchasers as a temporary economic arrangement related to northward migration, seasonal work in the region, or as a first step to getting a colonia plot. For some the stay is long. Some residents find places for as many as five families, with the use of extra rooms, campers, abandoned cars, and out-buildings. These people have even lower incomes, and their crowded conditions are directly related to their low incomes and the absence of housing alternatives. In so many ways, colonias are problematic, yet they do serve, if inadequately, a badly felt need for inexpensive housing. Low-income housing is costly and scarce on the border. Much of what drives the demand for colonia lots is the promise of a home one can own, a chance to have a humble, largely self-built version of the middle-class suburban home. For some, however, it is the only alternative to no home at all. It is a positive sign to seek home ownership, especially for those so close to the economic line of survival (Velez-Ibanez 1993). These recent settlements are facing serious challenges. It is not certain that the hard-fought struggles for lots and homes (many people's only eq-

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uity) will be able to congeal into healthy communities in the future. Policy decisions and social service outreach efforts regarding colonias must take into consideration their frailties and vulnerabilities, as well as their potentials for improvement. They must appreciate that colonia residents are not wealthy enough to make any decision that would increase risk. Any fiscal misstep can mean foreclosure by the developer. As with so much else, the householder takes all the risk and lives precariously as a kind of neopeasant in the marginal areas of a late twentieth-century border landscape. Like James Scott's peasants, they are like the man standing up to his neck in water, in fear of the next wave. There must be action to help resolve the problems in colonias, but it must be deeply informed by local cultural, social, and political realities to be effective. To carry out effective outreach, however, one must know how to communicate with and gain the trust of residents. The following addresses research findings on this very issue. STUDYING COLONIA COMMUNICATION In 1995, a HUD Community Outreach Partnership Centers grant was received as part of an effort by the Center for Housing and Urban Development at Texas A&M University to study communication and outreach effectiveness in colonias. At the beginning of this grant, research staff under my direction set about to examine the communications approaches of different agents and agencies working with the colonias, for the most part in the Laredo area. We also examined, through ethnographic inquiry, what forms of intracolonia communication exists and colonia residents' views on how well different forms of outreach communications work. We were also interested in what kind of knowledge was gathered by those with experience working with colonias, and we undertook to make an analysis of this data. Our research team made dozens of field trips, three longer field stays, conducted fifty-seven phone interviews, and twenty-two in-depth, face-to-face interviews (on more than one occasion, usually) with either colonia residents or those who worked with them in some service capacity. Many additional hours of analysis were also put into the final assessments that are reflected in the results discussed below. The central applied anthropological problem being addressed was how to overcome the isolation that comes from lack of communication, and that in turn led to research about how people communicate in colonias, both between and among residents and with informed outsiders. Conflicts in Communication The conclusion that first jumps out at us from the data is that communication is not on the whole very good, either with outsiders or among colonia residents. Relations between residents and service providers are

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generally characterized by lack of trust, mutual suspicion, and the idea that the other side is hiding something or "pulling something over." This, despite cordial interaction. This social rift is not ethnic for the most part. The vast majority of the informants interviewed were Hispanic, both colonia residents and service workers. The differences between them were class based, and notable in terms of amount of acculturation and degree of integration into the U.S. system. For many, this intergroup antipathy has a basis in relations between classes that predate this century and is reinforced on a daily basis. Through interviews with social and health service providers, several examples of frustrated responses to the lack of resident participation revealed profound problems of communication. The underlying element of what appears to be communication breakdown in the methods and techniques used by service providers is here referred to as the "incompatibility of metacommunicative repertoires." This term, elaborated further below, can be summarized as meaning that the bases of understanding about communication itself are not the same for the sender and the receiver. Examples of successful methods of communication with residents were also revealed through these interviews, which also helped us understand the problem. Comments made by key leaders and residents of El Cenizo and the Highway 359 colonias east of Laredo provided clues suggesting what techniques of communication are successful in colonias and which are not. The interaction of service providers with the residents of the colonias is a rich starting place for this analysis. The problem of adequate communication with colonia residents finds its basis in clashes of styles and methods of communication between the social, economic, and political world of colonias and the outside world of "Anglos" and the more acculturated, middle-class Mexican Americans. As an example, let us look at the Rural Economic and Community Development (RECD) organization and La Gloria Development, Inc., two agencies that have worked in colonias in the Laredo area for some time with the objective of improving their housing. Their employees note the main problem in delivering bathroom and sewage connection services to those who have requested it, for example, is getting families to return after their initial request to finish the documentation required to begin construction. Almost no one completes all the follow-up stages. The problem, they claim, is that residents simply do not remember their appointments or do not understand that they need to come in again. From the outsider's perspective, the colonia residents appear irresponsible, slow, and disorganized. The process of obtaining this service requires an initial application to determine if the family is qualified according to income and family size. The papers are processed in about thirty days, followed by an inspection of the property to determine if the home is livable and if the family truly needs a bathroom. Then once their application is accepted and they are judged to meet requirements, an appointment is made

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to finalize the application. The problem occurs mostly in the third step when residents fail to make or keep the appointments they make. The service providers don't know how to resolve the problem. From the standpoint of the colonia residents we interviewed, the problem stems from lack of understanding based on communication obstacles, not on behavioral failures. The problem stems from not only the complexity of paper work, which they do not clearly understand, but also the difficulty of committing to a follow-up date when work schedules are unstable. There is also the inherently intimidating nature of written official papers in a specialized language that few have mastered even when it is in their own language. Paper breeds distrust. In this process, the method of communication is primarily by way of letters sent in the mail. This is the most reliable and efficient means of communicating, from the service providers' point of view. A letter of acceptance informs the family of the final acceptance of their application through the inspection. The letter also informs them of when the service provider has set an appointment to finalize the needed documents and construction dates. Many do not understand what it is they must still do. Gloria Padilla of La Gloria Development, Inc., gives reasons that place blame on the conditions under which the residents live. Padilla says the residents simply do not understand that they need to come in to fill out more paper work. She says they think they already have given all of their information and are not really aware they need to come in, even when they have been informed by mail. It does not relate to lack of interest. An element of fear enters into the situation as soon as formal papers come in the mail. Some people interviewed thought of that mailing as evidence that something had gone wrong in the process. This turned out to be related to past experiences with other government agencies in which being called in too many times might mean trouble, not success. If it is true, as San Juana Gonzales of the Literacy Volunteers maintains, that there is very low literacy in English and even in Spanish in the colonias, it is possible that the medium of communicating through letters will not be very successful. For those literate in English or Spanish, receiving a letter from RECD is often interpreted to mean they have been accepted into the program and not that another appointment is necessary. A partial reading of the letter might overlook appointment dates. If read from the residents' point of view as acceptance then it would appear that the information needed had already been given. As a result of this miscommunication, when the RECD interviewer is at the Community Center in El Cenizo he/she ends up driving out to the homes of the people who do not show up, to get them to their appointment. Telephoning residents is not a viable option because many do not have telephone connections, and there are often multiple households in one house compound, using the same phone. People who work for these agencies themselves complain of excessive paperwork.

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Imagine the problem for colonia residents! No one is happy with the project as a result. And this is but one project among hundreds that attempt outreach to the border colonias. Going Deeper: Paper, Authority, and Control Some more in-depth interviews revealed that many colonias residents dislike paper as a form of communication, especially those who are most vocal and powerful. To best understand this, we need to appreciate the social situation of households. While we talk about "residents" in colonias, the real social unit is a household, usually representing a family, nuclear or extended. In this family unit, our research shows that the single greatest source of domestic tension lies between generations, the oldest being typically Spanish-speaking and often not literate, the second being more educated and bilingual and the third being even more literate, and often with good English skills, better in many cases than their Spanish. Even those who are in very emotionally close families express distrust for what other (younger) members of their families read and translate for them. One man interviewed who lived alone with his mother, did everything for her, professed to love her dearly, yet she would not trust him to read anything for her. It seems that the main reason for distrust of her own son comes from the conflict between household authority which accrues to age on one hand, and knowledge of the new system of the United States, of which language is a part and which is generally greater among younger people, on the other. There are numerous other similar cases. Every letter in need of translation is an event that demonstrates painfully the potential loss of control of seniors over juniors. It provides an opportunity for younger people to "rub it in," to humiliate those in domestic authority by reason of their age because they are not in control any more when it comes to what goes on beyond the confines of the home. In addition, the schools that have provided this new literacy have frequent conflicts with parents over their children. Many colonia residents feel humiliated by school personnel and frequently will not go to schools even for community meetings, as they do not view schools as neutral in terms of colonias. This despite the fact that most colonia residents want their children to go to school and do well. Where outside authority is perceived to be confronting local, household authority, the latter retreats. Any activity that heightens colonia residents' sense of loss of control, of being inferior to their children, or that opens them up to possible ridicule will be strongly avoided, sometimes without consciously knowing why. Residents may very much approve of written materials for an outreach effort, and then not respond to them at all. They usually will not admit to the aversion, but it is evident everywhere. This aversion is especially strong with people of very low income and education levels, where documentation

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of citizenship is lacking or irregular, where there are families that are mixed documented-undocumented, or where knowledge of the language and culture of the outside mainstream is at a low level. This population of course is typically the most needy, vulnerable, and unnoticed. This problem of trust can be ameliorated by the use of a personal local contact, someone to go and communicate directly to residents, or who can review and verbalize a printed document with residents. This was discovered in the case of Mr. Avila, who currently works with housing rehabilitation in the Laredo area. He attempted to extend his outreach effort by passing out flyers in English and Spanish in a few of the colonias. He explained that he gets very little response even though he is passing out lots of flyers, which takes lots of effort. Clearly, this mode or act of communication does not work. Ms. Gonzalez, of Literacy Volunteers, argued that illiteracy is very high in English and Spanish. Gloria Padilla in subsequent interviews said that flyers do not work unless you go door-to-door explaining what they are. So the flyers that Mr. Avila hands out are ineffectual unless he explains them or goes door-to-door. This method of communication is more successful according to the residents and leaders of colonias. It is also unfortunately very time-consuming, and if done by an outsider the residents distrust, it may still not succeed in communicating. Problems with the Impersonal We who are used to the impersonal forms of communication that such things as form letters provide are not very responsive to them. So much is this the case that businesses spend millions of dollars each year to make communication more personal and personalized. For colonias residents, this is even more important. Personal contact is the difference between something feared and something accepted. This has been dramatically demonstrated in colonias, as it has been for years in developing areas of the Third World in the successful use of health promotores, people from the community trained in basic preventive health, who go door-to-door to communicate their health messages. While in our society, we may think that something written is more trustworthy than something spoken, here the reverse is more often true because of the social conditions associated with each form of communication. Impersonal communication is done by people with more power, and people in positions of power are there to abuse their position by taking advantage of other people. Papers are not to be trusted, any more than strangers who claim they want to help. Three different colonia residents told the same basic story about close relatives, such as a mother and son, where the illiterate one would not trust the other's reading of documents. That is how deep the distrust runs. Juan Idrogo, a resident of El Cenizo and former director of the A&cM

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Community Resource Center there, states that he likes to maintain contact with the community by what he describes as "walking the streets." By doing this he creates social relations that allows the community to interact with the center at a personal level. By going to people and telling them of the week's events he can get feedback from the community and also find out what else is needed. Flyers and letters, although high in utility and practicality, suffer from being impersonal, even if people are literate, he noted in an interview. This approach works much better, he added. The cultural norm for true communication in the colonias seems to be through personal relations, through word of mouth and conversation. Getting together with compadres and doing something together is a cultural form of social interaction and with it a form of communication. Mrs. Meiers, a leader in the Highway 359 colonias area northeast of Laredo, says that the best way to get residents to come to events is by telling them two to three days in advance at the most. If it is any earlier residents will not remember it as well. Gloria Padilla of El Cenizo says that the ideal is two to four days and a reminder. Clearly the success of the communication is because of its method (oral) and the social attributes of the sender (a known person). However, it is not just an issue of memory, it is that things don't keep to a stable and consistent rhythm of daily routine in colonias. A notice too long before an event gets lost in the shuffle. The situation arrives at something of an impasse. The economical way of delivering information, via print media, evokes distrust, even hostility. The most expensive way to deliver communication, face-to-face, one-toone personal communication by someone the colonia residents know and trust, is at the same time the most effective approach. But there are methods that have less investment than resident promotores and more impact than paper. Convivios and Pachangas: Bringing People Together The one way face-to-face communication can happen more efficiently is when the colonia residents come together in a group. The best way to attract them appears to be the sponsoring of a fiesta, sometimes called a convivio or pachanga, where families come and enjoy some food, perhaps some entertainment, while at the same time service organizations deliver their messages and demonstrate their services. Some think it suspect to try to lure people with food and fun. But given the suspicion, often based on experiences of people promising things they do not deliver, people doing surveys that never seem to help, and authorities trying to pry into colonia lives, there has to be more than future offers. There has to be some reciprocity up front, some reason to justify attendance even if none of the programs appear useful or appealing at first glance. As one man said after

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a social service fair in a colonia, "Well, who knows about what will happen beyond the talking, who knows what good will come of all this effort, but at least I had some delicious chicken and the music was sweet. Not for nothing I came out here after a hard day's work." The downside of such efforts involves what may be called communication "noise." The festive atmosphere may drown out the messages, and while a good time was had by all, few actually connected with what was being said by the outsiders. In other words, the medium can displace the message. That is a risk inherent in such efforts, unlike home visits. Community festivities have a long tradition in Mexico and the Hispanic communities of the United States. The fact that colonias suffer from excessive social and physical isolation, even from each other, makes these gatherings all the more vital and healthy for the people of these new settlements. Unlike bills, flyers, and announcements in the mail, fiestas are part of the culture of the residents, so that a modified one that includes service messages is far less of an alien or alienating experience. This has a second lesson: When attempting to communicate, use the existing cultural system as a starting point. This may seem obvious, but it is rarely undertaken. In fact, one of the most remarkable things about colonias is how little people understand about them and how little in-depth sociocultural study has been done on them. Many will believe there is no cultural system, what with people from all over Mexico, the border, and the U.S. farmlands residing there together. But however weak the social infrastructure of connection between residents, there is evidence of a true culture beyond the household. It is a hybridized Mexican culture, on the fringes of the borderlands, held together with cast-offs, hope, and hard work, but it has not vanished nor is it inaccessible. Telenovelas: Telling Familiar Tales One medium of communication in colonias that has become ubiquitous is the Mexican-style soap opera or telenovela (a "tele-novel"). These multiepisode stories set in fairly wealthy and fantastical settings attract a huge colonia audience, and—consistent with the notion of "using the existing cultural system"—I produced a pilot episode of a telenovela called "Neither Here Nor There" ("M agui, ni alia" in Spanish), set in a colonia and involving many serious issues that face colonia residents. Funding came from Housing and Urban Development (HUD). Anxiety about paying for the lot, the problems of public transportation, along with health tips, child care suggestions, information about recycling, and nutritional messages were among the subjects covered, all in the context of a love-interest tale. The disadvantage of this form of communication is the absence of personal dialogue or human contact. But the advantage over other methods comes from the attractiveness of the genre and the ease of distribution. Imitating

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the successful tropes and ploys of the popular telenovela, the "social videonovel" has the advantage of being set in a familiar setting and having the drama revolve around issues and people very close to the patterns of local life. The screenplay was presented to a focus group of residents for their own input, and some of the actors were members of the colonia. Initial trials have shown great success with this medium of presenting social, legal, and health information, and funds are being raised for a twelve-episode series following along the lines of the pilot. The episodes will be delivered by means of videocassettes as well as by broadcast, so that the irregular schedules of residents will not interfere with access. Remarkably, almost everyone in the colonias has access to a video tape player. This fact represents additional evidence of the problem of isolation. Copies will also be shown at community centers and other sites of contact with residents. The point of this novel means of delivering information is that it appropriates an existing medium for more socially responsible and responsive purposes. That is, while the tale of tortured and tumultuous romances grabs the attention of those already accustomed to such fare, at the same time valuable information is presented as "background" or as features that hold together plot lines. In addition, by being set in an attractive home with attractive people in a colonia, it sends a message of hope to the viewer without that hope being unrealistic and impossible fantasy, such as is usually the case in commercial "soaps." If Bruner's claim that most effective communication is done in the form of a coherent story is true, then this story-making promises to be an effective outreach tool. Very recent data collected in two El Paso hospitals also strongly suggests that the medium of video is the optimum way to communicate with low-income clients about health matters. CONCEPTUAL EVALUATION Metacommunicative Repertoires and Intercultural Knowledge Charles Briggs in his book Learning How To Ask (1986) points to a basic flaw in any quantitative surveys that attempt to bridge cultures or classes. When people interact within their own or any culture, much of the background context is understood without explanation. When addressed by someone taking a survey, we know how to frame this communicative event in a context that we agree upon. Outside our own culture, the assumptions about communication (metacommunication) break down, and what one side sends is not received in the same way by the other side. They fail to share metacommunicative repertoires, common understandings about what constitutes legitimate forms and contexts and implications of communication. The result of such "ships passing in the night" frequently

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is mutual loss of respect and trust. Each side thinks the other stupid or crafty or both. In fact, it is this researcher's position that only through ethnographic research while living in colonias and establishing a credible social role can in-depth cross-cultural communication become possible. The only other solution is intermediaries, those bicultural and multicontextual people who can translate across the gulf. It is this group that makes effective promotores, community center directors, and survey takers, as well as deliverers of social services and other forms of outreach. Only through knowledge of the local cultural "logic," including how people expect to appropriately communicate, can outreach efforts succeed. This can only be learned in the field. The Need to Know the Social and Power Landscape Understanding colonia culture is necessary, but in many cases not sufficient. In addition, one has to understand the social relations in colonias, especially what may be called the landscape of power. Many colonias are divided between different political interest groups; some may, for example, support the local developer while others oppose him or her. Some may be divided by religion, by region of origin, by time and degree of acculturation within the United States, or by occupational background (rural, urban, migrant worker, etc.). Failure to take these issues into account can lead to outreach problems. For example, take the case of unfortunate Mr. Avila. In his first attempts to work within a colonia he tried to do a community clean-up project and a tree planting project. With his first project he discovered that a clean-up was more complicated then he had imagined. In this particular colonia, which has become incorporated, the politics of trash pick-up had become a matter of political allegiance and power. The municipal body supposedly ran the trash pick-up with a dumptruck, originally purchased by the developer, but did so only irregularly. Because residents were unsure of when their trash would be picked up, they had given up on the service and did not pay the bill. One belief was that the city hall officials were pocketing all the revenue that they got from the trash collection and the other was that the money went to the already wealthy developer. Either way the result was seen as bad, so no one paid for the trash utility and the dump truck sat unused in a parking lot. Southern Sanitation, a private company that Mr. Avila initially approached and got to pick up trash as part of a volunteer project, soon became hesitant to go to El Cenizo because of the negative precedent set by the residents and city hall. In addition, El Cenizo has an outstanding bill with the city dump, so this makes it difficult if not impossible for Southern Sanitation to deliver services. Mr. Avila's second project, one that involved tree planting to beautify

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the colonias hardly got off the ground, hindered by the frustration of the first experience with local politics and the inability to communicate to the community the genuineness of his effort. They always thought he had an ulterior motive or represented "the other side." He admits to a social barrier by saying that he does not "understand their logic" because he did not grow up there. What this reveals is the clash among styles of communication between groups, as was mentioned above. What might seem very clear to him as the way of getting people involved, by planting trees, goes unnoticed or misunderstood within the community. Moreover, failure to understand the conflicts between residents and developer-backed municipal authorities led to another dimension of failure. One must know the political landscape and the players or risk making a mistake without knowing that it is one, as Mr. Avila did. Economic Understandings There is a third area, in addition to the sociopolitical and the cultural, that needs to be taken into consideration when addressing outreach communication. This relates to the economic realities of colonias and how that changes things, such as the relationship between labor and money. Colonia residents are chronically underemployed. Exact figures are hard to come by, but with the real unemployment rate of the county of El Paso being almost 20 percent, they must be at least twice that percentage. Most residents have low-paying wages when they are employed, and frequently these jobs are "on-demand," temporary jobs for some "just in time" or timelimited employment. Short periods of intensive employment punctuated by unpredictable times of no income create extreme economic anxiety. Like peasant societies, residents are risk-adverse, not wanting to gamble with so little. This anxiety connects to why it is that so many of the needs in the frequent needs assessments I have participated in can be traced back to employment issues. English language classes, child-care and day-care training, adequate transportation, primary health services, education for the young, all trace their attractiveness back to increasing income potentials. No efforts at outreach or other development initiatives will thrive without noting this reality. Any effort that interferes with employment that might be seen as a risk to it or takes time away from it will be fighting an uphill battle. By contrast, any effort that has a component that is perceived to enhance employment possibilities or lead to a source of income will enjoy special attention. Concretely, this means that it is difficult to expect a working colonia resident to consistently show up at a fixed time, say for a class, because often work hours are unstable. Programs that cost money, even a little, may be rejected. By the same token, any effort that is seen to potentially

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jeopardize employment (such as something that might lead to problems with authorities) will bear little fruit. On the other hand, projects that result in income generation, in which people are paid a stipend or in which some other economic benefit is forthcoming, will enjoy inordinate attention, especially if it is clear in the fairly near term what that benefit might be. Unlike the middle class, colonias are rich in labor, short on cash, and frequently unable to make long-term scheduling commitments. SUMMARY AND CONCLUSIONS The irony of our times is that we have developed so much attractive and complex communication technology, and yet the problems in communication between different sectors of society, and even within them, have never been more extreme. Not only do cultural and class differences set up barriers to communication, but so do religious, political, and intergenerational distinctions. Other kinds of differences based on diversities of experiences, views, opinions, and values also apply here. In such an era it should surprise no one that colonia communication is problematical, if we reflect the general and growing anomie in the middle class suburbs the colonias are supposed to imitate, both culturally and spatially. These colonias are for the most part new settlements, colonized by people from very different backgrounds and life experiences, despite the common general culture and language. Often, residents are people who have been cut off from more stable, traditional communities, and thrust into a world that is unfamiliar, hostile toward immigrants, migrants, and the poor and that works in ways that seem strange and mysterious. The divisions between immigrants and Mexican Americans and antagonisms between different regions of both countries represents another series of social borders difficult to bridge (Vila 1994). The skills in communication that might have been adequate in the past are sorely challenged in colonia life, even within the colonia, never mind with outsiders. For those outsiders making every effort to reach out to them, this difficulty can seem impossible to overcome. Even people with extensive education and professional abilities in Mexico can find themselves trapped in isolated and isolating colonias, without a way to establish social networks. I am reminded of a young mother with a masters degree from the National Mexican University who explained that she wished to do more for her family and her community, but she knew no one she could trust to leave her kids with. She felt terribly isolated from the outside world and was not able to find a way around it. The survey work revealed a great deal of prejudice on the part of the very people who are employed to serve the colonias, for some reason especially among the males, and regardless of ethnic background. Much of this prejudice centers around the outsider view that colonia residents are

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not doing what they "should" without appreciating the obstacles. Teachers want parents to have more involvement with their children in school, which becomes more and more difficult as they get older. The curriculum becomes unfamiliar, the older children begin to embrace a foreign culture that conflicts with their parents', and the time necessary to keep up with them is not there because of the constant need to locate and carry out more work, just to pay the land payments and buy food. Problems of inattention, substance abuse, social withdrawal, and other social pathologies are more symptoms of the problems in adjustment to a new society than causes. But in the typical posture of "blame the victim" there is a common temptation to blame community development failure on the colonia residents. This is a major lesson, a central contribution to the knowledge fund: If a program does not work, look first to cultural, social, economic, or political obstacles, and to the failure to understand the colonias from an insider's perspective (what we call in anthropology the emic view.) To blame colonia residents for not being more like the rest of us makes no sense and leads to unproductive responses guaranteed to fail. Those committed to communicating with colonias must take into consideration local cultural and social conditions, the landscape of power, and the economic circumstances that so seriously constrain the lives of America's poorest residents. In addition, and of equal importance, is the issue of reciprocity. Communication in outreach efforts will only come with the building of trust through personal contact, and through the offering of something of immediate value to compensate people for their time and attention. Finally, it must be done by way of media that makes sense and are familiar within the cultural practices of colonia residents. Otherwise, the assumption will be, on the basis of experience, "just more lies." REFERENCES Works Cited Briggs, Charles. 1986. Learning How To Ask. Cambridge: Cambridge University Press. Lamporte, R. 1992. "The Environmental Protection Agency's Integrated Environmental Plan for the Mexico-US Border: An Extante Assessment of Implementation Feasibility in El Paso Colonias." Unpublished manuscript, July. Towers, George. 1991. "Colonia Formation and Economic Restructuring in El Paso, Texas." Ph. D. diss., University of Arizona. Velez-Ibanez, C. 1993. "US Mexicans in the Borderlands: Being Poor without the Underclass." In Barrios: Latinos and the Underclass Debate, edited by Joan Moore and Raquel Pinterhughes, 195-220. New York: Russell Sage Foundation. Vila, P. 1994. "The Construction of Social Identities on the Border: Some Case Studies in Ciudad Juarez/El Paso." In Sociological Explorations: Focus on

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the Southwest, edited by Howard Daudistel and Cheryl Howard. Minneapolis MN: West Publishing Co.

Suggested Readings Acuna, Ida Hilda. 1990. "Quality of Life Perceptions Among Residents of Rural Unincorporated Subdivisions in Hidalgo County, Texas." Ph.D. diss., Texas-Pan American University. Brannon, Jeffrey et al. 1991. Socioeconomic Profile of a Colonia Population. Paper presented at the Meeting of the Association of Borderland Scholars, Reno, Nev. Brokensha, David, and Peter Hodge. 1969. Community Development: An Interpretation. San Francisco: Chandler. Browning, Harley L., and Rodolfo de la Garza. 1986. Mexico Immigrants and Mexican Americans. Austin: Center for Mexican American Studies Publications. Colonias Fact Book: A Survey of Living Conditions in Rural Areas of South and West Texas Border Counties. 1988. Austin, TX: Department of Human Services. Copeland, Claudia, and Mira Courpas. 1987. Border State Colonias: Background and Options for Federal Assistance. Washington, DC: Environment and Natural Resources Policy Division. Earle, Duncan, and Chang-Shan Huang. 1996. "Building Identity on the Border; Texas Colonias as Cultural Texts." In Traditional Dwellings and Settlements Series; Permeable Boundaries and The Construction of Space, edited by Nezar al Sayyad, 77-96. Berkeley: IASTE. Eyre, Gregg. 1990. "The Colonias of El Paso County, Texas: A Complex Interplay of the Lack of Ability and Desire to Regulate." School of Law, University of California at Los Angeles. Unpublished seminar paper. Gilbert, Alan, and Peter Ward. 1993. "Community Participation in Upgrading Irregular Settlements: The Community Response." World Development 12(9): 913-22. L. B. J. School of Public Affairs. 1977. "Colonias in the Lower Rio Grande Valley of South Texas: A Summary Report." Policy Research Project No. 18. 119. Austin: The University of Texas. Light, Ivan, and Parminder Bhachu. 1993. Immigration and Entrepreneurs hip— Culture, Capital and Ethnic Networks. New Brunswick, NJ: Transaction Publishers. Lower Rio Grande Valley Policy Research Project. 1977. Colonias in the Rio Grande Valley of South Texas—A Summary. Austin: University of Texas. Maril, Robert Lee. 1992. Living on the Edge of America—At Home on the TexasMexico Border. College Station: Texas A&M University. Ozuna and Associates. 1983. The Problems of Colonias and the Lower Rio Grande Valley of Texas: Cameron Park and Las Milpas. San Antonio, Tex. August. Patrick, Michael J. 1991. "Addressing the Colonia Problem in the Rio Grande Valley of South Texas." Paper read at the 5th Hispanic Symposium on Business and the Economy, South Padre Island, Tex., February 7-9.

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Rincon, Edward T., and Baltazar A. Acevedo. 1989. Hispanic Texas—A Sourcebook for Policy-Making. Claremont: The Tomas Rivera Center. Salinas, Exiglio, Principal Investigator. 1988. Colonias Factbook: A Survey of Living Conditions in Rural Areas of South and West Texas Border Counties. Austin: Texas Dept. of Human Services. U.S. Congress, House. 1988. Colonias Housing and Community Development Assistance. Hearing Before the Subcommittee on Housing Community Development of the Committee on Banking, Finance and Urban Affairs, Second Session of H.R. 4046, September 7. 100th Congress. Washington, DC: U.S. Government Printing Office. . 1990. Colonias: A Third World Within Our Borders. Hearings Before the Select Committee on Hunger. 101st Congress, 1st sess. Hearings Held in Eagle Pass, Texas, May 15. Washington, DC: Government Printing Office. U.S. General Accounting Office. 1990. Problems and Progress of Colonia Subdivisions Near Mexico Border. GAO/RCED-91-37. November. Washington, DC.

3 Life Histories of Four Chicano Heroin Injecting Drug Users in Laredo, Texas Avelardo Valdez and Alberto G. Mata Jr.

INTRODUCTION Presented here are the life histories of four Mexican American injecting heroin users, or tecatos, living in a U.S.-Mexico border city. Through their lives we begin to understand the social processes by which they become heroin users within the context of a low-income, Mexican American community in south Texas. The histories reveal the patterns and cycles of heroin users and the effect of addiction on the lives of their family and friends. These individuals share circumstances and choices that led to their heroin use and the subsequent decisions each has made. More significantly, this study introduces the tecato subculture from the perspective of the participants themselves. The Mexican American drug using population has consistently been characterized by a high prevalence of injecting heroin use (Casavantes 1976; Bullington 1977; Moore 1978; Desmond and Maddux 1984; National Institute of Justice 1996). Even with the popularity of crack-cocaine among other low-income minority groups, heroin still remains the drug of choice for most hard-core Mexican American drug users (Moore 1991). However, in contrast to the attention being accorded the growing prevalence of heroin use among middle-class whites, little attention has been focused on Chicano heroin users who tend to be lower-class Mexican Americans living in conditions of poverty with limited access to health benefits. These heroin users are commonly associated with subcultures such

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as Chicano gang members, ex-convicts, prostitutes, and other criminal and delinquent elements within the larger Mexican American population. Mexican Americans are distinct from other groups of heroin users in that they tend to use at an earlier age and have higher arrest rates. They also tend to have less formal education and are less likely to be in treatment (Moore 1978 and Chambers 1970). More recent studies have shown that they tend to be integrated into familial and multigenerational neighborhood networks more than other heroin users. Furthermore, Chicano heroin users are more likely to be employed at the time of admission into treatment, come from intact families, and be married (Valdez 1996; Codina et al. 1996). These new studies tend to present a portrait of Mexican American heroin users more complex than those that have presented them as highly marginalized compared to the more the conventional Mexican American population. In this study we will have the opportunity to get a glimpse into the lives of four heroin users whose experiences may provide greater understanding of injecting drug use and related social problems.

THE SETTING The U.S.-Mexico border separates the cities of Laredo, Texas, and Nuevo Laredo, Tamaulipas. These two cities have populations of 113,000 and 500,000, respectively. These twin cities are linked through an economic base centered on international transportation, manufacturing, and retail trade. Laredo has experienced a rapid economic growth with the gradual reduction of tariffs and other trade barriers between Mexico, the United States, and Canada with the passage of the North American Free Trade Agreement (NAFTA) in 1993. Despite these changes, Laredo and Nuevo Laredo are economically depressed cities with exceptionally high levels of unemployment and poverty. Laredo (Webb County) is one of the poorest cities in the United States. Limited economic opportunity results in a wide segment of the Nuevo Laredo and Laredo communities taking advantage of the illicit activities offered by the U.S.-Mexico border for their economic survival. Criminal activities center around smuggling undocumented immigrants, arms trafficking, stolen automobiles, and in particular, drug trafficking from Nuevo Laredo among the poor in Laredo. These activities and conditions make drugs widely accessible in both cities. As a result of the wide availability of heroin in particular, many young men and women become users and are forced to support their habits by engaging in illicit activities such as breaking and entering, shoplifting, conning relatives and friends, and other predatory activities.

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Qualitative Study Design: The Life History Interview This study employed life history interviews to obtain qualitative data. Qualitative methods provide an understanding of the complex relationships that are central to understanding injecting drug users (Sterk-Elifson 1995). Standardized closed-ended questionnaires and other quantitative techniques cannot adequately pick up these complexities. Qualitative methodology also has the advantage of documenting specific social contexts, which can dialectically modify the quality of these data. Selection and Interviewing The principal investigators conducted all the interviews. Community researchers, indigenous to the targeted neighborhoods, were trained and used to assist in the sample selection. Some were recovering heroin users. They identified sites having a high concentration of heroin users and gathered data from field observations, field interviews, key informants, and their own previous familiarity with these neighborhoods. Physical locations associated with the networks of heroin users were visited, including bars, clubs, convenience and cash checking stores, restaurants, shooting galleries, and streets frequented by prostitutes. Persons selected for these life histories were limited to a specifically defined population of low-income and known injecting drug users. Based upon interaction with heroin users located in these sites, extensive fieldnotes and spot field interviews were conducted. These data allowed the research staff to make a preliminary classification of the various types of active heroin users in each site. These preliminary classifications formed sampling strata from which a selection of the cases was made by the principal investigators. These four heroin injectors were selected based on their representativeness of the different strata and their willingness to participate in a life history interview. The instrument consisted of interviews centered on several general themes such as family history, current marital status, drug use, and illegal activities. A series of questions and probes were used to solicit more details on each of these themes. No one refused to consent to the interview. The interviews lasted approximately an hour and a half, and were conducted and tape-recorded in settings in the field such as homes and restaurants. Pseudonyms were used in this study to protect the subject's anonymity. General Characteristics The four life histories selected for this study represent four distinct types of injecting drug users. They include a young male hard core addict, a

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mature male veterano, a woman who represents the female in the tecato subculture, and a young homosexual injecting drug user. These persons represent a segment of the wide spectrum of heroin users in this subculture. Bernardo Castillo: Hard-Core Tecato Bernardo Castillo is a 33-year-old native of Laredo, Texas, who started shooting heroin at the age of 13. Bernardo was raised in a single-femaleheaded household in El Catorce barrio, one of the poorest areas in the city. This neighborhood is an older business/residential district located immediately northwest of downtown Laredo. Along the major streets are numerous Mexican restaurants, bars and night clubs, automobile and truck related businesses, grocery stores, convenience stores, barber shops, beauty salons, and other businesses catering to the Mexican American community. Behind these commercial streets is the community residential area composed of dilapidated clapboard houses on unpaved streets. Bernardo's family was very poor, even in comparison to other families in the barrio. Bernardo had eight brothers and sisters, all with different fathers. He explained, "Mi mama era una mujer de cantina. [She was a hooker.] I understand her now, but then it was hard. Kids used to tease me about my mother." As a result of his mother's situation, he and his siblings received minimal attention and little or no adult supervision. He related that each of them had to learn to take care of themselves. Bernardo was shining shoes and selling newspapers by the time he was 7 years old. At the age of 13, Bernardo had already dropped out of school and was on his own in the streets. With his mother absent, Bernardo explained that his older brother became the disciplinarian at home and that he, Bernardo, was the victim of his brother's violent beatings. From this role model, Bernardo believes that he learned a pattern of violent behavior that would follow him through adulthood. He recalled bitterly how, as a young boy, he learned to take a beating. He explained, "I learned from my brother's violence that chingasos [beatings] don't hurt much." At the age of twelve, Bernardo stabbed his older sister's boyfriend. After that, his family, including the older brother, feared him. They realized how loco (crazy) he was. The violence at home soon spread to other parts of his life. Since he had learned to take a beating from his siblings, there was not much that Bernardo feared from others. He recalled, "I was beaten at home, so I started bullying the kids at school. I took money from smaller kids. Even stole a teacher's purse once!" Bernardo's antisocial behavior led him to numerous problems with the authorities. He was arrested over thirty times while still a juvenile. This path of crime and violence would continue throughout his life. Following the patterns of other heroin users, Bernardo started drinking beer in his early teens in an exclusive social network of other young teen-

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agers. These boys were in the same social situation as Bernardo. Most came from low-income and female-headed households. All had dropped out of school and were involved in petty criminal activities. It was during this period that this group introduced him to marijuana. Bernardo, however, quickly made the transition to harder drugs. At the age of thirteen he was using heroin intravenously. Bernardo recalled his early introduction to heroin by an older female injecting drug user (IDU) in Laredo. I was given heroin by this 30-year-old woman who was a junkie. I met her at a pool hall where I used to hang out. I had already stopped going to school. I was a "loco" even at that age. At the time, I was selling "paquetes de marijuana" [packs of marijuana]. I sold enough to use myself. This older woman asked to buy some marijuana. "<;Vendes mota tu?" [Do you sell marijuana?] She asked me. After that, she started liking me a lot. Bernardo explained how this woman and her male companion, a junkie named El Tango, used to hang out at Jarvis Plaza dealing heroin. He began to run small errands for these two people. Eventually they turned him on to heroin. "I am going to give you something you're really going to like," he remembers her saying. They went into a gas station, and Bernardo shot up for the first time. He recalled, "I didn't like it at first. It made me sick. But, they said I would get use to it. It was a different kick from marijuana." Bernardo explained that he eventually became addicted. He supplied his habit by delivering drugs and money as well as doing other chores for this woman and her male friend. According to other sources, these two people (El Tango and his female partner) were two of the first junkies in Laredo. Both of them have subsequently died. One of the chores young Bernardo was assigned to by his benefactors was to smuggle small quantities of heroin across the international bridge from Nuevo Laredo to Laredo. His youthful, innocent appearance cast him as an unlikely suspect to the Border Patrol. Becoming involved in heroin changed his reference group. He stated, "My cliqua [clique] changed from one based on marijuana and beer, to a heroin cliqua. I did this for a couple of years, until I was busted at the county jail." Bernardo explained that he was busted for smuggling heroin to a prisoner in the Webb County jail in Laredo. Because he was only sixteen, Bernardo was sent to the Job Corps, a federal youth work program. Upon his return to Laredo, Bernardo married a high school girl he had gotten pregnant. During the first years of his marriage, while still living in Laredo, things went well for Bernardo. After his marriage, he started to move mota (marijuana). He began by selling small quantities, but later a neighbor who was a University of Texas student introduced him to a major Austin drug connection. Bernardo boastfully stated, "I was selling 500

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pounds of grass to this UT student. I was making a lot of cash. There was not time for heroin at first." These connections led to others. He reached a point where he was moving substantial amounts of marijuana from Laredo to Austin, Dallas, and Houston. He purchased a house, furniture, appliances, cars, and other luxury items for himself and his family. But, as he became successful, Bernardo started to use heroin again. "I got hooked. I wasn't paying as a much attention to the business as I was before. I started burning people. Like the guy would want 200 pounds, I would send him 185 pounds. Pocket the rest for myself." As a result of these practices, business started to decline. Bernardo's buyers began to search out other suppliers. In turn, Bernardo's addiction to heroin became much greater. He said, "I started selling all my shit to get a fix: my stereos, TVs, cars. Began arguing with my wife. I used to beat her. I was a real ignorant mother-fucker." Eventually, Bernardo was arrested once again and sent to the federal penitentiary. From the time he was 16, he had spent much of his life in juvenile hall and county jails. At age of 24, Bernardo was sent to the federal penitentiary for transporting an illegal substance with the intent to distribute. As he explained it: "I was asked by two brothers if I wanted to make a couple of hundred bucks. All I needed was to let them use my car, to bring some grass from Nuevo Laredo. I drove over with them. They took the car and I walked back across." Bernardo explained that the car was returned to him a day later, along with some cash. A week later, he was with his family at a fast food restaurant, and he was arrested. He said, "I came out of the place and it was surrounded by law." Not as familiar with the law as he is now, Bernardo plea bargained with the DEA and was sentenced to fifty years in the penitentiary. He only served three years before being released. After his release from prison, Bernardo moved to Houston with his wife and two children. There, he again became addicted to heroin. For the next three years he dedicated himself to a life of burglaries, assaults, and armed robberies. During this period, he needed a fix (injection of heroin) around three times a day. "I even got my wife hooked on heroin," he said. He explained that his wife "was shooting up as much as I was. But she had a job as a nurse. My wife was straight. You would have never known that she was shooting up. She was cool about it. Never shoot up in front of others. Always in the bedroom alone, with her own needles." Bernardo went on to explain the different types of crimes he committed during this period in Houston. We used to rob mojados [undocumented immigrants] a lot. They were easy. My partner and I would find out where a bunch of them were living. You know, they always have their money stashed under the mattress or somewhere in the apartment. We would go in with guns and rob them. They were easy. Sometimes my buddy

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would dress his wife up like a hooker. Send her into a mo j ado bar. She would bring one out and we would rob him. Bernardo maintained this lifestyle for three more years. He claims Houston was the best place to make money. "It was so big, you just get yourself lost." In 1980 Bernardo and his crime partner were burglarizing a house in a wealthy Houston subdivision and accidentally set off a burglar alarm. Before they could escape, they were surrounded by police and arrested. He stated: "We had been doing robberies and assaults for three years. It was easy. Sometimes we'd rob three or four different convenience stores in one day. When the judge sentenced us, he said, 'I am putting you away not just for this burglary but for all those you have done over the years.' " Bernardo spent the next seven years, from 1980 to 1987, in the state prison. During this time, his wife divorced him. They had been married over sixteen years. The last time he saw his wife, it was in prison. They were allowed a conjugal visit. He said, "It was like she was a prostitute. We had sex, but it was ugly. I never saw her again." Shortly thereafter his wife turned over custody of their three children, ages 9, 16, and 17 years, to her mother. Bernardo explained: "I ruined my marriage and family. I married my wife when I was 16 years old. I got her pregnant. She was straight. She even finished high school. Her father hated me. I don't know what she's doing now. She never visits the kids. Maybe she's still shooting heroin." He has spent approximately thirteen years in federal and state prisons for drug related offenses. Bernardo was last released from prison in 1987. Upon his return to Laredo, he secured a job as a welder. However, he started using heroin shortly thereafter. Bernardo stated, "My habit got so bad that I started using 2 to 3 papers a day. One of my co-workers and I used to rob stores during our lunch hour just to get money for heroin." Bernardo discussed how he and his friend used to go to department stores dressed in their work clothes. The store employees thought that he and his friend were also store employees as the two carried out boxes of merchandise, which they fenced throughout the city. This went on until he was arrested for possession of heroin. When his employer found out, Bernardo was fired. As he explained it: "Four of us had just made a connection. We were in a friend's car. We were going to shoot up when a cop pulled over the car. As he walked toward us, I took the drugs and jumped out of the car and ran. They chased me down and found the drugs and kit. I took the rap for everyone." When asked why he took the rap for everyone, Bernardo commented on how older heroin users stick together. Why should everyone take the fall? That's the way veterano tecatos [junkies] are. They stick together. Los veteranos no son relajes. [Experienced heroin users or ex-

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convicts are not stoolies.] These same friends made my bond. I was out on the streets right away. Later the case was dismissed. I guess there are too many people to lock up. Bernardo went on to boast how a veteran narcotics officer offered him a deal if he told him where he got the heroin. Bernardo refused and quotes the officer as saying, "I knew you wouldn't but I thought I'd ask." He added, "Today, many heroin addicts will snitch the first chance they get. They are afraid to do any time." That has not been Bernardo's problem. In this particular instance, he was able to avoid conviction on some legal technicality. Bernardo's heroin use continued until last year's Christmas season when he got so sick that he was in bed shivering and crying, unable to participate in the family celebration. After this experience, he went into a detoxification unit and was free of drugs for about ten months prior to this interview. However, Bernardo is now on heroin again. Chispa Medrano: Veterano Tecato Chispa Medrano is 44 years old and has spent nearly twenty years of his life in state and federal prisons. Chispa is a small, wiry man who appears in excellent physical shape for a man of his age. He spoke entirely in Spanish, although he is fluent in English. He was courteous, yet guarded. Chispa represents the more mature and socially stable injecting drug user. This type of heroin user typically has extensive contacts within the tecato and criminal subculture. Many of Chispa's fellow heroin users are either in prison, murdered, or dead from either overdoses or general abuse of their health. Those of his generation who are actively shooting heroin are doing it in a very controlled manner. Chispa Medrano was raised in the Canta Ranas barrio in Laredo. Unlike many other families from that barrio, the Medrano family was intact. The family consisted of both parents, eight brothers and two sisters. Chispa was the youngest male in the family. Like many poor families from the border region, the Medrano family spent three to four months out of the year as migrant agricultural workers in midwestern states. Since their father was unable to find work in Laredo, the family, like many others in this barrio, had to survive on their summer earnings. Often the family would not return from the Midwest until late in the fall. This meant that the Medrano children would not enroll until the fall semester was half over. Facing this extreme academic disadvantage, all of the Medrano children dropped out before graduating from high school. Chispa dropped out by the age of 14. Once he left school Chispa began hanging out with age-grade cliques who had left school for similar reasons. His major reference group during this period was his older brothers and their friends, all of whom were involved in an assortment of illegal activities centered around a car repair

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shop. This shop functioned as a "chop shop" where stolen vehicles were stripped for their parts and resold. It became a social hangout for drug dealers and other assorted criminals in this neighborhood. Chispa became socialized to the world of alcohol, crime, and drugs within this subculture. He explained that within this circle everyone was always drinking and smoking marijuana. He and his young friends were supplied beer and marijuana by the older members of this group. He states, "My parents were too old to really look after me, they thought my brothers were doing it anyway." As long as the young Chispa was able to control his drinking and marijuana smoking, he never had any problems with his older brothers. The trouble between him and his family began when he started using heroin. At the age of 15, a friend of one of his brothers introduced Chispa to heroin. As soon as his family found out he was on heroin they tried to get him off of it. He claimed that he liked heroin too much to stay away from it, even if it meant being disowned by his family. His addiction and the related criminal activities from this early age kept him in juvenile detention centers, county jails, and finally in a state prison for six years from 1966 to 1972 for selling marijuana to an undercover cop. Most of these early years are a faint memory for Chispa. During the majority of the time he spent out of jail, he was seriously addicted to heroin. Chispa was married at 18 and has three children who are now 26, 23, and 22 years old. His wife was from the same barrio as Chispa. His children are all married and have families of their own. None of his children has a drug problem. His wife, who divorced him in 1969, is currently living with him. He claims his wife never gave him a chance to reform or helped him to go straight. She has been diagnosed with Alzheimer's disease and, according to Chispa, has no one to take care of her. He stated, "I thought I had an obligation to my children to take care of her. I don't touch her, she just lives at the house with my mother and I." Chispa was arrested in 1974 for possession of heroin with the intent to sell. According to Chispa, he was involved in a deal with some Chicanos from Fort Worth who were buying heroin in Laredo. A friend who turned out to be an informer had referred him to these Chicanos. When the deal was made, Chispa was arrested. He was sentenced to fifteen years in federal prison, but was released in 1980. Friendships he developed in prison became important vehicles to a criminal world outside of Laredo. After being released from federal prison Chispa decided to move to Houston, and teamed up with a network of former pintos (convicts) whom he had met in prison. Through these hard-core criminals and drug users, he gained entrance into exclusive Chicano heroin networks. In a matter of weeks he was shooting heroin and dealing to supply his habit. But in a matter of months he had to leave. As he explains: "I left Houston because I burned this guy for seventy papeles of heroin. The guy wasn't being

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straight with me. I was selling for him just to supply my own habit. So when I got the chance I burned him. That's when I returned to Laredo. Right after that is when I got busted with the mojados." Chispa had just returned from Houston where he had lived for a few months when he was arrested again for smuggling undocumented Mexican immigrants into the United States. He stated: I was released from the federal penitentiary after spending nearly seven years for smuggling mojados. When I was released in early 1987, I was in a halfway house. I was doing well. I had a job with a roofer. It was hard work, especially in the summer. One Friday I went to La Paloma and met a woman. I took her to a hotel and spent the night with her. Because I didn't return that night to the halfway house, they sent me back to the joint for fifteen months. Since his return from the parole violation charge, Chispa has been living with his mother. He explains that his family did not want anything to do with him while he was on drugs. Chispa has been using heroin since the age of 15. He has been sent to state and federal prisons for a variety of charges, all relating in some way to his drug addiction. Only after being released this last time was his family convinced that he was serious about going straight. "My family's been helping me out now. One of my brothers owns a cantina where I tend bar and clean up for him. I am staying away from my old friends. I could easily get some jale [heroin] fronted to me and begin selling it. I don't want to." Chispa is considered a veterano tecato pinto (veteran junkie ex-con). This constitutes a status high in prestige within the Laredo drug subculture. These types of heroin users are not involved in petty crimes such as shoplifting at department and retail stores in Laredo malls. His reputation as someone who is reliable and trustworthy and an individual who will not "snitch" or "burn" anyone is enough to provide an entrance into Laredo's organized criminal underground. Within this network, there are numerous opportunities to make money. He states: "But I don't want to get into that tecato vida. I want to get a job and a woman. I don't want to go back to prison. Drugs have ruined my life. I've lost my family. I have nothing now and I am 44 years old." Based upon interviews and observations, Chispa appears to be an intelligent and well-read individual. During the interviews, he often brought up current events and made references to books he has read. Chispa is also a talented artist who works with oils. One of his paintings is a portrait of Elizabeth Steinberg, the 10-year-old girl who was abused and killed by her parents in New York. His reason for that particular subject: "I painted her because I wanted people to remember her. Here was a small child who existed in a living hell and nobody did anything about it. I hope this picture keeps her memory alive. I know how easy it is for people to forget."

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Chispa has a reputation as one of the more talented artists in the federal prison system. A few years ago, one of his paintings was used as the cover for a regional arts magazine. Chispa also did the artwork at La Paloma Bar in downtown Laredo. As he drove away in his brother's new jeep, he extended an invitation to visit where he works to see his other paintings. Suzie Galindo: Heroin Injecting Drug User Suzie Galindo is a 39-year-old single parent who lives in Laredo's public housing with her five children in a two-bedroom apartment. This project is located on the northern fringe of the city, west of the interstate. This area is identified as "La Base" because a U.S. Air Force base had previously been located here. After the base closed in the 1970s, the federal government made the land available to the city and private developers. This area is a mixture of new subdivisions and apartments, public housing projects, trailer parks, new commercial and retail businesses, shipping warehouses, new office buildings and governmental agencies. All of the streets in this area are paved and many have sidewalks, a rare sight in Laredo's Mexican American poor communities. The housing project is comprised of single level buildings with two bedroom units typical of this region of south Texas. Many of the families were relocated from some of the more traditional barrios (Sacate Creek and Azteca areas) as a result of urban renewal projects during the 1960s and 1970s. Once these families moved into the La Base area they attempted to recreate their barrio lifestyles. On a superficial level they seemed to be successful, but these public housing project communities lacked the social structure of the older Laredo barrios. As a result, these communities lacked the normative controls of other barrios, which resulted in higher rates of burglaries and violence. The residents of the housing projects are often in direct conflict with their nonproject neighbors. During one interview, Suzie was preparing to give her daughter and the daughter's boyfriend a ride to a heroin connection. Suzie's daughter, a dark, frail, and thin girl who appears much younger than her 20 years of age, has a heroin habit of three papeles a day. Once the young couple got their cura (fix), they spent the rest of the day hustling in order to get money for her next fix. With a motherly sadness, Suzie confided, "My Prieta is hooked. I feel so sorry for her. I told her I would help her kick it like I did. Just lock yourself up in the house! Le digo. [I tell her.]" According to Suzie, her daughter and the boyfriend shoplift as a way to support their drug habit. They have been arrested several times already. The case of a mother and daughter both using heroin is not so unusual in the subculture. There were several other cases. In one, the mother lived a relatively straight life until her divorce at the age of 40. After her divorce she became a "runner" for her brother, who was dealing heroin in Detroit. She delivered a kilo of heroin every time she drove to Detroit from Laredo.

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She subsequently became addicted and, after her brother was incarcerated, began to hustle as much as any tecato. She ended up in prison for multiple counts of theft and dealing. Her daughter began doing heroin after being introduced to it at the age of 15 by an older sister's boyfriend in Detroit. Initially, the daughter began taking heroin from her mother's stash for herself and friends. Later, she and her mother both became runners for her uncle. Suzie suspects that her daughter is exchanging sexual services for money from out-of-town truckers along the interstate. Hundreds of truck drivers who are part of the high volume of trade between the U.S. and Mexico provide a client base in Laredo for many female heroin users who engage in prostitution. Many of these drivers have layovers in Laredo while they wait for their return cargos. The majority rent rooms in the cheap motels situated on the interstate's access road on the outside of the city where they can park their trailer rigs. Prostitutes, many of them IDUs, are frequently seen in this vicinity. Until recently, Suzie also had a serious heroin habit. She was injecting heroin four or five times a day. Suzie's boyfriend was a pusher and supplied her with all the heroin she wanted. "I got so bad that I couldn't do anything without shooting up first. I didn't care about anything else, my children didn't even matter. I just wanted more heroin." Women are often introduced to heroin use through their husbands or boyfriends. Once addicted, female injecting drug users generally face the singular option of association with a man who is a dealer, or is successfully engaged in some sort of crime, and supplies them with drugs. Recent studies do suggest, however, that female IDUs move toward more independence from men (Sterk-Elifson 1996). During the time of the interview Suzie was off drugs. In December 1988 she had decided to leave her boyfriend and the drugs. She stated, "I realized my kids needed the love of their mother. Someone to be there for them. All I was doing with my boyfriend was doing drugs and fucking him. That's not love." She kicked the habit by locking herself in her house. "I am clean," she said nervously as she pulled up her sleeves to show that she had no fresh track marks. She was very nervous and hyperactive during the interviews. She showed pictures of herself before she began to heavily use drugs and alcohol. She appears in these pictures as an attractive healthy woman. This is in sharp contrast to her appearance today. Most striking are the tattoos all over her body, including her hands. Pointing to some of the tattoos, Suzie explained, "I did all this when I was a kid. I tried to get this one off by a doctor. It is the name of some chavo [guy] I used to know." The tattoo looks a little faded and blurred, but a name is still recognizable. Suzie was raised in the Sacate Creek barrio in Laredo. She started doing drugs at the age of fifteen and developed a heroin habit shortly afterward.

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By that time, she had left her parent's home. She stated: "I was on my own at 15 years. My mother couldn't control me. They even put me in a convent for a year [it was probably a Catholic orphanage] when I was 8 years old. They treated me worse there than at home. I hated the nuns." Suzie explains that she attended school only sporadically before this time. Additionally, Suzie also indicated that she had a substance abuse problem prior to her heroin addiction: "I had been drinking and smoking pot for years before I shot up for the first time. I didn't like it at first. Este pinche jale no me movio mucho. [That shit didn't move me that much.] It gave me a hyper feeling. I didn't like it." Suzie was introduced to heroin by someone she had been dating. In a matter of weeks she was strung out on heroin. For the next two to three years Suzie frequented bars, hotels, and downtown apartment houses with other tecatos. "I would usually try to get a guy who was dealing heroin and be his woman. I went through a lot of men that way. I didn't care about them, I just wanted to get my cura." Suzie also supported her habit by shoplifting and burglarizing homes and businesses, and was been arrested numerous times for shoplifting, soliciting, and other minor offenses. However, none of the offenses were ever serious enough for her to do any prison time. She states. "I was lucky that I didn't go to prison or overdose. Andaba bien loca. [I was wild.]" Many of the people with whom Suzie associated during this period did meet tragic endings. All these friends, she claims, got old before their time. Many ended up in state and/or federal prisons. Others died of overdoses, other drug-related illnesses, and violence. Many male and female users who began shooting heroin as teenagers never reach middle-age unless they spend most of their lives incarcerated. Suzie relates that at the time she got pregnant with her oldest daughter, La Prieta, she had decided that she was going to try and change her life. She stopped doing drugs on her own, with no professional or clinical assistance. "I couldn't go on like I was living," she said. Not long after that, she met a man and lived with him for the next ten years. During these ten years, she never did any drugs. The man knew little about her past. During this period, her sons Beto and Jose were born. She explained, "I became a good wife. I worked for six years at Laredo Junior College as a cleaning lady. I never went to the bars, saw other men, or did drugs of any kind." It was the lifestyle that was supposed to make her happy, but it did not. According to Suzie, her husband started taking her for granted. He was spending more time at the cantinas than he was at home. She resented it: I worked all week, plus took care of my kids and the house. While I was slaving away, he was out spending our money. He used to borrow money from me during the week. When he got paid he was supposed to pay me back. I always had to beg him for my money. One day he said, "I'll pay you if you let me fuck you." I bent

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over and he did it, and paid me. I realized that's all he wanted from me, so I left him. She philosophically compared her various roles of mother, wife, heroin addict, and mujer de cantina (woman of the streets). She went on to explain: You know, las mujeres de las cantinas estan mas feliz que las casadas [women at the bars are happier than married women]. If you are at a bar, men want to be with you. Te hacen carinos. [They show affection.] They buy you beer, they take you out to eat. Some they want sex, but it's fun. When its over everyone goes his own way. Not the married woman. She gets treated like a dog. The only time the man speaks to her is to yell at her. I left my husband because that's the way he treated me. Suzie explained that after several violent confrontations, she and her common-law husband were separated. Suzie started going out to the bars and meeting different men once she was separated from him. Her t w o youngest children, Rachel and Irene, were born by this time. She became una mujer de cantina. It was not made clear during the interviews whether Suzie was a prostitute during this period of her life. However, she did indicate that she began to use marijuana, heroin, and cocaine at this time. She said, "I'd go with the men w h o had the most money and drugs to offer me. Sometimes I'd stay with a m a n for a few months just to get the d r u g s . " This is the pattern that is very c o m m o n among female injecting drug users. Suzie finally met an older m a n and became seriously involved with him for a couple of years. " T h e last boyfriend I stayed with was a big cocaine dealer. I could get all the coke and heroin I wanted from him. I started using it all the time. I didn't care about anything except shooting up and getting high." Suzie explained h o w she completely neglected her family. T h a t she never spent any time with her children. Her oldest daughter (La Prieta) took care of the other children. A few months ago, Suzie realized the trap she had fallen into. I was over at my boyfriend's house. We had just finished having sex. He was falling asleep. I started thinking about my children being home alone. I decided they needed me more than this man. I left him and stopped doing anymore coke. Los hijos necesitan el cariho de su mama. [Children need the love of their mother.] I wasn't giving them that because I was fooling around with this man who just wanted to fuck me. Upon returning to her family, Suzie realized that her children were having serious problems of their own. Her oldest daughter (La Prieta) was married and had a child. However, a m a n introduced her to heroin, and she sub-

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sequently became addicted. She abandoned her husband and child. Suzie had this to say about her son-in-law: "He is a buen muchacho [good boy]. He's still waiting for her with the baby. She's going to return once she breaks her habit. I feel so bad seeing her strung out. I sometimes give them [her daughter and son-in-law] money so they won't have to steal. But it's not enough." Suzie's first son is in a county jail waiting to go to trial on a burglary charge. The 16-year-old son is in a correctional institution. Suzie sadly relates: I turned my son in because he was sniffing glue. I used glue, and I know what it does to your brain. For his own good, I had him locked up. I've neglected my children, but I want to be a good mother. My two younger children, I wait for them to get home from school. We talk about our days. It's not like before when all I cared about was shooting drugs. At this point during one of the last interviews, Suzie was overtaken by her emotions, and she started to cry. "I didn't want the kind of life I had for my children." Pointing to a nurses aide textbook she is using in a class at Laredo Junior College, Suzie continued, "I am trying to better myself." Silvestre Flores: Male Prostitute Silvestre Flores is a 27-year-old male prostitute who for the past seven years has been selling sex to other men in order to support his drug and alcohol addiction. Silvestre is a tall, thin man. He has a fair complexion and light, sandy brown hair. His hair is cut stylishly and he makes an obvious effort, however strained, to appear fashionable. However, there is an overall pale look to Silvestre. It could be the dullness of his skin color or his yellowish teeth that projects this image. Silvestre speaks no English and lives with his invalid sister and her unemployed husband in the Azteca area. The Azteca barrio is composed of neighborhoods in the immediate downtown area and the business district east of the new international bridge and west of the sewer plant adjacent to the Rio Grande. The labyrinth of narrow unpaved streets in this barrio often lead to dead ends and cul-de-sacs. Many of the residents who live here are Mexican nationals with relatives living in the neighborhood (La Colonia Victoria) located immediately on the opposite side of the river in Nuevo Laredo. The proximity of the river and its immediacy to the downtown area provides ideal opportunities for small-time smugglers and injecting drug users. Silvestre was born in Laredo, Texas, but when he was 12 years old his mother took him to Toluca, Mexico, following her separation from his father. His father moved back to his hometown of Sabinas, Tamaulipas, which is a forty-five minute drive south of Nuevo Laredo. In Toluca, Sil-

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vestre lived with his grandparents in a slum outside of the city. Even at that early age Silvestre was hanging-out with small gangs of youth who were sniffing paint and committing burglaries and other petty crimes. On some occasions, Silvestre would not return home for days. He was considered uncontrollable by his family and was sent to live with his father in Sabinas. His father was busy starting another family with his new wife and did not want to deal with his unruly 15-year-old son. Since he was a legal U.S. resident, Silvestre decided to move in with his older sister in Laredo's La Azteca barrio. Overwhelmed by her own family responsibilities, his sister was unable to offer any parental guidance. She could offer her troubled brother only room and board. Upon returning to Laredo, Silvestre enrolled in the public schools where he encountered serious adjustment difficulties. Academically he was severely limited by his inability to speak English. Culturally he was much more mexicano than he was Mexican American. He was already displaying noticeable feminine characteristics; as a consequence, other students were beginning to harass him. He started to associate with other socially marginal kids in the school who did not fit with the other cliques. His group was overshadowed by other problem students in the school and never received much attention from school authorities. Nevertheless, Silvestre's group was involved in illicit activities, which were similar to the other problem student groups. These activities included truancy, shoplifting, burglaries, and using drugs. Silvestre never progressed past the eighth grade in school. He remained there until he finally dropped out at the age of 18. In the three years he spent in the Laredo public school, Silvestre did not learn to speak English. It was within his network of school friends that Silvestre was introduced to alcohol and drugs. Many of his friends went to Nuevo Laredo to buy drugs that they subsequently sold in school. Other students acquired the drugs from their older siblings. He recalls, "There was all kinds of drugs around the school. You could get anything you wanted, even in the seventh and eighth grade." During this period he primarily used marijuana, but experimented with a variety of prescription pills. He remembers using a variety of benzodiazepines, including "black mollies," Valium, and others. Silvestre also started to drink alcohol excessively at this early age. Once out of school, Silvestre began hanging around the young men that control most of the contraband that flows through the Azteca barrio. It was only natural that Silvestre would fall into the activities of this group since they were right in his barrio. Most of these men were injecting heroin users who supported their habit from illicit activities offered by the proximity of the international border, such as dealing drugs and smuggling Mexicans and other contraband across the border. Many of these young men had ties to larger drug networks in Nuevo Laredo and Laredo. These larger drug dealers used the young men from Azteca barrio for various

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tasks including smuggling heroin across the immigration checkpoints in both Mexico and the United States. On the Mexican side there is a check point about fifteen minutes south of Nuevo Laredo that is considered particularly difficult to cross by drug smugglers. The other difficult crossing is about ten miles north of Laredo, Texas. Silvestre's group often smuggled the drugs through Nuevo Laredo, crossed the river, and got them past the Laredo check point. Silvestre graduated from marijuana, pills, and alcohol to the use of heroin and cocaine shortly after being involved with this crowd. Since nearly everyone in this clique was shooting up heroin, he began using it. He said, "It was no big thing when I shot up at the time. It seemed like the right thing to do." Before long, he had acquired a habit of two to three papeles a day, which was approximately a $90 daily habit. He supported his habit by committing burglaries and robberies. However, he was much more timid than his other friends, who were more bold and daring in their activities. He said, "I was never too good at doing burglaries and other similar things. I was too afraid." Because of his fears, Silvestre found it easier to steal from people whom he knew, a behavior that is common among many users. Therefore, many of the robberies he committed were in his own neighborhood. Very often, his victims were friends and relatives, including his sister's husband. He explained that he was so desperate that he stole his neighbor's television. Instead of notifying the police his neighbor beat him in front of his sister, and thereafter Silvestre was taunted by other barrio residents referring to him as tecato faggot. At the age of 19, Silvestre overdosed and almost died. He was staying with a friend and misjudged the potency of the heroin he was injecting. His friend discovered him barely conscious and attempted to revive him by walking him around the house and having him drink milk. When that did not work he called an emergency medical service. This experience served to temporarily deter his heroin usage. He states, "I got so scared that I never wanted to do heroin again." However, he continued to be a heavy user of marijuana and alcohol, and still occasionally shoots heroin and/or coke. He explained that after his overdose in 1980 and several arrests, he turned to prostitution as a way of making a living and supplying his drug habit. A friend of his suggested that it would be an easy way to make money. He said, "I wasn't working and didn't have any money. I wasn't hooked on drugs. It was alcohol and marijuana. Also, I became afraid of committing more robberies and going to jail." His fear of jail was especially acute given his sexual orientation and the abuse and maltreatment of other young homosexual inmates. The few times that he had been incarcerated had been horrible experiences, which always included being raped by fellow inmates. While Silvestre has engaged in sex with other men, he does not consider

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himself a homosexual. He explains that he likes women more than men, but that most of his girlfriends did not want to have oral sex with him. He viewed his relations with other men as a means to get the kind of sex that he wanted and make money as well. Defensively, Silvestre explains he is not a homosexual: i6Yo les pico, o ellos me maman. [I penetrate them or they suck me.] I never let them have me. I like women, it's just that they don't like to have oral sex with me. And that's what I like." Silvestre's views correspond to those of many Mexican American men who tend to identify homosexuals as only those men who take the more submissive role in the sexual act. In prison, the men who are sodomized are identified as the homosexuals and the perpetrators are not. This same attitude is often carried over to life outside of prison by these former inmates. Silvestre has been an active male prostitute since the early 1980s in the Laredo area. Most of his activities center around Jarvis Plaza in the central business district of Laredo. This area has a high volume of pedestrian traffic from all parts of the city. Public businesses service all areas of Laredo from this location. During the day the square is bustling with shoppers, school children, office workers, peddlers, soap box preachers, undocumented Mexicans, shoppers from Nuevo Laredo, elderly pensioners, and others. Mixed in with this crowd are IVD users, small-time pushers, prostitutes, alcoholics, homeless people, and homosexuals. The homosexuals frequent the surrounding bars and cheap restaurants that cater to them. The area is an easy place to buy drugs and sexual favors. Silvestre stated: "Most of the time, I'll just go to Jarvis Plaza and walk around until someone stops and begins talking to me. I'll get in the car with them if they seem all right. He might take me to a restaurant or bar. Afterwards we go to his apartment and have some more drinks. Then we have sex." Silvestre made several observations about the clients he served: "The men that were paying me for these favors were generally young single Chicanos. Very few of them were Anglos or Mexicans. Most were well dressed and appeared to be professionals. They had new cars and money. I sometimes stayed overnight at their places, but most of the time I left right away." Silvestre also indicated that most of the men he catered to were Laredo residents. He thought few were married. He also pointed out that occasionally he would see these men around town, but that they often ignored him. Silvestre's contact with the Laredo gay community was also made at the gay bars, where he would frequently sell marijuana. There is one bar that he still occasionally visits. It is located across from the Laredo Junior College, before one crosses the railroad tracks. According to Silvestre, a lot of the Laredo gay community, as well as some drug pushers, hang out there. Silvestre also observed that gays like pills and marijuana and, unlike him, do not seem to use heroin. During this period he was arrested and convicted for cashing a stolen

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check. The check was an income tax return for a friend of his brother-inlaw who had used his address. Silvestre was residing with his sister and her husband at that point, as he is now. Silvestre explained that he forged some identification with the owner's name and cashed the check. However, he mistakenly left the receipt in a kitchen drawer, which was later discovered by his brother-in-law. His family turned him in to the police. Silvestre was placed on federal probation after spending several months in jail for the check cashing offense. While in the county jail he witnessed stabbings, rapes, beatings, robberies, and drug use. Silvestre said that over the months he was there, several Mexican nationals including himself were raped. Fortunately, he had some protection from some of his pals from La Azteca. The worst incident occurred when twelve men raped an 18-yearold boy in a holding cell. During the last seven years, Silvestre has continued to shoot heroin and/ or coke. However, he has not become as drug dependent as when he was younger and overdosed. At the present time, Silvestre's primary substance use is marijuana. He is also a heavy beer drinker. Silvestre stated why he was not using injecting drugs as frequently as before: "I can get just as high on beer and marijuana. A six pack and some joints only will cost me $10.00. If I started buying heroin, it's at least $30 for one fix. I can't afford it. Besides I am too afraid to rob anymore. I don't want to go to prison." Silvestre also confessed to sharing needles when he did shoot up. According to him, no one really cared about dirty needles. Though many of his friends in the Azteca are still shooting up, Silvestre seems to be serious about trying to stay as clean as possible. "I try and stay away from them now. I know all these guys, I know what they are doing; smuggling Mexicanos across, selling heroin and grass." Silvestre was asked if any of these friends knew that he was a homosexual male prostitute. He emphatically answered that no one knew except a couple of other friends who were doing the same thing. He also indicated that he no longer was prostituting himself. "I am trying to change my life. I occasionally see some of these men on the streets. One tried to pick me up the other day. I told him I was not interested." However, Silvestre's claims were contradicted by contacts familiar with him around Jarvis Square who claimed that he was still actively hooking and shooting heroin. CASE HISTORY ANALYSIS These cases describe the social dynamics dominating the lives of injecting drug users throughout their life cycle in a Mexican-American border barrio. These life histories represent the spectrum of themes and issues of different types of drug users during various stages of their addiction careers. The young addict, veterano, female, and homosexual heroin users are representative examples of this population. The histories provide insights into the

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lives of these drug users as children, young adolescents, teenagers, young adults, and adults. All four persons had undergone similar experiences: low-income families, family disruptions, lack of parental guidance, conflict in schools, early introduction to alcohol and marijuana, crime, heroin addiction, and long periods of incarceration. One of the common threads throughout these stories is the disruptive family lives that each experienced. Two of the cases (Bernardo and Silvestre) came from classical disruptive families. Bernardo grew up in a poor, single-parent, female-headed household in which his mother was unable to exert control or provide guidance: These responsibilities fell to an authoritarian and physically abusive older sibling. Silvestre is a product of divorced parents and was raised by his mother in Mexico until he moved back to Laredo with an older sister during high school. In the case of Chispa, his parents were burdened with ten children, which, along with living in abject poverty, left little time for significant parental attention. Chispa's family, like many others in Laredo, was forced to migrate to other states three to four months out of the year in order to survive economically. Finally, the case of Suzie Galindo is one in which a highly disruptive daughter was uncontrollable by more elderly parents. These families' economic situations and the schools' inability to provide a viable institutional alternative left these children susceptible to the vicissitudes of street life. Living in neighborhoods characterized by poverty, and social and geographic isolation in some of the worst barrios in Laredo, meant a social life centered on cliques of peers. These cliques, along with older users and criminals, socialized these young children into a lifestyle of crime, alcohol, and drugs. Once heroin was introduced into their young lives, addiction became the driving force of existence. As addicts, heroin users spend most of their time in criminal or quasi-criminal activities related to generating resources to purchase drugs. Also, addicts spend much of their time in the complex process of locating and obtaining their drugs (Ramos 1996). Although this activity is not as time-consuming as in other areas of the United States (Faupel 1991), it is still a major preoccupation for Laredo addicts. This eventually leads to numerous arrests and varying lengthy periods of intermittent incarceration for these individuals. Although each of the individuals in these case histories experienced periods of abstinence, all eventually returned to heroin use. The case of Suzie Galindo and her daughter illustrates the particular situation of female injecting drug users' relationship to men. Like other female injecting drug users, females in Laredo usually start using heroin as a result of their relationships to injecting drug using husbands and/or boyfriends. This was certainly the situation with Suzie and other women we encountered in the course of this study, although there were cases in which women exhibited more autonomy than the traditional gendered relation-

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ships. Once addicted, women become enmeshed in the street world of hustling to support their own habit as well as that of their partner. As in the case of Suzie Galindo, drugs become the primary objective. Everything else—including children, family, and other responsibilities—is subordinate to the drug use. Heroin use among women also seems to concentrate in those families that have other female users. This was situation of Suzie and her daughter, La Prieta, who was using heroin. The experience of these women support Rosembaum's (1981) theory that female drug users have a career of "reduced options" and consequently are subjected to more severe, long-term, social consequences as compared to their male counterparts. CONCLUSIONS Through the lives of these four individuals we see how persistent poverty, illicit opportunities, isolation, and scarce institutional resources profoundly impact real people. Persistent poverty in this region and setting has created the need for alternative economic strategies for community members to economically survive outside of the traditional economy. This means a disproportionate percentage of the community is involved in some manner of illicit activities centered upon the international border, including smuggling and drug dealing. Persistent poverty and alternative economic strategies create an atmosphere of comparatively greater tolerance of criminal activities than in other communities. Such tolerance, plus the presence of strongly influential marginalized groups and social contacts, is reinforced by the region's geographic isolation. This disenfranchised border community may represent what Banfield (1958) refers as an "amoral society." The decisions and adjustments made by these four persons reflect the devastating effects of such an environment. REFERENCES Banfield, Edward C. 1958. The Moral Basis of a Backward Society. New York: The Free Press. Bullington, Bruce. 1977. Heroin Use in the Barrio. Lexington, MA: Lexington Books. Casavantes, Edward J. 1976. El Tecato: Social and Cultural Factors Affecting Drug Use among Chicanos. Washington, DC: National Coalition of Spanish Speaking Mental Health Organizations. Chambers, Carl D. 1970. "Narcotic Addiction in Females: A Race Comparison." The International Journal of the Addictions 5: 257-78. Codina, G. Edward, Charles D. Kaplan, Zenong Yin, Alberto G. Mata Jr., and Avelardo Valdez. 1996. "Readiness for Treatment: Predictors of Drug Abuse Help-Seeking in Mexican America, African American and White San Antonio Arrestees." Free Inquiry for Creative Sociology 24: 17-24.

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Desmond, David P., and James F. Maddux. 1984. "Mexican-American Heroin Addicts." American Journal of Drug & Alcohol Abuse 10: 317-46. Dunlap, Eloise, and Bruce D. Johnson. 1996. "Family and Human Resources in the Development of a Female Crack-Seller Career: Case Study of a Hidden Population." Journal of Drug Issues 26: 175-98. Faupel, Charles E. 1991. Shooting Dope: Career Patterns of Hard-Core Heroin Users. Gainesville: University of Florida Press. Moore, Joan. 1978. Homeboys: Gangs, Drugs, and Prison in the Barrios of Los Angeles. Philadelphia: Temple University Press. . 1991. Going Down to the Barrio: Homeboys and Homegirls in Charge. Philadelphia: Temple University Press. National Institute of Justice. 1996. Drug Use Forecasting: 1995 Annual Report on Adult and Juvenile Arrestees. Washington, DC: U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. Ramos, Reyes. 1996. "Waiting Periods: Understanding Injecting and Sexual Behaviors of Mexican-American Injecting Drug Users." In Epidemiologic Trends in Drug Abuse, vol. 2, Community Epidemiology Work Group, edited by CEWG National Institute on Drug Abuse, 422-30. Rockville, MD: National Institutes of Health, Division of Epidemiology and Prevention Research, National Institute on Drug Abuse. Rosenbaum, Marsha. 1981. "Sex Roles among Deviants: The Woman Addict." The International Journal of the Addictions 16:859-77. Sterk-Elifson, Claire. 1995. "Determining Drug Use Patterns among Women: The Value of Qualitative Research Methods." In Qualitative Methods in Drug Abuse and HIV Research, NIDA Research Monograph, edited by E. Y. Lambert, R. S. Ashery, and R. H. Needle, 65-83. Rockville, MD: National Institutes of Health. . 1996. "Just for Fun?: Cocaine Use among Middle-Class Women." Journal of Drug Issues 26: 63-76. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. 1995. "Drug Use Forecasting. Annual Report on Adult and Juvenile Arrestees." U.S. Department of Justice, Office of Justice Programs, National Institute of Justice, Washington, DC. Valdez, A., G. E. Codina, and C. D. Kaplan. 1996. A Needs Assessment of Mexican American Injecting and Other Drug Use in Laredo. Hispanic Research Center, University of Texas at San Antonio, San Antonio, Tex.

4 Dangerous Relationships: Effects of Early Exposure to Violence in Women's Lives on the Border Joao B. Ferreira-Pinto, Rebeca L. Ramos, and Alberto G. Mata Jr.

INTRODUCTION On any given day in borderland communities, electronic and print media carry reports about serious injuries or fatalities related to intimate partner violence (IPV). Unless these incidents involve heinous crimes or reach a level of notoriety, intimate partner violence is generally perceived as victimprecipitated, as an accepted risk of walking on the "wild side," or as another outgrowth of the drugs and violence border nexus. Moreover, adolescent and young adult IPV in these border communities go the way of much domestic, family-of-partner violence—attracting the attention of a few, taxing limited existing services and resources, yet drawing little further meaningful action or response. While intimate partner violence is problematic for both sides of the border, its dimensions and dynamics have yet to be fully attended by research, policymaking, and practice on the U.S. side, and are even less so on the Mexican side. As it generally involves youth and young adults, the public and media discourse seems to be more concerned with questions of who the victimized young women are (i.e., what type of person, or where the victim came from), than with nature, course, or consequences of the violence and, of course, why some women are attracted to these men and these relationships. Moreover, there is a clear lack of attention to this issue by the fields of criminology, public health, and even social welfare/service researchers. The rise of IPV among young adolescents and young adults seems to be

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spreading and becoming a key concern in most border communities. However, while violence is assumed to be a "part of life" in the borderland's changing and more troubled neighborhoods and communities, there is little data to suggest its exact nature, dynamics, or toll. It is not clear whether IPV is related to the violence that some people experience earlier in the family and in their neighborhoods, to exposure to subcultures of violence, or is the outcome of the social disorganization and breakdown that these people endure. Others draw attention to the role of the pervasive and endemic nature of violence in communities on both sides of the border. For many, IPV is not unlike other types of violence common to some border towns. In these communities on both sides, there are areas that are defacto and dejure "partying locales," more tolerant of illicit, illegal, and amoral behaviors. IPV may also be a consequence of this tolerance. Many studies ignore key issues and dynamics shaping young women's experiences with violence. Although some women are also violent and abuse their male partners (Flynn 1990; Mezey and King 1989), in the great majority of the cases, the victim has been a woman abused by a man. It should also be noted that many abused women do not go on to abuse their spouses or their children. This chapter will deal with the question of the possible links between early exposure to violence and drug use (Rogan 1986; Worth 1991), to sexual abuse, and to becoming a perpetrator of violence in adult intimate relationships (Symonds 1979). It will also address questions dealing with how women get into and stay in abusive relationships. Attention is focused on cultural sanctioning of inequalities between men and women regarding economic and political power, which when coupled with the socialization of women to passivity and dependency on their partners, increases the probability of physical and emotional abuse in relationships. Finally, it will explore cultural issues regarding the definition of power in gender relationships. "THE CYCLE OF VIOLENCE" Bandura's Social Learning Theory (1986) has established that an important relationship exists between early exposure to violence and becoming a perpetrator of violent acts. He posited that by observing violent disputes between their parents, children learn and later model violent behaviors. This type of learning and modeling takes place not only in the home but also in the barrio (neighborhood). In many low income barrios, children see and experience interpersonal and street violence as the norm. In short, children who have been victims or have witnessed violence will later see these acts as common and natural, will become abusers/violent offenders themselves with their intimate partners, their children, and others

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Table 4.1 Comparison of Cycle of Violence and Intergenerational Transmission of Violence Theories Cycla of Violanca Theory

Male Female

Abused Child Abused Child

Abusive Adult Abusive Adult

Intarganarational Transmission of Violence Theory Abused Child - - Abused Adult Abused Child - - Abused Adult

in the community (Bandura 1973; Goldstein 1986). Some researchers refer to this process as the "cycle of violence" (Gelles 1976; Steinmetz 1977). The idea that violence begets violence not only makes intuitive sense, but is held to operate in many of these border communities on both sides. As shown in Table 4.1, the cycle of violence theory proposes that the abused child will become an abusive adult. This theory is based on criminal justice policies and records, and primarily focuses on examining early exposure to violence of male perpetrators. In fact, most studies do not deal directly with women and the consequences of violence in their lives. Although the cycle of violence has gained much popular and practitioner acceptance, contradictory to this notion is the fact that not all abused children go on to become abusers. Some violence researchers also cite examples of male violence being extended to young women (Gabarino and Gilliam 1980; Widow 1989b). Intergenerational Transmission of Violence We contend that most abused girls do not become abusive women, but are likely to become abused women. Widow (1989a) points out that the long-term consequences of abuse for females may be expressed in very indirect internalized ways. Women may suffer an increase in depressive episodes, instead of following the more male model of outward aggression. For some women, the internalized ways of coping with abuse turns into situations that some have termed "learned helplessness" (Seligman 1975). The concept of "learned helplessness" was developed from observations of the behavior of laboratory animals put in painful situations without much possibility of escape. Eventually, when presented with possible escape routes, the animals would not take them. The animals' refusal to escape from the painful situations was a result of perceptual distortions brought about by the previous helpless situation (Walker 1984). Seligman (1975) suggested that the concept of learned helplessness could explain why women find it difficult to leave abusive relationships and settings. The "intergenerational transmission of violence" (Curtis 1963) explains this event as a role modeling behavior that gets passed on from one generation to another. The hypothesis is recast, stating that an individual vi-

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olent response to a number of life situations tends to be passed from one generation to another by a process of behavior modeling (Gelles 1996) and unstated rules (Laing 1969). While holding that certain roles tend to become part of the individual's responses, Gelles posits the notion that exposure to violent behavior serves as a role model for the male perpetrator. But for female victims, rather than becoming abusive, they more likely will become abused (Gelles 1976). Staying in Abusive Relationships Sex-role stereotyping and self-imposed difficulties seem to prevent abused women from viewing their situation clearly or from making informed decisions about their futures (Ball and Wyman 1978). Walker (1984) suggests that abused women who remain in relationships tend to report that their childhood abuse was worse than that in their present domestic relationship. Cognitive dissonance theory (Festinger 1957) suggests that when a victim cannot remove herself from the situation and has to live with limited choices, she rationalizes that her present situation is no worse than her childhood and is therefore acceptable. Family system theories explain the maintenance of abusive relationships as part of the dynamics of the family system. They also draw attention to the lack of psychological, social, and economic resources and the lack of responsiveness of the policy, courts, and welfare systems, especially the insufficiency of protective orders and other court judgments. Other research suggests that women who have been involved in helpless situations many times are more likely to perceive their present situation as hopeless. They adapt instead of leaving or exploring meaningful alternatives. Many service providers who are developing programs and innovations to help with the problem propose solutions that are obvious. However, they fail to address the perceived and real difficulties of changing the internal dynamics of the family, the variability of social support, the lack of necessary social and economic resource programs for abused women and their children, and the lack of strict enforcement of existing laws (McDonald 1989). These difficulties are compounded when one takes into consideration the legal, political, economic, and cultural norms of the Mexican culture. Cultural and Class Conflict In Mexico, as in all Latin American countries, gender defines the limits of power in a relationship and in society. The culturally sanctioned inequality of economic and political power between men and women, coupled with the socialization of women toward passivity and dependency on their partners, increases the probability of physical and emotional violence in relationships. The implied threat or actual act of violence, which appears

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to be condoned by societal norms, is used by their sexual partners to maintain their dominant position. The fear of being estranged from their partners and from the family's protective milieu, together with the lack of socially acceptable alternatives, causes women to remain in long-term relationships that may be dangerous to their physical and mental health. Most of them never had an opportunity to tell their story or to discuss their violent experiences with anyone else. This lack of self-expression leaves them out of touch with their feelings. They appear not to have a sound basis by which to validate their identities or to examine alternatives. They accept the violence as normal. Many are not openly aware of the violence that has been committed against them when they were children by parents, siblings, or others. Men turn to external justifications, especially those related to their jobs, illnesses, financial strains, and the use of alcohol, to explain their violent actions, while women tend to blame themselves for the violent abusive situation in which they find themselves. This situation heightens these women's feelings of low self-esteem, dependency, and learned helplessness (Overholser and Moll 1990). This is particularly true of women who are injecting drugs users (IDUs) or who are sexual partners of IDUs. METHODOLOGY The Setting and Sample Selection Interviews were conducted in Ciudad Juarez, in the U.S.-Mexico border state of Chihuahua. Juarez is the fifth largest city in Mexico with a population of 1.5 million inhabitants and is the center of a burgeoning maquila industry (factories that use primarily U.S. raw materials to produce finished products for export back into the United States). Despite the favorable circumstances created by the maquiladoras, the level of unemployment and consequent poverty remains high. Social and educational services are lacking because of the high rate of population growth and the low rate of infrastructure development. A targeted sample was selected among women whose sociodemographic profiles closely matched those of the women participating in the National Institute of Drug Abuse and Prevention (NIDA AIDS Targeted Outreach Model-ATOM Project) funded study (ABT 1992), but who lived in different Juarez barrios. They were recruited by trained fieldworkers familiar with the drug users' patterns and demographics of the different neighborhoods in Ciudad Juarez. The ATOM project's inclusion criteria was used to select participants: women, older than 18 years of age, nonusers of injecting drugs for the past year, and who had been sexual partners of male active drug users within the last six months to the past five years. Women not meeting these criteria were excluded from the study.

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Data Collection Modified ethnographic interviews were used in collecting data. These are in-depth, semistructured, single-encounter interviews using an open-ended interview guide containing a set of questions that are asked of all informants. This data collection technique was chosen because it takes place in a shorter time frame than the conversational style of traditional ethographic interview. Prior to the interview, written informed consent was obtained from all informants. They were assured that their names would not be used in any publications or reports, nor would they in any way be identified to their partners or to any other women who were part of the study. They were also informed that their participation was strictly voluntary, and that they could leave the interview at any time or refuse to answer any questions. The respondents were paid a stipend equivalent to U.S. $15 for the interview. Fifty modified interviews were considered enough to elicit the needed information. Interviews were conducted in Spanish by a female psychologist trained in ethnographic interviewing techniques. Beyond general sociodemographic characteristics, the interview guide included questions examining a range of experience and behaviors over the informants' lifetimes. They encompassed childhood experience; histories of physical and sexual abuse; family influences; what attracted them to their partners; the effect of drugs in their relationships; and why they stayed in abusive relationships. The respondent was at liberty to discuss any topic she deemed significant. The interviewer was instructed to elicit and probe into those areas that she believed were important to the respondent. The interview data was collected in homes and in a neighborhood center, and lasted approximately two hours. If deemed necessary, there was a subsequent interview. In most cases, and with the permission of the respondent, the interviewer used a tape recorder as a memory aid to complement the field notes. After the interviews were completed, the tapes were transcribed into text, augmented by the fieldworker's notes, and were subjected to a qualitative analysis. FREE TEXT ANALYSIS Only thirty-six of the fifty women who met inclusion criteria were used in the analysis. The interviews were translated from Spanish into English. They were analyzed using a text analysis software package called AFTER (Analysis of Free Text for Ethnographic Research), developed by the data management subcontractor to the larger study (NOVA 1990). The program was used to separate and categorize portions of the narratives into factors that respondents referred to as important "markers" in their lives. These

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markers' importance in the past were always in relation to their present circumstances. We concentrated on the chronology of violence experienced by these women over their life courses. Four factors were mentioned frequently in relation to the violence experienced by these women: childhood abusive experience in the family, violence from the hands of strangers, attraction to "dangerous" sexual partners, and longstanding abusive relationships with these dangerous sexual partners. RESULTS Women's Characteristics All thirty-six informants were born in Mexico; all but one in Juarez. The age range was 15 to 45 years, with a mean of 27.9 years. This was substantially lower than the mean age of U.S. and Puerto Rican women in the ATOM study. Only fourteen respondents had an eighth-grade education or more. None had attended college. Reasons given by women for not completing their formal education were: (1) the necessity to help parents support the family, (2) having to stay home to care for siblings, and (3) the biological family's instability and violence. Their parents did not encourage schooling. One respondent said: "None of us went to school; my mother, she couldn't mind all of us because we were so many; that was her excuse." The level of instability reported by the respondents was a consequence of the violence at home, in the neighborhood, and in the school, especially where gangs were common. The home environment was so violent in some cases that for their own protection the girls were sent away by their mothers to live with a relative. Only seventeen of the women were raised by both parents. Nearly a fifth of the women were raised by their grandmothers. One woman stated, "The only nice memories I have of being a little girl are of my grandmother. Although she was old and frail she was the only one that fought, took sides for my sister and myself." In most instances who raised the women was determined by a family crisis—the death of a parent, financial problems, or abuse of the child by a male relative or friend of the family. For many who stayed with their parents after such a crisis, life became unbearable and many tried to move in with a friend or female relative. Many of the women stated that they had moved permanently to the house of an aunt or other relative. Twenty-one subjects received most of their economic support from their intimate male partners, and nineteen reported that they had to work to complement the household income and help the children and themselves. Their income was not steady as these women's income was largely derived from the informal sector of the economy, for example, selling and trading

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goods in neighborhood markets. None of the women stated that they earned enough income to be self-sufficient or to be able to live without their intimate male partner's income. Violence Exposed in the Paternal Family Sixteen of the women reported violence in their biological families' households while they were growing up. This violence was directed against themselves, their mothers, and siblings, and seven remembered seeing their mothers being physically abused by their fathers. Six stated that they themselves had experienced physical abuse as children at the hands of their parents. Many respondents reported having witnessed a severe beating of a sibling by the mother during their childhood or adolescence. Yet, most respondents were likely to charge their fathers with the most abuse and the most serious incidents of abuse. Nine attributed the violence in the household to the father's use of alcohol and other drugs. Only one woman attributed such alcohol and drug violence to her mother. Some of the actual physical actions reported were extreme. One respondent reported being made to lie down, tied to a grate covered with broken glass as punishment for a minor transgression. Many witnessed their mothers being physically abused. When the mother was pregnant "he still hit her." Another form of paternal abuse was the open use of drugs in front of the children: "He thought that if he and his friend went to the backyard we would not see . . . but they left all their drug paraphernalia laying around." Another woman reported, "Many times I saw my dad shooting drugs. My brother and I used to play at rolling joints. I was five; he was six." Besides the economic reasons mentioned above for not leaving an abusive relationship, these women also experienced the fear of their families' disapproval of the breakup. The social pressure to stay in the relationship, the fear of further social isolation, and the fear of having the full responsibility to care for themselves and their children alone was great. Many remained in the relationship to protect the family and the children's name. One respondent stated that she knew that "he had other women [and] I know who they were [but] I was pregnant [and] I never told the kids he had another woman, so the children would not despise him." History of Childhood Abusive Experiences: Physical and Sexual Abuse All informants mentioned that their mothers physically punished them for having failed to perform their household chores. Almost all reported that their fathers punished them for some violation of rules regarding haircut, makeup, or appropriate social conduct. Seven reported that in their parental homes serious physical abuse was triggered by their transgression

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of some part of the parents' strict behavior code. Although the description of verbal and emotional abuse is not as clear or graphic, they do include cases of continued abuse for many years. For example, they report being told almost daily that they were crazy or that they were hated by other members of the family. The women's transgression of their father's or mother's strict code of behaviors, such as "no makeup" or "not talking with anyone outside the family circle," produced verbal references to loose morals. Many of these women remember being called whores for such minor transgressions. Twelve women reported being sexually abused as children. One intriguing development during the interviews was that most recounted instances of sexual abuse involving penetration. Either these women did not experience nonpenetrative sexual acts or, most likely, they did not classify as abuse other sexual acts such as being touched, fellatio, fondling of male genitals, or lewd suggestions. With the premium placed on virginity in Mexican culture, this makes penetration the only "true" sexual act (Ramos and Ferreira-Pinto 1997); all the others are seen as a preamble to penetration. As long as these women did not lose their virginity, they may not even have thought of the act as sexual abuse. In fact, most women related these acts as examples of the irrational behavior to be expected from Mexican males. This idea was tested and found to be true by Gallegos (1996) in unstructured interviews with women who had reported sexual abuse as children. The women's responses to abusive episodes range from open confrontation to complete silence. Women who kept silent felt that other family members and friends would not be supportive of complaints about their plight. When a woman confronted her father about his sexual abuse of her, he only said, "It is that I need it," without any guilt. Another respondent stated that after she denounced her father's sexual abuse, all her mother said was that "I was a liar." Given this nonsupportive and threatening climate, the most common response to sexual abuse was silence, either to protect the mother's or the family name. One woman explained this protective attitude as a way to avoid upsetting the mother and make her mother "suffer more than she deserved." Even as children, women reported being depressed and feeling devastated by the lack of respect that the male abuser had shown herself, her mother, or her sisters as women. Attraction to "Dangerous" Sexual Partners Since their adolescent years, these respondents mentioned being associated with men who were full-fledged or surrogate gang members. Many of these males may be viewed by the respondents as t(pelados, desobligados, vagos callejeros, viciosos, o encarcelado" (in a nice translation: rascals or street hoodlums). Because of their involvement with la bola (the gang), these young women's association with these pelados was seen as affording

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them some form of protection from their families' chastisement, abuse, and predation from a dangerous and violent community. These women were attracted to and formed a bond with males whom many considered "dangerous and would not dare to challenge." For these women, their relationship with these men provided them with an experience that they perceived as giving them a sense of freedom from fear and a sense of respect and status among those that others viewed as dangerous and violent. One woman stated, "Nobody would dare say something to me, or insult me, because I was with [partner's name]." For both risk-taking women and women with low self-respect, the rewards brought about by bonding with these dangerous males was a powerful motivation for selecting sexual partners respected by those residing in dangerous and violent community and barrio settings. It is not uncommon for these women to select other males whose economic prospects are not much better than the current abusive partner, but who, because of their own dangerousness, appear to provide them a respite and asylum from their current storm of violence. These women often entered into relationships quickly and idealized images of their partners. "I met a boy and ran away with him. . . . I had known him for a week. . . . He was very handsome and strong. . . . He treated me nicely." Many women had the perception that IDUs would "understand them better" since many, like themselves, were the product of troubled, abusive families. One woman stated that her partner told her that "my father would hit me when he got high." Some women stated that they knew that their partners "did not drink too much . . . [but they] did not know he was shooting up. . . . I never thought that he would hit me." The rationale used by these women for choosing their sexual partners became a major source of disappointment in their lives. This is particularly true for women with low self-esteem and little social support. They did not expect the violence displayed by these men to be used against them in a conjugal relationship. The women expected that their partners, most of whom had been products of abusive or socially drained families, would be understanding, empathetic, and offer positive psychological support that was not available to them in their parents' homes. After the initial "honeymoon" period, the inverse of these expectations would become evident to the woman's circle of friends, to her family, to her personal work and social friendship networks, and to her. Women reported feeling that they were being isolated from family and friends through social pressure: "You chose him, now endure him." Sometimes these mujeres isolate themselves—they feel humiliated by their partners' behaviors, for example, drug use, violent outbursts, and womanizing. Womanizing partners make life particularly difficult for women in their communities: They try to hide their partners' womanizing from their significant others, especially their children.

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Conjugal Abuse Almost all (28/36) respondents met their partners through a family member, una amiga (a friend) or in the local barrio hangouts (a park, movie house, shopping center). Some of these women reported that they knew their male partners were part of a gang when they first met them. Others did not know of their partner's involvement with gangs until some conflict or some inadvertent remark revealed that they were part of a local or gang network. Even when making this discovery, they report that terminating the conjugal relationship was not even considered. Moreover, with many of these women, their men's participating in gangs was their least worry. For some, it was the beginning of more stark and startling discoveries, for example, that her man was involved in using, dealing, or transporting drugs or worse, a violent, convicted drug offender. More often than not, evidence of street violence manifested itself in a friend of her partner when he was brought to her home wounded and where her role was to clean and tend the wound, but not to question or discuss (Moore and Mata 1981). While all of the women reported some type of serious abuse, only half of the women stated that they had been physically abused by their sexual partners. The pattern of abuse could start early in the relationship, and in some cases it started immediately: "Right away I started to get mistreated" stated an informant. Sometimes it would not start for several years. One informant reported that: "I knew him when I was 14 . . . [but] he left for the U.S. . . . when he returned I left my house and moved in with him. He left me at his parent's and went back to the U.S. . . . He never hit me when we were living with his parents. . . . The hitting started when we moved to our own house." The initiation of an abusive episode was generally drug and alcohol related—the partner reaching the point where he would lose control over his state of intoxication (Rosenbaum 1981). Many of these women reported that their partners appeared to derive pleasure from being violent. The violent episodes' driving motivation is "to show the woman her place" and have her "respect her man." Often the violence has the overall end of ensuring that the male's authority should never be challenged—in the bedroom, in his house, or among their family and friends. Even in the most abusive episodes, many of these relationships persist for many years. The reasons for these mujeres to remain in these abusive relationships are many. For several of the respondents, economic pressure is the primary reason for staying. Twenty-one report that their main source of financial support is their partner. Although nineteen of these women reported working, one should keep in mind that most of this work is part time, unstable, and poorly paid. Formal prostitution or more "informal" exchange of sex for support was an option that only one woman in the sample contemplated. Given their overdependence on their partners, their

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options for moving out to live with relatives or friends, or "permanently" leave the abusive relationship are practically nonexistent, nor do other similar options appear viable to them. DISCUSSION The cycle of violence model fails to address reasons why a large number of women who were abused in their childhood do not later become abusers, as the theory proposes. It may be useful to apply the cycle of violence notion to young gang members and young men, but our research demonstrates that it fails to attend to and address key issues in women's lives. First, for most of these women, early exposure to violence is part of their family life and domestic routine. This abuse and violence is at the hands of their parents, siblings, relatives, and even very close friends of the family. In many of these communities, family norms beginning in their homes have many continuities and discontinuities with the larger community and society's agents of social control. The acceptance of these norms can be seen in the day-to-day activities of local barrio gang members, the presence of strangers, and in the actions of law enforcement personnel. These women's conflicts with their intimate partners serve as a basis for family norms supporting the acceptability of abuse and violence. The inability or unwillingness of others to intercede in these less than tranquil, stable, and nurturing relationships for some of these women and their children goes on to serve and to buttress local and family norms about the acceptability of interpersonal violence. For many of these women and children, the modeling of violence begins early. Some come to accept violence as a key technique for conflict resolution. Therefore, they seek and attach to other strong and dangerous men who have earned or can gain the necessary amount of respect to make them feel protected. When studying the intergenerational transmission of violence, one should be cautious not to concentrate solely on internal factors. By not examining the external structural, situational, and culturally grounded perspectives, one can end up blaming the victim, that is, putting all responsibility for this violence and efforts to ameliorate this violence on the woman herself. It is obvious that external environment, common poverty, and sexism in these women's lives should be focused upon and subjected to appropriate social policy and intervention. While there may be little in the short term that can be done about poverty, social, and economic factors, there is much that can be done to increase support for these women to abandon violent relationships and to manage their lives. The dynamic of the conjugal relationships reported by these women hinges on gender-related power structure. Many of these men try to control their female partners' physical movements, their interactions, their emotions, and even their sense of mental health and well-being by fits of rage,

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jealousy, and possessiveness. These struggles are focused on control issues. This scenario is played out constantly, and the behavior patterns experienced as children are reinforced through their adolescence, as these women come of age, and when they set up their own households. The continuing acceptance of the situation will prove immobilizing, if not fatal. Without real change, these dynamics only serve to perpetuate the intergenerational transmission of violence. It must be important to understand that for most women, the selection of intimate partners has little to do with the factoring-in of their partners' "dangerousness" to her, his friends, or family. His ability to command respect and fear so that she can be free from violence common in her home life, teen years, and her own outings in the barrio seem to loom over other considerations. If we are to provide these women meaningful information and alter norms and actions that narrows the acceptability of violence in the barrios, the appreciation and grounding of their decisions in these local cultural contexts is essential. It is also important to teach them how to identify and avoid partners who have the potential to become seriously abusive and to avoid otherwise violent domestic relationships. RECOMMENDATIONS Given the economic and social conditions surrounding these women, the most effective way for change to occur is not through programs that unknowingly set up a violent confrontation with their partners. In many of the barrios, confrontations without adequate support has undesirable consequences. Learning new ways of dealing with their own internalized anger and frustration is crucial. They must also learn how to repair a damaged self-image. Social interventions must attend to the need for programs that promote a woman's attending to her own needs, particularly her need for safety and freedom from abuse. Efforts to reduce the risk of serious violence in the short run must not lose sight of the need for transformative and long-term change. The public policy responses to violence against women should first take into account societal issues of economic development. Nonetheless, programming efforts must address individual issues of education, health, and job skills needed for self-support. Many of these women are accustomed to self-sacrifice for the family. For these women to take advantage of programs, support for their children and their livelihood during this transition must be a primary consideration. Implementing effective service and support systems for women and their children, such as shelters and enforceable laws during crisis, is essential. But for the change to take hold, the possibility of meaningful training and jobs would serve to encourage these women to explore alternatives to the fear and threat of violence (Davis 1988). Finally, in Mexico and the United States, policy makers and practitioners

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have been unwilling to address the power imbalance between intimate sexual partners, the class differences, the marginalization of large segments of society and how these factors intersect with episodes of interpersonal violence (Candib 1989). In Mexico, the therapeutic approach to crisis management of interpersonal violence must be implemented. This does not mean that uncritical adoption of traditional family values is the answer. Promoting family values among the more marginalized in these communities without analyzing oppressive culturally prescribed gender roles can lead to development of interventions that promote, or perpetuate, women's subordinate role. Social intervention must have a sense of how to address family values and practices that do not serve to continue to promote family, conjugal, and societal abuse of these women. Further research on the topic should focus on children who have been exposed to violence during their formative years and attempt to predict who may be more likely to exhibit violent behaviors at a later date or will have the tendency to become victims of violence. These data should allow us to design better targeted interventions to teach men to better channel their aggressive tendencies; to change the women's self-images; to promote less revictimizing of abused women; and to expand the economic and social resources available for these women to be self-confident and independent. NOTES This study was supported in part by the U.S. National Institute of Drug Abuse (NIDA). The ethnographic data used in this chapter was collected under the supervision of Dolly Worth, Ph.D. The study was made possible through the cooperation of the following researchers: Piedad Huerta, Apolonia Hernandez, and, particularly, Maria Elena Ramos of Programa Companeros. This chapter has been adapted for inclusion in this volume. The original article appeared as "Gangs, Drugs, and Violence," Free Inquiry, Special Issue #2 25(1) (May 1997): 109-16. REFERENCES ABT Associates Inc. 1992. "AIDS Outreach to Female Prostitutes and Sexual Partners of Injection Drug Users." Final report to NIDA Contract No. 271-888224. Ball, P. C , and E. Wyman. 1978. "Battered Wives and Powerlessness: What Can Counselors Do?" Victimology: An International Journal 2(3-4): 545-52. Bandura, A. 1973. Aggression: A Social Learning Analysis. Englewood Cliffs, NJ: Prentice Hall. . 1986. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice Hall. Candib, L. M. 1989. "Violence Against Women: No More Excuses." Family Medicine 21(5): 339-42.

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Curtis, G. C. 1963. "Violence Breeds Violence—Perhaps." American Journal of Psychiatry 120:386-87. Davis, M. 1988. "War in the Streets." The New Statesman & Society 1(23): 2 7 30. Festinger, L. 1957. A Theory of Cognitive Dissonance. Stanford, CA: Stanford University Press. Flynn, C. P. 1990. "Relationship Violence by Women: Issues and Implications." Family Relations 39:194-98. Gabarino, J., and G. Gilliam. 1980. Understanding Abusive Families. Lexington, MA: Lexington Books. Gallegos, N. 1996. Personal communication Gelles, R. 1996. "Abused Wives." Journal of Marriage and the Family 38(4): 65968. Goldstein, J. 1986. Aggression and Crimes of Violence. New York: Oxford University Press. Laing, R. 1969. The Politics of Family and Other Essays. New York: Vintage Books. McDonald, P. 1989. "Helping with the Termination of an Assaultive Relationship." In Interviewing with Assaulted Women: Current Theory Research and Practice, edited by B. Pressman, G. Camerron, and M. Rothery, 75-110. Hillsdale NJ: Lawrence Erlbaum Associates, Inc. Mezey G., and M. King. 1989. "The Effects of Sexual Assault on Men." Psychological Medicine 19:205-9. Moore J., and A. Mata. 1981. "Women and Heroin in a Chicano Community in Los Angeles." Chicano-Pinto Project, Final report to NIDA. NOVA Research Inc. 1990. AFTER (Analysis of Free Text for Ethnographic Research). Washington, DC: Qualitative Analysis Computer Program. Overholser J., and S. Moll. 1990. "Who Is to Blame: Attributions Regarding Causality in Spouse Abuse." Behavioral Science and the Law 8:107-20. Ramos, R., and J. Ferreira-Pinto. 1997. "Violence Against Women on the U.S. Mexico Border: The Role of Gangs and the Drug Subculture." Submitted for Publication Special Issue on Border Violence Pan American University Publications. Rogan, A. 1986. "Domestic Violence and Alcohol: Barriers to Cooperation." Alcohol Health and Research World (winter): 22-27. Rosenbaum, M. 1981. "When Drugs Come into the Picture Love Flies out of the Window." International Journal of Addictions 16:1197-1206. Seligman, M. 1975. Helplessness: Oppression, Development and Death. San Francisco: Freeman. Steinmetz, S. 1977. The Cycle of Violence: Assertive, Aggressive, and Abusive Family Interaction. New York: Praeger. Symonds, A. 1979. "Violence Against Women—the Myth of Masochism." American Journal of Psychotherapy 33(2): 161-73. Walker, L. 1984. The Battered Woman Syndrome. New York: Springer Publishing Co. Widow, C. 1989a. "The Cycle of Violence." Science 244:160-66.

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. 1989b. "Does Violence Beget Violence? A Critical Examination of the Literature." Psychological Bulletin 106(1): 3-28. Worth, D. 1991. "Sexual Violence Against Women and Substance Abuse." Paper presented to the Domestic Violence Task Force, NIDA, Washington, D.C.

5 The Difference a Line Makes: Women's Lives in Douglas, Arizona, and Agua Prieta, Sonora Ellen R. Hansen

INTRODUCTION It is often written today that international borders are disappearing in the face of globalization of the world economy and the new world order. At the local level, however, in the everyday lives of the people who live near them, borders remain not only visible, but physically as well as symbolically powerful. They often delineate a zone of safety, where one's own language is spoken and one's customs are accepted and practiced, but beyond which lurks a danger zone. Borders are complex socially constructed phenomena that play various roles in the lives of residents on both sides. This is true at the border between the United States and Mexico, where although language, customs, money, and information cross freely back and forth, and socioeconomic ties are strong, the two countries are different and unequal in almost every way. At the macro level, the economic relations between the United States and Mexico are skewed, dominated by the much larger U.S. economy. At the local level, however, the cities on the U.S. side of the border are dependent on Mexican shoppers for their livelihoods, and many cities on the Mexican side are dependent on the maquiladora industry—an important source of employment consisting of the mostly U.S.-owned assembly plants operating in Mexico. These structural factors have gendered effects on border residents. Women and men in border cities have different access to resources, and their priorities are differentiated by traditional and changing gender roles

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and relations. In order to gain a greater understanding of the reality of women's lives at the U.S.-Mexico border, research was conducted in Douglas and Agua Prieta by interviewing 100 women (50 in each city) about their daily mobility and their perceptions of how their lives are influenced by the border and the institutions that control and maintain it. The women were selected through purposive sampling, using the snowball technique. Subjects do not represent all women living at the border, but results show patterns, similarities, and differences among women on both sides. In this chapter a brief historical description of the two cities is followed by a discussion of how ethnicity and language use shape women's construction of identity. Patterns of women's border crossings are then identified. How these patterns are distinguished by place of residence and nationality and how they, along with ethnicity and language use, shape women's perceptions about their lives in border cities are then considered. BACKGROUND The cities of Douglas and Agua Prieta are situated in the southeast corner of Arizona and the northeast corner of Sonora, respectively. They date from the turn of the twentieth century, when copper mining reigned supreme in the region. The headquarters of the Phelps Dodge company was located in Douglas, and the city was planned and constructed to accommodate company management as well as workers at the smelter just outside of town. Agua Prieta grew alongside Douglas, serving as a gateway to Sonoran mining and ranching interests and as a Mexican customs port. Although it was not a planned city in the same sense Douglas was, Agua Prieta reflects the influences of traditional colonial town plans in Mexico, with its main plaza flanked by a church and (in the past) government buildings, and its grid pattern of streets (Arreola and Curtis 1993). Mexico's northern border has a higher standard of living relative to the rest of the country, drawing immigrants from the interior of border states as well as from other areas of Mexico (Chavez 1992). It also is attractive to longer-term residents who tend to stay in place. Before 1950, Douglas had a larger population than Agua Prieta; since then, the population on the Mexican side has grown more rapidly. In 1996, Douglas remained a small city of about 15,000 inhabitants, and Agua Prieta had mushroomed to an estimated 110,000 people (Center for Economic Research 1996). Agua Prieta's population increase parallels the growth of the maquiladora industry, which in 1997 employed over 9,400 people (the majority women) in thirty-two factories (Twin Plant News 1997). The continuing growth of the maquiladora industry and related employment opportunities in Agua Prieta drives its population increase. The stability of Douglas's population hides the demographic changes occurring there over the past decades. When the Phelps Dodge smelter closed

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in 1987, many former employees moved away. The newly dominant services and retail trade sectors offer lower-paying jobs compared to the smelter jobs, and represent a different gender division of labor. The large department and grocery stores that opened in Douglas in the 1990s provide low-paying, part-time jobs (e.g., clerks and stockers) that are more available to women than were the higher-paying, full-time jobs available mainly to men at the smelter. Young people continue to leave Douglas in search of greater economic or educational opportunities; at the same time older people have remained or are returning to retire. Douglas thus has an aging population, while Agua Prieta's is young and growing rapidly. In the past two years Douglas has recorded increasing numbers of apprehensions of illegal border crossers, and has become the site of concentrated interest on the part of the U.S. Border Patrol. But many more people cross the border from south to north legally than illegally, and their presence in the United States is vital for the survival of border communities, including Douglas. With the 1994 peso devaluation, Agua Prieta residents found their pesos worth so little in Douglas it did not make sense to shop there, so they stayed home and spent their money in Mexico. The boardedup store fronts in downtown Douglas attest to the community's dependence on Mexican shoppers. With the stabilization of the peso, cross-border shopping resumed its volume. Historically the two cities have had strong cross-border connections. The nature of such ties is changing as political and economic relations and demographics change the cities and the cross-border dynamic. Crossing the border mixes up notions of belonging, of identity. Women on both sides have distinct priorities and attitudes, and different patterns of border crossing. These differences are manifested at various levels and scales, from the most personal construction of identity to the larger scale economic and political relations across the border, and all have gendered consequences. CONSTRUCTION OF IDENTITY Identity has a direct bearing on women's comfort levels as they carry out their daily obligations, especially those who cross the border. Language and ethnicity are two building blocks in the social construction of identity. They are particularly interesting in the border context, where crossing from one side to the other changes the external forces shaping women's actions and possibilities, and can change internal and external perceptions of one's place in the world. For many, stepping across the border means becoming the "Other." One's perspective shifts to that of outsider, and even those who speak the language of the other side are conscious of changes in the rules of conduct and of differences in meanings. This transformation may be subtle, and further muddled when we attempt to understand the lives of certain groups—for instance, Mexican citizens living in the United States

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who regularly cross back and forth. Some do not speak English. The group of women in this study have the strongest ties to Mexico; they are regularly challenged by U.S. customs agents at the port of entry, and may be resented or viewed with suspicion by Hispanic residents on the U.S. side. Ethnicity Graciela would like to call herself Latina, but used the term "Mexican American" instead because "Latinas wear red flowers in their hair and recite poetry in Mexico." Susana wished she could say she was a Chicana, but, at 26 years of age, thought she had missed out on the movement. Selene, born in Agua Prieta to Mexican and Anglo parents, said she is Mexican by culture but not by blood. Juliana, born in Douglas to Anglo and Mexican parents, said she is Mexican by birth but not by culture. Isidra said there is no such thing as sangre pura (pure blood), regardless of which side of the border one is from or calls home. Of the 100 respondents in the study, 87 percent would be identified as "White, Hispanic Origin" by the U.S. census, the remainder as "White." The women used a much wider variety of labels to describe themselves, however, including Native American, Mexican American, Chinese Mexican, indigena, mestiza, hispana, indio-Mexicana, chicana, white, Anglo, Caucasian, and American. Because most of the women of Mexican or other Latin American heritage in the Douglas study group called themselves Hispanic, and most of the women in the Agua Prieta group called themselves Mexicana, I use these two labels in this chapter, with the understanding that they encompass a wide range of genealogies and ideologies, and that any one term is inadequate to convey a true sense of the rich heritage represented by this group of women. The term "Hispanic" is a label brought into popular use by the U.S. government for census purposes and applied to people originating in the countries of Latin America and Spain (Oboler 1995). A long-time resident of Douglas hesitated when I asked her ethnicity, then said "Hispanic." She said that asked in Spanish, she would say "Mexicana" and that a few years ago she would have answered "Mexican American." She was not sure why her definition had changed. One woman in Douglas, who chose to emphasize the Native American part of her ancestry, explained that her father was half American Indian and half Irish, and her mother was born in the United States of Mexican and Spanish descent. She said her husband, born in Douglas to Mexican parents, called himself "white American." This respondent's daughter-inlaw identified herself as Hispanic, then added that she usually said that because it was less complicated than explaining her true background: Her family was Italian, and she did not speak Spanish, but she "looked" His-

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panic. She identified her husband, son of the Native American respondent above, and her children as Hispanic as well. The literature on ethnicity in Mexico focuses on the historical divisions between the Spanish colonizers and the indigenous people, and the mestizos resulting from the collision and enmeshing of those cultures. In conversations regarding ethnicity, several women in Agua Prieta told me that Mexico was ethnically homogenous compared to the United States. Most of the women did not think of themselves or the community in terms of ethnicity. Instead, they identified themselves by place of birth or nationality. A Mexican woman living in Douglas called herself and her Agua Prieta-born children Mexicanos and her U.S.-born children Mexican American. One respondent said, "We are all mestizos, even those from the other side." Some Mexican respondents emphasized their Spanish or other European ancestors, others seemed proud of their indigenous heritage; most (80 percent) simply identified themselves as Mexicana. Ethnicity is a fluid concept whose edges are indistinct in any setting and even more so in the context of two cities divided by the international boundary, where the social construction of identity is entwined with the socially and politically constructed border. The ethnic minority on the U.S. side (Anglos) historically has held most of the political and economic power. Other kinds of divisions, such as employment and income levels, length of residence in the city and family ties are shaped by one's ethnic group, and influence women's access to resources such as transportation and employment. Ethnicity shapes how women are perceived and treated by their neighbors, by local government officials, and by workers in stores, and has an influence on where women feel comfortable and what places they avoid. Although ethnic categories are difficult to define and necessarily overly general, they shape the way women think about themselves and others, and how they find their place in the community. Language Use Whether one speaks Spanish or English is one of the dividing lines among women in Agua Prieta and Douglas, and is an important facet of women's identity. The opportunity to learn English, which can open doors to a variety of opportunities for Mexicans, is generally limited to those who have the resources to send their children to schools in the U.S. or to private lessons. In Douglas, in contrast, learning Spanish often is a natural part of childhood for children of Hispanic parents, and sometimes Anglo parents as well, but has not necessarily been seen as a skill that brings any sort of advantage to the children. Until the 1950s, Douglas's schools were segregated by ethnicity and language use (Bruno 1995). Some of the older Hispanic respondents in Douglas remembered being forbidden to speak Spanish at school and being punished for speaking it at home. Many His-

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panic women in Douglas grew up speaking English first, using Spanish only with their older relatives or when they visited Mexico. Others grew up speaking Spanish and English, as did some women from Agua Prieta. A bilingual Hispanic mother in Douglas said that her children had not been interested in speaking Spanish when they were younger, but now that they had reached their teens they wanted to learn. That Mexican border residents consider speaking English desirable is suggested by the fact that 20 percent of the respondents in the Agua Prieta study group were either themselves attending English classes or had family members attending English classes. Some Douglas residents complained that employees in Douglas stores did not speak English at all, and that one had to speak Spanish in order to find a job. Some Anglo women in Douglas resented that workers in stores spoke to them first in Spanish, and said they spoke back in English even if they understood Spanish. CROSSING THE BORDER Among women in this study, the most important factors shaping the frequency of border crossing included place of residence and nationality or ethnicity. The major difference between respondents from the two cities is that those from Agua Prieta cross the border much more frequently and regularly than those from Douglas: 42 percent of respondents from Douglas cross the border less than once per month, and 64 percent of those from Agua Prieta cross once a week or more. The Douglas respondents who crossed most frequently were Hispanic; half were Mexican citizens residing legally in the United States, the other half were U.S. citizens who regularly visited close relatives living in Agua Prieta. The one Anglo respondent in this group of frequent crossers was employed in the Douglas office of a maquiladora. Outside her business ties, she had no cross-border connections and rarely crossed for reasons other than visiting the company's office in Agua Prieta. Respondents from Agua Prieta who crossed most often included those who had friends or relatives in Douglas, as well as many who had no social ties across the line. Twenty-two percent of Agua Prieta respondents did not cross the border, prevented by structural factors: that is, they did not have the proper documents. Most of those who could not cross would like to be able to enter the United States to shop in Douglas; most had applied for crossing cards. The U.S. respondents who did not cross, in contrast, were responding to personal factors—several said they simply had no interest in going to Agua Prieta; two had no transportation and could not cross the border even if they had wanted to (which neither did). The Mexican respondents in this study experienced the imbalance of power in international relations in a

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personal way, as they had to show a passport and visa, or a crossing card in order to enter the United States. Several expressed displeasure at the fact that U.S. citizens, in contrast, have unobstructed admission to Mexico and easy reentry into the United States. Initially it was thought that lack of a crossing card would reflect shorter length of residence at the border, but of the women who did not have documents (ten respondents in Agua Prieta), only one had lived there less than a year and one was a life-long resident. That it took some women a long time to obtain a crossing card was likely a reflection of the availability of other household members to shop across the border and of the effort required to apply, rather than of women's length of residence. Traditional gender relations in Mexican households are both reinforced and altered by the institutions that establish requirements for certain actions, such as crossing the border legally, that are more difficult for women to meet than for men. For example, half the respondents without crossing cards lived in households where at least one other person, usually their husband, did cross the border. Given the requirements for obtaining a crossing card, it is not surprising that in some households, men would have a card and women would not, as the women were more likely to be involved in the informal sector, to have limited personal discretionary income, and to depend on their husbands for most or all of household income (see Table 5.1). In order to obtain a crossing card Mexicans must have a passport and proof of border residence (difficult if one does not receive utility bills, rent bills, or other official mail at a street address), must show they are employed and have an income (difficult for the self-employed or those employed in the informal sector) or that they have support from an employed person (difficult for the same reasons), that they have money in a Mexican bank account (many people do not use the formal banking system, as accounts and services are expensive and interest payments low), and that through their employer, they are registered for Seguridad Social (Social Security). Political structures control who enters the United States legally and for how long, and impose legal barriers to northbound crossings that do not exist for southbound movements. Passing through customs inspection in both directions can be intimidating for women from either side: The respondents from Douglas spoke of their fear of the uniformed and armed Mexican military guards stationed at the border, and respondents from Agua Prieta frequently mentioned the arrogance and authoritarian attitudes of the U.S. customs inspectors (also uniformed and armed). Mexican governmental institutions were sources of fear and anxiety for some Douglas respondents who crossed the border, but Agua Prieta residents rarely mentioned the presence of the Mexican military and police officers who patrolled the city's streets. Douglas respondents often spoke

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Table 5.1 Crossing the Border Those who cross (percent of all respondents) Douglas (n =50) Cross Do not cross Other household members cross*

Agua Prieta (n==50)

90 10 (n=45)

78

78 22 (n=48)

84

•Two respondents in Agua Prieta and five in Douglas live in single person households. Border crossing frequency (percent of all respondents) Never Less than once/year Less than once/month 1-2 times/month 1-2 times/week Daily, or 3 or more times/week More than once/day

10 4 28 36 14 8 0

22

—

2 12 30 30 4

positively, in contrast, of the presence of U.S. Border Patrol agents. This distinction reflects familiarity with one's own surroundings and confidence in being in the appropriate place. Sometimes respondents from both sides expressed fear of the other side of the border that was of a gendered nature, as they felt that women traveling alone were not safe, particularly at night but also during the day. In other instances their fear was culturally and spatially based, in that women did not feel safe crossing the border or going to certain places on the other side of the border. Most Agua Prieta respondents, though, even those who did not speak English, were not generally fearful of crossing the border. Self-imposed Boundaries Women from both sides of the border established limits on their border crossing, avoiding certain places, or not going out after dark, either alone or accompanied. When asked about places they avoided on the other side of the border, respondents from the two cities differed strikingly in their answers. Douglas respondents expressed fear of or distaste for going to specific places in Agua Prieta, or going across the line in general, but the women from Agua Prieta did not portray going to Douglas in negative terms. The women from Douglas were particularly uneasy about the Mexican police, the bars and discos, gangs, drug traffickers or other criminals,

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getting lost in the city, or driving there. Two women from Agua Prieta said they avoided the parks in Douglas after dark because they were dangerous, but for the most part Mexican women seemed to feel secure in the United States. Among respondents and other residents interviewed, especially in Douglas, it was a generally accepted fact that crime was higher in Agua Prieta than in Douglas, though statistics to support that folk wisdom are not readily available. The newspapers in Agua Prieta highlight crimes and violence more than does the newspaper in Douglas (based on personal observations). Citizens interviewed in Douglas (women and men) conveyed a sense that Mexico is a dangerous place. Because Agua Prieta has a much larger population than Douglas, the numbers of crimes committed could be higher in the former while the crime rate per capita could be similar in both cities. Statistics are not available to determine or compare the actual crime rates for the two cities. Although this negative image of Mexico in general and Agua Prieta specifically was voiced by many respondents from Douglas, few had any tales of personal experiences on which to base their fears. Some of those who were leery of going to Agua Prieta maintained strong connections with Mexican relatives and friends across the border. Their border crossing patterns did not always match their expressed fears of the possible consequences of crossing, because even those who described negative incidents experienced by others or seen on the news were among those who crossed the border alone. Rather than give up going to Agua Prieta, women in Douglas took steps to feel safer when they crossed the border; they always went with their children or husband, only went during the day, or patronized the stores closest to the port of entry, for example.

Cross-Border Destinations Reasons for crossing the border were similar even when the types of destinations were not. For example, a major motivation for crossing the border for respondents from both sides is to shop, but the respondents cross to buy different types of goods or services on the other side. The first destination mentioned by respondents from Agua Prieta was a grocery store, the second was a department store, and a distant third was restaurants (mostly the fast food outlets close to the border). Respondents from Douglas most often mentioned pharmacies as their cross-border destination, followed by restaurants and various grocery or specialty food stores. Women in Douglas tended to cross the border at irregular intervals to buy speciality products such as medicines, cigarettes, tortillas, and other products that do not need to be purchased weekly or more frequently, such as household cleaning products and paper goods. Respondents from Agua

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Prieta, in contrast, made frequent and regular trips to do much or all of their grocery and other household shopping in Douglas. Women from Agua Prieta crossed the border in response to the pull of structural differences, specifically the economic advantages offered by the stores in Douglas or other cities, and amenities such as the dollar economy, reliable postal services, and parks. Many of those who crossed frequently did not have social ties in the United States, and for those respondents, the economic advantages to shopping in Douglas were the main attraction. The frequent and regular trips across the border made by Agua Prieta respondents were for reasons most often related to the daily necessities of life, especially grocery shopping, and to a lesser extent banking and postal services. Crossing the border legally from south to north carries a certain amount of prestige and respect, as legal access to the United States is valued in Agua Prieta. Because of institutional restrictions on legal border crossings, and because more male household members had crossing cards, gender roles in the households of the Agua Prieta study group were changing. Thus, in the 10 percent of Agua Prieta respondents' households where the woman could not cross the border and the men did, men were responsible for the grocery shopping done in Douglas, traditionally a woman's chore. The husbands' involvement in grocery shopping created a household division of labor that reflected the context of residence at the border. The Mexican men participated more often on their own or with their wives in these types of daily household maintenance activities than they probably would in cities away from the border (see Chant 1992; Gonzalez de la Rocha 1994, 115-29; Alonso 1992) or indeed in Douglas. Border crossing destinations and motivations reflected gender roles in Douglas households also. Over a quarter of respondents cited different reasons for cross-border trips for the men in their households. For example, older men often crossed to get haircuts. One Douglas respondent's father, originally from Agua Prieta, went across every day to buy the newspaper and spend time with acquaintances "to be in Mexico." Some respondents' husbands went to Agua Prieta to buy medicines; others had business ties that took them regularly to Agua Prieta. Shopping Across the Line Better prices and higher quality were the main reasons women crossed the border to shop in either direction. Respondents from Agua Prieta said that Mexican products of equal quality were available in the city, but were more expensive. Grocery and department stores run the same advertisements in the Agua Prieta newspapers as in the Douglas newspaper; women took advantage of sales at the grocery and clothing stores to save money

Women's Lives in Douglas, Arizona, and Agua Prieta, Sonora • 87 Table 5.2 Cross-Border Destinations Major Destinations (percent of respondents who mention) Respondents from Agua Prieta (n=39)

Respondents from Douglas (n=45)

Safeway Wal-Mart Restaurants Visit family/friends Cochise College Basha's Mercado Doctor, Dentist Parks Downtown Other stores Bank Post Office Kmart Job-related

Pharmacy Restaurants Tortilleria, panaderia Visit family/friends VH grocery store/mall Curio stores Liquor stores Other grocery stores Doctor, Dentist Beauty Shop

87 67 28 18 15 15 15 13 13 13 10 8 8 5

60 49 42 23 19 19 16 16 7 5

by shopping in Douglas. Some Douglas respondents said items they purchased on the other side (medicines, breads, etc.) had become as expensive in Agua Prieta as they were in Douglas, so those who continued to shop across the border did so because of preference for the Mexican products. Some women from Douglas bought certain types of things in Agua Prieta that women from Agua Prieta elected to buy in Douglas, reflecting their personal preferences for specific products from the other country. Respondents from both sides declared the products from the other side to be of better quality (see Table 5.2). Cross-Border Travel for Health Care Crossing the border for health care was strongly differentiated by place of residence and reflected the distinct health care systems available to residents (Nichols 1992; Skolnick 1995; Ruiz 1992). Low-income residents of Douglas rarely crossed the border for health care services, as they depended on government-sponsored health care plans, such as the Arizona Health Care Cost Containment System (AHCCCS) and Medicare. Respondents in Agua Prieta who could afford to cross the line for health care were of higher income levels and carried U.S. health insurance. Those who saw doctors or dentists in Douglas or Tucson said they felt more confident of the doctors in the United States. Some noted that Mexico had good doctors, but for specialists or operations—the "big stuff," as two respondents said— they preferred to go to the United States, where they felt they obtained better care. Three women from Agua Prieta sought prenatal care and gave birth in

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the United States. In contrast to the image portrayed in the U.S. media, however, most of the Agua Prieta respondents did not seek to give birth in the United States, and most of those who could afford U.S. health care had, nonetheless, borne their children in Mexico. Only one said she gave birth in the United States because she wanted her children to be U.S. citizens. Pope's (1997) research indicated that women at the border were most likely to give birth in the country where their doctor's office was located. The high cost of most medical services and the relatively small number of health care providers in Douglas may also have a bearing on women's choice to have their children in Mexico. Most respondents in Douglas who said they go to Agua Prieta for health care use dental services, most commonly offering the reason that dentists in Mexico do good quality work at much lower prices. In addition to saving money, a common reason for seeing a doctor in Mexico is greater accessibility—respondents noted that it takes a long time to make an appointment to see a doctor in the United States, whereas doctors in Mexico can often see them the same day they call, even if they drop in without an appointment. Crossing the border to buy medications, with or without a prescription, has long been a practice of people in the United States. Pharmacies have strategically located close to the port of entry in Agua Prieta and posted signs in English to attract customers from across the line. Some respondents mentioned, however, that prices of medicines in Agua Prieta were increasing steadily, to the point that soon there would be no advantage to crossing the border to buy them, except, of course, being able to purchase medicines without a prescription. Cross-Border Social Connections For low-income families at the border, including some of the respondents in this study, social connections across the line form an important part of daily survival strategies (e.g., Anderson and de la Rosa 1991; Dwyer 1994; Heyman 1991; Ingram, Laney, and Gillilan 1995; Ruiz 1992). Ties to family and friends across the border did not motivate frequent trips across the border by the majority of respondents, although regular visits once or twice a month were common in both directions. The importance of cross-border connections was not necessarily indicated by the number of trips, but by the regularity and quality of visits. Some of the women in this study group counted on relatives across the line for everything from weekly housing for their children to extra food for their families. More respondents in Agua Prieta had relatives or friends in Douglas than vice versa. In addition, the percentage of Douglas respondents who have relatives or friends across the border is strongly differentiated by ethnic

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group, with a very small proportion of Anglos having cross-border connections. For a few women on both sides, visiting was an important activity when they crossed the border, but the major motivation for crossing was to shop, and visiting was mentioned much less frequently. Some women in Agua Prieta were reluctant to visit friends or relatives in the United States because it cost too much to go—they had to buy gas, would probably go out to dinner, and had to take their relatives gifts of tortillas, bread, or other things from Mexico. Others had relatives in places too far from Agua Prieta for visits on a regular basis, so they stayed in touch by telephone or not at all. One Anglo woman, a life-long Douglas resident, said that when she was young, people from both sides went back and forth across the border as if it were no more than one more street in one city, and everyone in Douglas knew everyone in Agua Prieta. She had few friends left in Agua Prieta, and they no longer visited across the line. Others in Douglas told similar stories, saying that their friends and relatives in Agua Prieta had moved to the United States or had died, so their connections were more distant and no longer drew them across the line. As the population of Agua Prieta continues to grow due to in-migration from other areas of Mexico, the proportion of those who do not have social ties on the other side of the border will rise, and correspondingly, the economic relationship between the populations of the neighboring cities will assume relatively more importance. Examining the border crossing patterns among respondents within the study population, it becomes clear that although frequency of crossing and motivation for crossing vary among the different women—based on ethnicity or income level, for example—crossing patterns cannot be described simply according to single characteristics or categories of women. Most respondents on both sides of the border crossed into the other country at least occasionally. Some women from Agua Prieta crossed so often as to indicate that the border was merely an inconvenience that required them to stop briefly on their way north. For many women on the U.S. side, however, the border represented the end of a safe zone, beyond which exist no guarantees of security or peace. Many of the U.S. respondents felt no need to go to Agua Prieta unless they had visitors from out of town who wanted to see Mexico because it is different and exotic. They did not cross the border for that reason on their own at other times, however. THOUGHTS ON BORDER LIFE Living at the border makes a difference in women's lives in one obvious sense: away from the border it is easy for most people to disregard it, but those who live close to it can hardly avoid awareness of the presence of the border at some level. Residents from one side encounter people from

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the opposite side or go across themselves, they watch the Border Patrol in Douglas or see tourists in Agua Prieta. The border is a fact of life for those who live in communities along it, though the differences that are conspicuous to outsiders are often lost in everyday routine for residents. For example, a woman in Douglas described watching illegal immigrants crawling out of a storm drain on the street near her house, but then could not explain how life was different at the border. Nevertheless, even women who did not feel that life at the border was different from other places, and those who could not put a name to the differences they felt, described border phenomena that would not be part of their lives if they lived elsewhere, such as crossing the border to eat or shop, for example, or seeing the Border Patrol in action in Douglas. In general, the women in Agua Prieta lived there—or, if they were born in Agua Prieta, stayed—because it is near the border, and the community offered opportunities and prosperity not available to them in other places. Only a few women in Douglas lived there because they wanted to be close to the border, which most tended to view negatively. Place of residence is significant in shaping women's attitudes regarding life at the border, and national origin appeared to cut across place of residence and ethnicity in terms of shaping women's attitudes. Mexican women residing in the United States, for example, had more in common with women in Agua Prieta than with U.S.-born Hispanic women in Douglas; they viewed life at the border in more positive terms and felt comfortable traveling in Mexico. Agua Prieta respondents said that women on the Mexican side of the border are more open, liberated, and liberal than those in the interior— characteristics that appealed to them. They also appreciated being able to shop for U.S. products and having ready access to dollars. The American influence on Mexican culture at the border is criticized by Mexicans from other parts of the country, however, and residents of the border who have adopted U.S. cultural practices or do not speak proper Spanish are called pochos by Mexicans from the interior. This derogatory categorization has not stopped migration to the northern border nor participation in crossborder activities and adoption of U.S. customs. The U.S. popular media focus on illegal immigration and drug trafficking, encouraging a generally negative view of the border as a dangerous and unseemly place. This image is perpetuated in the attitudes of many of the women in Douglas who, out of concern for their or their family members' personal safety and health, did not cross the border at all or crossed only in the company of their husbands. Some appreciated the proximity of Mexico, the cultural differences in food, holidays, and art, and the availability of less expensive medicines or medical services. Many, though, saw Mexico as the source of criminals and danger, and would have preferred it to be located a bit farther from their community.

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CONCLUSIONS Women on both sides of the border, with varying levels of success, find ways to negotiate the socioeconomic structures of the two cities and the larger structures of the two countries. Some, because of personal choice or structural barriers, participate only peripherally in the unique cross-border cultural mix, and could as well be living in the interior of their country. Differences in language use and ethnicity among women contribute to the ambiguity and complexity of the borderlands in general, especially to the outsider who at times may not be able to distinguish between residents of Agua Prieta and Douglas, particularly those who cross the border freely and frequently. Women from other parts of Mexico continue to be attracted to the border, including Agua Prieta, because of the availability of jobs in the maquiladora industry, even though the majority of those jobs are low-paying and provide few benefits or possibilities for advancement. Their migration and employment reflect the impact of global and national political and economic structures on local lives. Agua Prieta's poor infrastructure, reflecting the city's rapid growth and the priorities of industrial development, makes the stores, restaurants and parks of Douglas more attractive to residents of Agua Prieta. Many women in Douglas have even more limited employment opportunities than those in Agua Prieta, and must also choose among various minimum-wage jobs with few or no benefits (no industry comparable to the maquiladoras provides significant female employment in Douglas). As a declining resource-based town that historically offered jobs for men, it has not developed a tradition of female-employing industry, and is only now developing a strong service sector. The demographic structures of Douglas and Agua Prieta also suggest that the nature of residents' connections to their respective cities is dynamic. That is, the young population of Agua Prieta has a different set of resources, priorities, goals, needs, and desires than those of the overall aging population of Douglas. The demographics of both cities will continue to change, as the city of Douglas works to attract temporary and permanent retired residents, and in Agua Prieta as the maquiladora industry grows and provides jobs to young people, especially women. Gender roles are significant influences on women's cross-border behavior. Cross-border patterns tended to reflect the gender division of labor in the household, and although some traditional roles were changing within the border context (illustrated, for example, by the high percentage of women on both sides employed outside the home, and by some Mexican men's involvement in grocery shopping in Douglas), others were reinforced. Women continued to be responsible for most child care and transportation, for instance, even when that involved crossing the border multiple times in a day, as was the case for parents of children in Agua Prieta who attended

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Douglas schools. In addition, although some men from Agua Prieta crossed the border to go grocery shopping in Douglas, this remained an activity primarily performed by women. Frequently the respondents went grocery shopping after they spent the day at the workplace and made multiple trips to take children to school and babysitters. Some men participated in transporting children, but this usually meant they also controlled the family's vehicle for the remainder of the day, thus limiting the women's transportation. The factors of importance to women at the border—personal safety, access to quality products at good prices, proximity to friends and family, for example—are those that affect the quality of life for people on both sides. Which side of the border they live on affects how women structure their days and, for some, where they feel comfortable and the businesses they choose to patronize. Their ability to speak English or Spanish affects how they are received on both sides of the border, as well as their access to resources such as jobs, health care, and education. The manner in which women construct their own sense of identity and the ways others categorize them based on how they speak and look and which the side of the border they call home all make a difference in their ability to satisfy the needs and desires of daily life and to build and maintain social ties. Growth and socioeconomic change at the border will continue. Rapid population growth on the Mexican side continues to impact the cities on the U.S. side, and changes in the economic structures of U.S. cities affect those in Mexico. The nature of cross-border connections is dynamic, and economic factors are increasingly important in relations between neighboring cities and the two countries. In spite of the growing importance of economic relations and the instant electronic transfer of information and capital, the international border is not disappearing. Its physical presence and symbolic power draw growing economic and human resources to it, some that frequently have conflicting goals (e.g., the U.S. Border Patrol on one side and Mexican immigrants seeking jobs in the maquildoras or in the United States on the other). Writing about women workers in Ciudad Juarez in 1987, Young asked what "organizational forms exist—or can be created—to enlarge Mexican [and, we must add, U.S.] women's opportunities and capacities for full and valued participation in the development of their society?" (Young 1987, 125). A decade later, the question remains relevant. Government policies and local development practices in border communities that restrict women's access to employment or a livable wage, or that inhibit their crossing the border to find the best quality goods and services (including health care and education) at the best prices simultaneously devalue their roles as providers and as builders of cross-border connections. The maquiladora industry provides jobs to many Mexican women, and women

Women's Lives in Douglas, Arizona, and Agua Prieta, Sonora • 93 constitute the majority of assembly line workers in the plants. It is also commonly held that economic growth in Agua Prieta depends on the maquiladoras, and that Douglas depends on Agua Prieta for its economic survival. As workers and consumers, w o m e n are intimately involved in the development and continued daily existence of the t w o cities. As mothers, grandmothers, wives, daughters, sisters, and friends, w o m e n cultivate and sustain the social connections across the border that contribute to its unique position as a distinct cultural area of both countries. These are qualities of value to communities on both sides of the border, and it is in the best interest of decision-makers in government and industry in both Douglas and Agua Prieta to pay attention to the movements and needs of women.

REFERENCES Works Cited Alonso, Ana Maria. 1992. "Work and Gusto: Gender and Re-creation in a North Mexican Pueblo." In Workers' Expressions: Beyond Accommodation and Resistance, edited by John Calagione, Doris Francis, and Daniel Nugent, 164-85. Albany: State University of New York Press. Anderson, Joan, and Martin de la Rosa. 1991. "Economic Survival Strategies of Poor Families on the Mexican Border." Journal of Borderlands Studies 6(1): 51-68. Arreola, Daniel D., and James R. Curtis. 1993. The Mexican Border Cities: Landscape Anatomy and Place Personality. Tucson: University of Arizona Press. Bruno, Lisa. 1995. "Silent Segregation." Unpublished student paper. Douglas, AZ: Cochise Community College, Humanities Department. Center for Economic Research. 1996. Douglas Perspective: An Overview of the Douglas Economy. Douglas, AZ: Cochise Community College. Chant, Sylvia. 1992. "Migration at the Margins: Gender, Poverty and Population Movement on the Costa Rican Periphery." In Gender and Migration in Developing Countries, edited by Sylvia Chant, 49-72. London: Belhaven Press. Chavez, Leo R. 1992. "Defining and Demographically Characterizing the Southern Border of the U.S." In Demographic Dynamics of the U.S.-Mexico Border, edited by John R. Weeks and Roberto Ham-Chande, 43-60. El Paso: Texas Western Press, University of Texas. Dwyer, Augusta. 1994. On the Line: Life on the US-Mexican Border. London: The Latin America Bureau. Gonzalez de la Rocha, Mercedes. 1994. The Resources of Poverty: Women and Survival in a Mexican City. Oxford, UK: Blackwell. Heyman, Josiah McC. 1991. Life and Labor on the Border: Working People of Northeastern Sonora, Mexico, 1886-1986. Tucson: University of Arizona Press. Ingram, Helen, Nancy K. Laney, and David M. Gillilan. 1995. Divided Waters: Bridging the U.S.-Mexico Border. Tucson: University of Arizona Press.

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Nichols, Andrew W. 1992. "Health Impacts." In Free Trade: Arizona at the Crossroads, 168-81. Background report for the Sixty-First Arizona Town Hall. Phoenix: Arizona Town Hall. Oboler, Suzanne. 1995. Ethnic Labels, Latino Lives: Identity and the Politics of (Re) Presentation in the United States. Minneapolis: University of Minnesota Press. Pope, Cynthia. 1997. "Babies and Borderlands: Factors that Influence Sonoran Women to Seek Prenatal Care in Southern Arizona." Master's Thesis, Latin American Studies Program, University of Arizona. Ruiz, Olivia. 1992. "Visitando la Matria: Los cruces trasfronterizos de la poblacion estadunidense de origen Mexicano." Frontera Norte 4(7): 103-30. Skolnick, Andrew. 1995. "Along US Southern Border, Pollution, Poverty, Ignorance, and Greed Threaten Nation's Health." Journal of the American Medical Association 273(19): 1478-82. Twin Plant News. 1997. "Maquila Scoreboard." Twin Plant News, October, 43. Young, Gay. 1987. "Solidarity among Maquila Workers in Ciudad Juarez." In Women on the U.S.-Mexico Border: Responses to Change, edited by Vicki L. Ruiz and Susan Tiano, 105-27. Boston: Allen and Unwin.

Suggested Readings Anzaldua, Gloria. 1987. Borderlands/La Frontera: The New Mestiza. San Francisco: Aunt Lute Books. Byrd, Bobby, and Susannah Mississippi Byrd, eds. 1996. The Late Great Mexican Border. El Paso, TX: Cinco Puntos Press. COLEF. 1993. Mujer y Frontera 8. Ciudad Juarez: El Colegio de la Frontera Norte y Universidad Autonoma de Ciudad Juarez. Gonzalez, Soledad, Olivia Ruiz, Laura Velasco, and Ofelia Woo, eds. 1995. Mujeres, Migracion y Maquila en la Frontera Norte. Mexico, DF: El Colegio de Mexico, El Colegio de la Frontera Norte. Lamphere, Louise, Helena Ragone, and Patricia Zavella, eds. 1997. Situated Lives: Gender and Culture in Everyday Life. New York: Routledge. Marmon Silko, Leslie. 1996. Yellow Woman and a Beauty of the Spirit. New York: Touchstone. Nathan, Debbie. 1991. Women and Other Aliens: Essays from the U.S.-Mexico Border. El Paso, TX: Cinco Puntos Press. Peria, Devon. 1997. The Terror of the Machine: Technology, Work, Gender, and Ecology on the U.S.-Mexico Border. Austin: Center for Mexican American Studies, University of Texas. Ruiz, Vicki and Susan Tiano, eds. 1987. Women on the US-Mexico Border: Responses to Change. Boston: Allen and Unwin. Velez-Ibanez, Carlos G. 1996. Border Visions: Mexican Cultures of the Southwest United States. Tucson: University of Arizona Press.

6 Creating a Future for Hispanic Mothers and Daughters on the U.S.-Mexico Border Josefina Villamil Tinajero and Dee Ann Spencer

INTRODUCTION Rosa felt the thump of her life hitting bottom. What kind of future could a laid-off, divorced factory worker possibly offer a 9-year-old son and an 11-year-old daughter? "I'd get depressed," Rosa said. "But I found the strength in my children." That was thirteen years ago. At age 39, Rosa tossed her graduation cap into the air with the class of 1992 at the University of Texas at El Paso (UTEP). With a fresh bachelor's degree and teacher certification in bilingual education, Rosa became the first college graduate of the Mother-Daughter Program. She went on to graduate school and completed her Master's Degree as a curriculum specialist with a specialization in bilingual education/math and science emphasis. Rosa and her daughter became involved in UTEP's Mother-Daughter Program in 1986, the first year of the program. That's where she found the spark she needed. The program's primary purpose was to encourage girls like Rosa's 11-year-old daughter Jessica to stay in school and prepare for college. Today it is Rosa who proudly displays her UTEP diplomas in the family's living room. Her daughter Jessica is following in her footsteps. Rosa is only one of some 1,100 stories of women in the MotherDaughter Program. She claims that her experience is no isolated success story, that it is but one of many testimonies of how much struggling single mothers can achieve once someone opens the door to their dreams. Food stamps and subsidized housing, she said, supported her family for a few

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years while she got her education. They were a necessary temporary help, she said, to be repaid now by devoting herself to a teaching career. The pay-back is indeed twofold. As a first grade bilingual teacher working with non-English speaking children in a campus with over 90 percent Hispanic children, she talked like a seasoned pro. "Children will deliver, but you've got to demand it," Rosa said four years ago. And she has now started her own grassroots education effort, urging other women in her housing project to see their dreams and to claim them by returning to school. Two years ago, Rosa left the classroom to dedicate herself to working with other teachers. Rosa remembers her own dark days of struggle, overwhelming personal problems and failed confidence. "I had never even dreamed of going to college," she tells other women. "I listened to other women who came to speak to us during the program and saw what was possible. Then something sparked in me, some hunger for learning." There were "rough spots," she confided, "the sleepless nights I spent studying, the difficulties of going to school and working to pay the bills, often leaning on my children as tutors. Many times I felt this was not for me that I was not smart enough to do it," she said. "But I thought if my children saw me quit, then how could I tell them, 'You have to go to college.' " No one in Rosa's family, male or female, had ever gone to college. "My mother Maria Luisa spent a lifetime working as a housekeeper. My mother never had an education." This is the hope, this is the future that the Mother-Daughter Program aims to instill in the mothers and daughters involved in the program. For the last thirteen years, program administrators have been working with young Hispanic girls and their mothers to help them to explore their interests, talents, and potential and to set goals, to set them high, and to reach for the stars. And they have lived up to those expectations. A program originally intended to help girls primarily had resulted in also empowering mothers to further their own education and to help their daughters finish theirs. This chapter describes a program developed at The University of Texas at El Paso, on the El Paso-Cuidad Juarez border that was designed to change the educational aspirations, expectations, and life successes of Hispanic girls and their mothers. We provide an overview of the need for such a program, describe the organization and activities of the program, and report the effects of the program on mothers and daughters who have participated.

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THE NEED FOR PROGRAMS FOR HISPANIC GIRLS The Growth of Hispanic School Enrollments Predictions of demographic growth in the United States show that by the year 2020, 15 percent of the population will be Hispanic—a significant increase from their current 9 percent, and by 2040 they will represent 18 percent, or one in every five, Americans. Furthermore, it is estimated that by 2010, Hispanics will surpass African Americans as the largest minority in the country (Rong and Preissle 1998). The growth of Hispanic population in the border states has had a dramatic effect on school enrollments. For example, the Hispanic enrollment in Texas schools increased between 1986 and 1994 from 32.5 percent to 36.1 percent. Where the U.S.-Mexico border meets in El Paso County, Hispanics represent 70 percent of the population, as compared to 25 percent for Texas. During the 1984-1985 school year, the enrollment of Hispanic students reached 75 percent, and in four of the nine school districts the proportion reached 90 percent. By 1993 the two largest school districts in El Paso County, the El Paso Independent School District (64,141 students) and the Ysleta Independent school District (49,388 students), had Hispanic enrollments of 80.2 percent and 86.8 percent, respectively (NCES 1996b). These figures showed continued growth throughout the county to the 1997-1998 school year. For example, Hispanic enrollments for the nine school districts were highest in San Elizario at 99 percent, followed by Fabens at 96 percent, Tornillo at 96 percent, Anthony at 94 percent, Canutillo at 92 percent, Clint at 90 percent, Socorro at 88 percent, Ysleta at 84 percent, and El Paso at 75 percent. Given the rapid demographic growth and majority representation of Hispanic students in border schools, it is crucial to look closely at the demographic characteristics that describe these students and identify areas of greatest need. For example, the high incidence of poverty (to be discussed later in this chapter) in El Paso and the surrounding border areas, creates inestimable problems for schools in attempting to meet the needs of children and their families who sometimes live not only in poverty conditions, but in colonias with no potable water and high rates of communicable diseases and dental caries. For students living under these conditions, staying in school is a formidable task. Such conditions are not taken into account when looking at dropout statistics and the underlying rationale that might explain Hispanics' higher dropout rates. Nevertheless, these statistics are summarized in the next section.

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Table 6.1 Dropout Rates for Students in the United States, by Ethnicity, 1975 to 1995

Hispanic African American Anglo

1213. 29.2 22.9 11.4

12&5. 27.6 15.2 10.4

1113. 30.3 12.1 8.6

Source: NCES, 1996a.

Hispanic Students' Persistence in School Hispanic dropout rates are much higher than those of Anglo and African American students. As shown in Table 6.1, although dropout rates for African American students dropped considerably between 1975 and 1995, and dropped somewhat for Anglo students, for Hispanic students, dropout rates stayed at the same high rate of about 30 percent, or two and onehalf times that of African American students and three and one-half times that of Anglo students. Although in 1975 dropout rates for Hispanic girls (31.6%), were somewhat higher than for boys (26.7%), by 1995 their dropout rates were the same (30%) (NCES, 1996a). Rong and Preissle (1998) further disaggregated these data and found that although the overall dropout rate for Hispanics was 30 percent, the dropout rates for 17-year-old Mexican students was 34 percent, and was 48 percent for 18-year-olds. While these figures represent yearly dropout rates, when looking at high school completion rates for 18-year-old Mexican immigrants, only 18 percent complete high school, the lowest rate of all immigrant students. The rates also were lowest among immigrant groups for Mexican children between the ages of 12 and 18 years who had completed five years of elementary school (94%) and for those between 14 and 18 years who had finished eight years of schooling (63%). Rong and Preissle point to the seriousness of this problem if it is considered that, "Between 7,000 and 10,000 Mexican foreign-born youth aged 17 and 18 who are not in school each year may never have been in school; they may be functional illiterates in both English and Spanish" (1998,105). This theme is continued in a recent report of the Hispanic Dropout Project, which concluded that dropping out of school limits Hispanic youth to unemployment or to low-skill jobs, which in turn relegates them to lives in poverty (Secada et al. 1998). Commissioned by the U.S. secretary of education, Richard W. Riley, to increase public awareness of the seriousness of issues related to high Hispanic dropout rates, a panel of experts concluded that "the career and employment prospects for [Hispanic] dropouts are dismal" (6). This prospect, coupled with the fact that in the near future Hispanics will become the largest ethnic minority in the United States,

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means that there will be a large proportion of this minority group who will not be prepared for employment in the twenty-first century (Secada et al. 1998). Aspirations to Higher Education In 1997, of Hispanics 25 years and older, only 7.5 percent had received bachelor's degrees (as compared to 16.5% for Anglos and 9.5% for African Americans), 1.8 percent master's degrees (as compared to 5.5 percent for Anglos and 3.0 percent of African Americans), and .5 percent doctorate degrees (as compared to 1.1 percent of Anglos and 0.3 percent of African Americans) (U.S. Census Bureau 1997). A comparison of the educational aspirations of high school seniors in 1972 and in 1992 showed that Hispanic seniors were much less likely than Anglos and African Americans to aspire to four-year colleges, and much more likely to aspire to a two-year academic program (NCES 1996a). For example, in 1992 only 20 percent of Hispanic seniors planned to attend a four-year college compared to 55 percent and 52 percent for Anglos and African Americans, respectively. Although there were increases between 1972 and 1992 for all groups in choosing a four-year college, Hispanics showed the largest gain in the percent who planned to attend a two-year program (from 1 1 % to 26%). Among the three groups, Hispanics were the most likely to delay the transition from high school to college. The report concludes that this factor, combined with Hispanics' choice to go to twoyear colleges and attend as part-time students, made it less likely they would seek and complete a bachelor's degree. At UTEP, which draws students from both the El Paso and Ciudad Juarez areas, has an Hispanic enrollment of 79 percent. Although 40 percent of freshman students drop out of the university, of the 60 percent who continue only 13 percent graduate in four years, 19 percent graduate in six years and 31 percent in more than six years (UTEP 1998). These figures would indicate that Hispanic students do graduate in greater numbers than some sources would indicate, but they take more years to do so. Longitudinal studies of incoming Hispanic students would provide a clearer picture of their educational persistence and should take into account that these students work and support families while continuing and completing their education. The Needs of Hispanic Girls Although the dropout rates for Hispanic boys and girls are at the same high rate, girls face far more obstacles to completing their education than do boys. Among them are a greater probability of becoming pregnant, being a single head of household, and living in poverty. These factors greatly

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limit females' access to and information about higher education and the possibilities for entering the work force in careers that would change their economic conditions. Teen Pregnancies One of the most alarming statistics describing conditions of children in Texas was their rank of forty-eighth among the states in teen birth rates (Annie E. Casey Foundation 1997). Stoddard (1993) has pointed to an even more acute problem in border regions of Texas. He reported that in El Paso, for example, between 1978 and 1993, one of every seven teenagers was a mother. Between 1987 and 1990 alone there was a 26 percent rise in the number of births to girls between the ages of 10 and 14 years. Of these extremely young girls who were mothers, Hispanic and African American girls had 50 percent higher birth rates than did Anglo girls. The effects of this problem are far-reaching, as Stoddard vividly describes: El Paso has unusually high numbers of early school dropouts, early marriages and high birth rates (including teenage mothers), all of which lead to high dependency ratios and subsequent economic struggles. Its poverty climate forces an unusually heavy demand upon local, state and federal welfare services while its limited tax base is inadequate to develop the required infrastructure to provide these services. Limited state funds for welfare aid are made available but educational occupational opportunities have traditionally been redirected to more politically-powerful regions of the state (1993, 88).

Poverty Startling data is also revealed when looking at the incidences of poverty among families and among children under the age of 18 in El Paso County (U.S. Census Bureau 1998). In 1993 there were 201,749 people of all ages in poverty, or 30.2 percent of the population of the county. When looking only at the city of El Paso for children under the age of 18 in poverty, this figure jumped considerably to 41.7 percent (Annie E. Casey Foundation 1998). This percentage is a significant increase over a twenty-four-year period when, in 1969, there were 25 percent of children in poverty, 29 percent in 1979, 34 percent in 1989, and 41 percent in 1993. This figure is astronomical if we consider that according to the Kids Count Project, an annual assessment conducted by the Annie E. Casey Foundation (1998), Texas ranked forty-first among the states in their rate of child poverty at 28.6 percent. The figure of 41.7 percent for El Paso County is nearly one and one-half times that amount. Child poverty rates also are reflected in the fact that over half of all Hispanic female parents are single heads of household living in poverty (see Table 6.2) (NCES 1996b).

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Table 6.2 Percent below the Poverty Level: Total in All Families and Families with Female Householder (No Husband Present), by Ethnicity, 1975 and 1995

1113

All Families FfflBftlft ffftflti All All Races 10.9 37.5 White 8.3 29.4 Black 30.1 54.3 Hispanic 26.3 57.2

1113

Families Ffffllfllft ffftflti 12.3 36.5 9.9 29.8 28.5 48.2 29.2 52.8

Source: NCES, 1996b.

Hispanic Women in the Work Force The effects of high dropout rates, high pregnancy rates, and high levels of women who head households in poverty conditions among Hispanic women are interrelated to their opportunities in the workforce. For example, of Hispanic young women aged 16 to 19 years, 26.4 percent are unemployed. As seen in Table 6.3, the earnings for Hispanic women who are full-time workers are significantly less than for any other group (Kirk and Okazawa-Rey, 1998). The fact that the pay of Hispanic women is far lower than for any other group is an indicator of their high levels of poverty, their high rates of unemployment or part-time employment, or their employment in low paying, dead-end jobs.

RECOMMENDATIONS FOR CHANGE The sobering statistics that describe the socioeconomic conditions of Hispanic women in border regions call for special programs that address these issues early in girls' development and educational levels. Such programs should communicate information to girls and their mothers who experienced the problems associated with low levels of education, poverty, underemployment, and early pregnancy. This perspective is supported by a study by Van Fossen and Sticht (1991) that found that a mother's education is the greatest predictor of her children's success in school. They continued that if a mother had limited basic skills, it was difficult for her children to succeed in school. But if her basic skills and educational level were enhanced, her children had a greater chance to improve their educational level as well. In the traditionally close-knit Hispanic family, the mother exerts a particularly powerful influence on her children. In a study on the modeling influence of Hispanic mothers, Fleming (1982) found that 49 percent of Hispanic respondents said their mothers influenced them a great deal, com-

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Table 6.3 Average Earnings for Year-Round Full-Time Workers, by Gender and Ethnicity Gender and E t h n i c i t y W h i t e men A l l men B l a c k men W h i t e women A l l women H i s p a n i c men B l a c k women H i s p a n i c women S o u r c e s : U.S. Census Bureau,

Average Earnings $30,266 29,421 22,075 20,794 20,553 19,771 18,720 16,244 1991/ Kirk and Okazawa-Rey,

1998.

pared to 40 percent of Anglo respondents. Thus, Hispanic mothers have the potential for influencing their daughters' and sons' educational career choices. However, because most Hispanic mothers come from low socioeconomic backgrounds and have relatively low levels of educational attainment, they often do not model appropriate educational and career aspirations for their children. And yet it has been shown that even for Mexican American women in college and graduate school, maternal encouragement was one of the key variables predicting achievement (high grades and continued enrollment). Building upon these needs and possibilities for changing the pattern for Hispanic women, a program was developed at UTEP—the MotherDaughter Program. This program was used as an exemplary preventative model by Stoddard (1993) in his analysis of data on the high rates of pregnancy among Hispanic girls in border region reviewed earlier. In addition, the program has addressed the other social problems faced by Hispanic girls and women in El Paso: low levels of education, high rates of poverty, underemployment, and early pregnancy.

THE MOTHER-DAUGHTER PROGRAM Goals and Objectives The Mother-Daughter Program was developed in 1986 at the University of Texas at El Paso by concerned individuals from the university, the YWCA, El Paso's school districts, and the community. The program was designed to encourage Hispanic girls and their mothers to value education, to improve their academic and life skills, to develop their leadership potential, and to encourage them to aspire to professional careers. The MotherDaughter Program model developed with a clear understanding of and sensitivity to the cultural, linguistic, geographic, and socioeconomic realities

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of the lives of the girls, their families and the community in which it was implemented. Significant among the many factors that shaped the model was an understanding of both the traditional cultural norms and values of the Hispanic family, as well as the on-going effects and pressures of acculturation on first and second generation family members. More specifically, the program aims to (1) build girls' self-esteem; (2) support girls' completion of high school and raise expectations of attending college; (3) orient girls to higher education and professional careers; (4) provide girls with academic and life skills training to support preparation for higher education; and (5) increase Hispanic parental commitment to higher education by involving both mothers and daughters in the educational process. The Mother-Daughter Program differs from most other educational retention and leadership programs in three important ways: (1) sixth-grade girls rather than high school girls are the focus of the program's primary efforts; (2) mothers are considered to be an integral part of the program and are required to participate with their daughters; and (3) the girls and their mothers are exposed to role models and new life options through interactions with Hispanic university students, professors, and other professionals, as well as with successful women in many other careers. Selection of Participants Since 1986, each year increasing numbers of mother-daughter teams are selected to participate in the program. Criteria for selection includes having parents who have not graduated from college and have low incomes and being identified by school personnel as having potential (not merely grades) to achieve. By 1998, 2,200 mother-daughter teams have participated in the program from nine out of ten school districts in El Paso County. Program Philosophy and Activities Program activities are linked to the program philosophy as follows: 1. High expectations and a strong academic curriculum challenge both teachers and students and have far-reaching effects. Low expectations result in a watered-down curriculum. As Mother-Daughter alumnae enter high school they are encouraged to enroll in college prep courses and honors courses as early as possible in their high school career. In the early stages of the program, tutoring was offered by the program's staff counselors in order to help the girls succeed in their endeavor. 2. Early identification of college-bound students enhances chances for better preparation. Early identification should not be rigid, should avoid tracking, and the selection of college-bound students should not be left entirely to school personnel, or be based entirely on test scores and grades.

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Given a proper explanation of the expectations and responsibilities, students should be allowed to enter the college process at any point in their high school careers. Mother-Daughter district and campus coordinators work closely with school counselors to address the academic needs of our alumnae as determined by the monitoring of their course choices, grades, and extracurriculars. Those having difficulties receive tutoring and if more serious difficulties arise, they are referred to district programs already in place to correct these. 3. A well-developed information system is especially important in schools where Hispanics have not traditionally been part of the collegebound program. Students need to be alerted about visits from college recruiters, admission tests deadlines, college days/nights, college fairs, college orientation days, scholarship deadlines, and so forth. Teachers need to be attuned to these activities in order to plan lessons accordingly and to provide assistance whenever necessary. Parents need to be aware in order to provide support and encouragement. Counselors need to be sensitive to the community's language preference, which may require that they provide translated information and will ultimately impact many areas of students performance on standardized tests. Mother-Daughter Program staff and the district and campus coordinators have established this type of "information network" for program alumnae and schedule weekly school visits, parent workshops, and individual counseling in order to provide these services. During the first year, sixth graders visit UTEP on four occasions throughout the year in order to reinforce these efforts: an open house and tour of the university, a career day, a leadership conference, and a summer camp on campus, which culminates in an awards ceremony. These activities provide the girls with their first exposure to a college atmosphere, including classes, seminars, and dormitories; to Hispanic university students who discuss their career goals and experiences; and to an array of career options. They meet with successful Hispanic women role models from a number of professions who talk with the girls about the advantages of pursuing a college education, as well as the ways they overcame obstacles while going to college. 4. An organized effort to prepare students for standardized testing, college admissions, and financial aid applications is essential. Students need not only information on deadlines, workshops, visits, and so on, but also an understanding of the importance of these processes for getting into college. Activities have been designed by the Mother-Daughter Program staff and district and campus coordinators in order to help our alumnae successfully complete each step in the college-bound process. Our alumnae attend "U.T.E.P. Alive," an event sponsored by the university in order to inform

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future students of the college admissions process. They are also informed of college fairs and financial aid workshops. 5. A well-defined role for resource groups, including parents, teachers, and community organizations should be creatively designed to fit the needs of the individual learning environment. The Mother-Daughter Program's collaboration with community organizations has resulted in a series of workshops provided by those organizations to address several areas of personal development by creatively integrating community resources with their "Life Planning Education: Youth Development Program" curriculum. Instructional field trips have been scheduled in order to further acquaint the girls with the day-to-day realities of numerous professions. In addition, the Mother-Daughter Program staff and district and campus coordinators keep the girls and their families informed of community services of all types. In addition to these activities, the mother-daughter sixth grade teams meet one Saturday each month for a year. Sessions are held at the university, in the schools, at the YWCA, or in the community. All activities are planned around four areas important to the development of both mothers and daughters. These are: (1) career development, (2) academic development, (3) community life development, and (4) personal development.

RESULTS OR EFFECTS OF THE PROGRAM Assessment of the program has included a range of methodologies. Among them are examination of students outcomes or performance and persistence in school, focus group interviews with participants and their mothers to ask questions about their opinions of the program as well as about the impact it has had on their lives, and written life histories. Performance and Persistence in School In the spring of 1992, indicators were identified to help determine program successes in terms of whether or not the girls appeared to be college bound and preparing themselves to succeed in college. The following indicators were examined for the girls in the program: (1) enrollment in high school college preparatory honors courses, (2) GPA, (3) level of mastery on the Texas Achievement Assessment Skills test, (4) reported dropouts, and (5) pregnancy rates. Data for girls participating in the program in 1986-1987 and 1987-1988 who were in the ninth and eleventh grades in the spring of 1992 were collected from the three school districts participating at that time (Tinajero 1992). From these data we found that:

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1. Ninety-eight percent of the 233 girls were still enrolled in schools. This represented a 1.5 percent dropout rate among Mother-Daughter participants, compared to a 7 percent dropout rate reported among Hispanic girls attending the same high schools who did not participate in the program. 2. Sixty-two percent were enrolled in college preparatory courses with almost 50 percent enrolled in honors courses. 3. Seventy-six percent of the first-year participants and 62 percent of the secondyear participants were A-B students. 4. Mother-Daughter alumnae achieved complete mastery on the Texas Achievement Assessment Skills test at higher rates than district averages. 5. From 1989 through 1991, only three Mother-Daughter alumnae in one school district had become pregnant, and none had become pregnant in the other two school districts. Another study conducted in May 1993 collected data on the first thirtythree girls to enter the program in September 1986. The following results were reported: 1. Thirty-two of the thirty-three girls graduated from high school in 1993. (One girl died while in high school.) 2. The average grade point average (GPA) among the thirty-two girls was 86 percent (B+). 3. Ten of the thirty-two girls had GPAs of 90 percent or above (A); the highest was 97.8 percent. 4. Thirty of the thirty-two girls enrolled in college. These statistics reflect the tremendous positive impact of the MotherDaughter Program on project participants, particularly as it pertains to persistence in school. They provide support for the underlying philosophy of the program, which aims to raise expectations and educational outcomes for Hispanic girls. For it is by raising the expectations of young Hispanic girls and their mothers that the program helps them create their own hopes and their own bright futures.

PERSPECTIVES ON THE PROGRAM In the spring of 1994, focus group interviews were conducted with daughters and with mothers to ask them about their perceptions of the program. The following presents a synopsis of these interviews.

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Junior High School Girls' Perceptions of the Program. These girls had just completed their first summer and school year participation in the program. The girls' overall perceptions of the programs included comments on activities, on prospects for their future, and their involvement in community service projects. They also commented on their parents' feelings about the program, the influence of role models they had contact with, the influence of the program on their school work, as well as their goals for the future. Among their comments were: • It's a great experience. • My family thinks it's great because it will probably bring me to college. • My mom and my dad like it; it's even made them think about going back to school to finish college because my dad was in college, but he got out. So he's thinking of going back in and so is my mom. • They (speakers on career day) just want us to fulfill our dreams, pushing us to go all the way through college and make our goal. The girls mentioned a number of ways that the program had helped them. One of the things mentioned was improved family communication and becoming closer to their mothers. Another said she was making the honor roll now, and a few of the girls spoke about more motivation in school and "trying to get better grades." One of the girls mentioned being less shy, and several mentioned changes in attitudes and pride in being part of the program. They also said that the program encouraged them to go to high school because "a lot of people are dropping out." One of the girls shared that "they teach us not to go the wrong road, to keep on track and try to make straight A's or try not to drop out." They also reported that in talking to older girls already in high school, they see that they are making special efforts to do well and to aim for higher education. High School Girls' Perception of the Program These girls had been in the program for at least three years at the time of the interview. Asked the same questions, they had vivid memories of their trip to UTEP as sixth graders and felt the program continued to have a strong, positive impact. • Seeing all those women and the things they were doing, I got insight into engineering because I always liked math and science. I got to look at my options. • We were told, 'You don't need your boyfriend or your husband to be telling you what you are going to do. As long as you want to do it, that's all that matters.' But I always remember that now, and even with my teachers, especially when it's

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a male teacher and he's trying to get you to do something, you're like, no excuse me, I'm sorry, you're wrong. I guess she taught us to be strong willed. The girls commented that the p r o g r a m impacted on their school careers and preparation by influencing the courses they took or didn't take, as seen in the following example. • I went and talked to my English teacher and finally got to be a tutor for writing and reading. It took me away from just being in a regular homemaking class. It helped me not being shy, and now I can stand up for what I believe in. These girls, like the younger girls, also mentioned that the program had helped improve communication within their families. "I guess I got close to my m o m . Before I didn't really tell her stuff, but now, 'Hey, M o m , talk about this.' " Mothers' Perceptions of the Program The mothers w h o participated in the focus group interviews had daughters w h o had been in the program from their first year to as long as seven years. They discussed the role of the program in their lives and the influences of the program on their daughters. "It makes mothers aware of funding to help kids go to college," they said. " T h e girls think they can make money without college, but Mother-Daughter shows girls that college is important even to raise a family and that financial success comes from a good career." The program was said to show them " m a n y different avenues they can pursue, and the need to p l a n . " "It shows them what's i m p o r t a n t . " In general, the program had given mothers a support system for themselves and for their daughters. • I decided to get really into it because it was at that particular time that I had been laid off from my job and I realized I was having such a hard time that I realized that if I had more education I wouldn't be going through such a tough time. I decided to take my daughter because I wanted her to realize also and if somebody was taking the time to select my daughter and she was lucky enough to be selected and somebody was taking the time to show her the other side, then I wanted her to be a part of it. I like what they showed her and I wanted to be a part of it. • They introduced her to different options that she could take and they also introduced both of us to the information that we needed to seek a college education as a possibility rather than a dream. I had that dream for my daughter and I especially would talk to her about it, but I really didn't see it as a reality. The mothers agreed that the program had brought them closer together with their daughters. " W e ' r e communicating more in a not child-mother

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way but more her equal, her friend." Another mother said that she listened more to her daughter, "No matter how silly her ideas may be or how shocking, O.K., I have to sit back and listen." Not only did the mothers feel that they were paying more attention to their daughters, but that the attention and understanding were active in both directions. "It [the program] has brought us closer; she has become aware of what I have to do." The mothers reported direct effects on their self-perceptions, concomitant with a new sense of self-esteem and an awareness of possibilities they had never had previously. One of the women related a not-unfamiliar story: "I had always been told by a male that I would get nowhere, that I would never amount to anything and that if I left him he would never help me with my children and that I would be in the street. So when MotherDaughter told us that they believed in us, I said, well, maybe I should believe in myself too." Among the unintended consequences of the program was the influence it had on the mothers' own educational aspirations. In gaining information for their daughters about college entry and requirements, they began to see the possibilities for themselves. They indicated they felt excited about the possibility of going back to school. "The program has made me realize that at my age of 33 I am still young enough to do something with my life," said one mother. And another explained, "I don't feel as scared as before, when I used to think about going back to school." • I love the point in my life that I'm at and I feel that I owe most of it to being a member of the Mother-Daughter Program because it really, I mean, you think about it and you have all these excuses why you don't come back to school and I can't afford it and I can't do it. But you start, you know, I don't see any other way to go now, just to stay in school. • When I started going to school, it was like a light had come into my life and it was the most wonderful experience. As I saw myself there with other older people and with younger people, I thought to myself, this is exactly what it's all about and I loved it. SUMMARY

Interviews with mothers and daughters over time, as well as in journals they wrote to document their feelings and perspectives, showed that the program has had a positive impact on both mothers and daughters. After their first year they knew the direction the program was taking them, they talked about careers and college, and were closer to each other. The girls indicated that their participation had helped them learn about different academic fields. Campus visits and classroom exercises gave them a flavor of university life, a better understanding of what is expected of college students, and the preparation needed to succeed. The girls also reported that they learned about the importance of studying and earning good

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grades. Mothers reported that the program had given them higher expectations for their daughters and their other children, and they took a more active role in their daughter's education. Both mothers and daughters reported that the program had created a hope and a brighter future for them because they received the extra attention they needed to stay in school and to go on to college. Most important, both mothers and daughters reported that the program had instilled in them the confidence to believe in themselves, to set goals, to maneuver past any obstacle, and to reach for the stars.

CONCLUSIONS The Mother-Daughter Program has made a significant positive impact on the lives of hundreds of girls and the mothers in the El Paso area. It has specifically targeted the needs of women living in U.S.-Mexico border regions where low levels of education; high dropout rates; unemployment or employment in low paying, dead-end jobs; teen pregnancy; and poverty have characterized life for many women. By targeting the factors of greatest need, as well as creating a supportive network through which women perceive and understand options for changing their lives, change has been possible for an ever-increasing number of women. The Mother-Daughter Program is a prototype of the kind of programs recommended by the Hispanic Dropout Project mentioned earlier in this chapter. Although the project offered extensive recommendations for curbing the Hispanic dropout rate, in brief, they recommended a collaborative approach between teachers, parents, schools, local communities, and colleges of education for providing students with a high quality, challenging, and meaningful education. Such efforts would demonstrate respect for students and their parents, would begin early intervention with students (in elementary school), would include opportunities for students to meet successful Hispanic college students and professionals, and would provide help for parents to envision a future for their children. They would also necessitate caring teachers who have high expectations for students as well as an understanding of their culture, and would support the creation of effective schools that offer, and regularly monitor and assess, programs and services that work best with Hispanic students. Such a collaborative effort has been created through the Mother-Daughter Program. The program's proactive approach, rather than stop-gap approach, to dealing with serious social problems has been instrumental in establishing new expectations for success in school and in professional careers among the participating mothers and daughters. In the long run it will also help ameliorate the negative consequences of social conditions for women living on the border. The

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impact of the p r o g r a m is best illustrated in the words of Jessica Juarez, w h o was in the first cohort of girls in 1986. My name is Jessica Juarez. I am an 18-year-old senior at Ysleta High School, and I am proud to be Ysleta District's Mother-Daughter Alumna. Mother-Daughter, for me, has been that little voice in the back of my head that says, "Keep on going, don't give up because you can do it\" Through exposure to the Hispanic female professionals I received as a sixth grader, I realized the reality of me going to college. It was always a dream of mine and something that I considered doing because I saw how my mother suffered because she was not able to make enough money due to the fact that she had not gone to college. That little spark for a better life was instilled in me by my mother, but it was made an outrageous fire by the Mother-Daughter Program. They added to the spark by showing me professional Hispanic women who came from where I was and were in the same situation and facing the same worries I was. They each had a message and were living proof of that message: "You can do it!" is what they told us. "Don't settle for anything less than what you deserve, and you deserve it all." They themselves were proof enough. Listening to them talk made it all real. I admired them and saw them as hope for my future, but what made the fire outrageous for me was the fact that one of my own had done it, and I witnessed it all. The day my own mother graduated from the University of Texas at El Paso was the proudest day of my life. Sometimes we joke around about me being my mom's mother because she's still very much a kid at heart, a characteristic that contributes to her being a stupendous teacher. That day, I felt like a proud mother and cried like one, too. For a moment I saw myself having the diploma handed to me because it is I who will be the next college graduate in the Juarez family with my brother Michael succeeding me because he, too, was inspired by the program. At first he resented being dragged out to UTEP on a Saturday morning with "a bunch of girls," as he put it! But his feelings soon changed because he too was inspired by Hispanics earning college degrees. You could catch all three of us most any week night doing homework on the dining room table sharing ideas and asking each other for help. Now I know that there are so many things I can do with a college education that deciding on a specific major has become very difficult. What I do know for a fact is that I will be the second college graduate in my family and that whatever it is I decide to do I will not forget who I am, where I came from and what I have to do—and that is to encourage young people like myself to not shortchange themselves by not bettering themselves and failing to take the opportunity of obtaining an education. I'm considering becoming a pediatrician, but as Winston Churchill said, "We make a living by what we get, but we make a life by what we give." I plan to make the best of this life by becoming the best that I can be. Thank you Mother-Daughter for showing me the way.

Jessica gave this speech in 1993 as a high school senior who was awarded her school district's Mother-Daughter Alumna Award. She is currently

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working t o w a r d completion of her bachelor's degree at the University of Texas at El Paso. REFERENCES Annie E. Casey Foundation. 1997. Kids Count Data Book: 1997. Baltimore: Annie E. Casey Foundation. . 1998. City Kids Count: El Paso, TX Profile. Baltimore: Annie E. Casey Foundation. Fleming, L. 1982. Parental Influence on the Educational and Career Decisions of Hispanic Youth. Washington, DC: National Council of La Raza. Kirk, G., and M. Okazawa-Rey. 1988. Women's Lives: Multicultural Perspectives. Mountain View, CA: Mayfield Publishing Company. National Center for Education Statistics. 1996. The Condition of Education. Washington, DC: U.S. Department of Education. . 1996b. Digest of Education Statistics. Washington, DC: U.S. Department of Education. Rong, X. L., and J. Preissle. 1998. Educating Immigrant Students: What We Need to Know to Meet the Challenges. Thousand Oaks, CA: Corwin Press. Secada, W. G., R. Chavez-Chavez, E. Garcia, C. Muiioz, J. Oakes, I. SantiagoSantiago, and R. Slavin. 1998. No More Excuses. The final report of the Hispanic Dropout Project. Washington, DC: U.S. Department of Education. Stoddard, E. R. 1993. "Teen-age Pregnancy in the Texas Borderlands." Journal of Borderlands Studies 8(1): 77-93. Texas Kids Count Project. 1998. The State of Texas Children: Fact Book 3. Austin: Center for Public Policy Priorities and the University of Texas, Center for Social Work Research. Tinajero, J. V. 1992. "Raising Educational and Career Aspirations of Hispanic Girls and Their Mothers." The Journal of Educational Issues of Language Minority Students 11 (Winter): 27-43. University of Texas at El Paso. 1998. Fact Book: 1997-98. Center for Institutional Evaluation, Research and Planning. El Paso, TX: UTEP. U.S. Census Bureau. 1997. Selected Characteristics of the Population by Race. Washington, DC: U.S. Census Bureau. . 1998. Estimated Number and Percent of People Under Age 18 in Poverty, 1993. Washington, DC: U.S. Census Bureau. Van Fossen, S., and T. Sticht. 1991. Teach the Mother, Reach the Child. Washington, DC: Wider Opportunities for Women, Inc.

7 Living with HIV/AIDS in a Rural Border County: Women's Service Delivery Needs Donna Castaneda

HIV/AIDS is increasingly a health issue in the U.S.-Mexico border region. Among women aged 25 to 44, AIDS ranks as the fourth leading cause of death on the U.S. side of the border (Wortley and Fleming 1997); on the Mexican side, AIDS ranks as the twelfth leading cause of death among persons aged 25 to 44 (del Rio-Zolezzi et al. 1995). Similar to the United States and Mexico in general, the percentage of women with HIV/AIDS in this region is increasing rapidly, particularly among Latina women. Nationally, women are more likely to be exposed to AIDS through intravenous drug use, 47 percent compared to 37 percent for heterosexual exposure (Centers for Disease Control 1996, 12). However, in the U.S.-Mexico border region, heterosexual exposure is the leading risk factor for HIV infection among women (Barnes, Buckingham, and Wesley 1997, 91). Rural counties along the U.S.-Mexico border present a very different context for HIV/AIDS than those that are urban. Not only does the small size of the communities within these counties affect their experience and response to HIV/AIDS, but proximity to Mexico creates a distinct social and cultural context that may contribute to barriers in development of HIV/ AIDS prevention and care services, as well as to possibilities for development of innovative and locally meaningful services. The purpose of this chapter is to investigate elements that can act as a barrier to, as well as those that may facilitate, service delivery to women in Imperial County, California. Clearly, certain aspects of HIV/AIDSrelated service delivery will be unique to this area, but the experience of

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developing and maintaining these services may also contain similarities to that of other rural counties along the U.S.-Mexico border. Although the care and support needs of women living with HIV/AIDS are increasingly acknowledged, these needs remain little understood (Patton 1994, 8). Programs for women with HIV/AIDS are fewer in number than those for men (Center for Women Policy Studies 1995, 3), and they may be even less available or nonexistent in rural communities along the U.S.Mexico border. Although the prevalence of HIV/AIDS among women in these areas is still comparatively small, the number of women exposed to HIV in rural areas in the United States overall is increasing rapidly (Berry 1993, 294; Lam and Liu 1994, 488). In the context of high poverty and fewer health and social services that characterize many of the rural, U.S.Mexico border counties, efforts to develop meaningful and effective care and support services for women living with HIV/AIDS are essential. On the other hand, virtually no published studies are available that focus on HIV/AIDS care service delivery to women in these rural, border areas. A series of interviews with service providers who work with persons living with HIV/AIDS in Imperial County is the basis for the information contained in this chapter. The results of these interviews are supplemented by an interview with one woman who has HIV/AIDS and resides in Imperial County. Because of the limited research on HIV/AIDS in border communities, particularly those that are rural, this study is conceived as a preliminary and exploratory one. Results, however, may provide a better view of the difficulties and needs surrounding service delivery to women with HIV/AIDS in the border region. IMPERIAL COUNTY CHARACTERISTICS Imperial County sits in the southeast corner of California. It is bordered by San Diego County to the west, Riverside County to the north, and the state of Arizona to the east. Along with San Diego County, it is the only other county in California that shares a border with Mexico. Although Imperial County, like San Diego County, shares a border with Mexico, it is socially, economically, and ecologically quite different from San Diego County. In many ways, it is more similar to rural, border counties in other states than to San Diego County. With irrigation canals that supply water from the Colorado River, Imperial County is one of California's, and the nation's, major agricultural regions. The estimated population of Imperial County is 140,500. It is significant that 66 percent of the population is Latina(o), the largest Latina(o) percentage in any of California's fifty-eight counties. Other groups make up a much smaller proportion of the total county population with white, 29 percent; African American, 2 percent; and other groups (Asian/Pacific Islander, American Indian, etc.), 3 percent. Towns and communities within

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the county range in population size from El Centro at 37,500 to Westmorland at 1,700. Similar to other rural, U.S.-Mexico border counties, Imperial County is characterized by high poverty and unemployment levels. In Imperial County, 23.8 percent of the population live below the poverty level, compared to 12.5 percent of the population in California overall. The unemployment rate in Imperial County tends to be the highest in California. For example, the unemployment rate in California in 1994 was 8.6 percent. During the same period, the unemployment rate in Imperial County was 23.2 percent, even after adjustment for seasonal workers. The largest employer is the agricultural industry, followed by the government, retail trade, and service sectors. Although most agricultural workers in Imperial County are Mexican, especially those who work in the fields, instead of the typical migrant farmworker who lives and works in the United States, large numbers of Mexican fieldworkers with jobs in Imperial County agriculture commute back and forth across the border each day. Mexicali, the Mexican city that sits just across the border from Imperial County, is the state capital of Baja California. With almost 700,000 inhabitants, its population size is much larger than that of Imperial County. As in many U.S.-Mexico border communities, proximity to Mexico produces what is commonly referred to as border culture. Many families are extended across the U.S.-Mexico border. A high degree of bilingualism is apparent both in private and public interactions. In stores, businesses, and restaurants Spanish is sometimes spoken more often than English. The economies of Mexicali and Imperial County are intricately linked and the economic upswings or downturns in one very much affects the other. Residents from both sides of the border interact in a region characterized by internationality and ethnic variation, the sum total of which creates a border way of life (Martinez 1997, 294). HIV/AIDS IN IMPERIAL COUNTY AND THE U.S.-MEXICO BORDER REGION Imperial County, like many rural counties in California, has a low prevalence of HIV/AIDS. However, it is bordered by San Diego, which ranks third in California in number of AIDS cases, and Baja California, the Mexican state adjacent to California, which ranks fourth in AIDS cases in Mexico (Valdespino-Gomez et al. 1995, 561). The latest official count indicates that Imperial County has ninety-five AIDS cases, with a mortality rate of 48.42 percent. One of these is a pediatric case. This compares to 7,344 AIDS cases in San Diego and approximately 600 in Mexicali. Despite the relatively low HIV/AIDS prevalence, the rate of new AIDS cases is increasing rapidly in Imperial County, as it is in rural regions of the United States in general.

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Table 7.1 Reported Cases of AIDS in Imperial County by Year, Age, Gender, and Ethnicity/ Race, 1984-1997 YEAR 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 , 1994 1995 1996 1997 TOTAL

AGE

CASES (Deaths)

1 (1) 2(2)

KD

3(3) 2(2) 9(9) 4(3) 10(7) 6(3) 11(6) 15(6) 20(3) 8(0) 3(0)

<13 13-19 20-29 30-39 40-49 >49

1 3 16 33 28 14

ETHNICITY/RACE (1%) (3%) (15.7%) (34.7%) (29.0%) (14.7%)

Latina/o 62 White 22 Native American 1 Unknown 1

(65.2%) (23.1%) (1%) (1%)

GENDER Female Male

8 (8.4%) 87 (91.5%)

95 (46)

For example, in 1995, fifty-eight AIDS cases were recorded for Imperial County (Imperial County HIV Prevention Plan 1995, 12). With thirtyseven new AIDS cases recorded, the number of AIDS cases has increased by almost 64 percent since 1995. Furthermore, these numbers represent AIDS cases only. The number of persons in Imperial County who are living with HIV is likely much higher than AIDS case data indicate. Table 7.1 provides a breakdown of the reported AIDS cases in Imperial County. As can be seen from this table, Latinas(o)s are most impacted by AIDS, 65.2 percent; followed by whites, 23.1 percent; African Americans, 9.4 percent; and American Indians, 1 percent. Seven of the reported cases are among adult women. The majority of AIDS cases is among men who have sex with men, 62 percent. Among women, the primary exposure category is heterosexual contact, 57.1 percent. Among men, heterosexual contact accounts for 4.5 percent of AIDS cases. Intravenous drug use is the second most frequent exposure category among men, 13.7 percent. Among women, intravenous drug use is the third most frequent exposure category, 14.2 percent. The second most frequent exposure category for women is receipt of blood transfusion, components, or tissue, 28.5 percent. The proportion of women in this last category is much higher than the national average of 4 percent reported for women in the United States overall (Centers for Disease Control 1996:12). Whether women in this last category were diagnosed early in the AIDS epidemic before the blood supply in the United States began to be tested for HIV antibodies is unknown. Although not ascertainable at this time, the high proportion of women in this exposure category may be related to the fact that blood transfusion is the

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leading exposure category for AIDS among women in Mexico (del RioZolezzi et al. 1995, 586). Thirty-nine percent of women with AIDS in Mexico contracted the disease through receipt of contaminated blood. Since 1986, when the blood supply in Mexico began to be screened for HIV antibodies, exposure to AIDS from contaminated blood among women has been decreasing, and exposure to HIV through heterosexual contact is increasing rapidly among women. Heterosexual exposure now accounts for 32.5 percent of AIDS cases among women in Mexico (del Rio-Zolezzi et al. 1995, 586). An attempt to clearly delineate the characteristics of women who are living with HIV/AIDS in Imperial County is difficult. Important information such as the mortality rate, ethnicity, age, and year of diagnosis of the seven AIDS cases among women is not available. Service providers who see women living with HIV/AIDS, however, indicate that all the women clients they have seen have been exposed through heterosexual contact. These service providers also indicate that all the women living with HIV/AIDS they have seen are Mexican or Mexican American. County health department HIV testing data reveal that the one woman out of ten persons who tested positive for HIV in 1994 was Latina and was exposed through heterosexual contact (Imperial County HIV Prevention Plan 1995:13). Such a small number of women with HIV/AIDS does not permit accurate assessment of trends, but both anecdotal and official data suggest that heterosexual exposure may be the largest source of risk for women. Furthermore, women of Mexican descent in Imperial County appear to be most at risk compared to women from other ethnic/racial groups. The Imperial County Social Service Department reported that up to eleven women, infants, and children with HIV/AIDS received services through Medi-Cal in Imperial County in 1997. These cases are in addition to the ones that are seen in any of the services that are funded specifically to provide services to persons with HIV/AIDS. The existence of these cases demonstrates that more women, infants, and children are living with HIV/ AIDS in Imperial County than current county and state HIV/AIDS case data indicate. Equally important, these data suggest that women in this area are not well-integrated into available HIV/AIDS-related services. The reasons for this may have to do with the services themselves, such as inadequate outreach or lack of sensitivity to special needs of women. On the other hand, women in a small, rural county where HIV/AIDS stigma may be high may be concerned about confidentiality if they seek services from local HIV/AIDS-related providers. HIV/AIDS SERVICES IN IMPERIAL COUNTY The existence of HIV/AIDS care and prevention services in Imperial County has a relatively short history. Furthermore, in a county with

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strongly conservative social and political leanings, the development of these services owes a great deal to the perseverance and courage of a few individuals. Up until relatively recently, awareness of HIV/AIDS as a critical health issue in Imperial County was minimal, even in the public and private health systems. A prevention program, funded with federal monies and channeled through the State Office of AIDS, was in place in 1988. This prevention program, called the HIV Bilingual Project, was administered out of Pioneers Memorial Hospital, one of the two hospitals in Imperial County. Before 1992, however, no services specifically for persons living with HIV/AIDS were available in Imperial County. Persons who tested positive for HIV either had to turn to their own physicians or to a publically funded health system, both of which saw few individuals with HIV/AIDS. Often these individuals made the two-hour trip to San Diego or Palm Springs in order to obtain needed medical care. Outside of the small HIV Bilingual Project, almost no resources were available for those who desired HIV prevention information. In 1992, through the efforts of Arthur Hernandez, program coordinator of the HIV Bilingual Project at Pioneers Memorial Hospital, federal funds, again channeled through the State Office of AIDS, were provided to Imperial County to develop a continuum of care infrastructure to meet the needs of residents with HIV/AIDS. These funds became available through the federal Ryan White CARE Act, named after the young boy who died after contracting HIV from the clotting factor he needed to inject every day due to his hemophilia. With these funds, a small consortium of care providers and others interested and concerned with HIV/AIDS issues was organized, and it met, and still meets, monthly. This consortium is responsible for reapplying to the State Office of AIDS for this funding every year, setting service priorities, reviewing grant proposals submitted by agencies to provide HIV/ AIDS-related care services, and selecting agencies to receive Ryan White funds. This consortium also monitors and evaluates service delivery in each of the agencies that has been awarded these funds. Imperial County was the next to the last county in California to apply for the Ryan White funds, which had been available since 1990. The HIV Bilingual Project, renamed the Bilingual Community Education/ Prevention Project and Services, continues to operate out of Pioneers Memorial Hospital. With Ryan White funds the consortium has been able to fund agencies to provide benefits counseling, health care, mental health care, and support services such as a support group and a buddy system. Housing and drug payment assistance are also available. The scale of these services continues to be small. For example, a doctor from another county travels to Imperial County to provide medical care at the only HIV/AIDS clinic two evenings per month.

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THE STUDY Open-ended interviews were carried out with four care providers, two men and two women, and a woman with HIV/AIDS who is a client at the bimonthly HIV/AIDS clinic. Three of the care providers were interviewed at their work site, and one participated in a telephone interview. Two of the care providers provide health-related services, one provides support services, and one works exclusively in coordination of care and prevention services in the county. All are members of the consortium, and have been since its inception. All are considered key players in the HIV/AIDS arena in Imperial County. Questions for care providers focused on the perceived barriers to HIV/ AIDS service delivery to women, challenges they felt in developing these services in Imperial County, how the border context influenced service delivery, and positive aspects of this area that influence service delivery to women. The client interviewee was asked a series of questions about how she found out she was HIV positive, the reactions of her family to her HIV status, where she first turned for help when she realized she had HIV, and how living in a border community influenced her experience living with HIV/AIDS. Interviews with the client took place on one of the evenings of the HIV/AIDS clinic during the time she waited to be seen by the doctor. Interviews lasted approximately an hour to an hour and a half and were conducted in English. All six participants were Mexican American and had lived in Imperial County all or a significant portion of their lives. The client interviewee was 29 years old, with a 6-year-old daughter. She had recently reunited with her husband, who was also the father of her daughter, after being separated for almost six years. During the time she was separated from her husband, she and her daughter lived with her parents, but after reuniting with her husband, she had moved to a house with him and her daughter. Her husband died of complications due to AIDS, and that was how she learned that he had AIDS. After his death, she was tested and found she had the virus. Her daughter was also tested, but did not have the virus. RESULTS Barriers to Provision of Services for Women All of the service providers believed that service delivery to women living with HIV/AIDS in Imperial County needed to be improved. Women were not represented in the available services in the numbers they knew were "out there." They all agreed that improvement of women's access to services, particularly the HIV/AIDS clinic, was a priority. Although women

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could receive health services with other health care providers, they all believed that coming to the HIV/AIDS clinic was critical. The doctor in this clinic is highly knowledgeable about HIV/AIDS symptoms and treatment, and this is not necessarily the case with other doctors. Furthermore, the clinic offers a positive and supportive atmosphere, benefits counseling is available during the clinic hours, and often other care providers attend the clinic to offer services and information. For example, a mental health professional who receives Ryan White funds to provide counseling to persons living with HIV/AIDS recently began attending the clinic nights in order to be more accessible to clients. The client interviewee also indicated that increased awareness of women's risk for HIV infection was important to develop. Shortly after reuniting with her husband, he became ill, and she took him to the doctor twice for stomach pains. She said doctors could not find the cause of the pain. After only a few months he became very ill and died from complications due to AIDS. It was only at that point that she was tested for the virus. Before that point, the possibility of HIV never occurred to her, her husband, or the doctors who treated her husband. When asked about perceptions of barriers to service delivery to women with HIV/AIDS, service providers said that the history and nature of the epidemic both nationally and in Imperial County has influenced service delivery. Because in earlier stages the epidemic impacted primarily men, it was men's needs that were the model for services. One service provider indicated that the first activists relating to HIV/AIDS in Imperial County were men, and their perspectives and experiences played a part in shaping HIV/AIDS services. Another pointed to the lack of a programmatic focus on women saying that service delivery to women "has been a failure on providers' part. We have not had a specific effort to bring in women who are HIV positive." A lack of female physicians was mentioned by one service provider as a reason for women's lesser use of services. The doctor in the HIV/AIDS clinic is male, and this service provider suggested that "Women may have specific issues they feel more comfortable talking about to a female physician. It opens more doors for them if they can talk to a female." Two service providers mentioned the social and political conservatism of Imperial County as a barrier to service delivery to women. One stated: "It has to do with the conservatism of Imperial County. Still, after so many years into the epidemic we find a lot of people who think this is a gay disease." All the service providers brought up the issue of Latina(o) culture as a type of barrier, although they each spoke about it in somewhat different ways. One person referred to what he felt was a "Latino conservative religious structure." He gave the example of a very religious Latina woman living with HIV/AIDS, who was infected by her husband. When she first

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found out that she and her husband were HIV positive, her response was to worry more about him than herself. She takes care of him not only at home, but she also interfaces with service personnel to take care of both her and her husband's affairs. This service provider says that not all Latina women are as selfless as this woman, but he feels that a significant constituency of women respond in similar ways, where they place their emotional and physical health second to that of their spouse or partner. Another service provider explained this issue in the following way: "Latina women need encouragement and support to increase self respect and self worth. The lack of that is always a barrier to effective prevention and care." Another indicated that Latina women may have a harder time talking about HIV/AIDS with their partners. She says: "How can you send them [women] back to their [male] partners with nothing to help them talk about their HIV. Especially not in Hispanic culture. It will be impossible for them to deal with their partner's responses all by themselves." Perception of Women's Needs When asked about their perceptions of women's treatment and care needs, one service provider pointed out that, because no programs are available specifically for women, she has no place to refer women when they bring up issues related to HIV/AIDS with their male partners. These are issues related to empowerment in the relationship that women talk to her about much more often than do men. She says she wishes some type of program was available to refer these women to that would be an empowerment resource for them. Because the women seen by HIV/AIDS service providers have all been Latina, one service provider stated that Spanish-language ability on the part of providers was essential. In addition, this person stated that Spanishlanguage materials were also important, but that those appropriate to women were harder to find. The client interviewee, who had only recently learned that she was HIV positive, expressed practical and emotional needs. She was concerned about how she would be able to pay for her health care and medication. She was covered by Medicare, but she was unclear about whether she would have to pay part of the costs or if these costs would be covered by Ryan Whitefunded services. She was just beginning medication, and she was concerned that if the side effects of these were severe, she would have to quit her job. "How will I pay the rent and take care of my daughter if I get sick?" A particular concern was confidentiality surrounding her HIV status. She did not want anyone in her job, social network, or family to know that she was HIV positive, and she had, up to this point, told no one of her HIV status. She was briefly hospitalized at one point due to a negative reaction to medication she was taking. She said: "I got sick in KMart and they had

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to call 911. I had to stay in the hospital until 10:30 at night. I thought maybe it is better if I die from this than from AIDS. So no one will know. I know my parents will take care of my daughter." She especially did not want her parents to find out about her HIV status. She said she believed her parents would be very hurt if they knew of her illness. But keeping her HIV status a secret from her parents, especially her mother, distressed her, and she indicated that doing so was becoming increasingly difficult for her. The client interviewee also spoke about emotional needs due to finding out about her HIV positive status. She experienced significant grief due to the sudden loss of her husband. He died while visiting his family in Mexico, and she could not be with him when he died. The news from his sister that he had AIDS when he died was also a shock. She expressed a strong need for support from others at this time in her life, but felt that such support was not available, particularly from her family. As she says: "I feel I am all alone. Nobody knows about this. I really do need to talk to someone. At least my husband had his family to support him when he got sick. I don't have the support of my family right now." When asked what she would say to another woman who found that she was HIV positive, the the theme of social support was again present. This client said the following: "I would tell her get seen by a doctor right away. I would try to listen to her, try to be her friend. I have just one close friend, but I am afraid to tell her about this. What if she doesn't want me after I tell her?" In addition to the loss of her husband and knowledge that she was HIV positive, the client interviewee spoke of another type of loss that women are more likely to experience than men. She spoke of her sadness at the realization that she could have no more children. Related to this, a service provider also indicated that in her work with HIV positive women, one of most repeated concerns of these women is who will take care of their children if they become ill or if they die. This is the case even for the women who are married or have a partner. Providing Services in a Border Context Each interviewee was asked how HIV/AIDS service delivery, particularly for women, was affected by Imperial County's location at the U.S.-Mexico border. All felt that the border influenced the development and provision of services. In fact, according to the Imperial County HIV Prevention Plan, one of the groups targeted for HIV/AIDS prevention services is referred to as the "border crossing population." These are individuals who cross the border regularly (coming from both sides) for shopping, visiting family and friends, recreation, work, and a myriad of other reasons. Such a target group is not one likely to be found in any other county in California except

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San Diego. Just as people cross borders so does disease. As one person observed: "With HIV there are no borders. The experience with HIV in Mexicali very much affects what happens in Imperial County and the disease crosses over both ways very easily." Another way that being on the border affects service delivery is that clients may seek services, particularly health care, on both sides of the border. One service provider indicated that part of providing medical case services to clients is to warn clients not to get medical services or medications in Mexicali after they find out they are HIV positive. This is done as part of medical case management so that clients do not receive inconsistent treatment and medication plans. This warning is not necessary for everyone, but for some people, seeking medical services and buying medications in Mexicali are common activities. The client interviewee indicated that before she knew she was HIV positive she regularly went to Mexicali for medical services. When at one point after finding out she was HIV positive she became sick, her mother wanted to take her to Mexicali for treatment with the family doctor she has in that city. She did not go because she knew that she was under the care of the doctor at the HIV/AIDS clinic. Persons from the Mexican side who have HIV/AIDS also come to Imperial County for services. Use of publically funded services by noncitizens is a sensitive political issue in Imperial County and in California generally. No service providers knowingly provide services to noncitizens and all clients meet residency requirements. But invariably services will include undocumented persons who have HIV/AIDS. Mexicali has very limited resources to provide care and treatment to the growing population of residents with HIV/AIDS. As one service provider says: "Being at the border makes a big difference. We are a small county next to a very large city (Mexicali), but they do not have nearly the resources they need to treat the persons who have AIDS. So we will end up seeing some of them here. We do not have many people who come here just to get medical services, but there are some." Positive Aspects of this Region Related to HIV/AIDS Service Delivery When asked to think of positive aspects of Imperial County that may enhance HIV/AIDS service delivery to women, interviewees mentioned that living with HIV/AIDS in small communities may be more difficult due to concerns about confidentiality and limited services; on the other hand the small scale of communities may make services more easily accessible. One service provider told of a woman client who is from Imperial County, but who goes to stay with relatives in Los Angeles in the summer. This client tells her that getting services in Los Angeles is much more difficult than in Imperial County; the lines are longer, times between appointments are

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longer, and she misses the easy familiarity she has with service providers in Imperial County. Service providers are able to develop strong and personalized relationships with clients. Another service provider mentioned that: "The majority of providers here are from this area. Many of them have a similar background where their parents worked in agriculture so they are better attuned to the needs of clients. You know about the conservative climate here so it helps us identify needs and concerns here." Another positive aspect of Imperial County is that with a large Latina(o) population, the availability of bilingual staff is greater than in other areas. Furthermore, many of the service providers are Latina(o), and as one persons says: "When you go someplace and see someone of your skin color, speaks your language, and understands your culture, you are more at ease, more comfortable." DISCUSSION Overall, results in this study show areas of convergence in participants' perception of the service needs of women living with HIV/AIDS in Imperial County. One of the major areas of convergence is an understanding of the need for greater community awareness building of women's risk for HIV infection. Along with this is the understanding of the need for greater marketing of available HIV/AIDS services to the community, and to women in particular. HIV/AIDS has little immediacy in the lives of Imperial County residents, and this is particularly the case for women. Paradoxically, communities in Imperial County, and in border regions generally, are at once part of the global community, particularly with the advent of NAFTA, but at the same time they can remain quite provincial in character. A sense of being on the periphery of events that take place in the rest of the state or nation can be evident. HIV/AIDS is decidedly part of the health context in Imperial County, but it is often viewed as something that happens elsewhere. The realization that the nature of the HIV/AIDS epidemic is related to types of services provided is an important one. The situation of women and HIV/AIDS in rural, border communities such as Imperial County is similar to that in the United States during the first decade of the epidemic. Because a much smaller number of women were infected with HIV, the epidemic among women was overshadowed by that among men, and it was characterized by a lack of attention on the part of researchers, funders, program planners, and the general public (Castaneda 1998, 8). However, service providers appear to have some insight on this history and its relation to the present, and the same scenario may not be completely replayed in Imperial County. The need for services that are sensitive to women's particular experience is a theme in several of the service provider comments. For example, the

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doctor in the HIV/AIDS clinic is male, but the availability of a female doctor for women may be important. Anecdotal information indicates that the current HIV/AIDS clinic doctor is highly regarded by clients and service providers. However, in a study of contraceptive use and pregnancy among Latina women on the Texas-Mexico border, 64.3 percent of El Paso and 56 percent of Juarez women said they prefer to see a female doctor (Russell et al. 1993, 377). The extent to which this may be the case among Latina women in Imperial County is not known, but is highly likely to be similar. The specific and personal needs expressed by the client interviewee in some ways complement more general ones referred to by service providers. She spoke of practical concerns such as worry over meeting the cost of her medical care, keeping her job if she got sick, paying the rent on her house. She also spoke of the difficulty in coping with the tremendous emotional toll from the death of her husband and the resulting knowledge of her HIV positive status. When asked what she would tell other women who found themselves HIV positive, she mentions the importance of obtaining medical care, but even more her comments reflect her need for someone to talk to at this time in her life, or in other words, social and emotional support. The client interviewee also stressed her concern that no one find out about her HIV positive status. The concern for confidentiality is expressed by many people who find they are HIV positive, regardless of their locale. This concern is related to the stigma that is associated with HIV/AIDS, even after so many years of public awareness of the disease. In Imperial County, however, it may be a particular concern due to the general conservatism of the area and the small, close-knit communities. In small communities, confidentiality is more difficult to maintain. People may not know you personally, but they may know of you and others in your family. Workers in the hospitals, social service agencies, stores, and schools may be the same ones who live in your neighborhood or that you see at the local grocery. Service providers are not necessarily unaware of the types of needs expressed by the client interviewee. In fact, they are acutely aware of the need for confidentiality surrounding all clients. Furthermore, a Ryan Whitefunded therapist is available to HIV positive clients, and the client interviewee has already been referred to him. A support group of HIV positive persons is also available. The therapist and most of the support group participants, however, are men. Studies show that commonality in ethnicity and gender can facilitate empathy in therapeutic contexts (Atkinson, Morten, and Sue 1989, 18; Comas-Diaz 1994, 293). Greater attention to development of a support group for women and the option of a female therapist may be important to consider. Another aspect of conservatism that plays a role in HIV/AIDS service to women related by participants was conservative Latina(o) attitudes surrounding women's roles. Women are expected to be caretakers in the fam-

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ily. These attitudes may be ones women themselves have accepted, and they may influence effective HIV/AIDS care and treatment. Thus far, women who have tested positive for HIV/AIDS in Imperial County have contracted the virus from their male partners. Thus, not only must women take care of their own health, they may also have to take care of that of their male partners. In some cases, women may do this at the expense of their own health needs. Participants in this study realize that programs that increase women's sense of self-worth and assertiveness in relation to their male partner represent a gap in available services in Imperial County. The lack of such a focus in current programs is also an example of how HIV/AIDS care services are implicitly based on a male model. Men living with HIV/AIDS are less likely to be expected to care for children or an HIV positive partner, in addition to themselves. Many aspects of life in Imperial County are affected by proximity to an international border, including health and illness. In fact, public health officials recommend that the U.S.-Mexico twin communities, such as Imperial County and Mexicali, be considered as a single epidemiological unit (Brandon et al. 1997, 39). This interdependence also affects service delivery to those with HIV/AIDS. For example, the number of reported AIDS cases in Mexicali is much higher than in Imperial County, but the resources to meet the needs of persons with AIDS in Imperial County, small by U.S. standards, is much greater than in Mexicali. The most basic medications to treat HIV/AIDS are extremely limited or unavailable. Inevitably, undocumented individuals with HIV/AIDS will appear in Imperial County service systems. On the other hand, individuals from Imperial County commonly seek medical care and medications in Mexicali, which may complicate treatment plans. In border regions, the economic resource asymmetries between the United States and Mexico are most apparent. Thus the context for HIV/AIDS in Imperial County is affected by this asymmetry between the United States and Mexico, as well as the profound interdependence of the two countries (Ganster and Sweedler 1990, 491). The proximity and interdependence of Imperial County and Mexicali point to the importance of interaction between public health entities on both sides of the border to consider and develop strategies to meet the challenge of HIV/AIDS care and prevention. In fact, such interaction does occur. This interaction takes the form of meetings, exchanges of information, and for three or four years a binational HIV/AIDS conference was held in Imperial County and Mexicali. This connection and ongoing exchange was initiated and maintained not by the most powerful health players on each side of the border, but by HIV/AIDS community activists on both sides. Those in Imperial County are associated with the community-based services developed with federal funds. In Mexicali, those who have been most active are associated with the school of medicine at the Universidad Autonoma de Baja California. At this point, the involve-

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ment of high level representatives of Imperial County and, in Mexicali, state and city health departments occurs, but their involvement has been a relatively recent phenomenon. This informal, but regular, cooperation between U.S.-Mexico border communities, often occurring without federal direction or intervention from governments on either side of the border, is common in U.S.-Mexico twin city areas (Ganster 1997, 261; Ganster and Sweedler 1990, 424). It is a consequence not only of the proximity of U.S.-Mexico communities and attempts to develop regional solutions to common problems, but also the remoteness of communities in the U.S.-Mexico border region from national centers of economic and political power in both countries. The potential of regular cooperation between HIV/AIDS workers in Imperial County and Mexicali has yet to be fully realized. Cross-national health efforts are complex endeavors. But the existence of these interactions, and the understanding of the need for them, reflect a reality that is not fully appreciated at the state or national level. The border, internationality, and interdependence in relation to HIV/AIDS, so clear to those who live in the region, is still at the edge of the discourse on HIV/AIDS outside this area. When asked about the positive aspects of this area that contribute to HIV/AIDS services for women, the small size of communities in Imperial County was a consistent theme. Even though small communities are able to offer only limited services compared to larger communities, they may be better able to sustain feelings of connection and significance—a client is more than just a case to service providers. The small scale of HIV/AIDS services in Imperial County may actually facilitate women's utilization and satisfaction with services. Another positive aspect of Imperial County is the high degree of bilingualism. With such a large proportion of the county population that is Latina(o), bilingualism in service delivery is almost a requirement, but the importance of its presence should not be underestimated. Many areas in the United States have large Latina(o) populations, but bilingual staff are difficult to find, and persons who speak only Spanish are underserved. In Imperial County, bilingualism is an explicitly valued and integral part of the HIV/AIDS service system. Although the study described here focused on service delivery needs of women living with HIV, it also presents certain implications for prevention interventions with women in rural, border regions. First, a need for greater awareness building of women's risk for HIV is apparent. Because women often are not engaging in the traditionally defined HIV/AIDS risk behaviors, that is, sex with multiple partners, intravenous drug use, and so forth, they are less likely to perceive themselves as at risk for HIV infection. Education and prevention efforts in rural, border regions should focus on increasing women's awareness of their risk for HIV from their relationship partners,

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and greater efforts to encourage women to seek HIV testing and counseling should be made. Efforts to increase women's understanding of their risk for HIV infection should be done in conjunction with agencies that work with the most vulnerable women, such as those in battered women's shelters, homeless shelters, low income women, sex industry workers, and those who seek testing for sexually transmitted diseases other than HIV. Because the awareness of HIV/AIDS as a woman's issue tends to be low in areas like Imperial County with a low prevalence of HIV/AIDS among women, efforts to increase women's awareness of their risk for HIV infection should also be done at a larger community level. Awareness building at the larger community level creates more sensitivity to the needs of women and greater receptivity for more targeted prevention program development for them. Media campaigns that use television, radio, newspapers, and other media would be especially useful in HIV/AIDS community-level awareness building. As much as possible, however, these media should be locally based, as they may be more effective than media sources outside the area. Peer education or promotora models may be particularly useful for women. In these programs women volunteers are trained to work with women individually or in groups to provide HIV/AIDS education and prevention. In addition to the goal of HIV/AIDS prevention, inclusion of women in the development and implementation of peer education programs may lead to a sense of ownership of the issue of HIV/AIDS and its prevention among women in a community. In all HIV/AIDS education and prevention efforts with women, the themes of enhancing women's self-worth and empowerment should be prominent. Women, and Latina women in particular, tend to be socialized to care for and meet the needs of others before themselves. The extent to which Latina women are able to do this is often perceived by them and others as a measure of their value. But selflessness and caring for needs of others, although not necessarily devalued, should be presented along with opportunities for development of self-esteem and self-valuing. In fact, effective prevention of HIV/AIDS in women is linked to women's greater sense of empowerment (Amaro 1995). Another theme that should guide HIV/AIDS education and prevention with women in rural, border communities is sensitivity to the diversity within this group. Although Latina women appear to be most at risk for HIV infection in rural, border communities, they are not a homogenous group. Education and prevention programs that are able to reach women who differ in acculturation, Spanish-language use, social class, education level, and so forth, will be most effective. Limitations of this study should be kept in mind. It included only a small number of participants, and only one woman living with HIV was interviewed. Future work on women's service needs in rural, border areas should include larger samples of service providers and HIV positive women,

Living with HIV/AIDS: Women's Service Needs • 129 across a wider spectrum of counties in the border region. Despite these limitations, this study is one of the first to focus on w o m e n ' s HIV/AIDS service needs in a rural, border county. It opens the door to further investigation of HIV/AIDS that includes the impact of the unique social and cultural characteristics that make up border regions. REFERENCES Works Cited Amaro, Hortensia. 1995. "Love, Sex, and Power: Considering Women's Realities in HIV Prevention." American Psychologist 50(6). Atkinson, Donald R., George Morten, and Derald W. Sue. 1989. "Minority Group Counseling: An Overview." In Counseling American Minorities: A Cross Cultural Perspective, edited by Donald R. Atkinson, George Morten, and Derald W. Sue. Dubuque, IA: Wm. C. Brown Publishers. Barnes, Michael D., Robert W. Buckingham, and Allison M. Wesley. 1997. "Hispanics, HIV, and AIDS Along the U.S.-Mexican Border." In Border Health: Challenges for the United States and Mexico, edited by John G. Bruhn and Jeffrey E. Brandon. New York: Garland Publishing, Inc. Berry, David E. 1993. "The Emerging Epidemiology of Rural AIDS." The Journal of Rural Health 9(4). Brandon, Jeffrey E., Frank Crespin, Celinda Levy, and Daniel M. Reyna. 1997. "Border Health Issues." In Border Health: Challenges for the United States and Mexico, edited by John G. Bruhn and Jeffrey E. Brandon. New York: Garland Publishing, Inc. Castafieda, Donna. 1998. "HIV/AIDS Service Delivery to Women: The Rural Community Context." Manuscript under review. Center for Women Policy Studies. 1995. Womancare—In Their Own Words: Women's Programs and the Ryan White CARE Act. Washington, DC: Center for Women Policy Studies. Centers for Disease Control. 1996. HIV/AIDS Surveillance Report 7(2). Comas-Diaz, Lillian. 1994. "An Integrative Approach." In Women of Color: Integrating Ethnic and Gender Identities in Psychotherapy, edited by Lillian Comas-Diaz and Beverly Green. New York: Guilford Press. del Rio-Zolezzi, Aurora, Ana L. Liguori, Carlos Magis-Rodriguez, Jose L. Valdespino-Gomez, Ma. de Lourdes Garcia-Garcia, Ma. de Lourdes, and Jaime Sepulveda-Amor. 1995. "La Epidemia de VIH/SIDA y la Mujer en Mexico." Salud Publica de Mexico 37(6). Ganster, Paul. 1997. "On the Road to Interdependence? The United States-Mexico Border Region." In Borders and Border Regions in Europe and North America, edited by Paul Ganster, Alan Sweedler, James Scott, and Wolf DieterEberwein. San Diego: San Diego State University Press. Ganster, Paul, and Alan Sweedler. 1990. "The United States-Mexico Border Region: Security and Interdependence." In United States-Mexico Border Statistics Since 1900, edited by David Lorey. Los Angeles: UCLA Latin American Center Publications.

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Imperial County HIV Prevention Plan. 1995. Imperial County, CA: Imperial County Health Department. Lam, Nina S., and Kam-biu Liu. 1994. "Spread of AIDS in Rural America." Journal of Acquired Immune Deficiency Syndrome 7(5). Martinez, Oscar J. 1997. "Border People and Their Cultural Roles: The Case of the U.S.-Mexican Borderlands." In Borders and Border Regions in Europe and North America, edited by Paul Ganster, Alan Sweedler, James Scott, and Wolf Dieter-Eberwein. San Diego: San Diego State University Press. Patton, Cindy. 1994. Last Served? Gendering the HIV Pandemic. Bristol, PA: Taylor &c Francis, Inc. Russell, A. Yvonne, Martha S. Williams, Patricia A. Farr, A. James Schwab, and Sue Plattsmier. 1993. "Patterns of Contraceptive Use and Pregnancy Among Young Hispanic Women on the Texas-Mexico Border." Journal of Adolescent Health 14(5). Valdespino-Gomez, Jose L., Ma. de Lourdes Garcia-Garcia, Aurora del Rio-Zolezzi, Elia Loo-Mendez, Carlos Magis-Rodriguez, and Rey A. Salcedo-Alvarez. 1995. "Epidemiologia del SIDA/VIH en Mexico; de 1983 a marzo de 1995." Salud Publica de Mexico 37(6). Wortley, Pascale M., and Patricia L. Fleming. 1997. "AIDS and Women in the United States: Recent Trends." Journal of the American Medical Association 278(11). Suggested Readings Ferreira-Pinto, J. B., and R. Ramos. 1995. "HIV/AIDS Prevention among Female Sexual Partners of Injection Drug Users in Ciudad Juarez, Mexico." AIDS Care 7(4). Mishra, Shiraz I., Ross F. Connor, and I. Raul Magaiia. 1996. AIDS Crossing Borders: The Spread of HIV Among Migrant Latinos. Boulder, CO: Westview Press.

8 Community-Based Health Promotion and Community Health Advisors: Prevention Works When They Do It Mary Sanchez-Bane and Eva M. Moya Guzman

INTRODUCTION The United States has the most expensive health care system in the world. It consumes over 14 percent of our Gross National Product (GNP), up from 7.4 percent in 1970 (Neubeck and Neubeck 1997). Health care in the United States is the next largest industry after aerospace-defense, and health expenditures take up a fifth of the U.S. federal budget. No other nation spends as much per capita as we do. Yet, the health status of people in the United States falls short of what we might expect given these expenditures. Among all highly developed nations in the Western world, only the United States has no comprehensive system of universal health insurance or a national health service directed to providing care for all. The task of securing health care is, for the most part, left up to the individual. Unfortunately, not all people in the United States, especially on the U.S.-Mexico Border, are in a position to purchase health care services. The number of Americans without health insurance has steadily grown in the past ten years, from 31.8 million individuals in 1987 to 41.1 million individuals in 1996 (DHHS 1997a). This trend continues despite a strong economy, attempted health insurance reform in many states, and some periods of lower health insurance premium increases. The majority of Americans who lack health insurance are under 65 years of age. The U.S.-Mexico border states are among the most uninsured and underinsured in the United States. It is estimated that around 3 million people

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who reside in the U.S.-Mexico border states are without health insurance (DHHS 1997b). Most of these people are workers and have children. The results of a system that leaves one in six people completely responsible for paying for their health care is quite predictable. If people cannot afford to pay for care, they will ignore symptoms and likely end up in even greater distress. Lack of health insurance has been associated with delayed health care and increased mortality. Underinsurance also may result in adverse health consequences. Insurance coverage varies with age, locality, and ethnicity. A new federal study has concluded that the country's spending on health care is likely to double over the next decade to $2.1 trillion ("Health Care Costs on the Way Up" 1998). Each year in the United States, the cost of health care increases as does the number of uninsured persons who are indigent (meaning they cannot pay for health care). Poverty populations are increasing more rapidly than they have in the last decade. The developing system of managed care is having problems with both cost containment and quality of care (Slifkin et al. 1998). The media keeps reminding us that with prevention, we could reduce the cost of health care and live longer, healthier lives, but are health and medical providers equipped with the appropriate tools to conduct prevention activities within communities? The U.S.-Mexico Border: A Unique Cultural Habitat Along the U.S.-Mexico border, the number of indigent patients is higher than in most places in the nation. This border of 2,000 miles also has the poorest cities in the United States, with El Paso, Texas, being the seventh poorest and its neighbor, Las Cruces, Dona Ana County, New Mexico, the fifth poorest (Texas Comptroller of Public Accounts 1998). Health conditions on the U.S.-Mexico border are among the worst in the United States, so distressful at times that reports on health conditions suggest a remote country in need of health care missionaries (Texas Comptroller of Public Accounts 1998). Poverty, lack of transportation, limited formal education and literacy skills, and not knowing the English language or being unfamiliar with the health care system keeps many of the borderlanders from accessing health care services. In most instances, health care providers and health departments attribute the high cost of health care to those who cannot afford to pay. These two entities will generally advocate that health promotion and disease prevention be given to the socioeconomically disadvantaged. For the most part, health care providers and local health departments are located too far from these poverty pockets to deliver care. When care is delivered, many of the messages given are not linguistically appropriate nor are they culturally relevant. In contrast to U.S. border states' population growth, which also is ex-

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panding faster than national growth rates, border regional growth is stimulated by proportionately higher birth rates and foreign in-migration patterns. The higher birth rate, mostly among young Hispanic populations, and higher foreign in-migration, mostly from Mexico, plays an important part in understanding community dynamics and public health conditions along the border (Driessen 1998). Consistently, research findings have shown that Hispanic populations are less likely to have access to primary health care than the general population. The 1991 National Health Interview Survey reported that 80 percent of the total population had access to primary care, compared to 64 percent of Hispanics ("El Futuro" 1997). Hispanics are disproportionately represented among those without health insurance coverage; they receive fewer physician services and wait longer between and during visits than do Hispanics with health insurance. In a national review on access to health services for Hispanic populations, important structural problems were identified to include: (1) few providers locate their practices in Latino communities; (2) poor communication exists between patients and providers; (3) no regular source of health care is present, causing greater reliance on emergency programs and admissions for more serious conditions; (4) public health conditions (e.g., proximity to hazardous and solid wastes, poor housing conditions, exposure to infectious diseases, etc.) are frequently worse in Hispanic communities; and (5) lack of transportation and child care pose serious barriers for Hispanics. Nationally, Hispanics report longer periods between appointments and longer waits in medical facilities than do non-Hispanics. Culture and language can represent barriers to medical care in the border region. Although Hispanics constitute almost 10 percent of the U.S. population, less than 5 percent of all U.S. physicians and medical students are Hispanic (Hayes-Bautista 1997). Differences in culture and language between medical providers and consumers contribute to underutilization of medical services (Loustaunau and Sobo 1997). Hispanic patients are frequently more comfortable with the personal approach shown by many Mexican-trained providers, as opposed to the "seven minute" physician interaction that is becoming more common in the U.S. managed care practice environment (Slifkin et al. 1998). Preliminary results from recent focus groups organized in Arizona's border communities regarding why people cross into Mexico to receive medical care indicated that Mexican physicians were considered more "holistic" in that they treated the entire medical condition and everyone in the patient's family, as opposed to referring patients to multiple specialists or for unnecessary laboratory tests. In the patient/provider interaction, U.S. trained physicians may attend more to biomedical considerations and rely on medical technology, while the patient is attending to verbal communication skills and personalismo (personal concerns) (Loustaunau and Sobo 1997).

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Unfortunately, too often being Hispanic in America means living in poverty. Hispanics have the highest poverty rate of all Americans: 30.3 percent of Hispanics live below the poverty line according to the 1995 census figures published by the National Council of La Raza ("El Futuro" 1997). Specific segments of the Hispanic population constitute the poor, including single mother families and children. Two-in-five Hispanic children are poor (40 percent) compared to one-in-six Anglo children (16.2 percent). Border communities are among the poorest in the nation. Of the 313 metropolitan statistical areas (MSAs) in the United States, the border region contains five of the seven poorest. More than 35 percent of the Texas border region lives in poverty (Texas Comptroller of Public Accounts 1998). In Arizona, all three main cities located on the border have sections that have been federally designated as Economic Empowerment Zones because of their poverty characteristics. Unemployment and low-wage labor are common in U.S. border communities. In those regions influenced by the economics of agriculture, low wage labor is accompanied by seasonal employment with extended layoff periods. The unemployment rate is 250 to 300 percent higher in the border region than the national average (National Council of La Raza 1997). Approximately 39 percent of border residents have incomes below 200 percent of federal poverty guidelines. The Children's Defense Fund estimates that 23 percent of U.S. children under 18 years are poor, while the numbers and percentages rise for border states. They are as follows: Arizona (28 percent); California (26 percent); New Mexico (31 percent); and Texas (29 percent) (Status of Children Report 1997). Poverty correlates with low formal education. In the border region, eleven counties had two to four times the proportion of people without high school education when compared with national rates. In Texas, about 350,000 people have been estimated to reside in more than 1,300 colonias (rural, unincorporated regions characterized by substandard housing and inadequate plumbing and sewage disposal systems) (Texas Comptroller of Public Accounts 1998). There are key distinctions that make the border region unique in the determination of health status. Border cities experience a confluence of social and cultural differences that are apparent in every aspect of community life. Similar to human twins, sister cities are interdependent in almost every respect, yet, with this interdependence, there are extreme differences that influence health status (Driessen 1998). For more than fifty years, the vision of access to health care and health promotion has been linked to a hospital-based paradigm. More recently, the focus has shifted to primary health care and then to managed care. A new vision is needed, one that is more closely attuned to individuals, their families, and their communities. In times of scarce resources, we must find creative, cost-effective, and efficient solutions that will generate a new vi-

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sion of health for all. This new vision needs to look at the health problems of the U.S.-Mexico border with a view toward finding solutions by maximizing assets, not just focusing on problems alone. While the U.S.-Mexico border communities might appear to be without resources, we forget about the hundreds of men and women that serve their neighborhoods and their communities everyday. They are community health workers (CHW)/community health advisors (CHA) or promotores de salud. Community health worker/advisor is one of many terms used to denote an indigenous community member who provides a bridge between his/her peers and the local health and human services team. Often they are referred to as lay health educators, community health advisors, health aides, natural helpers, community health representatives, resource mothers, promotores, and so on, but what all of these programs share in common is that their key role is to be a bridge that connects health and human service networks with local communities (Rosenthal 1998). This chapter is about the challenges of the present health care system and the need to develop, implement, and evaluate culturally competent and community-based health promotion strategies that have at their core the use of CHAs. More important, it is about making the reader understand and appreciate that CHAs may not have much formal education; nevertheless their commitment, outstanding sense of service, and work for their communities have extraordinary value. WHO AND THE ALMA-ATA CONFERENCE From the World Health Organization Alma-Ata Conference held in 1976, emerged the Declaration of Alma-Ata. This declaration has been reviewed and discussed in subsequent international conferences. The Declaration of Alma-Ata laid down the principles of primary care as agreed to by all the World Health Organization's (WHO) member states who made an ambitious commitment to a global strategy for health for all (WHO 1987). Their premise was as follows: Health promotion is the process of enabling people to increase control, and to improve their health. To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond health life-styles to well-being (WHO 1987). The related principles established by Alma-Ata were to: (1) advocate for health; (2) enable all people to achieve their fullest health potential by

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reducing differences in current health status and ensuring equal opportunities and resources; (3) strengthen community action in setting priorities, making decisions, planning strategies, and implementing them to achieve better health; (4) develop personal skills through providing information, education for health, and enhancing life skills; and (5) reorient health services so that health services are shared among individuals, community groups, and health professionals as they are primarily trained to treat illnesses; few patients come to see a health provider when they are well. The concept of health promotion and disease prevention in the United States has been a difficult concept to implement, since this country is oriented toward treatment and has the most advanced medical technology available for the purpose. Staying well or the status of well-being is not a priority in the medical industrial complex. The working class as well as a sound economy depends upon health insurance to take care of the expenses of being ill. Unfortunately, the costs of care keep climbing. One method of keeping costs down through implementing some of the Alma-Ata principles is being utilized along the U.S.-Mexico border. A significant portion of the work of health promotion and disease prevention is currently being conducted by promotores de salud (community health advisors), networks of existing community and migrant health centers, and private and public organizations along the border. CHA interventions have been shown to increase and improve access to health and human services. Health Promotion along the Border Persons below the poverty level living in rural and/or isolated, medically underserved areas face many barriers to accessing health care. Among them are language, transportation, understanding of the health care system, financial difficulties, and cultural beliefs. The majority of these individuals do not seek health services unless it is an emergency, and by then, the problem is no longer a primary care problem. In 1993, 33.8 percent of all nonelderly adult Hispanics in the United States lacked health insurance coverage (either private or public) compared to 8.1 percent of the entire nonelderly population (Frontin, Goldberg, and Robins 1997). Because Hispanics are more likely to be uninsured than any other ethnic group and because they are the fastest growing minority group in the United States, the increase in the Hispanic population is likely to increase the proportion of Hispanics without health insurance. Therefore, since the majority of the Hispanic population lives along the U.S.-Mexico border, the financial barrier to accessing health care services will be even greater than before. Since the financial barrier is there, it would stand to reason that the medical industrial complex would make health promotion and prevention a priority in this area. Prevention is extremely inexpensive when compared

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to the cost of care for disease and advanced conditions. Diabetes, lack of prenatal care, and lack of immunizations for children are among the greatest concerns for Hispanic populations. The latest reports by the President's Advisory Commission on Education Excellence for Hispanic Americans indicate that in 1996, Hispanic children became the largest minority population group in the country ("El Futuro" 1997). According to the U.S. Census bureau, 26 percent of the U.S. Hispanic population is under the age of 15. Assuring their health status is very important in order to produce a healthy adult population for the future. Promotores de salud can play a very important role in promoting good health practices and eliminating most of the barriers to accessing health care. History of CHA Programs As early as the seventeenth century, a shortage of doctors in Russia led to a formation of lay health workers and healing relationships. Lay people known as feldshers were trained to provide medical care to members of the military (WHO 1986). After the Chinese Revolution of 1949, Mao Tse Tung promoted the training of "barefoot doctors," so called because most were peasants, many of whom could not afford shoes. Beginning in the 1950s, in conjunction with the development of the labor unions and "liberation theology," community health promoter or worker programs flourished throughout Latin America and Africa. Because lay health workers were determined to remedy an unequal distribution of health resources by bringing health care to the poor and underserved, they were seen as a threat by many Latin American governments. Hundreds were captured, tortured, and killed. While the community health advisors model is often associated with the developing world, CHAs were also on staff of domestic programs in the 1960s. These programs were frequently located in communities of people of color in larger cities. Community health advisors have been a staple of the health care delivery system for decades, both in the United States and abroad (Schaefer et al. 1995). In the 1960s, the U.S. government supported the development of CHA programs as a means to improve health care for underserved communities. The Federal Migrant Health Act of 1962 and the Economic Opportunity Act of 1964 mandated outreach efforts in neighborhoods with high poverty levels and in migrant labor camps. Since 1968, the Indian Health Services (IHS) has trained and deployed community health representatives to serve the Native American population in Alaska, Montana, Arizona, New Mexico, and other states. The IHS program is the only federally funded community health representative program (Rosenthal 1998). Community health work/advisor programs experienced a resurgence in migrant and seasonal farmworking communities in late 1980s. Existing

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programs founded during this period include the Camp Health Aide Program sponsored by the Migrant Health Promotion; the Comienzo Sano Program/Health Start, based at the University of Arizona Rural Health Office; and El Nino Sano/La Familia Sana program based in Hood River, Oregon. Community Health Advisors (CHAs) Throughout the United States today, providers of health and human services are challenged by the diversity of communities they seek to serve. At the same time, community residents are confronted by a complex array of systems that must be navigated to obtain services. Nowhere is this more evident than in the U.S.-Mexico border region, where cultural diversity and international and tribal boundaries shape daily existence. In order to promote an improved and more efficient link between services and those for whom they are intended, community-based CHA programs have been developed to become a part of the health care team. In partnership with CHAs, health care providers overcome barriers and strengthen their ability to gain access to underserved populations. This model is thus not necessarily new, but rather builds on numerous programs developed during the late 1950s and early 1960s in the United States and the developing countries. Community health advisors mobilize individuals, families, and communities one-on-one and in group settings. They serve as advocates for individuals attempting to access health and medical care, provide empowering knowledge to community residents about health issues, and can be a voice within the community on matters of health and welfare policy. Basically, these programs work in the following manner: A communitybased organization is concerned about a particular health and human service issue in the community. Often the organization may be the local health department, the community health center, not-for-profit agency, or the medical school in the area. The issue may be as broad as general access to health services or may be more specific, such as targeting health issues like prenatal care, cervical cancer, substance abuse, violence prevention, breast cancer, diabetes, and so forth. Usually, a group of community activists and residents form an advisory group to the project. An educational and informational curriculum about this health issue of concern to the community is then identified, developed, implemented, and evaluated. Individuals from the community to be served are recruited to participate in the CHA program. There are two basic criteria for selection: The individuals must be culturally, linguistically, and socioeconomically representative of the community to be served, and they must be respected within the community as "natural leaders" or persons within the community to

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whom individuals turn for advice and support. These individuals participate in a training program on the specific health issue being addressed. At the same time, they share their knowledge and expertise about the community with the trainers, resulting in the modification of curriculum and materials throughout this process. Upon completion of training, the CHAs begin outreach through neighborhood activities, social networks, and informal referrals. They are identified by name badges issued by the sponsoring organization, and their presence in the community is supported by local health and human services networks and reported by the news media. Their primary outreach activities include: contacting friends, neighbors, and family members; going door-to-door in specific neighborhoods; organizing small social gatherings of neighbors on the charla (informal group presentation that frequently centers around a common theme or interest) and/or "Tupperware Party" model; distributing educational materials and their cards to community residents and health care providers in the community; as well as giving presentations to agencies and groups and assisting families with transportation, translation, and information. Their outreach to community residents takes the form of informal discussion on the particular health issue targeted and information about services in the community. Their outreach or inreach to agencies focuses on helping agencies to understand and address the obstacles and barriers to getting care. Community health advisors log both their community contacts and agency contacts, providing rich information on community needs and concerns, as well as success rates in accessing the system. What may be different about the programs that were developed during the late 1950s and early 1960s and the models utilized in border communities today is that in the past, outreach workers were often viewed as passive agents of the system, without specific training and knowledge of health issues. Today, CHAs are highly trained—that is, they receive intensive training on the particular health issue or issues that they will be discussing with other community members. Community health advisor programs in the U.S.-Mexico borderlands are built on the belief that knowledge is power. Informal programs begin with intensive (25 to 100 hours) training that includes health issues knowledge, information and referral knowledge, communication skills, community mobilization strategies, and advocacy training. Once CHAs are working in the community, the orientation training is continually reinforced on a regular basis through monthly in-service training. Second, CHAs are recognized as experts—that is, just as health care providers and scientists bring specific expertise to the table, community health advisors are experts on their own communities. Not all CHAs are volunteers, but rather paid members of the health care delivery team. They

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share their knowledge about the community with health care providers and are key to ensuring that educational efforts are culturally competent and sensitive to community context. Third, community mobilization and advocacy play a critical role within the CHA programs—that is, community health advisors become the voice for the community in affecting both the delivery of services in the community and the development and/or changes in policy. As a bridge between the system and the community, they provide essential information as to where there are gaps in the system, and at the same time, give information to the community on the existing limits of the system. Both points of information are ripe for bringing about policy changes. The following three elements are what provide an avenue for actual community empowerment. First, knowledge on health issues is shared. It is no longer the mystery-mastery situation for the community—that is, it is no longer the health care providers, scientists, and policy makers who have all the knowledge. Second, a built-in mechanism is put in place for providers, researchers, and policy makers to understand the community. The CHA brings to the table a true understanding of the community issues and needs. And, finally, through community mobilization and advocacy by CHAs, policy at the local, state, and national levels can be influenced. This arrangement presents a "win" situation for all. It is assumed that, in the end, policymakers, researchers, and health care providers are working to provide appropriate policy and services to meet real community needs, since community health advisors along the U.S.-Mexico border are responsive to the unique needs of the individual communities. Programs offer more commonalities than differences. A crucial characteristic of the CHA work is that it is genuinely holistic. The most effective CHA's work is with the whole person, not just with the illness or the disease. The nature of their work makes it impossible to impose false distinctions between physical, mental, and psychosocial health. Their definition of health is broad and comprehensive; it encompasses adequate and safe housing, stable employment, appropriate nutrition, affordable health care services, respect, dignity, and love.

THE FIRST NATIONAL COMMUNITY HEALTH ADVISOR STUDY In 1995, the Annie E. Casey Foundation began contacting people in the CHA field, and in early 1996 a multidisciplinary team of staff and consultants began the work of the First National Community Health Advisor Study. The study identified steps to be taken to strengthen outreach services delivered by paid and volunteer CHAs throughout the United States. The study focused on issues that need to be addressed to build capacity and

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respect for CHAs programs to carry out their work in a manner that can be more easily recognized and reimbursed (Rosenthal 1998). The term CHA was used in the study to encompass an array of health practitioners known nationally and internationally by many different titles. Some of the names for these practitioners include lay health advocate, promotor, outreach educator, community health representative, peer health educator, and community health worker. In the study's national survey, which included respondents from more than 150 programs, 66 distinct titles for CHA were identified. These varied titles reflect the diversity of the field, diversity that contributes to CHA programs' success in meeting the needs of culturally distinct communities. The purpose of the national study was to provide guidance to policy makers and practitioners on a number of areas that could improve the overall status of the CHAs field. The study incorporates the perspectives of CHAs as practitioners. Through its recommendations, the study aims to strengthen the CHAs profession itself, as well as its capacity to serve communities in need and to enhance the health and human service systems in which they work. In recent years, there has been an increased interest in community health advisors; however, there is a pervasive lack of understanding and appreciation of their roles and skills. This lack of knowledge and recognition has caused many CHAs to be underevaluated by members of the health and human service systems.

Highlights of the National Study Four broad issues confronting youth and adult community health workers are explored in the NCHAS study: 1. Development of CHA core role and job competency definitions 2. Evaluation strategies for CHA programs 3. CHA career and field advancement 4. Integration of CHAs within the changing health system, including managed care environments.

The study, conducted under the auspices of the University of Arizona Rural Health Office by an interdisciplinary team of staff and consultants from across the country, utilized a participatory research framework. A majority CHA Advisory Council reviewed findings from the field and then developed recommendations from practice, policy, and research.

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The Number of CHAs The most comprehensive documentation on CHAs programs in the United States is found in the Center for Disease Control and Prevention's (CDC) CHA database, which contains profiles of over 200 programs representing more than 10,000 CHAs (Brownstein 1998). Despite CDC's update of the database, the growth in CHA programs appears to be outracing CDC's efforts, which depend on a volunteer self-registration of programs. According to estimates of the National Peer Helpers Association, there are also an estimated 50,000 school-based programs and 900 university-based programs, primarily made up of volunteer CHAs. Using assumptions from the literature as a reference, there are approximately 12,500 CHAs throughout the United States, with approximately 25 percent estimated to be volunteer. As the U.S.-Mexico border population grows increasingly diverse, the demand for accessible health and human services takes on a new meaning. Barriers associated with access and utilization of care are exacerbated by the growing influence of language, economics, and cultural barriers. Overcoming those barriers demands that those who deliver health promotion information and health care services find responsive and creative solutions. However, fragmentation in the CHA field, linked to multiple funding sources and lack of sustainable avenues prevents the field from functioning in an optimal way. The gaps between the needs and availability and accessibility of services are too wide. Community Health Advisors at the U.S.-Mexico Border The hundreds of CHAs who live and work along the border have invested, and many times volunteered, hundreds of thousands of hours of service in building healthier communities and creating paths toward finding and mobilizing community assets. They are primarily oriented to the development of activities and policies that are based on the capacity, skills, and assets of low-income people and on their neighborhoods. Creative neighborhood leaders and CHAs working in border communities have recognized the hard truth that development must start from within the community. CHAs identify local assets, begin connecting them with one another in ways that multiply their power and effectiveness, and begin harnessing the local health and human service institutions and organizations that are not yet available for local development purposes. CHAs build on the capacities of the community's residents. Household by household, building by building, block by block, colonia by colonia, the CHAs and the community volunteers discover a vast and often surprising array of individuals' talents and productive skills, few of which are being mobilized for health promotion and disease prevention and community building purposes. To accomplish this, a CHA's core qualities include, in

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general terms, the possession of social, environmental, and ethnic qualities of a subculture. In specific terms, they include the sharing of a verbal and nonverbal language with a client (Rosenthal 1998); an understanding of a community's health beliefs and barriers to health care services; and an enhanced empathy with and responsibility toward a community and its health services needs. Among the benefits associated with CHAs are cost-saving, expansion of health professionals' roles, and increased outreach services. While there are significant successes reported, difficulties in implementing and sustaining programs include a lack of clarity in a paraprofessional's role and training for these roles, difficulties of CHAs working with health professionals and being accepted by them and their clients, restriction of their responsibilities to minor tasks, limited or no active involvement in determining program goals and objectives, lack of planned evaluations, and an absence of sustained funding for these positions. CHAs accomplishments have been primarily measured by comparing CHAs to health care professionals (Watkins 1994) and comparing clients receiving CHA services to those not receiving services (Arron and Perez 1995), by group comparisons (Schellhammer 1997), and by index to matched control group comparisons. In general, the findings of these studies are that clients' health was enhanced by receiving the CHAs' services. Limited attention has been given to assessing the association among characteristics of CHAs, program tasks to be performed, client acceptance of services, the nature and extent of CHAs activities, and health outcomes. CHAs who reside and work in the border region are mostly women; they are homemakers, wives, partners, and friends who with great dedication struggle to better themselves even with the lack of understanding from their husbands or partners, children, and families. There is also a small number of male and youth CHAs throughout the border region. With altruism and philanthropy, CHAs give part of their time and life to benefit their communities by sharing their knowledge and wisdom, or sabiduria y conocimiento, on nutrition, maternal and child health, chronic diseases, HIV/ AIDS, prenatal care, domestic violence, organic gardening, and environmental health, to name a few issues. Whether advocating and lobbying for works in urban or rural infrastructures or advising community leaders and residents, these CHAs are agents of change and leaders in their communities. For the past twenty years, the CHA field in the border region has offered a series on core training and instruction themes that cut across the four border states, which include the following areas: Maternal and Children's Health This area covers involvement in maternal and child health activities, nutrition education, family gardening programs, and parenting skills building. It also primarily includes recruitment, referral, and health promotion edu-

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cation. Encouraging community involvement and improving access to health and human services remains the perennial problem of community based initiatives. Leadership Development Development of leadership qualities come through friendships, emerging relationships that develop into psychologically positive networking systems, achieving role model status, increased family involvement, and selfempowerment. Self-Care and

Motivation

For most women, the motivation to become a CHA/promotora stems from the deliberate search for ways to improve the quality of life for themselves, their families, and their communities. The desire and passion to learn and grow are recurring themes of their stories. Learning and Teaching The notion of learning, skill building, and participatory education that emphasize cultural competence, consciousness raising, problem solving, and social support are central themes to their stories. Outreach and Increased Access to Health Care Cultural and language differences and barriers between health and human service providers and patients are addressed. Street and community outreach, risk reduction education, referrals, and screening services are among the core themes of the outreach interventions. Transformation and Social Change Adequate health care should be a human right and made accessible and affordable to all. As one CHA from El Paso puts it: "The more money you have, the better able you are to avoid exposure to the kinds of hazards and stresses that affect your health negatively." These themes, as well as input from a series of border miniforums, became part of the strategy when in 1995, the U.S. Department of Health and Human Services, Health Resources and Services Administration awarded a contract to the University of Arizona College of Medicine Rural Health Office to conduct a U.S.-Mexico Border Health Outreach Demonstration Initiative called Border Vision Fronteriza (Nichols and Moya 1997). The goal of the initiative is to develop four effective communitybased health outreach models that can be replicated in both urban and rural areas throughout the U.S.-Mexico borderlands. The key to the initiative is the broad array of agencies, institutions, and organizations from throughout the border region participating as contractors, collaborators, and partners.

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The four BVF Outreach Demonstration Models 1 have a core set of elements that constitute a common thread that ties them to one another. These include structures that allow community residents to determine what they want in their health care system and define how the health care system should be identified; community participation in group action and dialogue efforts directed at enhancing community control, so that people may change their lives and their health care status; advocacy and community mobilization through community health advisors and promotores de salud; resourcefulness; local autonomy capacity and partnership building with multisectorial entities and communities-at-large; and finally, institutionalization of the demonstration models. There are a number of exciting examples of CHA programs that have been successful in helping people and families access health and human services, learn better self-management of chronic conditions, and in the process save medical and health care costs along the U.S.-Mexico border region. The following is an example of such a program. Mano a Mano Program (Hand to Hand) The sister cities of Brownsville, Texas, and Matamoros, Mexico, share more than a border. They share a river, large polluting industrial centers, and young, poor, and rapidly growing populations. In response to the disturbing statistics, the One Border Foundation initiated a community outreach program to positively impact women's access to prenatal care and overall health of women and children. The Mano a Mano Program was then established. Mano a Mano is a grassroots organization comprised of community health volunteers/promotoras. More than fifty women from the target communities have been trained to provide health information to women and families in need. The promotoras are highly skilled and committed, and they spend many hundreds of hours serving their respective communities (National Audubon Society 1997). Each promotora visits ten to twenty homes per month, seeking out pregnant women in their communities, and provides them with home visits, transportation to their community clinics, referrals to social services, peer counseling, and advocacy. These efforts are taking place on both sides of the Texas-Mexico border. Policy and Funding Support to CHA Programs In all U.S.-Mexico border states, as well as throughout most other states, CHA programs continue to struggle to build policy and revenue necessary for long-term sustainability. Prenatal and child health programs tailored to address high-cost births and infant medical complications or to reduce child abuse, appear to have an advantage over other types of programs. The Community Health Representative Program (CHR), directed to Na-

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tive American populations, is the only C H A program directly funded by the federal government. The program has approximately 1,500 CHAs that are employed in twelve tribal regions serving about 2 3 0 tribal groups a r o u n d the country. In 1994 and 1995, the National Community Health Advisor Act was introduced by Congress. Both the 1994 and 1995 versions of the act would have established a national program of CHAs to assist states in attaining the goals of Healthy People 2 0 0 0 and called for federal funding. A number of the health care reform bills introduced in Congress in 1994 incorporated versions of the C H A act. Although not enacted, in the past t w o sessions the bill has served a valuable consciousness-raising function in Congress (Community Health Workers: A Leadership Brief 1997). In 1998 the Health Outreach Act was partially enacted by the Maryland General Assembly. The Health Outreach Act is designed to overcome cultural, language, and knowledge barriers that separate low-income families from essential health services. RECOMMENDATIONS Supporting and Financing CHA Outreach • Community Health Advisors play an instrumental role in improving access to health and human services/and should be considered integral members of health care delivery teams. Respect from other health care professionals is paramount to their integration and ability to affect change. • Investment in community outreach is crucial to improving access to health care in low-income and ethnically diverse communities. Long-term support is needed for community outreach programs to assure viability and sustainability. (Demonstration projects should be funded for more than two years, to allow more time for the projects to develop a foundation in the community, evaluate their interventions, and plan how they will be sustained.) • The variety of outreach strategies and the uniqueness of individual models must be appreciated and built upon. It is also imperative to build on the level of readiness and existing ongoing efforts in the communities. • CHAs can play an important role in outreach regarding Women, Infants, and Children (WIC), Medicaid, children's health, and the state children's health insurance programs. Their role should focus on providing information, education, and referral, however, and not exclusively on enrollment. • Training of CHAs needs to go beyond health-specific knowledge and skills, to include strategies to motivate individuals and communities to adopt and maintain healthier lifestyles and behavior. • Legislation must be passed to enhance the importance of community outreach

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and health promotion and disease prevention interventions, advocating for adequate funding, and for impact evaluations of these programs. Building Networks • The Border Vision Fronteriza (BVF) experience suggests that multilevel networks (local, regional, national, and international) can be very effective. These networks should include public/private and government/nongovernment partnerships. • There is a need to further develop the communications network between community outreach programs across the country. Suggested strategies for network development and enhancement include: a directory of community outreach programs; regional and national CHA resource centers and conferences (and support for CHAs to attend the conferences); newsletters; distance learning; electronic communication; and books or other publications in which CHAs "tell their stories." • U.S.-Mexico cross-border collaboration has been central to the success of BVF. It is recommended that this type of collaboration be continued and expanded, as it is only in partnership that we will be able to solve problems along international (as well as state and local) borders. What Can W e D o N o w ? States can support C H A programs in the following manner: • Pass appropriations that include adequate funds for evaluation of program impact and outcome; • Appropriate and earmark funds for prevention intervention; • Support meetings to inform managed care organizations and other providers and health professionals about CHA Programs; • Enact Medicaid and managed care quality standards that encourage preventive approaches; • Leverage cost savings from prevention; • Develop incentives to contract with community-based providers; • Provide formal recognition and compensation of successful CHA programs • Encourage comprehensive wellness networks; and • Disseminate CHAs program health impact as cost-savings. CONCLUSIONS As the U.S.-Mexico border population grows increasingly diverse, the demand for accessible health and h u m a n services takes on a new meaning. Barriers associated with access and utilization of care are exacerbated by the growing influence of language, economics, and cultural barriers. Over-

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coming those barriers demands that those who deliver health promotion information and health care services find responsive and creative solutions. However, fragmentation in the CHA field, linked to multiple funding sources and lack of sustainable avenues prevents the field from functioning in an optimal way. The gaps between the needs and availability and accessibility of services are too wide. Primary health care continues to gain acceptance as a strategy for bringing basic health services to all people who do not have access to such services. Health promotion and disease prevention by CHAs also have a significant impact on health by focusing on health problems that are preventable by means of simple relatively low-cost interventions. Community-oriented health promotion programs are more effective than traditional "top-down" programs because local residents identify the root causes and strategies to address them, and health promotion initiatives organized by the community have a greater degree of ownership than those initiated by public health professionals. CHAs believe that the key to improved health-related outcomes lies in community-based health promotion programs. However, the CHA field in the United States is in need of strategic coordinated efforts to support its growth and development. Those efforts must be forthcoming, in view of the fact that the work of CHAs throughout the United States and the world has made and continues to make a difference in many lives, with tremendous potential for the future. EXCERPT OF A PARTING LETTER FROM MARY SANCHEZ-BANE, TO THE PROMOTORAS WITH WHOM SHE WORKED: . . . You are an excellent example of strong women who care for their community and are willing to become involved with your community to better it. My father always told me that if I wanted my world to be better, I needed to better the community I lived in. He also taught me that we have to give back to our community for the home it has provided us regardless of how good or how bad. You all are doing just that. I think you have tremendous strength within you to go into your community and see all the great need there is and still be willing to work at it. You are willing to go one step further and bring on to your mission other volunteers who share the same desires for a better community. That takes courage, vision and determination all of which each and every one of you have . . . Remember, it will not be done in one year or in five years, but with each little process you do, you are creating a change within that community and those persons you touch, and they will never be the same again. Everything you do, say, touch, and feel may not affect the whole community, but it will affect one person each time and that is change.

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Keep the faith, hope, and the vision and remember the power you have is within you. . . . My best to you, Always—Mary E.

NOTE 1. In California: The Border Health Initiative; Arizona: Rio Colorado Border Volunteer Project; New Mexico: Promotores for Community Mobilization; and in Texas: Border Partnership Training.

REFERENCES Works Cited Arron, J., and M. Perez. 1995. Community Health Workers: Bridging Research and Practice, 2-4. Midwest Latino Health Research, Training and Policy Center. Chicago, 111., October. Brownstein, J. Nell. 1998. Community Health Advisor Program Directory, 4-6. Vol. 3. National Center for Chronic Disease Prevention and Health Promotion. Washington, DC: Center for Disease Control and Prevention. Carpenter, M., and L. Kavanagh. 1998. Outreach to Children: Moving from Enrollment to Ensuring Access, 4-6. Arlington, VA: National Center for Education in Maternal and Child Health. Community Health Advisors. 1997. Programs in the United States Health Promotion and Disease Prevention. Vol. 3. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention (September): 3-4, 11-15. Community Health Workers: A Leadership Brief on Preventive Health Programs. 1997. Washington, DC: Civic Health Institute at Codman Square Health Center and the Harrison Institute for Public Law at Georgetown University Law Center and the Center for Policy Alternatives (May): 4-5. "Declaration of Alma-Ata, Primary Health Care." 1978. Report of the International Conference on Primary Health Care, Alma-Ata, USSR (September 612), jointly sponsored by WHO and UNICEF. "Health for All" series 1(30). De Zapien, J., J. Meister, and E. Rosenthal. 1994. "Community Health Advisors: A Model for Community Empowerment." Paper presented at the Symposium of Health Research and Need to Ensure Environmental Justice, Washington, D.C. DHHS. 1997a. U.S.-Mexico Border Health Strategic Planning Report, 14-15. Washington, DC: Health Resources and Services Administration. DHHS. 1997b. United States-Mexico Border Priority Program. Washington, DCHealth Resources and Services Administration. Driessen, K. 1998. Border Vision Fronteriza Borderwide Children's Health Outreach Strategy, 11-13. Tucson, AZ. "El Futuro." 1997. National Latino Children's Institute 2(1) (spring). Frontin, P., L. Goldberg, and P. Robins. 1997. "Differences in Private Health In-

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surance Coverage for Working Female Hispanics." Inquiry 34(2) (summer): 171-80. Giblin, P. 1991. "Effective Utilization and Evaluation of Indigenous Health Workers." Public Health Reports: 364-65. Hayes-Bautista, D. 1997. "Workforce Issues and Options Along the U.S.-Mexico Border." USMBHA Journal of Border Health 2(4): 12-21. "Health Care Costs on the Way Up." 1998. The Arizona Republic. September 15, 1. Los Ninos Inc. 1998. Experiences of a Community Promotor: Oral History, Our Life Experiences, 9-13, 23-25. San Diego, CA: Aztec Printing. Loustaunau, M., and E. Sobo. 1997. The Cultural Context of Health, Illness, and Medicine. Westport, CT: Bergin & Garvey. McDonough, J. 1998. Health Care Policy: The Basics. The ACCESS Project. Moore, I., and J. Steward Jr. 1972. "Important Variables Influencing Successful Use of Aides." Health Services Report 87: 55-56. National Audubon Society. 1998. "Population and Habitat Update "Mano a Mano"—On The Border." Newsletter 10(1) (January-February): 1-3. National Council of La Raza, Inc. 1993. Understanding Community Health Promotion, 8-12. Washington, DC: Center for Health Promotion. Neubeck, K., and M. Neubeck. 1997. "Health Care." Social Problems: A Critical Approach, 121-27. 4th ed. New York: McGraw-Hill. Nichols, A., and E. Moya. 1997. "Border Vision Fronteriza Initiative." USMBHA Journal of Border Health 2(4): 2 - 3 . Rosenthal, E. Lee. 1998. The Final Report of the National Community Health Advisor Study, 8-12. A Policy Project of the University of Arizona funded by the Annie E. Casey Foundation. Tucson, AZ: University of Arizona. Schaefer, M., and J. Reynolds. 1995. Operations Research Issues in Community Health Workers, 7-13. Primary Health Care Operations Research, Center for Human Services, Chevy Chase, Md. Monograph Series: Issues Paper 2, May. Schellhammer, K. 1997. "Experiences of Hispanic Community Health Promotoras." A Qualitative Study (May): 21-25. Slifkin, R., S. Hoag, P. Silberman, S. Felt-Lisk, and B. Popkin. 1998. "Medicaid Managed Care Programs in Rural Areas: A Fifty-State Overview." Health Affairs 17(6) (November/December): 217+. Status of Children Report. 1997. Washington, DC: Children's Defense Fund. "La Tercera Cultura." 1996. Perspectivas de Salud. Oflcina Regional de la Organizacion Mundial de Salud. WHO 1(2): 14-17. Texas Comptroller of Public Accounts. 1998. "Bordering The Future." Report. July, 113. University of Arizona. 1998. Final Report of The National Community Health Advisor Study Policy Research Project (June): 1-2, 21-22, 83-84, 126-30. U.S. Department of Health and Human Services. 1995. Annual Report on Health, United States 1995. Washington, D.C. U.S. Department of Health and Human Services, Health Resources and Services Administration. 1997. Border Health Strategic Planning Report, 14-15. Washington, D.C.

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Watkins, E. 1994. "Assessing the Effectiveness of Lay Health Workers with Migrant Farmworkers." Community Health 16(4): 72-73. World Health Organization. 1986. "Strengthening the Performance of Community Health Workers in Primary Health Care." Technical Community Health Worker Report, 4-16. Report of a WHO Study Group, Series 780. Geneva, Switzerland: WHO. . 1987. The Community Health Worker: Working Guidelines for Training, Guidelines for Adaptation, 3-7. Geneva, Switzerland: WHO.

Selected Readings Airhihenbuwa, Collins O. 1994. "Health Promotion and the Discourse on Culture: Implications for Empowerment." Health Education Quarterly, 21(3): 3 4 5 53. Discusses the need for health educators to promote cultural diversity by centralizing hitherto marginalized groups in program and curriculum development. Buchanan, David, Edna Apostol, Dalila Balfour, Carmen Claudio, et al. 1994. "The CEPA Project: A New Model for Community-Based Program Planning." International Quarterly of Community Health Education 14(4): 361-77. Describes a new model of community-based program planning developed by the Centro de Educacion, Prevencion y Accion (CEPA) project. Community Health Advisors/Workers: Selected Annotations and Programs in the United States, Vol 3. 1998, June. This publication contains bibliographic abstracts of journal articles, reports, literature, resource materials and program descriptions from the 1970s through the present. Contact: J. Nell Brownstein, CDC, 4770 Buford Hwy., NE, Mailstop K-45, Atlanta, GA 30341-3717 (770) 488-5440. Erzinger, S. 1994. "Empowerment in Spanish: Words Can Get in the Way." Health Education Quarterly 21(3): 417-19. Final Report and a Summary of the National Community Health Advisor StudyWeaving the Future. 1998, August. This summary highlights findings and recommendations from the National Community Health Advisor Study. This summary is to be used to educate the health field about the role of CHAs, develop effective training resources for CHAs, and obtain support for the future of CHAs. Contact: Annie E. Casey Foundation, 701 St. Paul Street, Baltimore, MD 21202 (410) 223-2890. Frankel, Stephen, ed. The Community Health Worker: Effective Programmes for Developing Countries. 1992. Oxford/New York: Oxford University Press. Impact of Community Health Workers on Access, Use of Services and Patient Knowledge and Behavior. 1998, January. This publication presents a study by the Bureau of Primary Health Care to understand better the role of community health workers (CHWs). Contact: Bureau of Primary Health Care, 4350 East West Highway, Bethesda, MD 20814 (301) 594-4450. Implementation of Healthy Start-Lessons for the Future. 1997, September. Mathematica Policy Research, Incorporated examined fourteen Health Start programs in urban and rural communities around the nation. A noteworthy conclusion of this research revealed that a lay worker model holds great

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promise for providing services that are accessible and satisfying to the Health Start community served. Contact: Mathematica Policy Research, Incorporated, Attention: Jan Watterwoth, PO Box 2393, Princeton, NJ 08543-2393 (609) 275-2334. Journal of Border Health 2(4) (October/November/December 1997). This special issue of the journal focuses on the work of the Border Vision Fronteriza Initiative and presents five issue papers commissioned by the Initiative, which provide an overview of border health issues. The issue paper titles are: "Community and Economic Development in Health Care: The U.S.-Mexico Border Case"; "Workforce Issues and Options in the Border States"; "Health Policy in Mexico: With Special Reference to the U.S.-Mexico Migrant Population"; "Community Outreach and Community Mobilization: Options for Health at the U.S.-Mexico Border"; and "Research and Technology in the Underserved Populations of the Border: A Description of Technological Needs of Border Communities and Methods to Address Those Needs." Contact: U.S.-Mexico Border Health Association, 6006 N. Mesa, Suite 600, El Paso, TX 79912 (915) 581-6645. Mahon, J., J. McFarlane, and K. Golden. 1991. "De Madres a Madres: A Community Partnership for Health." Public Health Nursing 8(1): 15-19. McFarlane, J., and J. Fehir. 1994. "De Madres a Madres: A Community, Primary Health Care Program Based on Empowerment." Health Education Quarterly 21(3): 381-94. Describes a five-year community empowerment process by a program designed to encourage Hispanic women in a Texas community to seek and receive prenatal care. Meyer, Jack, and Nancy Bagby. 1998, May. Beyond Enrollment: Are SCHIP Plans Linking Children to Quality Health Care? This study reviewed nineteen State Children's Health Insurance Program (SCHIP) plans. Meyer and Bagby provided numerous recommendations for the betterment of all SCHIP plans. Contact: New Direction for Policy, 1015 18th Street, NW, Suite 210, Washington, DC 20036-5203 (202) 838-8877. 1998 Inventory of Managed Care Activities In the Maternal and Child Health Bureau, Health Resources and Services Administration. This publication provides a list of organizations and their projects/activities in relation to managed care. Contact: Maternal and Child Health Bureau, 5600 Fishers Lane, Room 11A-22, Rockville, MD 20857 (310) 443-2778. Opening Doors: Reducing Sociocultural Barriers to Health Care Lessons Learned. 1998, August. This report summarizes the lessons learned from Opening Doors: Reducing Sociocultural Barriers to Health Care, a national program of The Robert Wood Johnson Foundation and the Henry J. Kaiser Family Foundation. Contact: Opening Doors, c/o Hospital for Sick Children Health System, 1025 Connecticut Avenue, NW, Suite 1100, Washington, DC 20036 (202) 974-4694. Outreach to Children: Moving from Enrollment to Ensuring Access. 1998, August. This publication documents the barriers that programs have faced and the strategies that have been implemented to provide effective outreach services to uninsured children. Contact: National Maternal and Child Health Clearinghouse, 2070 Chain Bridge Road, Suite 450, Vienna, VA 22182-2536 (703) 356-1964.

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Sherer, Jill L. 1994. "Neighbor to Neighbor: Community Health Workers Educate Their Own." Hospitals & Health Networks (October 20): 52-56. Describes how hospitals can work with community health workers, giving examples from California. Stinson, W., M. Favin, and B. Bradford. "Training Community Health Workers." Information for an Action Issue Paper. Washington, DC: World Federation of Public Health Associations (APHA).

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9 Rural Health on the Border and New Mexico's Models for Care, Community Empowerment, and Cooperation Martha Oehmke Loustaunau

Rural areas have often been thought of as healthy and robust—environments where there is fresh air, clean water, plenty of exercise, no urban stress and pressures, no noise and pollution, and a healthy diet with lots of fresh fruits and vegetables. All this is bound to add up to good health and a long life expectancy. What this rosy vision fails to consider is that food may not be plentiful, use of fertilizers and pesticides pose extreme hazards, accidents with no access to rapid emergency medical care are common, and water is easily contaminated. In addition, labor may be intense or sporadic, and the stresses of isolation, economic forces, and other limitations may create an environment that can, indeed, be hazardous to one's health. Add to this set of circumstances the lack of access to transportation, preventive care, social services, educational opportunities, and basic facilities, with rapid population growth in many areas and often relative or abject poverty, and urban areas may in the long run be "healthier" for their populations (see Hassinger and Hobbs 1992; AHCPR 1998, 1-2). In addition, while some rural areas are somewhat isolated, others may be close enough to urban centers to catch the spillover of urban problems as well, often without the benefits. Both types of rural areas are found in the U.S.-Mexico border region. Health problems are common in the more isolated areas, as well as in those communities close to large urban centers such as the El Paso, Texas/Juarez, Chihuahua area located just across the line from New Mexico. These New Mexican communities still maintain a distinctly rural character and have limited access to health care.

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This chapter explores the rural environment in southern New Mexico and the role of two community health centers in addressing the health care needs of the local border population in the broadest sense, through networking and services that encompass community education and empowerment. In examining the specific problems and the role of the rural community health centers in offering solutions that seem to work, the question of the survival of these centers and the uniqueness of their approach in the face of a changing system, tighter funding, and the incursion of corporate managed care must be considered. DEFINING THE RURAL As cities grow and spread out, the definition of "rural" becomes an issue, primarily because areas designated rural are eligible for some types of supportive monies and programs, and those that are designated "urban" can apply to other sources for funding. The lines between urban and rural can often become blurred. Kathleen Murrin (1982) cites two common definitions of rural from Madison and Bernstein (1976) as (1) "the population residing in the open country and in communities of less than 2,500" and (2) "the population located in a county outside a Standard Metropolitan Statistical Area (1982, 5). Murrin, however, suggests the more practical definition of Copp (1976) that includes trade centers of 2,500 to 10,000 population. As larger cities begin to assume more of the service and economic functions, the smaller trade centers begin to resemble rural areas with many of the same deficits. Hassinger and Hobbs (1992) note that "Although the metropolitan and nonmetropolitan designations have gained official status, they are not without drawbacks. Statistically, non-metropolitan includes everything from isolated and extremely small ranching communities in the West to small cities having a population of up to 50,000. Thus, the 'rural' umbrella is very large" (179). In southern New Mexico, along the forty-five miles separating two cities of considerable size, El Paso, Texas, and Las Cruces, New Mexico, lie several small communities that are most certainly rural in character. Sunland Park, just outside El Paso, is a community of 11,000, with the look of a suburb. Mesquite, La Mesa, Vado, Chamberino, and La Union are villages of around 800 to 1,000 inhabitants. La Mesilla, just outside of Las Cruces, is larger, with around 2,000 inhabitants. These communities are all located in Dona Ana County, which includes the city of Las Cruces, which was designated as an SMSA (Standard Metropolitan Statistical Area) in the late 1980s, meaning that the city had surpassed a population of 50,000. And yet, these communities, without the rural clinics and programs that provide them with access to health care, would have little or none. They are rural areas surrounded by growing urban centers, but they retain

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the unique features of a rural society. Distance and density are not the only factors that must be considered in designating rural environments. Rural Characterization In fact, environment is seen as the crucial factor in defining and characterizing a rural population. Hassinger and Hobbs (1992) discuss three major features of the rural environment which have an impact on health care, and which are relevant in southern New Mexico as well as other border regions, as being (1) size and density of population and their effect on social organization and group relationships, (2) economic deprivation, and (3) center/perifery relationships. Smaller populations with low density are problems since dispersed populations are more difficult to serve with a cost effective range of services. Although general needs may be filled from local grocery stores and shops, users of more specialized services such as health care must often travel further to obtain those services. The services then become more costly per capita and add the cost of transportation. Rural communities are also affected by their organization; they have been characterized as less anonymous, with less division of labor and less heterogeniety, with fewer impersonal and prescribed relationships, and fewer symbols of status that are independent of personal acquaintance (Dewey 1960; Proceedings 1986). Rural areas are generally seen as more informal overall, with closer community ties, few secrets among community members, and a distrust of "outsiders." This includes suspicion and distrust of "experts" and larger government sponsors of rural programs. These programs, being tied to outside support and regulations, diminish the sense of local control. Community consensus, however, may be deceiving. There are generally those community members who want growth and services, and those who staunchly defend the status quo and wish to retain local control. This twotier characteristic of rural communities, introduced with mass society, thus may become a source of conflict (Hassinger and Hobbs 1992, 182), particularly when resources become constrained and more costly. This applies to the current era of scarce health care resources, competition among providers, and privatization of care. This is in contrast to the Hill-Burton era from the late 1940s to the 1970s, when funding resources for facilities were plentiful through the Hill-Burton Act, which provided monies for development of rural hospitals (Starr 1982) and conflict was low. Poverty, of course, has been shown to be a major problem in rural areas, as it is in urban areas. In rural areas, however, the elderly population is likely to be larger, since youth may migrate to larger urban areas with job opportunities. Rural children are also more at risk with lack of prenatal care, poor nutrition, and lack of preventive care. Mobility may be limited

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as transportation costs rise, with serious implications when health care services are located at any distance. Individuals may thus be seen as relatively isolated when residing even within 20 or 30 miles of large urban facilities. Poverty, as we have seen, is itself an indicator of poor health (Link and Phelan 1995) and most certainly is a barrier to preventive services. Center/peripheral relationships concern the interdependence between rural and urban areas and populations. Since the 1920s, a shift has taken place in the structures and social and economic environments of social organizations. Small regional trade centers have grown up that supply their periferal areas with goods and services, and are in turn supported by their trade. Smaller community health care services, such as local rural hospitals, however, have not always survived and have closed due to higher costs, lack of service providers, a poorer and largely uninsured population, and unpredictible needs (Ricketts 1993; Pirani 1994). Some of these services have consolidated with other, larger organizations, creating a loss of local control and sense of community ownership. Both the community-perceived needs and the role or participation of the rural communities themselves in addressing those needs are then at issue. Whether this type of systemic change becomes the norm and can provide the types of rural health care required (and desired) by residents, remains to be seen. HEALTH-RELATED NEEDS IN THE NEW MEXICO BORDER AREA Whether extremely or relatively isolated, whether labeled as rural, periferal, nonmetropolitan, or other, populations living in these areas have a large number of needs related to health care. This is particularly notable in border areas like southern New Mexico, which has a number of problems unique to the location and environmental conditions. In the El Paso/ Juarez area, population is growing rapidly due to the development of the maquiladoras, large industrial manufacturing plants located on the Mexican side of the border, but without the accompanying infrastructure of basic services for the labor pool. Many of the workers in these plants live in semirural areas outside the cities on both sides of the border, often in colonias, which are unincorporated settlements that have grown up rapidly and are without paved roads, sewer systems, electricity, gas, or safe water, not to mention such services as police and fire protection, education, and health care (Salinas, Bensenberg, and Amazeen 1988; Skolnick 1995). Moreover, the more isolated villages and colonias offer little or no employment opportunity. The general health care needs of the border area are broadly known and include both individual needs and public health concerns. Most health

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problems are basically connected to poverty and stress, environmental and occupational conditions, and some, like the high rate of diabetes, appear to be related to ethnicity (Becker et al. 1993; Lipton et al. 1998). Diabetes, in fact, is especially common in Hispanic populations. On the border, poverty, low educational levels, and lack of preventive care and screening make the consequences of diabetes particularly severe. Resulting disabilities include blindness, loss of limbs, and ultimately death (Lipton et al. 1998). Communicable diseases such as tuberculosis, cholera, and AIDS are also serious public health concerns for both sides of the border. Tuberculosis is especially worrisome, since diabetes, substance abuse/alcoholism, and AIDS are shown to be important tuberculosis mortality and morbidity indicators. Therefore, "Management and control of these associated conditions is closely linked to successful tuberculosis control" (Escobedo and de Cosio 1997, 46). Denial of care to noncitizens is obviously not the answer to these problems, which must be seen as issues to be addressed by joint cooperative efforts of the nations on both sides of the border. This is perhaps especially true of those environmentally caused diseases and illnesses such as poisoning from pesticides, intestinal disorders from contaminated food and water, respiratory ailments from tainted air, and any variety of ailments from chemical dumping and industrial contaminants. The source of these problems is economic and political, rather than medical. The problems can always be treated medically, but until the sources are addressed, there will be no change. The source of many health problems, in fact, lies within the social structure, which in turn has behavioral effects producing problems of malnutrition; birth defects; sexually transmitted diseases; childhood diseases from lack of immunization; skin cancer; rabies; crime and violence-related health problems, both domestic and nondomestic; teen pregnancy; problems from lack of pre- and postnatal care; accidents; and asthma (see Loustaunau and Sobo 1997). Assessing the Needs A variety of needs assessments conducted in the area by several organizations have revealed some of the more pressing needs as perceived by the populations themselves. One informal assessment, conducted by the Catholic Diocese in Las Cruces in 1989, concerned dialogues with a number of small communities in the area, using interviews and directed particularly to migrant communities. Approximately 265 interviews were done, with the purpose of helping people to voice their needs and to recognize the potential of organizing in order to improve their conditions. Major needs

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expressed did not include access to primary care, but for paved streets, lighting, housing improvement, sewer and water facilities, and public safety. A more recent and formal needs assessment relating to a grant from the Kellogg Foundation, administered through the Southern New Mexico Area Health Education Center (SoAHEC), was directed to facilitating community empowerment to improve access to primary care and related services. The assessment concerned the small community of Chaparral, New Mexico, located 45 miles southeast of Las Cruces and adjacent to East El Paso, Texas. The results closely mirrored the results of an assessment done previously by La Clinica de Familia, which operates a facility in the village. The final Data Report (Chaparral Community Health Council 1997) gives a profile of the rural population (from 235 surveys returned) with average age of 42.5 years, 65 percent Hispanic, 61.3 percent of households having children 18 years of age or less, a quarter of the households with residents of 65 years of age or more, with 67.5 percent of respondents living in trailer homes and 94.9 percent living in their own homes year round. General perceptions of family health status was mostly good (35.5%) to fair (27.7%). Most prevalently perceived health problems included asthma (24.35), diabetes (18.7%), chronic bronchitis (15.3%), and kidney problems and heart murmurs at 14 percent each. Additional health-related problems mentioned included depression, drugs/alcohol, family violence, and AIDS. Although 78.7 percent of Chaparral residents were on a public water system, 71.2 percent of those remaining wanted hook-ups. With regard to access to health care, the most frequent source was the doctor's office (45.1%). Other sources were clinics and emergency rooms. Transportation was primarily by using one's own vehicle (77%), with the average trip taking over 30 minutes (57.9%). Most residents were "somewhat satisfied" with their care (45.1%), but 18.7 percent had not accessed health services in the past year. Twenty-eight percent purchased medications in Mexico, and reasons listed for lack of access to care included cost, long waits for appointments and then equally long waits in office or clinic, unavailable care, and inconvenient hours. The most needed services seemed to be dental care, family practice care, eye care, immunizations, and pediatrics. Other services that would be used were mental health/counseling, obstetrics/gynecology, health education, family planning, and geriatrics. Over 87 percent of respondents said that they would utilize a clinic in Chaparral, and 61.3 percent would attend special health-related programs. More than half said they would be interested in joining a Chaparral Community Health Council. Since this needs assessment was completed, the community has become much more involved in addressing their own needs. In 1997, the existing La Clinica de Familia (the Clinic of the Family), which was then providing limited services one day per week, merged with the Chaparral Public

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Health/WIC Office to form the Chaparral Health Center. Monies were obtained from the state by the local townspeople and the Chaparral Community Development Association to purchase a larger facility. Staff has expanded, services now cover a range of behavioral health and medical care, and they have brought in a pediatric mobile unit from Memorial Medical Center's First Step Clinic in Las Cruces to provide services one day per week. Needs assessments can identify a number of mutual problems, and can often highlight problems particular to a specific area. Needs perceptions can be influenced by local conditions, location, and the degree of available services. However, a major problem with identifying needs is perhaps overrather than underassessment. Although needs may change, surveys and assessments have been taking place over the years until in some areas, residents are no longer interested in being "assessed to death" with no result. It is far easier to assess needs than to address them, both politically and economically. Public participation requires the comments and opinions of local residents, but too often results are not shared or acted upon, and must be considered only a first step toward helping rural populations in addressing the needs they themselves have identified. Hence the additional need for coalescing and empowering community members to work together with aid and support of outside agencies by building trust and cooperation to succeed as shown in the case of Chaparral. This approach to addressing the needs of rural populations in general has a history of development. The problem of how to provide access to health care in all rural areas, however, was not really recognized until the 1970s. THE RURAL INITIATIVES OF THE 1970s The 1970s was a period of activism and recognition that rural areas were growing, and that rural populations required more attention and aid. To address the problem, a number of programs were devised, including the federal Rural Health Initiative (RHI) and the Health Underserved Rural Area program (HURA) (Rural Health Systems 1979). A large number of additional programs were developed at both federal and state levels, and the establishment of the National Health Service Corps offered a promise of getting physicians into rural areas, which the Hill-Burton program had largely failed to do since construction of facilities did not guarantee a physician to work there. Further changes in the 1980s grew out of state efforts. In New Mexico, the Governor's Conference on Rural Health, held in 1979 followed by another in 1986, resulted in establishment of the Rural Primary Health Care Act, with the charge of planning, attracting personnel, designating health manpower shortage areas (HMSAs) and medically underserved areas

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(MUAs), empowering local communities to identify and solve their own health problems, and to provide technical and financial assistance as it became possible. Since at the time only one New Mexico county had been classified as urban, primary care access in rural areas held a high priority (McCloskey and Luehrs 1990). The rural health care system in New Mexico has been described as both fragile and complex (Proceedings 1986, 65). It remains so today, but both fragility and complexity have changed somewhat in character. There is always the threat of loss of or lack of funding, and the way the system is administered, even when successful, may also be at risk. The structure of the system has become stronger however, with the forging of links and networks with the state, with public health, with other medical facilities, with local agencies, and through grants and contracts. In addition to finances, two questions that loom large are issues of control and participation. Funding formulas are often quite complex, including federal aid, state support, local and collaborative support, revenue-based programs, grants, and other means of funding, as well as any number of combinations, but the monies are generally tied to regulatory requirements that may change intermittently. This requires a great deal of administrative finesse as well as balancing resources with needs, once those needs have been identified. An additional question, then, is what role, if any, does the community itself play in determining needs, as well as types of services to be provided and how those services are to be delivered. One of the major attempts to address health needs in all rural areas has been through the development of rural clinics and community health centers in the United States. The borderland has benefitted from these initiatives, and provision of services has adapted to address special needs and circumstances of the border populations. In southern New Mexico, growing out of the rural health initiatives of the 1970s, two major rural community health centers have developed and evolved over time, identifying and adapting to their own client populations. These centers may be seen as models for meeting the needs of their populations and providing community care and empowerment through their flexibility, creativity, and very important, through community linkages and networking. They have managed to generate trust by working with and through the local populations, providing accessible and culturally sensitive services that are needed and that go beyond basic medical care to encompass many of the real health problems of their clients. They must, however, continue to find new ways to survive and respond in the face of increasing underserved populations, extreme environmental challenges, serious public health threats, restricted funding, the advent of managed care, and highly charged political and economic conditions.

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TWO BORDER CLINICS OF NEW MEXICO La Clinica de Familia La Clinica de Familia (the Clinic of the Family) emerged from the federally funded Rural Health Initiative in 1976 through the then-Department of Health, Education, and Welfare and the Bureau of Community Health Services. The program was implemented through the Home Education and Livelihood Program (HELP) in Albuquerque, New Mexico, along with other rural programs in health, education, issues related to farmworkers, community infrastructure, housing, and other services. The idea was for these programs, once started, to evolve into self-sufficiency. La Clinica actually opened in Las Cruces, but quickly established a second site in Anthony, New Mexico, a small unincorporated town adjoining Anthony, Texas, the two Anthonys being split by the state line. The staff consisted of a local volunteer physician, two family nurse practitioners, and was assisted by a number of VISTA volunteers. The availablity of VISTA volunteers in New Mexico at the time served to help in responding to the need for maintaining and expanding the clinic. In 1978, a small building in the rural community of San Miguel near Las Cruces that was renovated by these volunteers ultimately became a third site for La Clinica. The following year, a contract was signed with the state's Women, Infants and Children (WIC) nutritional program, and HELP decided that La Clinica would become an independent corporation. The governing board would consist of local residents from the service communities. The Las Cruces clinic was then moved to La Mesilla, just outside the city, which was classified as a rural area. Initially, bringing physicians into the clinics and keeping them there was not easy. In 1980, the National Health Service Corps began to provide primary care physicians, but two doctors assigned to La Clinica quickly defaulted and moved to other areas. Subsequent physicians finished their obligations, but eventually went into practice in Las Cruces or other areas. Physicians seemed to find that the isolation and demands of the patient load were difficult. Physicians from other areas of the country and other cultural backgrounds found themselves with culture shock. Language barriers and use of folk medicine and care alternatives could be disturbing and frustrating. The difficulties in retaining physicians in the rural clinics also included the fact that they were the only physician available to the population, and that wives and families often found little to interest or occupy them in sparsely populated rural areas. In 1983, La Clinica continued to expand, receiving funding to offer services in Sunland Park, 45 miles south of Las Cruces, near the El Paso/Juarez

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area. Dental care was not to be available until 1985 and also came through the National Health Service Corps. Other grants were forthcoming for new programs such as the Adolescent Family Life Program and a limited prenatal care program begun in southern Dona Ana County, which began to address a major health problem that is still a challenge today—that of teenage pregnancy (New Mexico Teen Pregnancy Coalition 1998). Compliance with licensing regulations has and continues to be a problem. Many regulations make it difficult or impossible to maintain needed services since regulations are often specific and unrealistic. The mountains of paperwork and pharmaceutical duties of physicians take time from patient encounters, and physicians are required to show 4,200 patient visits per year. It is also pointed out that when the purpose of the clinic is to keep people well and reduce the number of visits, the requirement to show productivity to justify funding through so many patient visits is excessive and often illogical. Community monies and resources are often made available, as in Sunland Park's donation of land and Community Development Block Grant monies that helped build the medical/dental facility in Anthony. Other funding for various programs has been made available through the state and county, as well as various legislation and special grant monies. By the 1990s, the staff at La Clinica had expanded enough to require strategic planning for the community-based corporation. For the 1990s, the plan that resulted designates broad comprehensive services dealing with border, agricultural, and poverty issues. Collaborative and partnership models are to be used for future funding support. Both board and staff of La Clinica are seen to be advocates of the program, and stress that both services and sites should be expanded to fulfill the mission of broad-based care. Additional issues for staff include salary equity, cultural sensitivity training, and expansion of the promotora program. As can be seen, the slow development and growth of La Clinica has required a great deal of ingenuity, tenacity, creativity, and support in order to survive. Grant monies from a variety of sources for a variety of coordinated programs were essentially responsible for initial expansion in caring for mothers, infants, and teens where need was great and will continue to be vital to the comprehensive program in the future. The expansion of clinic programs and linkage with other programs and initiatives since the early days has been phenomenal. The list in Table 9.1 gives an idea of the variety and importance of administrative ingenuity, community role, networking, and outreach, as well as the need for a variety of funding sources and support in order to survive. It also shows what can be done through a network of related programs and the void that would result from their loss. Evaluation is also necessary to note the gaps and any individuals who "fall through the cracks" or who are not being served for a variety of

Table 9.1 La Clinica de Familia Partnerships and Networking FINANCIAL PARTNERS

COMMUNITY PARTNERSHIPS:

U.S. Department of Health/Human Services: Health Resources Services Administration National Health Service Corps MM Department of Health Rural Primary Health Care Act Maternal/Child Health Health Service Corps Healthier Communities

MEDICAL/DENTAL SERVICES

Healthier Kids Program Families FIRST Public Health Border Health Office N.M Children, Youth & Families Dept N.M Human Services Dept SALUD! Presbyterian, Lovelace, Cimarron, Doral Dona Ana County Indigent Program UbitedWay City of Sunland Park (land, facility) W.K. Kellogg Foundation NABCO/Avon Foundation Paso Del Norte Foundation Border Health Environment Coalition National Reach Out and Read Program AmeriCorps Program Southern New Mexico Human Development

EDUCATION SERVICES University of New Mexico Medical School Preceptorships New Mexico State University Interns Health Science, Sociology, Social Work, Family & Consumer Science, Nursing National Rural Health Association

HEALTHCARE POUCY AFFILIATES Nat! Assn. of Community Health Centers N.M Primary Care Association N.M. Integrated Services Network Southwest Primary Care Association National Farmworkers' Association Migrant Clinicians' Network

Gadsden I.S.D.- School-based Services Migrant Head Start Screenings Presbyterian Medical Services LCDF Behavioral Health Services Memorial Medical Center MD. Privileges & City Call Services First Step Prenatal & Delivery Provider Specialty Referrals Children's Medical Services

SOCIAL SERVICES REFERRALS Behavioral Health Agencies Housing/Domestic Violence Shelter Financial A0******'^ WIC (Women, Infants and Children Program) Juvenile Justice

MAJOR COMMUNITY NETWORKS Maternal & Child Health Council Border Health Border Health Environment Committee Southern Area Health Education Center & Border Health Education Training Center Colonias Task Force-Catholic Diocese Gadsden School Health Advisory Council Las Cruces & Gadsden Schools N.M Teen Pregnancy Coalition Las Cruces Teen Pregnancy Consortium Families & Youth, Inc. La Pinon Rape Crisis Center Turning Points N.M Community Health Workers; Assn. March of Dimes Diabetes Association Walkathon U.N.M Prenatal Care Network Cimarron HMO

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reasons. Most people do receive services, although a number of people seek those services in Mexico. Others may seek care in local emergency rooms. Today, La Clinica de Familia consists of administrative offices in Las Cruces and service sites in five areas. There is now an additional urban site in Las Cruces, where 52 percent of county residents under the poverty line reside. La Clinica serves more than 40 percent of the residents of Dona Ana County through its diversity of programs. The client population consists of about 90 percent Hispanic, generally low income (although anyone can receive services and many others do), with about 10 percent migrant workers. Most are seasonal agricultural workers, with small percentages (8 percent and 28 percent respectively) of Medicare and Medicaid patients. Community health centers have a waiver from the federal government to serve noncitizens, as do some other programs, such as housing. They do not ask their clients for proof of citizenship or residency. Contrary to common beliefs, however, only a very small percentage of clients are estimated by clinic workers to be noncitizens. In addressing the client population, from the time of inception, La Clinica has sought to build a trusting relationship that encourages clients to feel that the clinic essentially belongs to them. Bilingual personnel are a necessity, as are printed materials in Spanish. Culturally sensitive care requires an intimate knowledge of the customs, beliefs, and practices of the client population (see Loustaunau and Sobo 1997). Factors of establishing trust and a sense of "ownership" as well as a sense of "cultural comfort" are essential in encouraging clients to seek help for any health-related problems. Many of these problems are intensely personal, such as teen pregnancy, sexually transmitted diseases, and domestic violence. Clinic staff estimates that 30 percent of pregnant teens have been abused. Since physicians have not always been either from the area or the culture primarily involved, much of the cultural connection has been carried out through staff members. The promotora program, discussed in detail by Sanchez-Bane (who was the original executive director of La Clinica) and Moya Guzman (in this volume) has been instrumental in carrying out this function. The women (and some men) involved in the program, instituted in 1992 through the New Mexico Department of Health, break down barriers and create trust through their bilingual abilities, their cultural knowledge, and the fact that they actually come out of the client population. As noted by staff, in addition to language, in order to deliver effective care it is necessary to understand folk beliefs and practices related to selfcare, the difficulties of transportation, and economic or family necessities that must be met before meeting a medical appointment or a purchase of medication. It is also necessary to create a sense of self-efficacy and pride that builds confidence and trust in relating to clinic personnel. That cannot be done by denigrating folk customs or heritage; many folk remedies are

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efficacious, and they provide a personal and psychological comfort and connection to fill the gap when people have no other recourse (Loustaunau and Sobo 1997). Trust is also vital, since physicians must know what remedies people are taking that may actually be dangerous or may interfere with prescribed medications. In addition, since many patients may obtain their medications in Mexico, clinic doctors must spend extra time in consulting the Mexican Physicians' Desk Reference to check different equivalencies when they issue prescriptions. La Clinica must now deal with the introduction and implementation of welfare and immigration reform, and managed care for Medicaid patients in rural areas. The introduction of the State of New Mexico Medicaid Managed Care Program, known as SALUD (health), has created some changes, requiring the community health centers to become members of designated managed care organizations that manage the Medicaid clients. As per previous policy, those patients who are uninsured or cannot pay for their care are charged on a sliding scale. Similar problems and policies are noted by the second major community health center in southern New Mexico, but with some differences in both population and priorities. The Ben Archer Health Clinic The village of Hatch, New Mexico, lies at the northern edge of Dona Ana County, about 35 miles from Las Cruces. Hatch is more isolated than the villages farther to the south, although a few small settlements and colonies are located in the vicinity. Even though farther from the border and unique in its own needs and character, Hatch, too, can be considered a border area. It is most certainly rural. The Ben Archer Health Clinic serves an essentially stable, agriculturally based population with a smaller percentage of migrants than areas closer to the border. There is not as much movement in and out of the area. The nearest city is Las Cruces, 35 miles to the south, and Truth or Consequences (known as T or C), a city of around 6,000 about 30 miles to the north, where there are satellite clinics with specified services. In 1969, a recognition of the need for primary care services by the community resulted in the purchase of a building to serve as a clinic by the Village of Hatch Trustees. The Ben Archer Clinic now serves a smaller client population than does La Clinica, but that population is also growing. In addition to two satellite clinics in Truth or Consequences and Las Cruces, the Ben Archer Clinic plans to develop another site in Columbus, New Mexico, directly across the border from Palomas, Mexico. Clients have also been known to travel to Ben Archer all the way from Silver City, located almost 100 miles to the southeast, due to reasons of satisfaction, anonymity, and confidentiality. About 80 percent of the client population is His-

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panic. Like La Clinica, patients residing within Dona Ana County, if not insured through private or public sources, are charged on a sliding fee scale, as are all patients from outside the county. In addition to conventional primary medical care, the Ben Archer Clinic conducts numerous educational programs, a local annual health fair, and networks with assorted social services from Head Start and day care to the Southwest Counseling Service and substance abuse services. Monthly meetings are held with representatives of agencies within the network, as a community agency partnership, to coordinate and discuss various needs and services. Unfortunately, there is still a lot of interagency competition for resources, which hinders collaboration. Many efforts at collaboration are, however, quite successful. Community agency partnerships promote new educational programs for highly relevant issues such as hantavirus (Garvey 1995) and diabetes for area residents. There are also collaborative efforts with Sierra County to provide cross referrals, educational opportunities, and appropriate prenatal care, education, and case management for all clients who need them. Maternal Child Health Program/Councils are seen as automatically collaborative in identifying gaps and delivering services. Maternal Child Health, it is noted, is unique in that "It holds no clear definition within the lifespan since all family members provide a support mechanism to the focus of children!" (Ortiz-Smith 1998). Care is thus defined as a collaborative team effort, meaning both clients and providers. Educational programs cover areas from teen pregnancy and prenatal care to safety awareness and pesticide education. Accidents from machinery, automobile accidents due to dark, narrow country roads, and dog and snake bites are common emergencies. From experience, and due to the problems of illiteracy and monolingual Spanish-speaking workers, the Ben Archer Clinic is developing pesticide programs to take into the fields using visual aids and examples. Recently, a case of employment-related contamination surfaced when two workers appeared at the clinic and charged that due to no prior notification, they had been sprayed with pesticides while working in the fields. They told health workers that they were threatened with job loss if they reported the incident. Other workers, they said, were afraid to come forward for that reason (Las Cruces Sun News 1998). This demonstrates the importance of pesticide education and the fact that agricultural owners also require training to keep up with legal requirements for use of pesticides. Educational programs also address the problems of diabetes and high cholesterol/blood pressure management, as well as women's health issues, which include contraception and prenatal and postpartum classes. More teenagers attend the prenatal classes, while older clients, especially from Truth or Consequences, which has a much older retired population, attend

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the programs for diabetes, blood pressure, and depression. Males traditionally have more problems with alcohol. Domestic violence is a problem often hidden due to cultural or personal issues, and is difficult to treat. Referrals are made to Southwest Counseling Services, but appointments are often not kept. It is pointed out that although the whole family works, the man has the legal status to work, so the paycheck is in his name. This is one more reason that women refrain from seeking help when they are abused. The problems facing the clinic are numerous, but the staff is dedicated and active in promoting trust and communication. Clients also are involved in identifying needs and planning programs. A suggestion box hangs on the waiting room wall, and forms are distributed to measure complaints and satisfaction. The clinic also utilizes numerous community health advisors (promotoras) through funding provided by the Border Health Office to deliver outreach care and to develop client trust and participation, and to meet specific community needs as well as those of the health care facility. The problems identified at the various clinic sites are often different. The population in Hatch includes a high number of agricultural working families, mostly Spanish-speaking, while the population of T or C includes a large number of Anglo retirees, which creates some intergenerational tensions. The new site in Columbus will undoubtedly present a new set of needs, being just across the border from Mexico. The clinic must deal with all of these. General needs at all sites, however, include transportation, the need for outreach, and more prevention programs. Ben Archer Clinic owns a van, which is used to bring people to appointments when they have no means, and to transport people to area hospitals when required. Prevention programs have been developed, but more are needed. In some cases, such as prevention of teen smoking, since parents often buy cigarettes for their children, parents must be targeted as well as young people. Communication and parenting are also important, and in relation to youth violence, substance abuse, and teen pregnancy, parents again must be targeted as well. The present Ben Archer Clinic is the only provider of primary medical and dental care in northern Dona Ana County. They are struggling with the need for expansion while resources become scarce. The clinic also recently affiliated with three health maintenance organizations (HMOs) under the state Medicaid Managed Care Program, SALUD, and faces the same resulting difficulties and adaptations as La Clinica de Familia. THE ADVENT OF MANAGED CARE The major focus of managed care is the efficient, cost-effective delivery of health services, with consequent increased access to primary care and

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control of uncertainty in treatment and outcome. Instituted through the New Mexico Human Services Department, SALUD began operations in July 1997, implemented in stages through enrollment fairs held at different times throughout the state. New Mexico contracted with three health maintenance organizations—Presbyterian SALUD, Lovelace Community Health Plan, and Cimarron SALUD—for their Medicaid patients. Recipients could choose any of the three, and both community health centers became members of all three plans. The problems of learning to "manage" managed care have begun to emerge. The idea behind the plan is to have health care needs, both physical and behavioral, coordinated by an integrated system. Costs, however, have been rising steadily (Sneider 1997). The biggest problem for the clinics has been a tremendous increase in paperwork. Each of the three different contractors has a different formulary, which means that there are three different plans with different requirements for reimbursement and different rules, instructions, and reporting requirements. None of the educational or prevention programs are reimbursed, but are offered by the clinics to all clients. Although there has been some improvement in reimbursement for care delivered, there is also no reimbursement for pharmaceuticals, and federal regulations require contracting for pharmacy services. Dental reimbursements are reported by clinic directors to be the lowest in the nation. Clinic personnel point out that they have always provided "managed care" through coordination of a large variety of related services and client involvement. Promotoras are "case managers" and are well acquainted with their clients in the clinic and in the field. Aside from the problems of managing managed care in the larger system of health care, the community health centers are feeling the squeeze and attempting to adapt to outside entities and new agendas. Preliminary studies and reviews show that there is some diversity in the approach of various states as to implementation of managed care programs. Mueller (1998) predicts that the Balanced Budget Act of 1997 will affect rural care by causing some belt-tightening, but that it will create incentives for networking to increase access. Mueller points out, "The potential impact of market changes and managed care on the viability and capacity of the rural health system is still unclear. Of greatest concern to advocates for rural health are the loss of income for health-care providers, which may persuade them to leave rural areas, and the loss of control local policymakers have over decisions about what services will be provided in their communities" (100). Mueller urges that, in any case, changes will be profound and that now is the time when rural providers and community leaders must develop appropriate delivery systems. Mueller also notes that managed care can help rural areas, but not if those plans depend upon competition (Director's Newsletter 1996). Slifkin et al. (1998), in a review of Medicaid managed care programs in

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rural areas, found a preference for primary care case management (PCCM) programs over the health maintenance organization (HMO) model. "In general, state officials were sensitive to the difficulties of rural health care delivery and, in most cases were careful to design programs that were workable in their state" (126). Provider choice was narrowed so that states had to use various strategies to ensure that traditional rural providers are included in health plan networks. Cost control was also less likely to be realized in rural areas, since resources and personnel are scarce. Casey (1997), however, sees rural health networks as a way to improve rural care systems, improve access, reduce costs, and improve quality of care. "Networks provide a means for rural providers to contract with managed care organizations, develop their own managed care entities, share resources, and structure practice opportunities to support recruitment and retention of rural physicians and other health care professionals" (2). In rural areas of New Mexico, Harrison (1998) points out that "it appears that the implementation of managed care in rural areas has contributed to fewer job opportunities" (7). However, adjustments to the new fiscal system is predicted to return the number of vacancies to previous levels. "Organizations currently focus on building networks and new contractual relationships, while reconfiguring business activities to reflect new modes of reimbursement, such as capitation. Also, as the private market absorbs services previously offered by the state, job opportunities should increase" (7). What this means for established and understaffed rural clinics is far from certain. The main point of agreement is that rural areas are very different in character and structure, and if managed care is to succeed, new models and individual adaptations must be developed by providers and local leaders. Whether monies paid to managed care corporations will ultimately cut costs and increase access to rural care, or whether the additional regulations and requirements will curtail community participation and provision of a broad variety of health-related services, remains to be seen. ISSUES AND EVOLUTION The decade of the 1970s was characterized as a time of "momentous change" in rural health care, while the 1980s were a time of "unprecedented change" (Straub and Walzer 1992, xi). The 1990s have generally been what Straub and Walzer predicted—"the decade in which significant departures from accepted wisdom will be debated by health care decision makers" (xv). As this prediction relates to the U.S.-Mexico borderlands, "accepted wisdom" has been debated and challenged for some time. Whether one interprets "accepted wisdom" as fee-for-service care, control of policy and care by the medical profession, a narrow view of what constitutes "health care,"

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the dominance of the biomedical model that excludes cultural factors and culturally sensitive care, or the passive patient, situational realities have long been visible on the border. The strong relationship of lifestyle and environmental conditions to health and illness; the relationship of lifestyle to political and economic conditions; the cultural variability and reliance on alternative medicine; the need for client and community participation in education and services; and the problems of providing primary care to a poor, rural, and largely uninsured population have all been present for some time. It is not, however, at the clinic or community level that these issues have been most debatable. Policymakers, those with vested political and economic interests, and administrators with little real knowledge of the borderlands have been most challenged by local administrators, advocates, and public health officials from both sides of the border. Service providers at the grass-roots level are also strategically aware of the need for support and action, and the possible disastrous consequences for both nations if those needs are not met. The community health centers of the border area in New Mexico are not only models for a grass roots approach to the problem, but have much to teach relating to the reform of the health care system. They have broadened the definitions of "health" and "health care" and have expanded the medical model to recognize the social, economic, political, and environmental origins and effects of illness and disease. They have also been forced to recognize the role of cultural diversity in both care and prevention, as well as the need for patient education, self-care, and participation as partners in the client-provider relationship. They address the problems of poverty, isolation, trust, specific and relevant needs, and the problems of community dynamics and organization. These community health centers have also shown the advantages in and the vital need for collaboration (networking) with other agencies and departments rather than adopting a competitive perspective or duplicating unneeded services. In 1995, for example, the New Mexico Border Health Office instituted a Border Health Mobile Clinic to provide such services as immunizations, primary care, and breast and cervical cancer screening, among other services, to rural residents in various sites in the four border counties. These services were coordinated with both La Clinica and the Ben Archer Health Center among other entities, including the Luna County Promotora Project, the village of Columbus, and New Mexico State University. The principles of managed care are not new to community health centers. The changes taking place in the delivery of health care due to implementation of a managed care system must be tracked, but the results are unclear at this point. The twenty-first century promises to bring changes and challenges that were practically inconceivable in the 1970s. A major

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issue of the 2000s may be h o w the cuts in funding and the incursion of corporate medicine and managed care (which experts judge is "here to stay") into rural areas, will mesh with the rural community-based models of control and empowerment. The role of both government and business will have to be redefined and aligned (for an interesting perspective on this topic, see W o h l 1984). The question also becomes whether the community health centers will be able to increase or even maintain their levels of broadbased care in the face of growing populations, increasing needs, and shrinking economic resources, and w h a t will happen if they do not. The answers will shape life in the borderlands, which will in turn carry serious implications for the t w o nations on both sides of the line. NOTE The author would like to thank the administrators and staff of La Clinica de Familia, especially Harriet Brandtstetter and Martha Liefeld, and the Ben Archer Health Center, especially Dr. Enrique Martinez and Mary Alice Garay, for their time, help, suggestions, and review of this chapter. REFERENCES Works Cited AHCPR. 1998. "Improving Health Care for Rural Populations." 1-2 (April 6) at: http://www.ahcpr.gov.research/rural.html Becker, T., C. Wiggins, R. Elliott, C. Key, and J. Samet. 1993. Racial and Ethnic Patterns of Mortality in New Mexico. Albuquerque: University of New Mexico Press. Casey, M. 1997. "Rural Health Network Development: Public Policy Issues and State Initiatives." Journal of Health Politics, Policy and Law 22(1): 23-47. Chaparral Community Health Council. 1997. "Summary Report of a Needs Assessment." Chaparral, New Mexico, May 28. Copp, J. 1976. "Diversity of Rural Society and Health Needs." In Rural Health Services: Organization, Delivery and Use, edited by E. Hassinger and L. Whiting. Ames: Iowa State University Press. Dewey, R. 1960. "The Rural-Urban Continuum: Real but Relatively Unimportant." American Journal of Sociology 66(1) (July): 60-66. Directors' Newsletter. 1996. "Article Quotes FP on Rural Managed Care." Academy of Family Physicians News Department, June 20 at: http://www.aafp. org/dnl/062096/ruralcar.html Escobedo, M., and F. de Cosio. 1997. "Tuberculosis and the United States-Mexico Border." Journal of Border Health 2(1) (January/February/March): 40-46. Garvey, G. 1995. "Hanta Virus—The Sin Nombre Virus." In The Columbia University College of Physicians and Surgeons Complete Home Medical Guide, edited by D. Tapley et a l , 465. New York: Crown Publishers 465-(l). Harrison, J. 1998. "Some Trends in Health Professional Employment in New Mex-

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ico." Rio de Nuevas. Southern Area Health Education Center, Las Cruces, N.M., March, 7. Hassinger, E., and D. Hobbs. 1992. "Rural Society—the Environment of Rural Health Care." In Rural Health Care: Innovation in a Changing Environment, edited by L. Straub and N. Walzer, 178-90. Westport, CT: Praeger. Las Cruces Sun News. 8/15/98, Workers say they were Sprayed with Pesticide, 1; 8/28/98, Doctor Reports on Workers Sprayed by Crop Duster, 1; 9/27/98, Small Clinics: The Frontline of Public Health, 1. Link, B., and J. Phelan. 1995. "Social Conditions as Fundamental Causes of Diseases." Journal of Health and Social Behavior, extra issue:80-94. Lipton, R., L. Losey, A. Giachello, J. Mendez, and M. Girotti. 1998. "Attitudes and Issues in Treating Latino Patients with Type 2 Diabetes: Views of Healthcare Providers." The Diabetes Educator 24(1) (January/February): 67-71. Loustaunau, M., and E. Sobo. 1997. The Cultural Context of Health, Illness, and Medicine. Westport, CT: Bergin & Garvey. Madison, D., and J. Bernstein. 1976. "Rural Health Care and the Rural Hospital." In Community Hospitals and Primary Care, edited by J. Bryant et al. Cambridge, MA: Ballinger Publishing Co. McCloskey, A., and J. Luehrs. 1990. State Initiatives to Improve Rural Health Care. Washington, DC: National Governors' Association. (Health Policy Studies, Center for Policy Research, NGA in cooperation with Office of Rural Health Policy, Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services. Mueller, K. 1998. "Market Forces, Rural Health." Forum for Applied Research and Public Policy 13(2) (summer): 98-100. Murrin, Kathleen L. 1982. "Laying the Groundwork: Issues Facing Rural Primary Care." In Management of Rural Primary Care—Concepts and Cases, edited by G. Bisbee Jr., 3-29. Chicago: The Hospital Research and Educational Trust. New Mexico Teen Pregnancy Coalition Newsletter. 1998. "U.S. Teen Birth Rates Still on the Decline." (winter/spring) at: http://www.flash.net/~nmtpc/webdoc3.html.htm. Ortiz-Smith, P. 1998. Ben Archer Health Center Update. June 30 at: www.nmsu.edu/ Academic Progs/Colleges/Health and Social/bho/p . . . mchbenarcher.htm. Pan American Health Organization. 1990. US-Mexico Border Health Statistics. El Paso, TX: Field Office, PAHO. Pirani, M. 1994. "Understanding the Effects of Small Hospital Closures on Rural Communities." Ph.D. Thesis, University of Washington. Proceedings of the Governor's Conference on Rural Health Services. October 3031, 1986. 1987. Santa Fe, NM: NMHED, Health Planning Division. Ricketts, T. 1993. The Future of the Small Rural Hospital: A Policy Review for the Milbank Memorial Fund. Chapel Hill North Carolina Rural Health Research. Rural Health Systems. 1979. "The Rural Health Initiative: Primary Care Research St Demonstration." Washington, DC: U.S. Department of Health, Education, and Welfare. (Public Health Service, Health Services Administration,

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and Bureau of Community Health Services.) Washington, DC: U.S. Government Printing Office. Salinas, E., M. Bensenberg, and J. Amazeen. 1988. The Colonias Fact Book: A Survey of Living Conditions in Rural Areas of South Texas and West Texas Border Counties. Austin, TX: Department of Human Services. Selected Health Statistics, New Mexico 1993. 1993. Santa Fe, NM: Department of Health, Public Health Division, Bureau of Vital Records and Health Statistics. Skolnick, A. 1995. "Along US Southern Border, Pollution, Poverty, Ignorance, and Greed Threaten Nation's Health." Journal of the American Medical Association 273(19) (May 17): 1478. Slifkin, R., S. Hoag, P. Silberman, S. Felt-Lisk, and B. Popkin. 1998. "Medicaid Managed Care Programs in Rural Areas: A Fifty-State Overview." Health Affairs 17(6) (November/December): 217+. Sneider, J. 1997. "Health Care Costs Rise with Demand for Information." The Business Journal. November 10 at: http://www.amcity.com/milwaukee/stories/111097/story3.html Starr, P. 1982. The Social Transformation of American Medicine. New York: Basic Books. Straub, L., and N. Walzer, eds. 1992. Rural Health Care: Innovation in a Changing Environment. Westport, CT: Praeger. U.S. Congress, House. 1990. Colonias: A Third World Within Our Borders. Hearings Before the Select Committee on Hunger. 101st Congress, 1st session. Hearings Held in Eagle Pass, Texas, May 15. Washington, DC: Government Printing Office. Wohl, S. 1984. The Medical Industrial Complex. New York: Harmony.

Suggested Readings Bisbee, G., Jr., ed. 1982. Management of Rural Primary Care—Concepts and Cases. Chicago: The Hospital Research and Educational Trust. Brumley-Shelton, Angela F. 1997. "Relational Communication Practices among Women Patients and Health Care Providers in a Rural Health Care Clinic along the US-Mexico Border. Master's Thesis in Communication Studies, New Mexico State University. Collado Ardon, R. 1978. "Rural Medical Care or Rural Organization for Health?" In Modern Medicine and Medical Anthropology in the United States-Mexico Border Population, edited by D. Velimirovic, 22-30. Proceedings of Workshop in El Paso, Texas, January 20-21, 1977. Washington, DC: PAHO. Gow, L. 1997. "Predicting Community Health Clinic Use and Familiarity Near the United States/Mexico Border: A Case Study of Chaparral, New Mexico." Master's thesis in Agricultural Economics, New Mexico State University.

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10 The Medical Care Systems in Mexico and the United States: Convergence or Deterioration? The View from the Border David C. Warner

The medical care systems in both Mexico and the United States are undergoing rapid change. Some of the changes have been mandated by rapid developments in medicine and the need for consistent training of many practitioners, some have been occasioned by the need to economize on tax supported guarantees of coverage, and some have been motivated by the need for more accountability on the part of providers to patients and to those who pay for the care. Mexico and the United States are starting from quite different systems of payment for and provision of medical care, and it will be interesting to see to what extent they will evolve toward more similar systems. In order to sketch some of the main issues it will be useful to provide a description of each system and then to discuss the ways in which they might converge and the implications of such convergence on the population at the border. THE MEXICAN HEALTH SYSTEM Health care is a guaranteed right of all citizens of Mexico under Article Four of the Constitution. The government fulfills this commitment through the national health system created in 1943. All Mexicans are eligible to receive health care through either the social security system or the Ministry of Health (Bloom 1995, 13). The level of commitment is quite different depending upon which system the person is eligible for and uses. A number of citizens choose to pay for private care either out of pocket or with private health insurance.

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Approximately 43 percent of Mexican citizens were entitled to care from the Instituto Mexicana del Seguro Social (the Mexican Institute of Social Security, IMSS) in 1995 (Gomez de Leon 1995, 30). IMSS is available to all private sector employees and retirees and their dependents who are employed in the formal sector and who must pay into the system. The IMSS provides coverage in all urban areas and some rural areas through hospitals, clinics, and other facilities throughout the nation. Individuals who would otherwise be ineligible for coverage can also buy into the IMSS. The premium for health services for the IMSS prior to 1997 was 12.5 percent of the employee's wage, up to twenty-five times the minimum wage in the federal district (Albro 1997, 257). The 12.5 percent was apportioned 8.75 percent to the employer, 3.125 percent to the employee, and .625 percent to the federal government (257). Since January 1997, employers, employees, and the government contribute variable amounts depending on the income of the employee (Ross 1996). For the lowest income workers only the government and employer contribute. For workers above three times the minimum wage, the employee and employer contribute. An additional 10 percent of the population is covered by ISSSTE (the State Workers' Social Security and Services Institute), which provides health care to government employees. The health care institutes of PEMEX, the government-owned oil company, and the military also have their own hospitals and clinics, and each cover about 1 percent of the population (Gomez de Leon 1995, 29). The rest of the population is covered by the public health system overseen by the Ministry of Health (Secretariat de Salubridad), which includes clinics and some hospitals. Decentralization of the delivery of public health services to the state governments is now well underway. This has been the result of a long process of decentralization. One of the most difficult aspects of this process has been the movement of public health employees from federal to state employment. Although the funding and delivery of services have been decentralized, the Ministry of Health has retained a role in establishing regulations, developing guidelines for accreditation of facilities and certification of physicians, computing and publishing health statistics, organizing vaccination campaigns, public and environmental health initiatives, and international representation (Albro 1996). Citing Espinosa (1996), Albro recounts that a survey conducted by the Ministry of Health in 1995 (Diagnostico Nacional de Cobertura de la Secretaria de Salud) found that only 34.1 million Mexicans received health coverage through one of the social security institutions. The remaining 59.2 million residents relied on public health services and to some extent on private services. The survey also estimated that more than 7 million Mexicans living in 109,270 rural communities (including 600 municipalities) lacked regular access to health services (Albro 1996, 21-22). Public health services are generally not well funded and rely for much of their physician

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staffing on physicians who are doing their year of community or social service as a condition of receiving the right to practice medicine. Public hospital services are often limited and in many areas are not available or rely on a local civil hospital that is often minimally funded by a local government. A comparison of expenditures in 1991 found that the annual health care expenditure per user ranged from 289 pesos for those covered by the Ministry of Health to 792 pesos for those covered by the IMSS to 967 pesos for those covered by PEMEX (Cochran 1996, 30). In 1991, the exchange rate was approximately 3 pesos to the dollar. The private sector includes many physicians who work for one of the social security or public health institutions and maintain a private practice as well as physicians who only have a private practice. In large cities there are generally private hospitals of some size with up to date equipment and services. Often there are also small 4 to 10 bed hospitals that are owned by individual physicians and that operate as an adjunct to their medical practice. Users of private providers and facilities generally pay out of pocket or with health insurance. It is estimated that expenditures for health insurance in Mexico were approximately $305 million in 1995 (Latin American Information Services 1996, 13), $320 million in 1996, and $650 million in 1997 (Aldrete and Williams 1999, 5-9). Health insurance ranges from high deductible plans with limited benefits to plans that cover care in the United States as well as in Mexico. It is difficult to purchase private health insurance when one is above the age of 65 in Mexico. The largest firms in health insurance include: Seguros Comercial America, which is owned by Grupo Pulsar Internacional (Grupo Pulsar has purchased Clinica Medica Sur—a hospital in Mexico City—and is developing a chain of outpatient surgicalcenters); Grupo Nacional Provincial; Seguros Monterrey Aetna, which is owned by Valores de Monterrey and Aetna; Seguros Tepeyac; and General de Seguros (Aldrete and Williams 1999, 5-9). Reform of the IMSS pension system in 1995, whereby there was a partial shift from a pay-as-you-go system to an investment system, and other pressures on the social security institutions are likely to have a significant impact upon the organization of health services and the availability of private health insurance coverage in the future. By requiring the portion of IMSS contributions that are for pensions to be used exclusively for pensions, the reforms severely curtail the ability of the agency to subsidize health services with pension funds (Cochran 1996, 22-26). The shortfall in funds available along with coverage of an increasing share of the population by the IMSS has led to increasing shortages at the level of clinics and hospitals. This in turn has led to increased dissatisfaction with delays in receiving care and the adequacy of care on the part of employees and employers (Albro 1997, 260-65). Mexican law has included two clauses governing payment by IMSS for private health services. The 1995 legislation provided some guidelines to

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expand the approaches spelled out in these clauses to cover a larger proportion of the population (Aldrete and Williams 1999, 15). The first approach, subrogacion de servicios, or contracting for services, relates to agreements whereby private providers can provide packages of health care services to IMSS beneficiaries selecting that option. In return for agreeing to provide a package of services and accepting legal responsibility for the IMSS beneficiaries, IMSS would pay the provider a percentage of the employer and employee contributions. According to an article in March 1998 in El Reforma, the government planned to spell out the terms under which this subcontracting could take place by June 1998. Companies seeking to contract with IMSS to be private health administrators would have six months to apply and demonstrate sufficient infrastructure. IMSS and government authorities would have sixty days to approve or deny the application. The article estimated that by March 1999 between 8 and 15 percent of IMSS beneficiaries would have the option to choose private health insurance over IMSS under this approach (Castillo 1998b). The success of this approach will depend on the percent of premiums that the government will pay—currently the commission in charge of regulations is said to be considering paying 60 percent of the employer and employee contributions (Castillo 1998a). The second approach, reversion de cuotas, or refund of contributions, allows companies to pay directly for private health care using a portion of their IMSS contributions by contracting with an insurer or a management company or hiring physicians and providing hospitals themselves. This arrangement was traditionally reserved for banks and a few firms in Monterrey that had provided health benefits before the advent of IMSS. They are required to provide all IMSS benefits to their employees in return for a return of 64 percent of employee and employer contributions (Aldrete and Williams 1999, 16). This second arrangement is preferred by a number of firms because it would permit them to subsidize a better coordinated level of service and deduct the contributions as a business expense. Currently, when a number of firms do provide some private coverage in addition to IMSS, they are contributing double for the same employees. Under reversion de cuotas they would continue to contribute 36 percent of the required contributions, but they could retain the balance and supplement it to design a comprehensive package of services for their employees. The extent to which the government will be willing to implement these privatization initiatives is unclear. The IMSS workers union with 300,000 employees and the Social Security Commission in the Chamber of Deputies are both antagonistic to increased privatization (Aldrete and Williams 1999, 17). For the first time since the Revolution, opposition parties to the Revolutionary Institutional Party (PRI) have taken control of the Chamber of Deputies, the lower house. Gonzalo Rojas Arreola, president of the commission, spoke against privatization by saying that the lack of appropriate

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equipment, infrastructure, and services in IMSS stems from a systematic drive to weaken the social security system in Mexico (Castillo 1998a). THE MEDICAL CARE SYSTEM IN THE UNITED STATES The United States also has a mixed private and public health care system. The difference is that rather than "guaranteeing access to medical care," the federal, state, and local governments have stepped in when there has been market failure or demand for services that the private system does not provide adequately. The three principal sources of coverage are private health insurance provided predominantly through place of employment; Medicare, a federal program that covers physician and hospital services for most persons older than 65 and some of the disabled; and Medicaid, which is a state-federal program that covers certain poor children and families, provides wrap-around coverage in addition to Medicare for the poor elderly, and covers many of the disabled in a number of ways. In addition, Americans pay out of pocket and also depend on other direct service delivery programs for special populations funded or provided by the federal government, state governments, local governments, and charitable organizations and institutions. These programs include charity clinics, the Veterans hospitals and clinics, state-funded mental hospitals and centers, municipal and county hospitals, and children's hospitals, to name a few. This hodge podge of financing and entitlement programs is difficult for even the most sophisticated person to navigate, and it has created an environment in which there is little accountability. In part for this reason and also to keep burgeoning costs under control, many of those financing medical care have turned to managed care. Under managed care, enrollees generally are assigned a primary care physician who supervises care received and approves referral to specialists and hospitals for diagnosis and treatment. The private insurance system has provided coverage to the majority of the population in the United States since the 1950s. In 1996 total health insurance premiums in the United States were $337.3 billion, of which $316.4 billion was for employer-sponsored plans and $20.9 billion was individual policy premiums. Of the employer sponsored plans, $263.9 billion was contributed by the employer and $52.5 billion was contributed by employees—primarily to cover spouses and dependent children (Levit et al. 1998). The viability of employment-based health insurance is under question for a number of reasons. The percentage of the population under 65 covered by employment-based insurance declined from 69 percent to 64 percent between 1987 and 1996 (Frontsin 1997). This erosion is due to the increase in self-employed contractors, to the increased amount employees have to pay for coverage of dependents, to some decline in the numbers of employers offering coverage, and the increase in part time employment

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in which the employee is not eligible for coverage (Frontsin and Snider 1996-97). For low income workers the erosion may also in part be due to the availability of Medicaid coverage of maternity care and children. Because of the rapid increase in cost of medical care in the eighties and early nineties, employers developed a number of strategies for reducing costs. These included increasing co-insurance and deductibles, requiring larger contributions for dependent coverage, mandating managed care or at least motivating enrollment in managed care with structured incentives, development of business groups on health, and engaging in direct contracting (Bodenheimer and Sullivan 1998). These initiatives have helped slow the rate of cost increases, but many of the problems and adverse incentives implicit in an employment-based system remain. Out of pocket expenditures for medical care in 1996 totaled $171.2 billion. These were expenditures by the uninsured as well as for co-insurance and deductibles by the insured and expenditures for goods and services not covered by the individual's coverage, such as nursing home care and outpatient pharmaceuticals for the nonindigent elderly not otherwise covered by insurance (Levit et al. 1998). Due to the growing unavailability of health insurance for the elderly, Medicare was passed as Title 18 of the Social Security Act in 1965 to provide hospital and physician care for elderly beneficiaries who were eligible for Social Security benefits. In 1972 coverage was extended to persons who were entitled to Social Security or Railroad Retirement disability benefits for twenty-four months or more and to persons with end-stage renal disease. Total expenditures for Medicare in 1996 were $203.1 billion (Levit et al. 1998). Medicare consists of two parts—Part A, hospital insurance, which is funded by a 2.9 percent tax on all wages paid equally by employers and employees; and Part B, supplementary medical insurance, which is funded 25 percent by premiums usually deducted from monthly Social Security checks and 75 percent from general tax revenues. Participation in Part B is optional. Medicare is an entirely federal program although fiscal intermediaries and carriers are used to administer the program at the state level. The idea in designing Medicare was to develop a federal program that would provide federal funding to beneficiaries who could then use this coverage to purchase services from private hospitals and physicians much as if they had private health insurance. In 1996, Part A provided coverage to about 38 million beneficiaries, of whom 33 million were aged and about 5 million were nonaged disabled beneficiaries. Medicare covered inpatient hospital care with a deductible for each stay of $760 in 1997. Physician services are covered subject to an annual $100 deductible at 80 percent of approved charges. Home health care, necessary diagnostic tests, and a limited number of days of care in a skilled nursing facility are also covered. The most significant gaps in coverage under Medicare are for outpatient pharmaceuticals, most dental care,

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most nursing home care, and for virtually all care received outside the United States. Many Medicare beneficiaries have additional coverage either through a former employer's plan, a Medigap plan, or Medicaid. These plans are all designed to cover some of the gaps in Medicare coverage. The Balanced Budget Act of 1997 broadened the kinds of entities that could contract to provide capitated services to Medicare enrollees, called for reimbursement of telemedicine consultations in rural areas after January 1999 and mandated the development of a Medicare-funded medical savings account experiment for a limited number of enrollees. Even with increasing numbers of beneficiaries enrolling in managed care plans and with increased vigilance regarding fraud and abuse reducing per beneficiary costs somewhat, the demographics of Medicare are such that it will have to be restructured to remain solvent. Because it is based on a transfer between workers and retirees and because the system is nearly out of money at present, the rapid growth in costs and retirees after 2010 will bankrupt the system unless taxes are raised substantially, the benefit package is changed, or the intergenerational compact is reworked (Gramm, Rettenmaier, and Saving 1998). Medicaid is a more complicated program. It was passed in 1965 as Title 19 of the Social Security Act. Medicaid offers matching funds to states that develop an approved program of medical assistance to the poor. In this case, approval means at a minimum covering certain mandated groups (children under the poverty line and SSI eligible populations) and mandated services (physician, hospital, screening, and rural health clinic services, among others). In addition states may cover optional groups and services. Services must be adequate, comparable among groups of beneficiaries, and implemented statewide. Enrollees must have free choice of willing providers. In order to cover additional groups or services or to restrict choice of provider, states must apply for waivers from the Health Care Financing Administration, which administers both Medicare and Medicaid. In 1996 total expenditures on Medicaid were $147.7 billion, of which $91.8 billion was federal and $55.9 billion was state (Levit et al. 1998). Medicaid is funded from general tax revenues at both the state and federal levels, and lower income states receive a higher percentage match from the federal government. Medicaid covers four main groups: low income children and in some cases their mothers, low income disabled persons, low income elderly, and low and moderate income elderly in nursing homes. By 2002 all children under 19 and under the poverty line must be covered by Medicaid in all states. The Child Health Insurance Program, passed with the Balanced Budget Act, encourages states to accelerate this entitlement and provides enhanced matching funds that can help states cover children up to 200 percent of poverty (Ullman, Bruen, and Holahan 1998). Medicaid's package of benefits for children is quite comprehensive since all states must

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cover any service provided by any state if the need is identified. For many low income disabled and elderly enrollees Medicaid often serves to cover the gaps in Medicare coverage. To control cost and in many cases to assure access to primary care physicians, most states have committed to convert to managed care contracting for many of their Medicaid enrollees. Medicaid enrollment in managed care increased from 2.63 million in 1993 to 7.66 million in 1996. Many states are continuing to roll out such coverage to additional parts of the state as well as to expand it from covering low income disabled and elderly as well. Medicaid does not cover poor adults who are not disabled or over 65 unless they are pregnant or head of a family receiving aid from Temporary Assistance for Needy Families (TANF)—the new shorter-term welfare program, which replaced Aid for Families with Dependent Children. Also, persons who came to the United States as legal immigrants after 1996 will have to wait six years for Medicaid eligibility, and undocumented immigrants are not eligible at all. The one exception is that Medicaid will pay providers for emergency services or for child birth on an emergency basis. One problem with Medicaid historically, especially when it was more tied to welfare, is that many children would go on and off eligibility depending on the employment situation of their mother. As eligibility is increased to 200 percent of poverty for children in many states, this problem may be reduced. Even with Medicare, Medicaid, and private insurance the number of uninsured in the United States remained around 40 million and lack of access to care remains a major policy issue (Shoen et al. 1997, 163-71). There are a number of programs at the federal, state, and local levels designed to fill in the gaps for special populations and persons with inadequate coverage. Federal programs administered by the Health Resources and Services Administration (HRSA) include the Ryan White Act, which funds programs at states and localities for people with AIDS; the Community and Migrant Health Centers program, which provides grants to community and migrant health centers throughout the country; and the Substance Abuse and Mental Health Services Administration (SAMHSA), which provides grants to states to fund mental health and substance abuse services through local community providers. In addition, HRSA subsidizes many newly graduated physicians who choose to locate in underserved rural and urban communities. Other federal programs include block grants to states for public health and for children with special health care needs. Many states support medical schools or teaching hospitals that provide services to the poor and uninsured as well as supporting indigent care services at the local level to some extent. At the local level public hospitals, local clinics, and some form of indigent care program is usually in place to provide services to those unable to pay.

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CONVERGENCE ON THE U.S.-MEXICO BORDER On the border, individuals, employers, providers, and state and local public health entities all adjust to the system of their own country and also attempt to take account of the population and resources across the border. Although development of an integrated delivery system is far in the future, the degree of interdependence and coordination of care has increased significantly over the last twenty years. As the population of both sides of the border has grown rapidly and as many individuals from one side of the border are employed on the other, the need for coordination has become even more pressing. Individuals cross the border for care for a number of reasons. Those who cross from the United States to the Mexico side usually do it for lower cost or cultural reasons or for availability of unique services. Many elderly U.S. residents cross for dental care and pharmaceuticals since these are largely excluded from Medicare coverage and are much less expensive on the Mexican side (Moss and Abend 1993). A much-cited survey by San Diego Dialogue in 1992 found that of 5 million border crossings a month at Otay Mesa and San Ysidro, 250,000 crossings were made to Mexico to obtain medical or dental services ("Crossing the Border" 1994, 1). Many who have limited or no insurance on the U.S. side go to Mexico for more affordable care (Stys 1995). Historically, many people with private coverage would go to Mexico for care and their insurance would cover it—often with a copayment. With managed care we found that a number of persons now have insurance that penalizes out-of-network care and charges a nominal amount for care authorized by the primary physician gate keeper. As a consequence, some employers identify a reduced likelihood of cross border utilization (Albro and Norton 1997). A study in Nogales found that mothers were more likely to go to Nogales Sonora for prenatal care even though they tended to give birth on the U.S. side. Also because of strict standards, the United States often does not permit certain therapies or drugs even though they may have already been approved in Europe. In recent years, for example, certain eye operations were not yet approved in the United States, and potential patients would fly or take buses to the Mexican border for the treatment. Another example is thalidomide, which was banned in the United States in the 1960s because it caused birth defects although it continues to be an effective treatment for leprosy, tuberculosis, certain types of cancer, and some types of blindness (Hall and Jahnke 1997). Another reason some persons go to Mexico to have children is so that one child in the family will be able to own land in areas only reserved for citizens. Mexican residents go to the United States for more specialized care, often with Mexican insurance. One difficulty many elderly Mexicans face is that

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if they visit relatives in the United States, they are not able to purchase private insurance in Mexico above a certain age, and IMSS does not cover services in the United States. Also Mexican residents may be entitled to Medicare or private health insurance coverage in the United States due to prior employment or their spouse's prior employment, but they must go to the United States in order for the coverage to be valid. Mexican residents do sometimes cross the border for care at community health centers or in the emergency rooms of hospitals and to have children who will be U.S. citizens. On the border many of these distinctions, although important, are quite blurred. Employers who increasingly have a binational work force on both sides of the border have to work out solutions they can afford, but that will also be attractive to their employees. The Western Growers Association operates its own preferred provider organization (PPO) network in Mexico for its workers in the United States and their families who may live in Mexico. It is significantly cheaper for workers to receive their care in Mexico. If they use care in the United States, they pay a deductible and a 20 percent copay. In Mexico there is just a $2.50 fee. Since 1987 Frontera Health Services has offered a PPO in Mexico to employers in San Diego for their employees who live in Mexico (Stys 1995). In 1997 Aetna/U.S. Healthcare, in partnership with Seguros Monterrey Aetna and Meximed, began to offer HMO coverage in California that provides benefits in Mexico (Davenport and Willliams 1999). On the Mexican side, many of the maquiladoras do provide their highest paid employees with private health insurance, which in some cases may include an option to receive services in the United States (Albro 1997, 270). The IMSS has an arrangement whereby migrant workers in the United States may buy IMSS medical coverage for their dependents in Mexico through the United Farm Workers. In 1994, the IMSS provided coverage to 26,208 beneficiaries in Mexico at a cost of $250 per year to each worker in the United States (Albro 1997, 270). Providers similarly attempt to attract paying customers from the other side of the border. Many U.S. providers serve a number of Mexican residents from the border area and further into the interior of Mexico (Zinnecker 1990). And many providers in Mexico try to attract U.S. residents (Arrendondo 1998). Insurers and hospitals are developing preferred providers and affiliates on the other side of the border, and some hospitals on the U.S. side are considering acquiring hospitals on the Mexican side. The growing population of U.S. retirees in locations such as Guadalajara, San Miguel Allende, and Ensenada and Rosarita are one population that is targeted by U.S. providers. And, if Medicare were to pay for services in Mexico, they would be a major potential market for integrated networks of providers who would provide services on both sides of the border (Warner 1999). Another major potential market is the Mexican origin elderly

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population who live in the United States but who would be far more likely to retire to Mexico if benefits like Medicare were covered there (Garcia 1999). If risk HMOs were able to provide services in both Mexico and the United States, then the development of binational service delivery systems would be further along. In the San Diego-Baja California area there are insurance policies to cover the cost of medical evacuation that have been developed by San Diego hospitals that also include access to primary care networks in Mexico. Governments on both sides have increasingly identified the need to work together in public health. A Border Health Commission Act was passed in the U.S. Congress in 1994, which was intended to strengthen binational cooperation in public health between the United States and Mexico. The act authorizes the president of the United States to form an agreement with Mexico concerning the establishment of a binational border health commission. This commission would be charged with several duties, the first of which would be to carry out a comprehensive needs assessment of the U.S.-Mexico border that would identify and evaluate existing and potential health problems. Once the assessment is completed, the commission's responsibilities would include: 1. assisting in public and private health efforts to prevent and resolve potential and existing health problems; 2. developing and implementing programs that will educate the population about health issues; and 3. determining which of the governments would reimburse each other's public and private health care providers for the cost of the services incurred by nonpaying citizens or resident aliens of the neighboring country (U.S. House of Representatives 1994). In the summer of 1997 the U.S. congress appropriated some start-up funding, and the commissioners on the U.S. side are in the process of being named. The Mexican authorities have been hesitant to endorse this legislation or to pass similar legislation because of the third clause above that might have onerous fiscal implications. At the cabinet level, a number of U.S. secretaries met with their Mexican counterparts in Mexico City in the spring of 1996 in the first of what are anticipated to be annual meetings. In this meeting, U.S. Health and Human Services secretary Donna Shalala and the Mexican minister of health, Juan Ramon de la Fuente, convened the Health Working Group, which was established as a medium for interaction. The working group established migrant health, women's health, smoking prevention focusing on adolescents, and immunizations as priorities (U.S. Department of Health and Human Services 1996). Most recently, the secretaries met again in Washington

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in July 1998. Other initiatives for the border states in areas such as tuberculosis have followed. Many of the problems in each county can be exacerbated at the border. While the northern states are among the richest in Mexico and higher percentages of the population are eligible for IMSS or other social security benefits, wages of physicians are determined nationally and it appears to be harder to keep physicians practicing in these programs. Similarly, in Baja California, a number of low income retirees have located around Ensenada and, although they are entitled to care in the United States, it is a strain to get there. And, when one is immunized on both sides, with different protection against TB, or has eligibility for some services in both countries then arranging for care and coordinating it becomes particularly difficult. Many long-time residents of border U.S. cities are undocumented and now are not eligible for Medicaid or prenatal care. Increasingly, they will have to seek less expensive care in Mexico. And different levels of awareness of HIV risks and AIDS on each side of the border pose great potential risks to the border population and beyond. Similarly, many immigrants from the interior of Mexico come to the Mexican border cities to find work, often in American- or Japanese-owned maquiladoras, where they have some health benefits. As they shop and socialize on both sides of the border and begin families, their future well-being will be of concern to both countries. While Mexico may have begun to loosen up the IMSS to private contractors, the United States has begun to attempt to develop some federal oversight of health insurance portability between jobs and assuring coverage for children. How a convergence between the two health systems will take place is difficult to predict. It does seem clear that there will be great risks and opportunities on the border. REFERENCES Albro, Katherine J. 1996. "Reform of the Mexican Health System: Decentralization of the Public Health Services in the 1990s." Unpublished professional paper, Institute for Latin American Studies, University of Texas, Austin. . 1997. "The Provision of Health Services in the Maquiladoras." In NAFTA and Trade in Medical Services between the U.S. and Mexico, edited by David C. Warner. U.S. Mexican Studies Program, Policy Report No. 7, LBJ School of Public Affairs, University of Texas, Austin. Albro, Katherine J., and Kindra Norton. "Cross Border Collaboration in Medical Practice." In NAFTA and Trade in Medical Services between the U.S. and Mexico, edited by David C. Warner. U.S. Mexican Studies Program, Policy Report No. 7, LBJ School of Public Affairs, University of Texas, Austin. Aldrete, Horacio, and Ann Williams. 1999. "Insurance Companies and Processes in Mexico." In Getting What You Paid For: Extending Medicare to Eligible Beneficiaries in Mexico, edited by David C. Warner. LBJ School of Public

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Affairs. They are citing Pablo Schneider, "Arizona/Texas International Briefing," an unpublished summary of the health insurance market in Mexico and Claire Poole, from "Prescription Mexico," US/Mexico Business (April 1998). Arrendondo, Jorge Augusto. 1998. "The Case of the Mexico-United States Border Area." In International Trade in Health Services: A Development Perspective, edited by Simonetta Zarilli and Colette Kinon. Geneva: UNCTADWHO. Bloom, Erik A. 1995. Health and Health Care in Mexico. Mexico, DF: Consejo Nacional de Poblacion. Bodenheimer, Thomas, and Kip Sullivan. 1998. "How Large Employers are Shaping the Health Care Marketplace." In two parts: New England Journal of Medicine 338(14) (April 2): 1003-1007, and 338(15) (April 9): 1084-87. Castillo, Jesus. 1998a. "En puerta, privatizacion de IMSS." Reforma (March 10): 12a. . 1998b. "Afinan privatizar servicios del IMSS." Reforma (March 10): 1. Cochran, Norris W. 1996. When Goals Diverge: The Political Economy of Social Security Reform in Mexico. Professional Report, LBJ School of Public Affairs, May. He is citing Sistema Nacional de Salud, Boletin de Informacion Estadistica, 1992. "Crossing the Border for Medical or Dental Services." 1994. San Diego Dialogue, Border Fact Sheet No. 30 (August): 1. Davenport, Susan, and Ann Williams. 1999. "Extending Medicare to Northern Baja California." In Getting What You Paid For: Extending Medicare to Eligible Beneficiaries in Mexico, edited by David C. Warner, LBJ School of Public Affairs, University of Texas, Austin. Espinosa, Roberto Garduno. 1996. "SSA: 63.5% de la Poblacion, Fuera de Servicios de Seguridad Social." La Jornada (April 22); available from http://serpiente.dgsa.unam.mx/jornada/index/html Frontsin, P. 1997. Sources of Health Insurance and Characteristics of the Uninsured. Washington, DC: Employee Benefit Research Institute. Frontsin, P., and S. C. Snider. 1996-97. "An Examination of the Decline in Employment Based Health Insurance between 1988 and 1993." Inquiry 33 (winter): 317-25. Garcia, Olga Oralia. 1999. "Mexican Origin Population in the U.S. and Mexico." In Getting What You Paid For, edited by David C. Warner, LBJ School of Public Affairs, University of Texas, Austin. Gomez de Leon, Jose. 1995. The Demand for Health Care in Mexico. Mexico, DF: Consejo Nacional de Poblacion. Gramm, Phil, Andrew Rettenmaier, and Thomas Saving. 1998. "Medicare Policy for Future Generations—A Search for a Permanent Solution." New England Journal of Medicine 338(18) (April 30): 1307-10. Hall, Robert, and Lauren Rivera Jahnke. 1997. "Trade in Health Care Products Between the United States and Mexico." In NAFTA and Trade in Medical Services between the U.S. and Mexico, edited by David C. Warner. U.S. Mexican Studies Program, Policy Report No. 7, LBJ School of Public Affairs, University of Texas, Austin.

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Instituto Mexicano Del Seguro Social (IMSS). 1994. 1988-1994: Vision del Cambio en la Seguridad Social. Mexico City: IMSS, Robles Hermanos y Asoc. Latin American Information Services. 1996. Lagniappe Letter, August 2. Levit, Katharine, Helen Lazenby, Bradley Braden, and the National Accounts Team. 1998. "National Health Spending Trends in 1996." Health Affairs 17(1): 35-51. See Exhibit 6, Expenditure for Private Health Insurance, Dollar Amount and Percent Change, by Sponsor, Calendar Years 1990-1996. Levit, K. et al. 1998. "National Health Spending Trends in 1996." Health Affairs 17(1): Exhibit 4, National Health Expenditures by Source of Funds, Amounts, and Average Annual Growth, Selected Calendar Years 1960-96. Moss, Kendall, and Nicole Abend. 1993. "Overview of Medical Care for Americans Crossing the Border." In Health Care Across the Border: the Experience of American Citizens in Mexico, edited by David C. Warner and Kevin Reed. Policy Report No. 4, LBJ School of Public Affairs, University of Texas, Austin. Ross, Stephanie N. 1996. "Bright Future for Health Insurance." Business Mexico (August 1). Shoen, Cathy, B. Lyons, Dianne Rowland, Karen Davis, and E. Puelo. 1997. "Insurance Matters for Low Income Adults: Results from a Five State Survey." Health Affairs (September-October): 163-71. Stys, Jeffrey J. 1995. Crossing the Border for Private Care: Issues and Innovations for the Texas Insurance Industry. Professional Report, LBJ School of Public Affairs, University of Texas, Austin. Ullman, Frank, Brian Bruen, and John Holahan. 1998. The State Children's Health Insurance Program: A Look at the Numbers, Occasional Paper No. 4, Urban Institute, Washington, D . C , March. U.S. Congress, House. 1994. Bill to Establish a United States-Mexico Border Health Commission. 103rd Congress, 1st sess. H.R. 2305. USDHHS, XII Meeting of the US-Mexico Bi-national Commission. 1996. Conclusions of the First Meeting of the Health Working Group. Warner, David C , ed. 1999. Getting What You Paid For: Extending Medicare to Eligible Beneficiaries in Mexico. U.S.-Mexico Policy Center, LBJ School of Public Affairs, University of Texas, Austin. Warner, David. 1997. NAFTA and Trade in Medical Services between the U.S. and Mexico, U.S.-Mexican Studies Program, Policy Report No. 7, LBJ School of Public Affairs, University of Texas, Austin. Warner, David, and Kevin Reed, eds. 1993. Health Care Across the Border: The Experience of American Citizens in Mexico. Policy Report No. 4, LBJ School of Public Affairs, University of Texas, Austin. Zinnecker, Anita. 1990. Health Along the Texas-Mexico Border: Insights on the Utilization of Health Services by Mexican Nationals. Professional Report, LBJ School of Public Affairs, University of Texas, Austin.

11 The Sunland Park/Camino Real Partnership: Landfill Politics in a Border Community Ellen Rosell

The location and management of landfills is among the many controversial issues confronting many American communities. Greatly increasing the controversy is the issue of interest group politics in the local landfill siting and international waste trading policies. Exploring the historical and political controversies, this chapter examines landfill politics in a publicprivate partnership. The analysis reveals the vulnerability of local public authority and citizen participation in this kind of partnership. INTRODUCTION Trash disposal is a costly nuisance for communities. Confronted with burgeoning mounds of garbage, stringent regulatory environments, and fiscal and technical constraints, municipalities are struggling with how to get rid of their solid wastes. Partnerships with private companies are attractive answers. Landfill entrepreneurs can relieve municipalities of major financial, management, and liability burdens. This case study is about landfill politics in a public-private partnership. The public partner—Sunland Park, New Mexico—relies on the landfill for handling its solid waste and for revenues to help cover its operating expenses. The private partner—the Camino Real Landfill—generates employment opportunities for local residents, provides cost-effective waste disposal services for southern New Mexico and southwest Texas, and has passed every environmental inspection without a violation. Accounting for over

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half (52%) of the state's existing landfill capacity, it is New Mexico's largest landfill (New Mexico Environment Department 1993). Despite its spotless record of no violations, the landfill is provoking considerable controversy within the local community. Several years ago, the national media headlined the sorry spectacle of a garbage-loaded barge with no place to go. Solid waste entrepreneurs with available landfill capacity are in a business in which "trash is cash." Seizing market opportunities and buoyed by its landfill capacity, the Camino Real Landfill has targeted those barges of wastes vehemently unwelcome in other communities. The partners are in a political tug-of-war with a vocal interest group that wants the landfill site closed down. This chapter explores the historical and political controversies in the community underlying the landfill debate. Initially, it traces the evolution of the city's partnership with the private landfill company. The next section highlights the regulatory tensions between the partners with the company's ventures into hazard and maquiladora wastes. Discussions of the positions of the city and the interest group follow. The chapter concludes with the debate over the legitimacy of the interest group participating in landfill decisionmaking and with lessons from the city's experiences with a privately operated landfill. LOCAL DUMP TO REGULATED LANDFILL As long as the residents of Sunland Park can remember, they dumped their garbage on Nora Green's property, the site of today's Camino Real Landfill. Pictures of the old dump show ten-foot mounds of broken glass and piles of household trash interspersed with discarded refrigerators, tires, and cars spreading over approximately twenty-six acres. The Sunland Park racetrack contributed horse manure and barn refuse that routinely would catch on fire. For three weeks in June 1987, a burning mountain of manure cast a pall of smoke over the border regions. The county occasionally sent a bulldozer into the unregulated dump to dig trenches in the sand dunes and to cover the trash with soil. Incorporated in 1984, the city of Sunland Park is located in the Rio Grande Valley of southern New Mexico. Its municipal boundaries border El Paso, Texas, on the east and Mexico on the south. The new city was challenged immediately with the solid waste management regulations of New Mexico's Environmental Improvement Act of 1971. The regulations require municipalities with populations greater than 3,000 persons to collect household waste at a minimum of once a week, and to transport and dispose solid waste in a sanitary landfill. Throughout 1985 and 1986, the city struggled with incremental strategies to provide solid waste services. The New Mexico Environmental Improvement Division (NMEID) initially rejected the Nora Green dump site,

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as it did not meet the definition of a sanitary landfill. City staff pursued plans to construct a landfill and provide waste collection services. The city's 1985 operating budget of $157,636 constrained efforts to develop a landfill site, estimated at $1.7 million for permitting and construction costs and $309,600 for annual operation and maintenance costs. Projected fees of $19.85 per month per household for waste disposal services in an area with an average family income of less than $10,000 discouraged the city from undertaking the service. Ultimately, the city "decided that efforts must be made to get county or private sector help" (Sunland Park 1991, 3). In June 1986, the city negotiated agreements with Nora Green to operate a landfill on her property, with the county to provide landfill maintenance services and with a private contractor to collect and haul waste to the landfill site. Less than a year later, in February 1987, Nora Green notified the city that she was selling her landfill property and terminating the lease agreement. The new owner of the landfill was Nu-Mex Landfill, Inc. Encompassing 160 acres of land sited within the city of Sunland Park, the landfill began operations in April 1987, under the management of JOAB, Inc. In May 1987, the city passed Ordinance No. 1987-4, approving the company's petition for rezoning the landfill site to M-l-heavy industrial use. The city and Nu-Mex negotiated an agreement acknowledging the landfill's service area as "the general market area of Dona Ana County, New Mexico, and El Paso County, Texas. Users may include municipal and other government subdivisions, commercial haulers, private citizens, and others" (Sunland Park 1987, section 3). Provisions limited the use of the landfill to solid waste disposal, "including salvage of discarded materials" (section 3), and prohibited "Hazardous Waste, Liquid or Semi-solid Waste or Septic Waste as defined by city ordinances" (section 4A) and "intentional burning of waste" (section 4G). Sections of the eight-page agreement stipulated further operating standards, joint participation in cleaning up and closing the current dump, and procedures for collecting fees, charges, and taxes. Emphasizing the latest solid waste management practices and technologies, Nu-Mex focused on bringing the landfill into regulatory compliance. The company established new landfill areas and waste disposal operations after spending more than four years to clean up and close the old dumping grounds. At a cost of more than $1.6 million, it was the first landfill in the region to install a linear and leachate collection system in compliance with the new EPA requirements. After a lengthy review process under the state's new landfill regulations, the New Mexico Environment Department issued the Nu-Mex landfill a solid waste permit in November 1992. More than thirty-four formal and unannounced state inspections from 1992 through mid-1995, and an intensive EPA investigation in 1993, have found no violations of environmental or landfill regulations. With a subsequent name change to Camino Real, the landfill serves as a

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disposal facility for solid waste from southern Dona Ana County, New Mexico, and El Paso County, Texas, and for maquiladora waste from Juarez and Chihuahua City, Mexico. Nearly two-thirds of its waste (61.4%) is from out of state, with 5 to 7 percent originating in Mexico (New Mexico Environment Department 1993). The landfill handles approximately 4,500 cubic yards (1,200 tons) a day of residential, commercial, industrial, construction, and demolition waste, along with petroleum contaminated soils and municipal waste water treatment sludge processed at separate sites. With approximately 390 acres available for land filling, the Camino Real landfill has an expected life of 205 years, compared with eighteen years of expected life for all municipal-owned and -operated landfills in New Mexico (New Mexico Environment Department 1993). Nora Green's dump site has evolved into the largest and most-inspected landfill in New Mexico. Despite its spotless record of no violations and unlimited capacity to handle the city's future disposal needs, the landfill's ventures into hazardous and international waste trading are generating political controversy in the community and pressures on the city to close it down. NU-MEX/JOAB/CAMINO REAL: A CORPORATE CITIZEN The initial relationship between the city of Sunland Park and Nu-Mex reflected an amicable partnership. They cooperated in cleaning up and closing the old dump site. The company rebuilt the access road into the landfill and routed its truck traffic away from a nearby subdivision. The partners negotiated and settled details for deeds and easements for the city's water storage tank sites adjacent to landfill property. The city contracted with JOAB, Inc. (Nu-Mex's related company) for residential solid waste collection, with residents paying a fee of $2.90 per month per household, quite low compared with that charged in nearby communities. Tensions in the partnership surfaced with the company's expansion of its landfill operations, particularly into medical waste incineration. THE MEDICAL WASTE INCINERATOR INCIDENT In December 1988, the company began building a medical waste incinerator that started operating in mid-1989. Alarmed by the incinerator's dense black smoke, Sunland Park residents and its mayor, along with other local governments and community organizations, sought public hearings from the state. The medical waste incinerator incident occurred during statutory and regulatory upheavals in the state environmental and solid waste management policies. Initially, NMEID determined that the incinerator did not require a permit, as its building had started a month before the new state toxic emission regulations took efect, in January 1989. The previous

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toxic emission regulations did not require a permit for incinerators emitting hydrogen chloride emission, as did the Nu-Mex incinerator. Responding to the Sunland Park mayor's request for a public hearing to consider the airquality impacts from the incinerator, NMEID claimed that "based on expected emissions from the proposed JOAB incinerator no permit was required," and therefore neither were public hearings (C. Clayton, letter, June 16, 1989). Citing the lack of sufficient public interest, NMEID also turned down Dona Ana County's request for a public hearing. In June 1989, NMEID notified the company that, although its incinerator was exempt from permitting under the toxic emissions standards, a permit was required under the new Solid Waste Regulations, effective May 14, 1989 (P. Westen, letter, June 19, 1989). In February 1990, Nu-Mex submitted an application requesting permits for a landfill, a biomedical waste incinerator, and a recycling facility, and for the handling and disposing of special wastes, including infectious wastes. The state legislature, however, had passed the Solid Waste Act of 1990, which directed the New Mexico Environment Department (NMED) to develop a comprehensive solid waste management program. The new law included provisions for dealing with medical waste incinerators. Regulations implementing the mandates of the 1990 act, however, had not yet been promulgated by NMED. Frustrated by the state's regulatory deadlocks and pressured by its citizens—particularly the Concerned Citizens of Sunland Park—the city filed a lawsuit against Nu-Mex in July 1990. The city charged that Nu-Mex's incineration operation violated its zoning ordinance and agreement. Settling the city's lawsuit, in April 1991, the Third Judicial Court ordered Nu-Mex to cease operation of its medical waste incinerator by December 31, 1991 (City of Sunland Park v. Nu-Mex Landfill, Inc. 1991). NMED reentered the contentious debate over Nu-Mex's operations, with public hearings in August 1991 on the company's 1990 permit applications. Approximately 100 Sunland Park residents, complaining about odors and various illnesses attributed to the incinerator operations, testified against the landfill and waste incinerator. In a detailed position paper for the NMED hearing (Sunland Park 1991), the city supported Nu-Mex's applications for the landfill and recycling facility, but strongly denounced granting the incinerator permit, citing its danger to public health. In November 1991, NMED granted Nu-Mex recycling facility and landfill permits, conditioned on the installation of a linear and leachate collection system (New Mexico Environment Department 1991a). NMED, however, delayed its decision on the incinerator permit. In December 1991, NMED Secretary Espinosa denied the biomedical waste incinerator permit, citing lack of compliance with the permitting and operating regulations. The permit application had failed to disclose on the application that Medical Compliance Service was the owner and operator of the incinerator.

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Operating violations included lacking air pollution control devices or equipment and emitting "hazardous substances, including hydrogen chloride, dioxins and heavy metals" and black smoke that indicated "an increase in dioxin and furan emissions" (New Mexico Environment Department 1991b, section 37). Charging the company with a "history of willful disregard for environmental laws of any state or the United States" (section 46), NMED ordered the company to cease its incinerator operations and no longer to handle infectious waste within thirty days of its December 20, 1991, ruling. THE MEDICAL WASTE TRANSFER STATION INCIDENT In April 1992, controversy between the city and Nu-Mex's operation of a medical waste facility erupted again. The city had discovered that Medical Compliance Service (MCS) was using the landfill site as a transfer station for the packaging of infectious medical waste. In addition, a building company had applied for a city permit to construct a "boiler room" at the landfill. MCS was assembling an autoclave, a sterilizer relying on steam and heat to render waste noninfectious. The president of Nu-Mex Landfill, Inc. had "informed" the mayor "that 10 tons per day of infectious medical waste had been imported to the landfill prior to the shutdown of the incinerator in January, 1992. He stated that infectious medical waste prior to that time was being imported from the Albuquerque/Santa Fe metropolitan areas in addition to El Paso/Dona Ana County. . . . As soon as the boiler is in operation all this waste would again be imported to the site" (Sunland Park 1992a, section 11). The city charged Nu-Mex with violations of its 1985 land use and zoning ordinances, the 1986 city/company agreement, the April 1991 court order, and the December 1991 state order denying its medical waste incinerator permit. In its response to the city's request to show cause why it should not revoke its building permit and M-l zoning for heavy industrial use, the company denied the boiler room "would be used to treat large quantities of infectious waste," but was "to house a boiler for the production of steam" (Nu-Mex Landfill, Inc. 1992, section II.4). Challenging the ruling in the 1991 court order, Nu-Mex claimed that it had "ordered the cessation of operation of a medical waste incinerator and specifically did not order a cessation of the handling, treating or staging of medical waste" (section III. 8). Quibbling with the city zoning ordinances, the company rebutted that "the ordinance itself states the list 'is for explanatory purpose and is not inclusive' " (section II. 10). As the ordinance did not prohibit specifically "the use of any M-l property for the treatment of infectious medical waste," the company argued that "its M-zoned property (can be) for such use without a 'permit' from the City" (section II.8). Furthermore, the city's

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1990 case against the company "did not raise the matter of zoning which it should have if it had a complaint that the operations were not within the zoning ordinance" (section 11.10). Arguing that the 1991 court order "specifically dismissed all other claims that the City had against Nu-Mex," Nu-Mex maintained that "any matter dealing with zoning is res judicata and cannot be brought up again by the City" (section III.9). Claiming that "the denial of legal use of the premises through the guise of zoning is a violation of Respondent's rights and causes damage to the Respondent" (section IV. 1), the company counterclaimed for $2,075,000 in damages ranging from lowering its property values and legal fees, to costs incurred in removing its infectious waste facility and shipping the wastes to another location (section IV.1-5). Company representatives met with the mayor and attorney, and on April 22, 1995, negotiated an agreement (Sunland Park 1992b). In exchange for terminating its proceeding to revoke the company's building permit and M1 zoning status, Sunland Park has "Free Use of Nu-Mex Landfill." The city can unload up to five trucks of either residential or commercial waste into the landfill without charge, providing the waste is generated and collected within city limits and delivered to the landfill by city personnel. The landfill charges additional loads at the full gate price for solid municipal waste. A farsighted provision stipulates an increase in the number of truckloads dumped without charge corresponding to the city's population growth. Agreeing to remove its infectious waste operations pending confirmation from NMED for another site outside the city, Nu-Mex consented never to allow any incineration, treatment, or handling of infectious medical or hazardous waste at its site without city council authorization and without all required state permits. Both parties agreed to reaffirm the May 1987 city/ company agreement, and not to issue any press releases without the other's approval. The city's solid waste collection contract with JOAB, Inc. also became a pawn in the infectious waste treatment debate. JOAB notified the city in March 1992 that it was canceling the contract (L. Stokes, letter, March 19, 1992). The company charged the city with "lack of cooperation" in moving to curbside services and eliminating 55-gallon drums as garbage containers. JOAB asserted that "the astronomically high legal costs for repermitting of the landfill, caused by the Concerned Citizens of Sunland Park" and the contract's "inordinately low rates" demanded cancellation of the contract. The city then contracted for one year with another company to collect and transport its solid waste to the Las Cruces landfill; monthly household fees increased from $2.95 to $7.00. Today, the city provides its own solid waste collection services for $7.95 per household per month and takes advantage of the free use of the Camino Real Landfill negotiated in the 1992 agreement.

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ASBESTOS, SLUDGE, AND MAQUILADORA WASTES DISPOSAL Other Nu-Mex operations have contributed to tensions with the community. In August 1989, the company applied with the state for an asbestos disposal permit. Six hours of citizen objections in a NMEID public hearing, in October 1989, prodded the company to withdraw its application the next day. Its initial sludge disposal site, located close to a nearby residential neighborhood, generated complaints of offensive odors. In 1990, the company relocated its sludge disposal operations to a new site outside the landfill and northwest of the city. Allegations of odors from the buried dry sludge and disposal of unauthorized materials continue from residents. The landfill is handling maquiladora wastes from Juarez and Chihuahua City, Mexico. Maquiladoras ("twin plants") are foreign-owned manufacturing and assembly companies operating along the United States/Mexico border. Under the 1993 La Paz Agreement between the United States and Mexico, American companies must ship their hazardous wastes and byproducts generated by the production processes back to the United States. Approximately 314 American-owned maquiladoras in Juarez, Mexico, are involved in manufacturing and assembling products, including electronic and electrical equipment, semiconductors, garments and textiles, petroleum-based paints and plastics, medical equipment, and construction materials (Romo 1994). Approximately 5 to 7 percent of the out-of-state waste deposited at the Nu-Mex landfill originates in Mexico (New Mexico Environment Department 1993). The landfill director emphasizes that it accepts only nonhazardous maquiladora waste and requires every maquiladora applicant to undergo an extensive two-month screening process (King 1995). A company profile, manifest, checklist, photographs, chemical analysis, on-site inspections, and extensive paper trails document every maquiladora truck load of waste. The maquiladora waste also passes through United States Customs and inspections by the Texas Water Commission and Natural Resources Departments. Enforcement questions and issues, however, plague maquiladora waste disposal. An official (Romo 1994, 44) with the Mexican Attorney General's Office emphasizes: Unfortunately, in respect to hazardous wastes, there has not been a matching program between paperwork itemizing import and export of such wastes which documents the numbers generated and correctly removed. Currently at the customs inspection stations, there is no physical verification of hazardous materials or wastes, only the paper documentation of generation and shipment information on particular shipments of wastes.

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EPA records for 1988 show that less than 1 percent of American-owned maquiladoras reported that they shipped their hazardous wastes back to the United States (Taylor 1993). They are dumping their toxic wastes into the sewage systems, garbage dumps, and canals of Juarez, and into the Rio Grande River (Taylor 1993; Romo 1994). As North American Free Trade Agreement (NAFTA) related organizations, such as the Border Environmental Commission on Cooperation, increasingly focus on border environmental concerns and if Mexico commits to enforcing its environmental protection laws, pressure will increase on the maquiladoras to return all their hazardous wastes to the United States. Despite Nu-Mex's claims of zealously regulating its wastes from Mexico, the Sunland Park community seethes with resentment over foreign waste in its landfill and with questions as to its health and environmental risks to their community. Nu-Mex recently has changed its name to Camino Real and replaced its former director, who had a history of antagonistic community relations, with one who has impressive public health and environmental certifications and extensive experience in religious humanitarian projects in Mexico. Candidly acknowledging the community's antagonism, the new director is shifting management philosophy and emphasizing the company's role "as a good corporate citizen" (King 1995). Community projects, such as giving the Boy Scouts camping facilities and donating funds to replace a trailer lost in a fire by a local resident, are on its agenda. Unfortunately, Nu-Mex's cavalier insensitivity to community relations and arrogant dismissal of citizens' concerns in the past jeopardize Camino Real's public relations efforts. Suspicions of the company's operations and motives, particularly as its landfill facility is in the repermitting process, threaten the future of the landfill. CITY OF SUNLAND PARK: POLITICAL ACQUIESCENCE OR ECONOMIC PRAGMATISM? A Sunland Park city council meeting in June 1995 illustrates the ongoing political controversies surrounding the landfill's presence in the community. City residents and council members continue to debate, and often repudiate, provisions of the 1987 City/Nu-Mex agreement: whether "salvage of discarded material" includes recyclable materials and if "the general market area of Dona Ana County, New Mexico, and El Paso County, Texas" encompasses the maquiladoras in Mexico. The city had issued a permit to the landfill for a recycling center building. Disputing the permit's validity, as the city council did not authorize it specifically, a city council member moved to revoke it. Testimony from the city building inspector indicated that the recycling center is complying with codes and ordinances. Clarification from the city attorney emphasized that the city's responsibility is

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limited to issuing building permits, as operations issues fall within the state's purview. The city attorney advised further that the mayor and council members are subject to a lawsuit if they revoke a permit that is in compliance. The initial motion died. Despite the legal warnings, two council members introduced and voted for another motion to stop all construction at the site. Cries of "traitors" from the audience heckled the three city council members voting against the motion. Suspicions of "selling out to landfill interest for political or economic gain" dog local policymakers. The city's former mayor, who negotiated the 1987 City/Nu-Mex agreement, became a registered lobbyist for the company and a state representative. A state senator has represented Nu-Mex as an attorney. Allegations of current city council members voting in support of company operations in exchange for money or future employment opportunities fuel rumors in the community. City council members and officials tell of residents who harangue them persistently with complaints about the landfill and demands to close it. City officials justify the collective good of the landfill. Its fees, charges, and revenues account for one-third of the city budget, contributing $300,000 to its operating expenses. Without the landfill revenue, the mayor insists adamantly that the city lacks the tax base to support its law enforcement and public works services (Aguirre 1995). The public works director calculates that Camino Real's proximity saves the city $150,000 in transportation costs and disposal fees, compared to using the county regional landfill instead (Moffatt 1995). Monthly household collection fees would double or triple to $16 to $20. Weary of persistent allegations and confrontations with interest groups, particularly the Concerned Citizens of Sunland Park, the mayor echoes the city attorney's position: "The city cannot close the landfill down. Opponents must fight it at the state level" (Aguirre 1995). CONCERNED CITIZENS OF SUNLAND PARK: NIMBY OR SAVVY RISK ASSESSORS? A burgeoning stream of literature supports the not-in-my-backyard (NIMBY) resistance to landfills. Bacot, Bowen, and Fitzgerald (1994) provide an excellent review of the NIMBY literature, documenting that citizens associate landfills with questionable operator and facility controls and risky physical, environmental, and health hazards. After living nearly ten years with the NuMex/Camino Real landfill as a neighbor, many residents of Sunland Park agree zealously with the opinions of other communities. Galvanized by Nu-Mex's medical waste incinerator operation, local residents organized the Concerned Citizens of Sunland Park (CCSP) in 1989. The CCSP's biggest complaints about the landfill are its threat to residents'

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health and "other people's garbage coming into my city," particularly from the maquiladoras (Santos 1995). It claims that the dumping of sludge, asbestos, infectious medical waste, and solid waste have contaminated the community's air and water supply. Citing names and incidents of cancer deaths, birth defects, and increasing health problems, including allergies, skin and eye infections, stomach disorders, headaches, and respiratory ailments, CCSP representatives blame the landfill. They want the landfill closed and moved out of the city limits. They do, at times, express a second policy choice: Allow only trash from Sunland Park residents into the landfill. With a core of approximately fifty members, CCSP has elected a member to the city council, registered voters, and garnered political clout and respect "as watchdogs out there." Without outside funding or a paid staff, CCSP protest activities rely on volunteers, donations, proceeds from enchilada dinners, and advice from legal aid societies, environmental groups, and the Catholic Diocese of Las Cruces. It has organized demonstrations, documented alleged violations through all-night vigils at the landfill, and forced federal and state involvement in their campaign against the landfill. Responding to CCSP complaints alleging illegal waste dumping and community health problems, EPA administrator Carole Browner ordered an extensive inspection of the landfill in April 1993. CCSP allegations have accounted for most of the NMED inspections of the Camino Real landfill from 1992 through mid-1995. Neither the EPA nor NMED inspections have found violations of federal or state regulations. However, CCSP is convinced that the landfill is collectively negative, threatening its community's health. Political cynicism and intense suspicion of government underlie CCSP's campaign against the landfill. Its representatives do not trust the findings of the EPA and NMED inspections. Justifying their position, they charge that the EPA did not allow CCSP representatives to participate in its inspection and that it has not responded to their requests for analyses of landfill waste samples forwarded over the years. Furthermore, NMED always sends the same inspector to the landfill. The Camino Real landfill is due for repermitting from NMED in November 1996. CCSP promises to be a noisy and contentious opponent at the repermitting public hearing. Vehemently targeting local government, CCSP cites a litany of water abuses: costly bills, high levels of chlorine and lead, and worms in the tap water. 1 Charging "politics in the past," CCSP officers vow to make changes in local governance. Voters in March 1996 elected a new mayor and council members empathetic with the CCSP position, but cognizant of the city's legal and financial entanglements with the landfill. The fate of the landfill promises to occupy the city's agenda.

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WHOSE COMMUNITY? Despite public officials' arguments that the landfill vitally supports community services and their reassurances that it complies safely with regulations, CCSP is not convinced. New Mexicans have an old saying: "En pais de los ciegos, El Tuerto is rey." ("In the land of the blind, One Eye is king.") Suspecting the motives of the politicians, technocrats, and bureaucrats, CCSP views itself as the community's environmental consciousness in the landfill debate. Policymakers are questioning whether CCSP speaks for all the citizens in the community. Its members dominate city council meetings, media headlines, and environmental agencies' agendas. In a survey of citizens in a North Carolina town where an influential interest group succeeded in blocking a biomedical waste incinerator, Sellers (1993, 474) found that the majority of citizens did not recognize the interest group "as representing their views." Suspicions of the CCSP's legitimacy as "the voice of the people" allude to issues beyond citizen participation in public decision making processes. CCSP members often are recent immigrants from Mexico, and several are not citizens. Critics charge they are importing "Mexican-style politics that never trusts government," and question their right "to come to this country and spit on us." Allegations of the CCSP misleading residents who are not citizens to register as voters fuels the adversarial climate in the landfill debate. Sensitive to the underlying resentment over immigration, CCSP retaliates with environmental injustice arguments: Authorities ignore the landfill violations and refuse to close it because they think "we are a poor and ignorant Mexican immigrant community." A disproportionate number of landfills and hazardous waste dumps are sited in minority communities (United States General Accounting Office 1983; Guerrero and Head 1993). More than 96 percent of the residents of Sunland Park are of Mexican origin. A player in this debate, however, points out that the entire region of southern New Mexico and southwest Texas is a minority community, and questions how CCSP can prove its environmental racism allegations. Indeed, the state of New Mexico is a "national sacrifice area" for its historical role in the research and development of nuclear weapons and its nuclear waste disposal sites (Bartimus and McCartney 1991). CCSP's concerns about importing international wastes into an American landfill confront the debate over community participation in landfill operations with new issues. Wastes, albeit in small quantities, are flowing into the Camino Real Landfill from Mexico. The Camino Real Landfill can expect more maquiladora applicants for its waste disposal services with increased enforcement of Mexican and NAFTA-related environmental laws and with New Mexico's Santa Teresa Port of Entry's accessibility and proximity to the landfill.

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Noting numerous and persistent violations in international waste trading, Shin and Strohm (1993, 133) emphasize that the rules of national sovereignty call for exporting countries to provide "adequate and timely information about a proposed hazardous shipment" and for importing countries to give prior informed consent. This case study raises divergent but valid questions in local landfill siting and international waste trading policies: How does an American municipality interject its informed consent into the international waste trade agenda? How do the residents of an American community become vocal and respected gatekeepers of their landfills in the global trade of toxic wastes? As the ultimate victims of potential environmental risks, CCSP is fighting with technocrats, bureaucrats, and politicians for legitimacy as key stakeholders in the landfill debate. Its battle for the right to meaningful community participation in local landfill siting decisions promises not only contentious debates on the city agenda, but also provocative contributions to international waste trading policies in borderland communities. LESSONS FROM THE PUBLIC/PRIVATE LANDFILL PARTNERSHIP Practical lessons derived from the city of Sunland Park's experiences with the Nu-Mex/JOAB/Camino Real Landfill are useful to other municipalities contemplating private ownership or management of their landfills. First, public officials and the landfill director emphasize the importance of educating the public about environmental risk assessment and landfill technologies. "Winning them over in the beginning" alleviates their concerns about potential environmental problems. Once residents presume health risks from the landfill, they caution, addressing their "environmentalphobia" concerns is very difficult. Second, the case illustrates vividly the vulnerability of local authority in partnerships with private entrepreneurs. Landfill operators deliberately will take advantage of loopholes in city/company agreements and in local and state laws. Nu-Mex has quibbled with the wording and meaning of the city zoning ordinances applying to its infectious medical wastes operations. It wittingly has internationalized the "general market area" provision in its 1987 agreement with the city to include maquiladoras in Mexico. Fragmented local/state responsibilities in solid waste management policies frustrate local governance. Municipal authority over the landfill is limited to enforcing its zoning codes, while the state has virtually unlimited control over landfill operations. Sunland Park officials complain that they are unaware of "what is transpiring" between NMED and Camino Real unless there is a violation. They do not routinely receive copies of correspondence and notices of permit requests or of operations changes. Statutory and regulatory upheavals, and the political influences of landfill

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lobbyists in state environmental and solid waste policies, can complicate municipal/private landfill agreements. Sunland Park's experiences with the landfill company and with intergovernmental regulations and enforcement argue for local governments to maximize their statutory authority aggressively in landfill agreements with private companies. Third, the case reflects how a community can become dependent economically, if not a hostage, in the business/political climate of landfill siting decisions. Sunland Park is a poor community lacking businesses and industries. If the landfill moves out of the city limits, its void in the budget will challenge city officials with limited options: increasing taxes and fees or eliminating services. Optimistically, the city's policymakers may recognize the importance of pursuing alternative economic development strategies. Finally, this case warns other communities of the political consequences of discounting community participation in landfill siting and operations decisions. Ignoring and minimizing public consent fortifies an interest group's position and spirals its concerns into public conflicts on many agendas. The CCSP has taken its crusade against the landfill to the federal and state levels. Galvanizing residents' suspicions of government mismanagement, it has mobilized persistent complaints into every facet of city operations. Routine municipal policy and program decisions become a contentious debate over the landfill. The technocrats and bureaucrats insist on disclaiming CCSP's health and environmental concerns with environmental risk assessment data and program cost analyses. These experts argue that the "public just doesn't get it." Communications are stalemated and positions are hardened. Reflectively, the city council might consider surveying residents, to gauge the extent of community opposition to the landfill or appointing a resident task force to provide oversight of landfill operations. All players, however, are positioning for the landfill's repermitting process. The saga of the Sunland Park/Nu-Mex/Camino Real landfill vividly supports empowering residents' voices and committing to community participation in landfill decisions. EPILOGUE The close of 1998 finds city officials asserting local public authority and presence in the community. Elected in March 1996, the new mayor and council members are pursuing alternative political and economic development strategies. Rebelling against the impression of the city as the landfill's economic hostage, the mayor has refused landfill revenues. The city continues to take advantage of the free landfill use negotiated in the 1992 agreement, but that is the extent of its relationship. Gross receipts from the new casino at the local racetrack and from businesses in recently annexed areas in nearby Santa Teresa are replacing the landfill's franchise contri-

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butions to the city's budget. Future municipal endeavors include developing a park and golf course along the Rio Grande River and an industrial park. In March 1997, the Camino Real Environmental Center did receive its ten-year permit. During the repermitting hearings, the CCSP voiced its litany of landfill objections. Once the landfill agreed to installing state monitoring devices, their objections abated. Today large signs at the landfill entrance proudly proclaim that the Solid Waste Association of North America designated the Camino Real Environmental Center the "#1 Landfill of 1997." This case study reflects the vulnerability of local public authority in partnerships with private entrepreneurs and also in local policy making with a hostile interest group. The new city administration, empathetic with the CCSP concerns yet wary of embracing its tactics, coopted its messengers. CCSP members have been elected to the city council and their energies evidently refocused. The CCSP is no longer an active organization with known officers or visible members in the community or at city meetings. The CCSP did raise important concerns about an American municipality's role in the international waste trade. With the demise of the interest group and of the municipal relationship with the landfill, questions relating to local landfill sites and international waste trading policies in borderland communities provoke further study. Underlying the case study is the question of who determines the public interest in this borderland community: an interest group, a private partner, or the public partner. The local government is undoubtedly flexing its municipal options. It is attracting satellite offices of state and county agencies. Residents no longer have to travel 40 miles to the regional/county seat for services. A branch of the Dona Ana County Community College is now located in the new Sunland Park Education Center on land bordering the landfill. Physical changes to the city's skyline include a fire station, police department/jail complex, the renovation of city hall, and lighting and sidewalks along the main street. A larger post office, recreational hall, counseling center, senior citizens center, and library are under construction. Relying on traditional funding sources such as the Community Development Block grants for construction, the city of Sunland Park is focusing on local delivery of public services. Recovery from its experiences with the private landfill entrepreneur, particularly the financial entanglements, will take time. Landfill politics, however, no longer dominate this border community. NOTE This chapter is a revised version of an article of the same name that was originally published in Policy Studies Journal 24(1) (spring 1996): 111-22, Policy Studies Organization, Urbana, Illinois.

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1. According to the city public works director, these worms may be moyote or horsehair worms that cannot survive in a high-pressure distribution system, but can be present in plumbing systems. The worms are not harmful, but the problem is under study by NMED. REFERENCES Aguirre, L. 1995, July 25. Mayor of Sunland Park, interviews. Bacot, H , T. Bowen, and M. Fitzgerald. 1994. "Managing the Solid Wage Crisis: Exploring the Line between Citizen Attitudes, Policy Incentives, and Siting Landfills." Policy Studies Journal 22:229-44. Bartimus, T., and S. McCartney. 1991. Trinity's Children: Living along America's Nuclear Highway. New York: Harcourt Brace Jovanovich. City of Sunland Park v. NuMex Landfill, Inc. IAC. 1991, April 23. No. CV-90592, Third Judicial Court, County of Dona Ana, State of New Mexico. Guerrero, M., and L. Head. 1993. "Environmental Racism: The Poisoning of Communities of Color." Journal of Proceedings, New Mexico Conference on the Environment, September 13-15, 1992, 444-54. Santa Fe: New Mexico Environment Department. King, J. 1995, August 8. Interview. Moffatt, K. 1995, August 25. Interview. New Mexico Environment Department. 1991a. Decision and order-(Part 1)-In the matter of the application of Nu-Mex Landfill, Inc. and JOAB, Inc. for a solid waste facility permit for the Nu-Mex Landfill facility. Sunland Park, NM: City Clerk's Office. . 1991b. Decision and order-(Part 2)-In the matter of the application of NuMex Landfill, Inc. and JOAB, Inc. for a solid waste facility permit for the Nu-Mex landfill facility. Sunland Park, NM: City Clerk's Office. . 1993. New Mexico Solid Waste Management Plan: Technical Elements, 1992. Santa Fe, N.M. Nu-Mex Landfill, Inc. 1992. Response of Nu-Mex Landfill, Inc. and JOAB, Inc. to request to appear and order to show cause. Sunland Park, NM: City Clerk's Office. Romo, L. M. 1994. Journal of Proceedings, New Mexico Conference on the Environment, April 24-26, 1994, 43-44. Santa Fe: New Mexico Environment Department. Santos, L. 1995, August 17. Interview. Sellers, M. P. 1993. "NIMBY: A Case Study in Conflict Politics." Public Administration Quarterly 16:460-77. Shin, R. W., and L. A. Strohm. 1993. "Policy Regimes for the International Waste Trade." Policy Studies Review 12:226-43. Sunland Park. 1987. Agreement between City of Sunland Park and Nu-Mex Landfill, Inc. Sunland Park, NM: City Clerk's Office. . 1991. Statement with regard to application for permit to operate a landfill—Nu-Mex Landfill, Inc. EID hearing—Monday, April 29, 1991. Sunland Park, NM: City Clerk's Office. . 1992a. Request to appear: Len Stokes, President, Nu-Mex Landfill. Sunland Park, NM: City Clerk's Office.

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. 1992b. Agreement in compromise in the matter of M-l zoning and building permits Clerk's Office. Nu-Mex Landfill, Inc./JOAB, Inc. Sunland Park, NM: City Clerk's Office. Taylor, L. 1993. "The Fast Track Agreement—Help or Hurt for the U.S.-Mexico Border Environment?" Journal of Proceedings, New Mexico Conference on the Environment, September 13-15, 1992, 320-30. Santa Fe: New Mexico Environment Department. U.S. General Accounting Office. 1983. Siting Hazardous Waste Landfills and Their Correlation with the Racial and Economic Status of Surrounding Communities. Washington, DC: GAO.

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12 Community-University Partnerships Addressing Environmental Issues along the U.S.-Mexico Border James VanDerslice, Amy K. Liebman, and Theresa L. Byrd

INTRODUCTION For many thousands of people, the U.S.-Mexico border has been seen as an area of opportunity, a place where individuals could make a better life for themselves and their families. Much of this optimism was based on the jobs created by the rapid expansion of the maquiladora industry in the border towns over the last fifteen years. However, the development of industry and the resulting growing population have outpaced the public sector's ability to provide the infrastructure, regulatory oversight, and economic incentives necessary to maintain a healthy environment. As a result, governments are now playing catch-up in their attempt to address the widespread environmental problems along the border. The environmental problems along the border became known to the rest of the United States during the debate about the North American Free Trade Agreement (NAFTA), as news crews documented and broadcast stories of "third world conditions" and uncontrolled hazardous wastes. Some environmental groups opposed NAFTA for fear of the environmental problems that industrialization and population growth would bring. Their fears were based on what had already occurred during the preceding fifteen years of the maquiladora program. While their concerns were well-grounded, in many ways the damage had already taken place. Underlying the debate about economic development versus environmental protection, and arguments regarding the appropriate roles and responsibilities of the two nations and their bilateral institutions, are hundreds of

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thousands of daily dramas played out in colonias and poor urban neighborhoods; daily dramas involving people making their best efforts to keep themselves and their families healthy in environments contaminated by lead, air borne particulates, or human wastes. This chapter does not focus on the statistics of environmental degradation, population growth, or adverse health effects. Nor does it focus on the many sad tales of mothers giving birth to babies with neural tube defects, residents storing drinking water in 55-gallon chemical drums, or families living in cardboard shacks. These stories and their associated images have been and continue to be "human interest material" for the popular press. The purpose of this chapter is to tell a story of many individuals who have joined together in their communities because of their concerns about how their environment is affecting their health and the health of their children. It is a story of how such groups can lead to meaningful, grass-roots public participation in addressing regional environmental problems. We tell this story through case studies of two programs involving partnerships between several community-based organizations (CBOs) and three universities in the metroplex of Cd. Juarez, Chihuahua, and El Paso, Texas. AGUA PARA BEBER (WATER FOR DRINKING) In many communities, the lack of reliable supplies of clean drinking water and adequate means for disposing of human wastes create some of the most pressing environmental health risks. Diseases such as hepatitis A and cholera are spread when water, food, or utensils are contaminated with pathogenic bacteria or viruses from the feces of an infected person. In the border regions of Mexico, these diseases are the second major cause of death among young children, while among children in colonias near El Paso, Texas, the prevalence of hepatitis A is 50 percent higher than the rest of the United States (Redlinger, O'Rourke, and VanDerslice 1997). Avoiding such diseases can be quite difficult for individuals living without adequate water and sanitation facilities. Because there is no immediate access to a piped water supply, colonia residents on the U.S. side of the border must haul their water for drinking, bathing, and washing. Residents get their water from a variety of sources: local clinics and churches or family and friends who live in areas that have water. In Mexico, tanker trucks called pipas deliver water to most residents that do not have piped water. Oftentimes used 55-gallon chemical drums are used to store water for the three days to two weeks between water deliveries. Nonetheless, colonia residents on both sides of the border are at risk as water stored in the open is much more likely to become contaminated. Furthermore, when water is so difficult to obtain, less water is used for cleaning and bathing. As a result, the household environment is much more likely to be contaminated by pathogenic bacteria or viruses.

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The situation is exacerbated by the lack of adequate excreta disposal. Many residents use pit latrines or cesspools, and children often defecate out in the open for fear of falling into the latrine pit (Bessenecker 1994). Under these circumstances the pathogens residing in human waste can be distributed around the community and brought into homes by dogs, flies, and cockroaches. In areas using shallow wells, the pathogens can be washed into the groundwater, contaminating the wells. To address some of these immediate needs on a large scale, the university1 conducted a series of community-based needs assessments. Based on these results, the university developed Agua Para Beber, a health promotion program directed at improving water quality and promoting safe hygiene practices in colonias through health education and low-cost water storage and treatment technologies to help families maintain clean drinking water. To deliver this program, the university decided to use health promoters, mostly volunteer individuals who were working or interested in working to promote health in their communities. The trained promoters each recruited ten families into the program. Through five home visits, the promoter delivered a series of health education messages regarding fecal-oral transmission, water disinfection and protection, safe food handling, and handwashing. Families were also taught two accessible, low-cost techniques for disinfecting drinking water: boiling and chlorination using household bleach. The program focused on only two disinfection methods to simplify the educational messages. To encourage safe drinking water storage practices, participating families received a five-gallon container fitted with a small faucet. Families were instructed to chlorinate the water when they filled the container, to keep the container closed, and to always use the faucet to remove water. This would assure that the water stored in the container was initially safe to drink and remained safe to drink during storage. Families who used 55gallon drums to store large quantities of water were also provided a polyethylene liner to help reduce the risk of poisoning from chemical residues. The water disinfection and hygiene messages communicated by the promoters were reinforced through educational labels on the water containers and drums, and an easy-to-understand comic book that explained safe water disinfection and hygiene practices and the fecal-oral routes of disease transmission. University personnel conducted all the Agua Para Beber trainings in English and Spanish in the various communities. The trainings focused not only on how to disinfect, protect, and store water, but also taught the promoters how to communicate important health related concepts and problems-solving skills to others in a nonformal, participatory setting. In other words, the training emphasized the methods of educacion popular, providing a variety of skills and knowledge that promoters would need to take their message into the community in a dynamic way.

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Agua Para Beber was developed and piloted in 1993 and 1994 in three colonias in El Paso, Texas, and three colonias in Cd. Juarez, Chihuahua. Although the university worked closely with nongovernmental and governmental health organizations on each side of the border to design the project, the initial program was university-based. University program staff trained fifty-one volunteer health workers and closely monitored their work in the community. In this initial effort, over 500 families participated in the program. Moreover, baseline survey data showed that there was a significant increase in the number of households safely disinfecting their water as well as a substantial change in the residents' understanding of the fecal-oral routes of disease transmission. The need for this type of program and the acceptance of the program at the community level lead to numerous requests by community organizations for more promoter trainings and an expansion of the program. It became clear, however, that the university did not have the resources to continue the level of effort and day-to-day involvement needed to maintain the program, much less to expand the program into new communities. To begin to meet the increasing demand from the growing number of communities who were interested in bringing the program to their area, the university shifted its implementation strategy to utilize the existing networks of health promoters to implement Agua Para Beber. Instead of directly training and supporting the health workers as it had initially, the university partnered with CBOs and worked with the CBO staff to implement, monitor, and evaluate the program. The university conducted trainthe-trainer sessions and provided the logistical support for obtaining the water storage containers, comic books, and other educational materials. The CBOs provided the trainers, arranged the promoter training sessions, and organized the promoter visits to the households. For example, the university worked with the Adults and Youth United Development Association (AYUDA) to deliver Agua Para Beber to residents of San Elizario, a small community southeast of El Paso, Texas. At that point in time, most colonias around San Elizario had no water systems or sewerage. While AYUDA had a large base of volunteers and had participated in a number of health initiatives, they had not been able to develop a program to address the serious water and sanitation problems in their community. The university trained five trainers who then conducted promoter trainings. The trained promoters were able to begin household visits within two months of the first planning meeting. Over the last two years, AYUDA has reached over 200 families. They have now begun to implement the program in neighboring colonias. This shift in approach was successful largely because it utilized the strengths of both institutions. The CBOs had the direct linkages to the community and experience conducting community based programs, while the university had a useful and thoroughly tested program to transfer to

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the CBOs. Since its inception, Agua Para Beber has involved 13 community groups, trained over 175 health promoters, and reached nearly 2,500 families (approximately 10,000 individuals) in Cd. Juarez and El Paso. CBOs on both sides of the border continue to implement Agua Para Beber even with no outside funding or support. Agua Para Beber has also expanded beyond El Paso and Cd. Juarez to Laredo, Texas, and Nuevo Laredo, Tamaulipas, and San Diego, California, and Tijuana, Baja California. In Laredo/Nuevo Laredo the university worked with an outreach program from the University of Texas-San Antonio, to obtain funding from the Border XXI Program to implement Agua Para Beber. UTEP provided UT-San Antonio and its local partners training and technical assistance to implement, monitor, and evaluate Agua Para Beber. In California and Baja California, Project Concern, a nonprofit development organization, has integrated Agua Para Beber into a larger promoter-based health promotion project and works with several CBOs to implement the program on both sides of the border. The university is currently assisting CBOs from Ojinaga, Mexico, in writing a proposal to fund the implementation of Agua Para Beber. COMMUNITY UNIVERSITY PARTNERSHIP FOR ENVIRONMENTAL JUSTICE AND HEALTH EDUCATION During the implementation of Agua Para Beber, some CBOs began requesting information from the universities regarding other environmental risks, particularly chemical contamination of drinking water, ambient air pollution, and exposures to agricultural pesticides. In collecting information for these groups it became clear that there was a dearth of Spanish language popular education resources on environmental issues. Fortunately two funding opportunities arose over the next few months that supported efforts to develop and implement community-based programs addressing a wide range of environmental issues. The Community-University Partnership for Environmental Justice and Health Education evolved out of the requests from community groups for better, culturally appropriate materials on environmental health issues other than water and hygiene. While the immediate objective of the project was to develop environmental education materials, the long-term goal was to develop the capacity of local CBOs to respond to environmental health issues in their communities. Specifically the program emphasized three components: • development and testing of a training-of-trainers curriculum for community leaders and promoters in nonformal, participatory environmental health education; • formation of a network of community groups to improve the interactions, com-

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munication, and exchange of information among community groups and between community groups and government environmental agencies; and • research to help community leaders and government agencies identify and understand perceptions, knowledge, attitudes, and beliefs of community members concerning health and environmental risks. This program included partnerships on both sides of the border. Each partnership included faculty and staff from the universities, a principal CBO, and other participating CBOs. In El Paso, UTEP and the UT-Houston School of Public Health worked with AYUDA and five other CBOs to implement the program. In Cd. Juarez, UTEP and UACJ, together with the Organization Popular Independiente (OPI), a community-based organization, and several other community groups, implemented the program. Both partnerships designed and implemented a comprehensive environmental outreach program. The initial efforts were directed toward gathering information and developing an environmental training curriculum to address specific community concerns. Using the train-the-trainer model developed in the Agua Para Beber program, the curriculum addressed a number of issues including water contamination, air quality, waste generation and disposal, pesticides, and other environmental health-related problems. Responding to the groups' requests for skills-based trainings, outside facilitators were brought in to train the trainers from the community groups in media advocacy, risk communication, and program design and implementation. In addition, training sessions were held to help trainers find and interpret environmental health information. The program also focused on assisting community groups to use computers to access environmental information. The program provided used computers to the groups, purchased modems, and conducted intensive trainings on how to use a computer, how to use e-mail, how to access the Internet, and how to develop a web page. Prior to this program, many groups either did not have access to computers or did not know how to effectively use the ones they had. One of the most important aspects of the partnerships was the development of a network of CBOs. On each side of the border, the partnerships brought together community groups working on environmental issues. While some of the organizations had had linkages prior to the program, none of the groups were currently working together to address environmental issues. While the universities were initially the key agents involved in facilitating these networks, the networks have developed to the point where they continue actively working together with little involvement from the universities. In the United States, the networking was primarily facilitated through monthly meetings of the CBO leaders and the university program coordi-

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nators and investigators. While the size of the network dropped from thirteen organizations to six over the first few months of the program, these six organizations formed a stable nucleus that continues to work together some two years later. In Cd. Juarez, OPI worked closely with the university to develop and facilitate environmental trainings and advocacy workshops for several interested community groups. The trainings brought together six groups and organizations, and resulted in the formation of a community environmental network. The network developed community environmental projects that resulted in the opening of recycling centers and community-wide environmental education campaigns. Efforts at networking expanded beyond the CBOs. The partnership also played a role in improving the dialogue between government agency personnel and the community groups. On both sides of the border the universities were able to act as a neutral party to facilitate meetings and communication between government agencies and CBOs. For instance, in El Paso several government agencies had loan and/or grant programs for the provision of water and wastewater services. The criteria for each program varied significantly, causing a lot of confusion among residents in need of such services. The university was able to bring together the various parties in order for the CBOs to better understand the program available to their constituencies and to share with the government agencies and other CBOs the difficulties residents were experiencing in trying to access these programs. In Cd. Juarez, the university hosted a roundtable with the network of community groups and governmental agencies. The university provided results of a risk perception study, the community groups discussed the barriers they faced in solving environmental problems, and the government agencies reviewed their current environmental programs. While such meetings may not seem extraordinary to residents of the United States, the roundtable was one of the first times that government agencies and community groups in Cd. Juarez had met face-to-face to discuss environmental problems in the community. As part of this roundtable, the parties signed a written agreement to form a formal, broader network of community groups and government agencies. The third component of the program was research focused on the perceptions, knowledge, attitudes, and beliefs of community members concerning health and environmental risks. While outreach programs often include a formal evaluation, few outreach programs specifically include research as a programmatic activity. In this situation there were several reasons to include this research as one of the primary partnership activities. First, it was important to document in a systematic manner the environmental risk perceptions of the communities involved so that the CBOs would have a basis for knowing whether government agencies were re-

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sponsive to the concerns of their communities. Second, incorporating research into the program increased the participation of faculty members from the academic institutions. Finally, it was important to show the CBOs that they could meaningfully participate and benefit from a research project. A number of these communities had been the focus of previous research projects that did not include input from the community in developing the research objectives, and did not, from the community's perspective, result in any meaningful change for the community. As a result, many community members felt that they had "been studied to death." The partner CBOs have become quite interested in conducting further studies to quantify the levels of health problems, such as asthma, in their communities. As a result of the training, networking, and research, each of the two partnership networks developed their own program for addressing environmental issues. OPI in Cd. Juarez now maintains its own network of CBOs addressing environmental concerns and has received funding to establish a permanent environmental information center for community residents. It has also developed linkages with several government agencies to address the lack of solid waste disposal services. In the United States, the group of six CBOs, with the involvement of a representative from the Texas Department of Housing and Community Affairs (TDHCA), has also decided to focus on the problem of solid waste disposal. They arranged to attend a meeting that included officials from many of the state, federal, county, and city agencies with an interest or responsibility for solid waste management issues. At this meeting they were able to express their view that the government agencies were not adequately addressing the solid waste issue in the colonias, and proposed some ideas for solving the problem. One of the leaders of AYUDA was interviewed for a local television news broadcast to explain the solid waste problems facing residents of the colonias. As a result of their efforts, some areas were provided with dumpsters that are emptied on a monthly basis. In addition, the groups are planning another meeting with agency directors to present the results of the risk perception study regarding solid waste and to lobby to provide other colonias with dumpsters. FOSTERING MEANINGFUL PUBLIC PARTICIPATION IN ENVIRONMENTAL ISSUES The success of the community-university partnerships is evidenced by the continued participation of the partner CBOs beyond the project period, the expansion of the roles and activities of these CBOs, and the adoption of this model for program implementation at other sites along the U.S.Mexico border. From our experiences it appears that the partnership between the CBOs and the university provided the necessary mix of skills and

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motivation to have an effective and sustainable outreach program. Universities or nongovernmental agencies often have little success working unilaterally to address community concerns and needs; community organizations are vital for building trust, maintaining close contact with residents, and understanding how to work in the local social and political environment. Conversely, many CBOs do not currently have adequate training or experience to obtain and interpret technical environmental health information, develop health promotion programs and materials, identify sources of funding and prepare competitive grant proposals, or develop and maintain contacts in the environmental regulatory agencies. While each party of the partnership may have something useful to contribute, such collaborations are often more successful when each party also has something to gain. For the CBO, the partnership provides a convenient source of technical information and the programmatic support to deliver this information to their community in an appropriate format. Further, the CBOs have had substantial input into the development of the materials and programs it wants to implement. The partnership also provides improved access to organizations, government agency officials, and other CBOs working on similar issues. For the most part the CBO receives these benefits with relatively few strings attached. The universities do not have strong ties to political parties or specific politicians, nor an agenda to either downplay or exaggerate the environmental problems in a community. Agua Para Beber exemplifies how community organizations have utilized technical assistance as well programmatic support provided by the university to successfully assist their constituencies in addressing important environmental concerns. The university, with much assistance from community organizations, has developed a flexible "canned" program that is easily transferred to organizations with direct linkages in the community. From the university's perspective, the partnership helps to fulfill one of the basic missions of academic institutions, using knowledge to serve the community. The partnership provides many tangible benefits as well. Students who participate in the program gain skills in research and program development, as well as practical direct experience in working with residents and community organizations. The students come from a wide range of majors, including environmental science and engineering, public health, and communication. Many of the professional opportunities in the environmental field are with public sector agencies. Having agency personnel who have had experience working with community groups will greatly improve the agency's ability to have meaningful public participation in environmental issues. Involvement of faculty as technical advisors has raised awareness of some of the specific environmental problems in these communities, as well as the important differences in perceptions of environmental risk between researchers and the residents. This in turn has lead to the development of

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new research projects focusing on community issues. In much the same way that the partnership has increased the CBOs' access to agency officials, the partnership has increased researchers' access to the community. The CBOs have helped introduce the researcher to the community, gain community acceptance for the research, and recruit residents into the study. In some cases CBO members have been hired to conduct interviews and collect other data. More important, through the partnership the CBO members have helped define the research issues from the community's point of view so that the research results can help further the community's agenda. The experiences of the faculty and students in working with the partnership filters back to the university as well, raising awareness of these issues through course lectures and seminars. There are other examples of successful programs in the Cd. Juarez-El Paso area that also have used partnerships to address environmental issues. The El Paso Interreligious Sponsoring Organization (EPISO) has been extremely successful advocating on behalf of several communities to get state and federal funding for water and sewerage systems. At the same time they have worked for several years with the university on a program to help residents install septic tanks at minimum cost. Engineering students from the university design the system, the residents provide planning and labor, and EPISO organizes the projects and arranges to buy piping and tanks at discount prices. WaterWorks is another organization that has partnered with CBOs to address water supply and sanitation problems. WaterWorks provides technical assistance and construction management expertise to communities who are willing to organize and contribute time and money for the construction of their water supply systems. While the partnerships between the university and the CBOs have been effective, such direct efforts cannot satisfy the vast needs of a large and increasing population along the U.S.-Mexico border. To address this need will require an exponential increase in such programs to meet the similar increases in population. This can be best achieved through a process of capacity building: developing CBOs that not only satisfy the basic community needs for information, government access, and immediate services, but can also assist other CBOs in developing this same capacity. This is the type of development that we have witnessed in a number of CBOs. The potential role for CBOs is quite extensive. As CBOs develop their capacity, they could begin training groups in other parts of the border, form collab o r a t e s and submit proposals for joint funding, or develop centers for the training of trainers. For example, OPI in Cd. Juarez has now received funding for maintaining a network of CBOs and developing environmental education programs for these groups. AYUDA, in San Elizario, Texas, has been awarded two grants, one to enroll residents in a program for constructing septic tanks and another to develop and implement an exercise program for their community.

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With the increasing capacity of the CBOs, the role of the university has also changed. For example, the university has recently received funding for a new program addressing water and sanitation problems on both sides of the border. In this program the university is soliciting proposals from CBOs to fund them to recruit and enroll families into the project, and to implement education programs in their communities. In addition, the university is finding matching funds to help households connect to water systems or improve sanitation. The foundation that funded this project gave the university the responsibility of designing and managing the granting process based in part on its experience in working with CBOs on other environmental projects. Federal and state government agencies on both sides of the border have explicitly recognized the importance of including community inputs in setting priorities and making decisions regarding environmental programs. In particular, Border XXI, the binational government program for addressing environmental problems along the U.S.-Mexico border, has explicitly chosen a strategy of "public participation in the development and implementation of the Border XXI program." To date such efforts have included public meetings in urban areas, telephone "hot lines," and providing environmental information on the internet. Unfortunately few of these efforts have reached low income communities. In fact, a recent survey conducted in some colonias of El Paso County found that less than a quarter of the respondents had even heard of the Environmental Protection Agency (Byrd, VanDerslice, and Petersen 1997). Expanding community-university partnerships would be an effective means of improving public participation through education and training, two-way communication between agencies and communities, and community participation in pollution prevention programs. However, such development will require investments from government agencies and private foundations. While universities can and do provide some institutional support for these programs, expanding both the role of the university and the scope of the program will require investments from government programs and private foundations. Solving the region's environmental problems is an extremely complex task requiring binational, multiagency cooperation in environmental monitoring to identify areas of contamination, development of regulatory infrastructure and economic incentives to maximize compliance with environmental regulations, and construction of basic water and sanitation infrastructure. Governments cannot solve the problems by themselves. Public understanding of environmental issues is necessary for cooperation in pollution prevention, monitoring activities in individual communities, and creating the political pressure to support funding for environmental programs. The community-university partnerships outlined in this chapter represent one way to encourage public understanding of environmental issues and community efforts to reduce environmental risks.

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NOTE The authors would like to acknowledge the invaluable contributions of several individuals who helped make the programs described in this chapter possible: Beatriz Vera, Chris Bessenecker, and Alma Galvan for their dedication and hard work on Agua Para Beber; Patricia Juarez, Veronica Corella-Barud, and Manuel Arroyo for their work on the Community University Partnership for Environmental Justice and Health Education; and Alcides Flores, Patricia Monreal, and Gloria Melendez for bringing these programs to the community. Funding to support these programs comes from the U.S. Environmental Protection Agency, the Southwest Center for Environmental Research and Policy, Johnson & Johnson, and the Levi Strauss Foundation. 1. The partnerships described in this chapter included input from three universities: the Center for Environmental Resource Management (CERM) at the University of Texas at El Paso (UTEP), the Universidad Autonoma de Ciudad Juarez (UACJ), and the University of Texas-Houston, Health Science Center, School of Public Health at El Paso. Personnel from each of these institutions participated in most aspects of these programs. To simplify the text, the term "university" is used to refer to personnel from some or all of these institutions.

REFERENCES Works Cited Bessenecker, C. 1994. "A Study of Child-Related Excreta Disposal Practices and Beliefs in a Peri-Urban Community of Ciudad Juarez, Mexico." Masters Thesis, University of Texas, Houston, Health Science Center, School of Public Health. Byrd T. L., J. VanDerslice, and S. K. Petersen. 1997. "Variation in Environmental Risk Perceptions and Information Sources among Three Communities in El Paso." Risk: Health, Safety and Environment 8:355-72. Redlinger, T., K. O'Rourke, and J. VanDerslice. 1997. "Seroepidemiology and Vaccination Program for Hepatitis A among High Risk School Children in a Texas-Mexico Border Community." American Journal of Public Health 19: 1715-17. Suggested Readings Galvan, A., and A. K. Liebman. 1996. Manual del Promotor. El Paso, TX: Center for Evironmental Resources Management. Liebman, A. K. 1998. "Trickle-up Activism: Agua Para Beber Tackles Neighborhood Water Quality Problems One Family at a Time." Borderlines 6(3) (April). Liebman, A. K. 1998. "Agua Potable En Las Colonias De La Frontera Entre Los Estados Unidos Y Mexico." La Jornada Ecologica (December). Southwest Center for Environmental Research and Policy. 1996. "Improving the Quality for Water in Colonias in the Ciudad Juarez-El Paso Area." Border Environmental Research Reports 3 (July).

Afterword

Asi es la vida. Life may be tough, but we know that life can be better. There are, unfortunately, things we cannot change, but conditions along the U.S.-Mexico border are not among them. There is solid evidence that various programs and projects are successful, even by degrees, at educating, at providing health care, at cleaning up the environment and developing strong communities, at improving labor conditions and relations, at attacking drug problems through providing opportunities and building self esteem, at bettering gender relations and preventing domestic violence, at dealing with serious public health problems and providing preventive and primary care, and at empowering individuals and communities to help solve their own problems. These programs and efforts are too few and far between. No one denies that there are very real problems concerning illegal immigration, drug trafficking, and human rights. Those problems, however, feed on mythologies, as well as political and economic perceptions. The realities are much more complex. Dealing with these problems is a tremendous challenge for both nations, but it is the borderland residents who have within themselves the power to change their lives and enrich other cultures through their own third culture. But the borderlanders can't do it alone. Solutions require funding, but they also require real grass roots knowledge, education, cultural sensitivity, respect, support, commitment, and a lot of hard work. The solutions also require a recognition that what affects one side of the line generally also affects the other. There are many who would prefer simple solutions to

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simplistically perceived problems with an ethnocentric bent—the divided identities of "us" and "them." In a discussion of the "we-they" fallacy as it relates to delinquents and criminals, Porterfield (1957) contended that we will never understand or deal with these problems until we understand that there is no "us" and "them." "We go on punishing the offender without developing the capacity to imagine ourselves in his place, to see that he is made like us and that he responds as we might in similar situations" (46). That can also be said of the two nations that meet at the border. But the myths and the vested interests do not have a clear field. Things are happening, to which contributors to this volume and countless others can testify. Borderlanders themselves are responding, becoming advocates, educators, health care providers, activists, and agents for change. There is recognition by public health officials, administrators, law enforcement agents, and educators on both sides of the border of the seriousness of the problems of disease, pollution, drug abuse, crime, and exploitation, and what can happen if they are not addressed. Recently, Catholic Bishop Ramirez of the El Paso Diocese called for a "Marshall Plan" for the colonias. The bishop, with the Colonias Development Council, seeks funding from Housing and Urban Development (HUD) to address the structural conditions in the colonies, which includes electric power, substandard housing and roads, public safety, and liquid waste disposal. Six hundred and forty thousand dollars has been received for developing the infrastructure with new housing construction. Once this has been completed, more monies will be available for community development. This is only one example of the organizations, proposals, and programs generated within the region, itself, to meet the challenges of a growing and distressed population. Still, with the rapid growth in population and in industry, the U.S.Mexico border is undergoing dynamic change. When we are still so far behind, the challenge to even catch up seems enormous, if not impossible. But people and communities, when empowered through funding, support, education, and commitment, are the real hope of the border. The twentyfirst century will reveal whether we have learned our lessons and whether we can look to and develop human resources in building a better future for all of us. REFERENCE Porterfield, A. 1957. "The 'We-they' Fallacy in Thinking About Delinquents and Criminals." Federal Probation 21 (December): 44-47.

Internet Border Sources

It should be noted that many border research and policy organizations are in the process of setting up web sites and many are only in the beginning stages. However, the following sources are good places to start in seeking more information on border issues such as those covered in this volume. Border Health Office http://www.nmsu.edu/~bho Offers vital statistics, meeting calendar, on-line versions of newsletters, mobile clinic information, a border profile, and other information on the border community. EPA Region 9 Home Page http://www.epa.gov/region09/ Page contains EPA Documents from Region 9: Air Programs, Water Programs, Solid and Hazardous Waste Programs, Cross-Program Activities (Air/Water/Waste/Toxics), U.S./Mexico border issues. Healthfinder http://www.healthfinder.gov This is the site for the Department of Health and Human Services. HRSA's U.S./Mexico Border Health Home Page http://www.ncfh.org/border/dirnm.htm Directory offers information on border counties, but specific information is given only for geographical areas within 60 miles of the border. Secretaria de Salud ican agencies.

http://www.ssa.gob.mx/servicio

Offers links to other Mex-

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Index Abusive relationships, 62, 66. See also Domestic violence Access to health care, 5, 7, 16, 17, 19, 20, 134, 144, 146, 155, 156, 160, 161 Acculturation, 10, 26, 33, 36, 103, 128 Acquired Immunodeficiency Syndrome (AIDS), 9, 15, 16, 65, 113-30, 143, 159, 160, 184, 188; barriers to service delivery and, 120; ethnicity and, 116; influence of border on services, 122, 123; prevention and, 117, 127; in rural context, 113-15; undocumented population and, 123, 126; women and, 113, 114, 116, 117, 124 Addiction careers, 57 Agendas, 7, 10, 170, 202, 204 Agricultural workers. See Farmworkers AIDS. See Acquired Immunodeficiency Syndrome Alcoholism, 159 Alma-Ata, 135, 136 Alternative medicine, 9, 172

Balanced Budget Act of 1997, 183 Bandura's Social Learning Theory, 62, 63 Bilingualism, 28, 81, 82, 96, 115, 124, 127, 166; social services and, 124 Binational cooperation, 12, 17, 20, 126, 127, 147, 159, 187, 214, 219 Binational health priorities, 9, 13, 187 Binational health programs, 9, 126, 186, 187, 219 Biomedical model, 172 Birth rates, 24, 100, 133, 174 Blame the victim, 36, 65, 72 Border: characterization of, 1-3, 7, 8, 15, 17, 20, 77, 90, 134, 209; crossings of, 6, 13, 19, 78, 79, 8 2 86, 89, 90, 122, 185, 186; definition of, 2; environmental status of, 5; health care services and, 123, 126, 133; health conditions and, 132-34; population of, 5, 6, 12, 78 Border communities, 7, 17, 61-63, 79, 92, 114, 115, 124, 127, 128, 13335, 139, 142, 152 Border culture, 115

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Border Environmental Commission on Cooperation, 199 Border Health Commission Act, 187 Border population, 8, 9 Border Vision Fronteriza, 144, 147, 149, 150, 152 Children: abuse and, 62, 63, 145; high mortality and, 10; Medicaid benefits and, 146, 183, 184; poverty rates and, 100, 134; sexual abuse and, 69 Chronic disease, 14, 15, 24 Collaboration, 2, 12, 20; doctorpatient and, 9, 10 Colonias, 3, 6, 7, 8, 12, 19, 22-38, 97, 134, 158, 167, 173, 209-12, 216, 219, 222; characterization of, 31, 35; communication in, 27; communication problems in, 23, 25, 26; economic conditions in, 23, 24, 34; health problems in, 24; population of, 6; social relations in, 33 Colonias Development Council, 222 Communication, barriers to, 25-27, 35; methods of, 25-36 Community, role of, 162 Community development, 26, 36-38, 142, 145, 161, 164, 204, 205, 222 Community health centers, 14, 156, 162, 166, 167, 170, 172, 173, 186 Community health workers/advisors: on the border, 142-46, 166, 169, 211; characteristics of, 138; history of, 137, 139; recommendations for, 146, 147; role of, 138, 139 Community outreach, 25, 144-47, 152 Community participation, 26, 32, 37, 145, 160-62, 167, 171, 172, 191, 202-4, 217, 219 Confidentiality, 117, 121, 123, 125, 167 Conservatism, 120, 125 Crime rates, 85 Cultural diversity, 138, 151, 172 Culturally sensitive care, 124, 125, 128, 162, 166, 172, 213

Cultural norms, 30, 64, 103 Culture, relationship of gender and power to, 64; influence on the border, 90 "Cycle of Violence," 62, 63, 72, 75 Death, causes of, 14-16, 210. See also Mortality rates Declaration of Alma-Ata, 135 Delphi Study, 17, 19 Demographic changes, 78, 79, 91, 97 Dental care, 8, 160, 164, 169, 182, 185 Diabetes, 14, 15, 137, 159, 160, 168, 169, 174 Domestic violence, 12, 61, 67-70, 75, 143, 166, 169, 221; consequences of, 63; family dynamics and, 64. See also Women, abuse and Dropout rates. See Hispanics: dropout rates in school and Drug addiction, 48. See also Substance abuse Drug trafficking, 40, 90, 221 Economic development, 1, 3, 5, 7, 2 1 , 73, 92, 152, 204, 209 Economic opportunity, 40, 79, 91, 137 Education, as a predictor of success, 101; Hispanic students and, 97; poverty and, 134. See also Fertility: education and Elderly population, 10, 132, 136, 157, 182-84, 187 Empowerment, 4, 5, 11, 121, 128, 134, 140, 144, 149, 151, 152, 156, 160-62, 173, 204, 222 Environment, 5, 7, 12, 14, 22, 37, 59, 67, 72, 105, 133, 135, 155-57, 159, 174, 175, 181, 192-96, 198, 206, 207, 209, 210, 217, 220, 221 Environmental Protection Agency, 2 1 , 219 Environmental racism, 202 Environmental risk assessment, 203, 204, 213, 215 Epidemiological transition, 14

Index Ethnicity, 78-82, 89-91, 117, 125, 132, 159 Evaluation, 32, 112, 141, 147, 149, 164, 215 Family: influence of mother in, 101, 103; systems dynamics and, 64. See also Domestic violence Farmworkers, 7, 168, 186; health care services and, 7 Fertility, 7; education and, 7, 8 Fertility rates, 8, 14; unemployment and, 7 First National Community Health Advisor Study, 140 Folk remedies, 163, 166, 167 Gangs, 24, 53, 60, 61, 67, 69, 71, 75, 84 Gender: drug abuse and, 58, 59; effects of on the border, 77, 79, 84; employment and, 79; the power structure and, 64, 72, 74; relationships and, 62, 83, 84, 126; relationship to cultural norms and violence, 64, 71, 73 Gender roles, 74, 77, 86, 91, 92, 125, 126 Generation gap, as source of distrust, 28, 36, 91 Globalization, 77, 91 Governmental agencies, 49, 215, 217 Grass-roots approach, 172 Hazardous waste, 5, 133, 193, 19799, 202, 203, 207, 209 Health care, 87, 88; access to, 10, 16, 17, 19, 88, 132-34, 144, 146, 160, 171, 178, 181, 184, 187; barriers to, 17, 18, 132, 133; barriers to access, 132, 133, 136, 142, 157, 158; cost of, 132, 145, 150, 175, 182; delivery of, 9; expenditures for, 9, 131, 179, 181-83, 190; as a fundamental right, 9, 144, 177; needs, 17, 156, 158, 170, 184; priorities, 10-13; undocumented persons and, 123, 126, 159, 166

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Health care systems, in rural areas, 162, 171; in Mexico, 9, 177-81; reform of, 172; in the United States, 9, 181-84 Health insurance, 9, 17, 19, 87, 1 3 1 33, 136, 146, 149, 151, 177, 17983, 185, 186, 188-90; lack of, 1 3 1 33, 136. See also Health care systems, in rural areas: in Mexico; in the United States Health Maintenance Organizations (HMOs), 169, 170, 184, 187 Health Manpower Shortage Areas (HMSAs), 161 Health plan networks, 171 Health promotion and disease prevention, 10, 132, 134-37, 142, 146-48, 1 6 9 , 2 1 1 , 2 1 3 Health status, 3, 12, 15, 131, 134, 137, 160 Heroin, 3, 12, 17, 75; effects of, 39; use of, by women, 59. See also Hispanics: drug abuse and; Substance abuse Heroin users, 41; addiction careers and, 57; characterization of, 39, 40, 42, 46, 58 Hispanic Dropout Project, 98, 110 Hispanics, 5, 7, 16, 19, 101, 104, 110, 111, 129, 133, 134, 136, 149; dropout rates in school and, 97-99; drug abuse and, 39, 40; educational aspirations of, 96, 99, 102, 109; education and, 69-99; ethnicity, identity and, 80, 81; family dynamics and, 101; health care services and, 16, 133; health insurance and, 9, 133, 136; health status of, 15, 16; population growth and, 97; poverty and, 97, 100, 101, 134 Holistic health, 133, 140 Homicide, 15, 16 Housing and Urban Development, 25, 31, 222 Illiteracy, 8, 27-29, 98, 168 Immigrants, 6, 7, 35, 37, 40, 48, 78, 90, 92, 98, 184, 188, 202

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Immigration, 6, 37, 54, 78, 90, 167, 188, 202, 221 Indigent care, 184 Indigent patients, 132, 182 Infectious diseases, 14, 16, 20, 22, 97, 159, 210 Inflation, effects of, 4 Infrastructure, 3, 5, 7, 31, 65, 91, 100, 118, 158, 163, 180, 209, 219, 222 Injecting drug users, 3, 39, 4 1 , 50, 52, 53, 57, 58, 60 See also Heroin users Instituto Mexicano del Seguro Social (IMSS), 178 Integrated delivery system, 170, 186 Intergenerational transmission of violence, 63, 72, 73 International waste trading policies, 203, 205 Intimate partner violence (IPV). See Domestic violence Intravenous drug use, 113, 116, 127. See also Substance abuse Isolation, 23, 25, 31, 32, 58, 59, 68, 155, 163, 172

Metacommunicative repertoires, 26, 32 Migrant farmworkers, 150, 159, 166, 186. See also Farmworkers Migrant health centers, 136, 184 Migrant Health Centers Program, 184 Migration, 1, 5-7, 14, 17, 20, 24, 8 9 91, 93, 133 Minority groups, 39, 97, 98, 137 Mortality rates, 8, 14, 16

Kids Count Project, 100, 112

Outreach, 3, 23, 25, 28, 29, 32-34, 36, 65, 74, 117, 137, 139-41, 14347, 149, 152, 164, 169, 213-15, 217

Landfills, 191, 194, 200, 202, 203, 205, 207 Life expectancy, 12, 155 Literacy, 132, 225; generational conflict and, 27-29 Managed care, 132-34, 141, 147, 150, 151, 156, 162, 167, 169-73, 175, 181-85; in rural areas, 170, 171 Mano a Mano Program, 145, 150 Maquiladoras, 4, 5, 65, 77, 78, 91, 92, 158, 186, 188, 192, 194, 198, 199, 201-3, 209 Maternal/child health, 143, 168 Medicaid, 17, 146, 147, 150, 166, 167, 169, 170, 175, 181-84, 188 Medicaid managed care, 167, 169, 170, 184 Medical industrial complex, 136 Medically underserved areas (MUAs), 17, 136, 161 Medicare, 87, 121, 166, 181-90

National Community Health Advisor Act, 146 National Community Health Advisor Study, 140, 150, 151 National Health Interview Survey, 133 National Health Service Corps, 161, 163, 164 Needs assessments, 34, 159-61, 187, 211 Networking, 14, 144, 147, 156, 162, 164, 165, 168, 170-72, 214-16 North American Free Trade Agreement (NAFTA), 3, 4, 20, 21, 40, 124, 18890, 199, 202, 209

Partnerships, 4, 14, 138, 144, 147, 164, 165, 168, 191, 203, 205, 209, 210, 214, 216, 217-20; binational, 214; community-university, 209, 210, 212, 213, 216-19; publicprivate, 147, 191, 194, 203, 205 Patient/provider interaction, 133 Pesticides, 168, 213 Population, growth of, 5, 6, 8, 132; on the border, 5, 6 Poverty, 23, 40; drug use and, 39, 59; effects of, 24, 97; levels, 3, 4, 100, 101, 134; rural areas and, 157 Power, 21, 29, 33, 36, 62, 64, 72, 74, 81, 82, 92, 127, 129, 139, 142, 148, 221, 222 Prejudice, 35 Prenatal care, 87, 145, 157, 164, 168, 185, 188

Index Prevention, 4, 10, 13, 17, 21, 60, 65, 113, 116-19, 121, 122, 126-28, 136, 138, 142, 147-49, 169, 170, 172, 187, 219. See also Health promotion and disease prevention Primary care services, 136, 148, 160, 167 Private health coverage, 180, 186 Private sector, 178, 179, 193; health insurance and, 181 Project CONSENSO, 12, 22 Promotores(as). See Community health workers/advisors Public health, 10, 12, 14, 2 1 , 22, 61, 126, 133, 148, 149, 152, 153, 15860, 162, 172, 174, 175, 178, 179, 181, 184, 185, 187, 188, 195, 199, 214, 217, 220-22 Public participation, 161, 210, 216, 217, 219 Quality of life, 11, 12, 23, 37, 92, 144 Racism, 202, 206 Regulations, 1, 157, 162, 164, 170, 171, 178, 180, 192-95, 199, 201, 202, 204, 219; toxic emissions and, 195 Rural areas: characterization of, 155, 157; definition of, 156, 157; health care services and, 170; poverty and, 157 Rural Health Initiative, 161, 163, 175 Ryan White Act, 118, 120, 121, 125, 129, 184 Seguridad Social (Social Security), 83, 177-80, 186, 188 Self-esteem, 128, 221 Self-sufficiency, 163 Service providers, 25-27, 64, 114, 117, 119-21, 123-25, 127, 128, 144, 158, 172 Sex-role stereotyping, 64 Single mother families, 134 Social construction of identity, 78-81, 92 Socialization, 62, 64 Social networks, 35, 88

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Social policy, 72 Social security system, 177, 181, 182 Solid Waste Act of 1990, 195 Solid waste disposal, 14, 193, 216 Subculture, 39, 40, 42, 62 Substance abuse, 2, 4, 16, 17, 20, 2 1 , 24, 36, 51, 75, 138, 159, 168, 169, 184 Substance abuse programs, 17, 184 Suicide, 4, 15, 16 Surveys, 30, 35, 178 Suspicion of government, 4, 27, 33, 157, 201, 204 Technical assistance, 162, 213, 217, 218 Teen pregnancy, 100, 110, 159, 164, 168, 169, 174 Telenovela, 31, 32 Traditional cultural norms, 103 Trust, 4, 12, 20, 25, 28-30, 32, 33, 35, 36, 157, 161, 162, 166, 167, 169, 172, 174, 175, 201, 217 Tuberculosis, 16, 159, 188 Underserved populations, 138, 152, 162 Undocumented immigrants, 6, 7, 40, 79, 90, 184, 188 Unemployment, 3, 4, 7, 8, 24, 34, 40, 65, 98, 101, 110, 115, 134, 158 Unemployment rates, 4, 24, 34, 115, 134 United Farm Workers, 186 Universal health insurance, 131 U.S. Border Patrol, 79, 84, 92 Violence: acceptability of, 62, 72; consequences of for women, 63, 64; cultural norms and, 64, 71, 73; home environment and, 68; intergenerational transmission of, 63, 72, 73; learning theory and, 6 2 64 VISTA, 163 Waste disposal, 14, 191, 193, 198, 202, 216, 222 Water quality, 211

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Welfare, 61, 64, 100, 138, 163, 167, 175, 184 Women: abuse and, 62-64, 169; choice of sexual partners and, 69, 70; as community health advisors, 143-45; education and, 9; employment and, 91; employment opportunities and, 101; ethnicity and, 81; as injecting drug users, 58, 59; learned helplessness and, 63-65; reasons for staying in abusive relationships, 64, 65, 68, 71, 72;

role in border development, 92, 93; role of, 78; self-esteem and, 65, 109, 121, 128; socioeconomic conditions of, 101. See also Acquired Immunodeficiency Syndrome (AIDS): women and Women, Infants and Children (WIC), 146, 161, 163 World Health Organization, 3, 22, 23, 135, 150 Zoning, 195-97, 203, 206

About the Editors and Contributors

ANDRES BOADELLA is a microbiology student with a minor in chemistry at the University of Texas at El Paso. He has worked and assisted in a number of border projects such as the development of tuberculosis research databases and of various publications for the U.S.-Mexico border region. He has also been involved with the development of health information educational materials relative to the border. In addition to his studies, he currently also does volunteer work at Providence Memorial Hospital. THERESA L. BYRD has spent the majority of her career working with U.S.-Mexico border and migrant populations, first in Arizona, and then in California, Texas, and Chihuahua. As a public health nurse, she became aware of the special problems of low-income, marginalized populations, including the difficulties they have accessing the health care system. After receiving her MPH from UCLA, she worked with colonia residents in Ciudad Juarez, Chihuahua, and El Paso, Texas, assisting in community development and health efforts. She has also been involved for several years with an organization dedicated to bringing appropriate technology water systems to the ejidos near Reynosa, Tamaulipas. After completing her Doctorate in Public Health at the University of Texas-Houston School of Public Health, she returned to El Paso as faculty for the University of TexasHouston, School of Public Health satellite campus. Her research interests include border health issues, maternal and child health, community organizing, and perceptions of risk. DONNA CASTANEDA received her M.A. and Ph.D. in social psychology from the University of California, Davis. She is currently an assistant pro-

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About the Editors and Contributors

fessor in the Psychology Department at San Diego State University, Imperial Valley Campus. Her research focuses of issues of gender and ethnicity in close relationships, health promotion in Latina/o communities, and HIV/ AIDS prevention among Latinas/os. FEDERICO GERARDO DE COSIO is the Operations Manager of the U.S.-Mexico Border Health Association and a Local Technical Officer of the U.S. Border Field Office of the Pan American Health Organization at El Paso, Texas. He has a medical degree from the Universidad Autonoma de Mexico, and a Master of Public Health Degree from the University of Minnesota. He has directed a number of studies and projects on border health issues over the last ten years. Dr. de Cosio is author and co-author of a large number of border health-related articles and has received numerous awards and recognition for his work on the U.S.-Mexico border. DUNCAN EARLE is Associate Professor of Anthropology at the University of Texas at El Paso. Since 1977, he has worked with low-income, indigenous, and Spanish-speaking populations in Guatemala, Mexico, and the United States in issues of health, housing, education, micro-lending, and other related issues of community improvement. Dr. Earle has received numerous grants and awards; served as an editor for the Journal of Borderlands Studies; co-edited a University of Texas, Austin Press series on Border Social Science; and directed the Center for InterAmerican and Border Studies for two years. He most recently has been engaged in HUD-funded research on the colonias on the U.S.-Mexico border, involving use of space and household ecology, social roles and networks, impacts of isolation, gender and intergenerational dynamics, and communication in outreach. He is now finishing a pilot EPA grant on indoor air pollution education training in the colonias, and launching a project to use Mexican-style soap operas (telenovelas) to inform low-income people about development issues. JOAO B. FERREIRA-PINTO, Ph.D. in Social Sciences from the University of California at Irvine, is Assistant Professor of Behavior Sciences at the University of Texas Houston School of Public Affairs in El Paso. His main research interests are in the area of HIV/AIDS prevention, especially as it relates to drug use and addictive behaviors, and in the role of social capital in development issues as they relate to health. He is currently working on the determinants of migration among injecting drug users and the diffusion of AIDS and other blood-borne infections among these populations. He is also interested in problems of violence related to women, especially those that are sexual partners of injecting drug users. EVA M. MOYA GUZMAN is President-Elect with the U.S.-Mexico Border Health Association, and serves as Senior Program Coordinator for the U.S.Mexico Border Health Collaborative Outreach Demonstration Project,

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"Border Vision Fronteriza Initiative" at the University of Arizona Rural Health Office in Tucson, Arizona. She has also served as Community Development Director for the Institute for Border Community Health Education, "Kellogg Community Partnerships," and was Social Services Director for Centro San Vicente, Daughters of Charity Community Services in El Paso, Texas. Her major expertise lies in management, strategic planning, and community health and education programs. ELLEN R. HANSEN received her Ph.D. in Geography from the University of Arizona. She is currently Assistant Professor of Geography at Emporia State University, Emporia, Kansas. She has participated in research in Arizona and Sonora, Mexico, as well as at the U.S.-Mexico border. Hansen has also served as a Peace Corps volunteer in the Andes of Ecuador. AMY K. LIEBMAN is a Program Coordinator for the Center for Environmental Resource Management at the University of Texas at El Paso. Her area of specialization is environmental health and community development. She has developed and authored related bilingual training manuals and other educational materials. She has a Master's degree from the LBJ School of Public Affairs and a Master of Arts from the Institute of Latin American Studies, both from the University of Texas at Austin. MARTHA OEHMKE LOUSTAUNAU is a medical sociologist in the Department of Sociology/Anthropology at New Mexico State University in Las Cruces, New Mexico. She received her Master's degree from the University of Illinois in 1966, and her Ph.D. from the University of New Mexico in 1973. She teaches courses in medical sociology, medical ethics, and social policy, and has served on numerous related boards and committees. Dr. Loustaunau served as chairperson of the State Health Planning Committee and the Governing Body of the New Mexico Health Systems Agency during its existence from 1976 to 1986. She is a member of the University Pre-Health Professions Committee and directs the Pre-medical Internship Program. Dr. Loustaunau is author of numerous related articles, and is coauthor of The Cultural Context of Health, Illness, and Medicine, with anthropologist Dr. Elisa J. Sobo. She lived and taught for a time in Guadalajara, Mexico. ALBERTO G. MATA JR. is Associate Professor of Human Relations at the University of Oklahoma, and is currently Visiting Research Scientist for the Pan American Health Organization in El Paso, Texas. He received his Ph.D. from the University of Notre Dame and completed post doctoral training in mental health evaluation and health promotion. Dr. Mata has published numerous articles on border topics including substance abuse, gangs, domestic violence, and AIDS prevention. He is presently engaged in research on U.S.-Mexico border violence, drug abuse, and community health interventions.

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REBECA L. RAMOS is Division Director in Training and Technical Assistance for the U.S.-Mexico Border Health Association in El Paso, Texas. Her education includes graduate studies in Ethnohistory at the National Institute of Anthropology and History and in Social Anthropology at the Universidad Ibero-Americana, both in Mexico City. She also holds a Master's degree in Public Health, University of North Carolina at Chapel Hill (1990). Ms. Ramos' main research interests are in medical and applied anthropology, and health promotion and disease prevention. She has extensive experience as a consultant and participant in programs on both state and international levels, dealing with such issues as HIV/STD prevention and maternal child health, and development of strategies for diabetes prevention along the U.S.-Mexico border. Research and publications deal with such issues as family violence, HIV/AIDS, disease prevention, and female empowerment. ELLEN ROSELL is the Director of Human Resources at Western New Mexico University in Silver City, New Mexico. She has a Doctorate of Public Administration and a Master of Social Work from the University of Georgia. She has taught for Troy State University in Europe, Memphis State University, the University of Central Florida, and New Mexico State University. Her publications include articles in Policy Studies Journal, Public Personnel Management Journal, Urban Affairs Quarterly, and chapters in Public Works Administration: Modern Public Policy Perspectives and in Case Studies in Public Budgeting and Financial Management. Rosell has assisted both state and local governments with human resources and economic development projects. Her research focuses on public-private partnership and citizen participation in infrastructure development. MARY SANCHEZ-BANE was Community Liaison for the U.S.-Mexico Border Health Association, in El Paso, Texas. She received her Bachelor's degree in Spanish Education and an M.Ed, degree in Education Administration, both from the University of Oklahoma, and had many years of experience in working with border populations in southern New Mexico. She was a native borderlander, and served as Executive Director of La Clinica de Familia, a federally funded community/migrant health center in southern New Mexico for many years. In her position with USMBHA, Sanchez-Bane traveled extensively on both sides of the border, conducting workshops and educational programs on numerous health-related topics, including most recently, AIDS prevention. DEE ANN SPENCER is a sociologist and Senior Research Specialist in the College of Education at Arizona State University. She has conducted research in schools in the fields of sociology and education for twenty-five years and has published articles, chapters, and a book, Contemporary Women Teachers: Balancing School and Home. In the past ten years, Dr.

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Spencer has focused on program evaluations supported by federal, state, local, and foundation grants and contracts, such as Title I and Title VII programs, which have involved school-wide reforms, the introduction of innovative strategies for developing school management systems, strategies for teacher professional development through action research, and the implementation of new instructional strategies for increasing students' literacy skills. Dr. Spencer has also been conducting research for over ten years, comparing the perspectives of teachers in the U.S. and in Mexico. JOSEFINA VILLAMIL TINAJERO is currently Assistant Dean of the College of Education and Professor of Bilingual Education at the University of Texas at El Paso, where she has directed the nationally acclaimed MotherDaughter Program for thirteen years. The Mother-Daughter Program was the 1997-98 recipient of the prestigious Eleanor Roosevelt Fund Award from the American Association of University Women. A featured speaker on bilingual education and on the recruitment and retention of Hispanic students in higher education, Dr. Tinajero is also the author of Raising Career Aspirations of Hispanic Girls and The Power of Two Languages: Literacy and Biliteracy for Spanish Speaking Students. Dr. Tinajero has been instrumental in establishing Mother-Daughter Programs throughout the United States. AVELARDO VALDEZ, Ph.D., is Associate Professor of Sociology at the University of Texas at San Antonio and is currently Director of the Hispanic Research Center. He received his Ph.D. from the University of California, Los Angeles. Dr. Valdez is principal investigator of two National Institute on Drug Abuse (NIDA) studies focused in south Texas and is recipient of numerous other research grants. His publications focus on issues related to culture, gender, violence, and substance use among the Mexican American population. He has published in journals such as Gender and Society, Urban Life, Social Science Quarterly, Journal of Drug Research, Substance Use and Misuse, and Journal of Border Health. Dr. Valdez has a book entitled Conjunto Music in Mexican American Society forthcoming from CM AS, University of Texas Press. He has been a reviewer for Journal of Contemporary Ethnography, Free Inquiry in Creative Sociology, Journal of Border Health, and others. He has also been a member of the American Sociological Association's section on Latino/a Sociology, Racial and Ethnic Minorities, and Alcohol and Drugs. JAMES VANDERSLICE is an epidemologist with the office of Environmental Health Assessment Services of the Olympia, Washington, Department of Health. He has worked in Guatemala and in the Philippines studying ways to improve health through improvements in water supply and sanitation. Over the past five years he has worked with several community groups along the U.S.-Mexico border addressing environmental

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health concerns. Dr. VanDerslice received his Masters and his Ph.D. in Environmental Sciences and Engineering from the University of North Carolina at Chapel Hill. His research interests include the interaction of behaviors and technology in water and sanitation programs, the communication and use of environmental and risk information by communities, and the use of Geographic Information Systems and remote sensing in environmental health. DAVID C. WARNER is Professor of Public Affairs at the Lyndon Baines Johnson School of Public Affairs at the University of Texas at Austin. He is also Visiting Professor of Public Health at the University of Public Health Branch in San Antonio. He has a Ph.D. in economics and a Masters in Public Administration. He was chair of the Texas Diabetes Council in the 1980s, and has written extensively in the area of health finance and health policy. He has directed a number of studies over the last twenty years on health care for Mexican Americans, health care on the border, and health care for U.S. citizens in Mexico.