Will new commission be key player on the border?

The task: Pulling threads into strong rope

In a region with lots of border-health wannabes, until lately a little-known panel called the U.S./Mexico Border Health Commission looked to be just one more bench-warmer, doomed to spend its days in boring design meetings where members talk loftily about goals and missions.

Late last year, the commission’s status as a player began to look more assured. President Clinton appointed eight new medical professionals as members, and the commission scheduled what members describe as its first working meeting. (See Q&A, p. 14.)

Now, some observers in the border region say they are cautiously hopeful about the impact the commission might be able to make.

"The border is sexy," says David Steffen, MSN, MPH, public health director of District 3 of the New Mexico Department of Health. "Relationships here are fragile and tenuous, and people who just pop in and out can mess things up pretty quickly.

And because it’s so sexy, it’s crowded, he adds. "You’ve got all these different entities that relate to border health, all doing their own thing. This commission has the potential to bring it all together and to channel these efforts. They can take all these little threads going out and twine them into a lifeline."

In the six years since its creation (by an act of Congress in October 1994), the commission has gotten the go-ahead from both Mexico City and Washington, DC. But unlike some other binational groups that talk at the federal level, the group has the teeth — almost — to get groups moving together at the local level, Steffen says.

You don’t pay, they won’t play

P> Typically, there are still a few knots that need to be untied. One is money.

"It’s kind of a Catch-22," Steffen explains. That is, American lawmakers are waiting to vote on the commission’s budget until Mexico City appoints members; the Mexican government, for its part, wants to see the money before it appoints commission members. "So it’s a question of who’s going to break first," says Steffen. Last month, there were hopeful signs: Mexico City had agreed to send, if not appointed representatives, at least some emissaries to Washington for the first working meeting.

That leaves only a couple of not-so-minor questions, such as which country will pick up the check for patient care when Mexican nationals get treated for, say, multidrug-resistant TB in American hospitals. Then again, no one ever claimed life along the border was for sissies.

According to Steffen, what makes border projects especially tough are, in order, poverty, followed by cultural differences. "The majority of the problems here — I’d say 75% — are poverty-related," he says. "You have the same issues you find in Appalachia or the south side of Chicago."

Problems include cultural differences

That leaves what Steffen terms "the critical quarter," the remaining 25% of problems that spring from cultural differences separating the two countries. "If you’re dealing with sister cities in the U.S., at least you have the same language, the same judicial system, the same history, business practices, and commerce," he says. Skip to El Paso and Juarez, and all those likenesses evaporate.

Not the least of the differences is structural, Steffen adds. Because Mexico’s public health system is heavily centralized, the authority for projects carried out on the border has to come from the federal level; on the U.S. side, public health agencies have much more autonomy.

"From the Mexican perspective, that means it makes sense to have a Mexico City-to-Washing ton, DC, effort around a lot of health issues," says Steffen. The trouble with commissions that operate at the federal level is that they tend to stay stuck at that level: "It’s not an on-the-ground emphasis," he adds. "The local piece tends to get left out. But solving public health problems locally is what ultimately has got to happen."