workshop ii - Mexico Border Health Commission

2010Proceedings Report of the Binational HealthCouncils’ Strategic Planning Workshop IIApril 19-20, 2010El Paso, TexasProviding internationalleadership to optimize healthand quality of life along theUnited States-México border

For additional information, please visit the BHC website at www.borderhealth.org.

ACKNOWLEDGEMENTSA special thanks to the following individuals for their invaluable time, expertise, and assistanceprovided to the second Binational Health Councils’ Strategic Planning Workshop, sponsored bythe United States-México Border Health Commission (BHC) and coordinated through the TexasOffice of Border Health (OBH) and the BHC Outreach Office of the Texas Department of StateHealth Services, in partnership with the Chihuahua Outreach Office of the Secretariat of Healthof Chihuahua.Binational Health Council Leadership: Co-Presidents and representatives for their dedicationover the past six months producing product information leading up to this workshop andproviding the results necessary to complete this report.Conference Support: Dan Reyna, General Manager, BHC-U.S. Section; Clemente VillalpandoPadilla, Executive Secretary, BHC-México Section; Dr. Elisa Aguilar Jiménez, Coordinator,BHC Chihuahua Outreach Office; Paul Dulin, Director, Office of Border Health, New MexicoDepartment of Health; Robert Guerrero, Director, Office of Border Health, Arizona Departmentof Health Services; Mauricio E. Leiva, Chief, California Office of Binational Border Health,California Department of Public Health; and Dr. Maria Teresa Cerqueira, Chief, Pan AmericanHealth Organization, U.S.-Mexico Border Office.Finally, special thanks are extended to all Texas OBH staff and OBH regional program managersfor their leadership and commitment in supporting this workshop.i

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TABLE OF CONTENTSAcknowledgements ......................................................................................................................... iExecutive Summary ...................................................................................................................... 1Overview of Workshop II ............................................................................................................. 3Purpose ........................................................................................................................................ 3Meeting Structure ........................................................................................................................ 3Objectives and Methodology ....................................................................................................... 3Welcoming Remarks ................................................................................................................... 4Background on Binational Health Councils ................................................................................ 4Agenda Discussion Items .............................................................................................................. 5Review of Available Local Data for Tier I Priorities .................................................................. 5Update on Projects Related to Obesity, Diabetes, and Tuberculosis ........................................... 6Update on Border Health Organizations’ Strategic and Operational Priorities ........................... 7Binational Health Council Presentations ..................................................................................... 8Summary of Priority Issues and Objectives .............................................................................. 14Summary of Recommendations and Next Steps ....................................................................... 16Appendices1Appendix A: Agenda ............................................................................................................... A-1Appendix B: Bilingual List of Border Health Organizations .................................................. B-1Appendix C: Map of U.S.–México Border COBINAS and Sister Cities ................................ C-1Appendix D: List of Invitees and Participants, Binational Health Councils’ StrategicPlanning Workshop II .............................................................................................................. D-1Appendix E: Glossary of U.S.–México Border Health Organizations ..................................... E-1Appendix F: Presentations ...................................................... F-Error! Bookmark not defined.iii

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EXECUTIVE SUMMARYThe United States-México Border Health Commission (BHC) sponsored the second Binational HealthCouncils’ Strategic Planning Workshop, Workshop II, hosted by the Texas Office of Border Health andthe BHC Outreach Office of the Texas Department of State Health Services, in partnership with theChihuahua Outreach Office of the Secretariat of Health of Chihuahua, on April 19-20, 2010, in El Paso,Texas.The purpose of this two-day workshop was to ensure binational community input on existing BHCinitiatives and priorities and to identify proposed interventions to address those priorities.Workshop I, which took place in June 2008 in San Antonio, Texas, was the first effort to enhance theorganizational capacity of binational health councils (hereafter referred to by the more commonly usedSpanish acronym “COBINAS,” meaning Consejos Binacionales de Salud), and analyze strategic planningand actions for the U.S.-México border, with special emphasis on the need for more effectivecommunication, coordination, and collaboration (the 3 Cs) among the COBINAS and with other state andfederal public health agencies in the border region. The workshop defined borderwide priority areas,including obesity, diabetes, and tuberculosis.Objectives for Workshop II included the following:• Revisit and reaffirm the strategic priorities (Tier I and II) and direction of COBINAS at the localand regional level, considering any recent structural changes (political and economic), currentpublic health challenges (e.g., the H1N1 Pandemic), and alignment of priorities with the BHC,the Pan American Health Organization (PAHO), the Border Governors Conference, and others asappropriate.• Synthesize the results of all the COBINAS’ operational plans into a borderwide operational plansuitable for technical and financial support.The COBINAS presented three-year plans with individual project costs working primarily with Tier Ipriorities (obesity, diabetes, and tuberculosis). Tier II priorities were also included in selected operationalplans, with the three most frequently identified being Early Warning Infectious Disease Surveillance(EWIDS), family violence in connection with mental health and substance abuse, and teen pregnancy,especially in the Arizona/Sonora border region.Key outcomes and agreements included the following:• The COBINAS are at different stages and levels of development as a local binational healthgroup of sister cities and/or county/health jurisdiction.• The COBINAS claim their autonomy as local binational public health organizations but alsorecognize that common needs or strategic priorities can be shared by COBINAS regionally oreven borderwide and proposed the following guiding principles:ooooWhen developing activities, focus primarily on disease prevention.Jointly propose recommended changes in public health policies.Search for technical and financial resources as one group, avoiding competition amongCOBINAS for the same scarce resources.Recognize the importance of the 3Cs among the COBINAS and with federal, state, andlocal health authorities.1

• The COBINAS consider developing an alliance.• The Binational Health Councils’ Strategic Planning Workshop should occur annually to updateand evaluate the COBINAS strategic and operational plans.The outcomes of this workshop will be reported and further elaborated on at the next Binational HealthCouncils’ Strategic Planning Workshop, Workshop III, in 2011.2

OVERVIEW OF WORKSHOP IIPurposeThe purpose of the second Binational Health Councils’ Strategic Planning Workshop, sponsored by theU.S.-México Border Health Commission (BHC), was to insure binational community input on existingBHC initiatives and priorities and to identify proposed interventions to address those priorities. WorkshopII was hosted by the Texas Office of Border Health (OBH) and the BHC Outreach Office (ORO) of theTexas Department of State Health Services, in partnership with the Chihuahua Outreach Office of theSecretariat of Health of Chihuahua, on April 19-20, 2010, in El Paso, Texas.Meeting StructureThe meeting was divided into four principal parts:Part I: Review available local binational epidemiological data (border states, counties, andmunicipalities) for Tier I priorities (i.e., obesity, diabetes, and tuberculosis) as defined in Workshop I.Part II: Update on projects related to obesity, diabetes, and tuberculosis by the Pan American HealthOrganization (PAHO) and the Centers for Disease Control and Preventions’ National Center forChronic Disease Prevention and Health Promotion.Part III: Update on border health organizations’ strategic and operational priorities, including theBorder Governors Conference Health Work Table, the Border Legislative Conference, the BHC, theNational Rural Health Association (NRHA), PAHO, and the Health Resources and ServicesAdministration (HRSA).Part IV: Present and discuss the binational health councils’ operational plans based on strategicplans presented in Workshop I 1 .Objectives and MethodologyWorkshop II objectives included the following:• Revisit and reaffirm the strategic priorities (Tier I and II) identified in Workshop I and directionof the binational health councils at the local and regional level, considering any recent structuralchanges (political and economic), current public health challenges (e.g., the H1N1 Pandemic),and alignment of priorities with the BHC, PAHO, the Border Governors Conference (BGC), andothers as appropriate.• Synthesize the results of all binational health councils’ operational plans into a borderwideoperational plan suitable for potential technical and financial support.The following methodology was used to develop the binational health councils’ (hereafter referred to bythe more commonly used Spanish acronym “COBINAS,” meaning Consejos Binacionales de Salud)operational plans:1 Workshop I took place in June 2008 in San Antonio, Texas, and was the first effort to enhance the organizationalcapacity of binational health councils and analyze strategic planning and actions for the U.S.-México border, withspecial emphasis on the need for more effective communication, coordination, and collaboration (the 3 Cs) amongthe COBINAS and with other state and federal public health agencies in the border region. To learn more aboutWorkshop I, refer to the proceedings report, available on the BHC webpage at www.borderhealth.org.3

• Focus activities on two priorities for the next three years (2010-2012) and develop an operationalwork plan, to include participation to the extent possible, in Border Binational Health Week(BBHW) as a means to communicate COBINAS’ project results and to further coordinatebinational activities.• Complete operational plans by—ooooCollectively defining the problem or situationDescribing the human, material, and financial resourcesMeasuring successCreating a timelineWelcoming RemarksDr. R. J. Dutton, Director, Office of Border Health, Texas Department of State Health Services (DSHS),provided welcoming remarks and explained the format structure of Workshop II.Dr. Elisa Aguilar Jiménez, Coordinator, BHC Chihuahua Outreach Office, also welcomed attendees andthanked the COBINAS for their effort in developing operational plans and participating in this workshop.In addition, she thanked the borderwide organizations for their attendance and support for the COBINASto develop their binational activities.Emma Torres, BHC Member-Arizona, and Clemente Villalpando Padilla, Executive Secretary, BHC-México Section, provided the sponsors’ welcome.Background on Binational Health CouncilsEstablishing COBINAS in cross-border jurisdictions along the U.S.-México border was first conceived in1963 at the U.S.-Mexico Border Health Association annual meeting in Nogales, Arizona. By 1975, sixCOBINAS were established as follows: 1) Lower Rio Grande (Brownsville, San Benito, McAllen, andEdinburg) and Matamoros / Reynosa; 2) Eagle Pass / Piedras Negras and Ciudad Acuña / Del Rio; 3)Ciudad Juárez / El Paso; 4) Agua Prieta / Naco / Cananea / Douglas / Tucson / Sierra Vista / FortHuachuca / Nogales / Nogales; 5) Imperial Valley / Mexicali; and 6) San Diego / Tijuana.Currently, 15 cross-border area sister cities organized COBINAS, identified as follows (from east towest):• Brownsville-Matamoros• Hidalgo County-Reynosa• Starr County-Miguel Alemán-Camargo(SMAC)• Laredo-Nuevo Laredo-Nuevo León• Eagle Pass-Piedras Negras-KickapooTraditional Tribe (HOPE-K)• Del Rio-Ciudad Acuña (AMISTAD)• Presidio-Ojinaga• El Paso-Ciudad Juárez-Las Cruces• Columbus-Luna County-Palomas• Nogales-Nogales (Ambos Nogales)• Cochise County-Northeast Sonora• Tohono O’odham-South Central PimaCounty-North Central Sonora• Yuma-San Luis Rio Colorado• Imperial County-Mexicali (underdevelopment)• San Diego/Tijuana (under development)4

AGE NDA DIS CUS S ION ITE MSReview of Available Local Data for Tier I PrioritiesThe U.S. Border ReportDr. Allison Banicki, Epidemiologist, Texas Office of Border Health, DSHS, reported on available data forTier 1 priorities (i.e., obesity, diabetes, and tuberculosis) for the U.S. border summarized as follows:Data are available at the national, state, and local (county) level for all three Tier 1 priority conditions.However, diabetes is of special concern throughout most of the U.S.-México border region. Amongborder counties, the highest diabetes mortality rates are in Maverick County, Texas. High diabetesprevalence rates are characteristic of many border counties. Even in areas where diabetes prevalence issimilar to or even below the national average, pockets with a disproportionate burden may exist. Forexample, the diabetes mortality rate for the American Indian population of Pima County, Arizona, is morethan three times the national rate.The prevalence of obesity in the United States has increased greatly since 1990. Obesity rates vary by agegroup and sex, and many border communities have disproportionately high rates of obesity. For example,adult obesity rates for 2007 were well above the national average in Webb and Hidalgo counties, Texas.National tuberculosis rates have declined since 2003 to a level of 4.2 per 100,000 in 2008. The bordercounties at the western and eastern ends of the border reported the highest border rates—from YumaCounty, Arizona, to San Diego County, California, in the west, as well as most of the Texas border east ofEl Paso County.Following Dr. Banicki’s report, participants discussed the contributing migration factors to the hightuberculosis rates in border states and counties.México Border ReportDr. Francisco Javier Navarro Gálvez, Epidemiologist for the Sonora Secretary of Health reported onavailable data for Tier 1 priorities for the México border summarized as follows:The diabetes mortality rates in México have increased from 2004 to 2008. Among the northern borderstates, Coahuila has the highest rates of mortality due to diabetes mellitus. Several border municipiosreported diabetes mortality rates well above the national average. From 2005 through 2007, Coahuila alsoreported the highest morbidity rates for diabetes mellitus, though figures for 2008 indicate that Chihuahuaexhibited the highest rates among the northern border states.The Encuesta Nacional Salud y Nutrición (ENSANUT) 2006 Survey, a national survey for children andadults, with results available at the state level, reported the most recent available overweight and diabetesdata. While the prevalence of obesity and overweight varied by age group and sex, the northern borderstates generally reported high rates. For example, the prevalence of overweight and obesity amongchildren 5-11 years of age was more than 30 percent in Baja California, Sonora, and Tamaulipas. Theprevalence of obesity among women 20 year and older was more than 75 percent in both Sonora andChihuahua.Mortality rates due to pulmonary tuberculosis were well above the national average in all northern borderstates except Coahuila. Baja California showed the highest rates in the country. From 2004 through 2008,the tuberculosis mortality rates increased more than 22 percent. Tuberculosis morbidity rates were also5

well above the national average for all northern border states except Coahuila. Baja California reportedthe highest morbidity rates among the northern border states from 2004 through 2008, followed byTamaulipas and Sonora. Many border municipios also reported tuberculosis morbidity rates well abovethe national average.Following Dr. Gálvez presentation, participants discussed local municipality-level data as a baseline andreference point for further discussion. Other Tier 1 condition indicators, such as the percentage of multidrugresistant (MDR) tuberculosis cases, included migration, prison population, and women in theworkforce.Update on Projects Related to Obesity, Diabetes, and TuberculosisTuberculosis, Diabetes, and Obesity on the Border: PAHO/WHO Technical CooperationDr. Maria Teresa Cerqueira, Chief, U.S.-Mexico Border Office, Pan American Health Organization(PAHO), provided an overview of the global tuberculosis situation. She stated that population dataindicate that the U.S.-México border states shoulder a disproportionate burden of tuberculosis cases ineach country, and U.S. counties that border México reported even higher rates than non-border counties.She identified that migration away from the interior of México is one of the main social determinants oftuberculosis on both sides of the border, and that to improve tuberculosis control along the border, socialdeterminants and health equity, with priority given to areas of high migration, also need to be improved.Dr. Cerqueira also summarized the PAHO-sponsored border study in diabetes and chronic disease riskfactors conducted in 2001-2002. She stated that results from this study were expected to be published in aspecial June 2010 issue of the Pan American Journal of Public Health.In addition, Dr. Cerqueira also provided an overview of the PAHO technical advisory group focused onexamining childhood obesity on the U.S.-México border.Following Dr. Cerqueira’s overview, border states and local communities discussed potential partneringopportunities with PAHO.Evidence on the Early Determinants of Chronic Disease, such as Diabetes and ObesityDr. Jill McDonald, Maternal and Child Health Epidemiology Assignee, National Center for ChronicDisease Prevention and Health Promotion, Centers for Disease Control and Prevention, presentedevidence of early chronic disease determinants summarized as follows:Evidence of early or fetal chronic disease determinants suggests opportunities for preventing problemssuch as obesity and diabetes. The Developmental Origin of Health and Disease model shows how earlylife factors, including both in utero and childhood experiences, may affect the occurrence ofnonommunicable diseases. Interventions during pregnancy or early childhood may help prevent obesity,diabetes, and other chronic diseases in adulthood.Following Dr. McDonald’s presentation, participants suggested several research and interventionopportunities such as examining the prevalence of overweight infants along the border and encouragingbreastfeeding.6

Update on Border Health Organizations’ Strategic and Operational PrioritiesBorder Governors Conference–Health Work TableRobert Guerrero, Chief, Office of Border Health, Arizona Department of Health Services, presented anoverview of the U.S.-Mexico Border Governors Conference Health Work Table and reviewed theapproved priority actions from the 2009 meeting in Monterrey, Nuevo León, as follows:• Request the BHC plan and conduct an annual U.S.-México binational infectious diseaseconference that brings together federal, state, and local partners to ensure better priorityalignment with the BHC.• Develop a multi-year comprehensive action plan to prevent childhood obesity along the U.S.-México border, in coordination with the Institute of Medicine and the National Institute of PublicHealth.• Request the México Secretary of Health and the U.S. Department of Health and Human Services(HHS) collaborate with state and local health authorities to establish a binational influenzasurveillance network encompassing the U.S.-México transborder region.• Continue to support and strengthen the Epidemiological Intelligence and Public HealthEmergencies Unit initiative for monitoring public health risks and threats for binational earlywarning.Border Legislative ConferenceMartha Castañeda, Director, Border Legislative Conference (BLC), Council of State Governments-West,provided an overview of the BLC organization and identified the following BLC committees: a healthcommittee, an economic development committee, an environmental committee, and an agricultural taskforce. She also identified the current co-chairs: U.S. Senator Denise Moreno Ducheny and MexicanRepresentative Ramiro Flores Morales (Coahuila).M. Castañeda noted that border health is one of the BLC’s top priorities and concluded by askingparticipants for suggestions on how the COBINAS can collaborate with their legislature on health issues.U.S.-México Border Health CommissionEmma Torres, BHC member-Arizona, and Clemente Villalpando, Executive Secretary, BHC-MéxicoSection, presented on how BHC priorities are aligned with most of the COBINAS’ priorities, especiallyTier 1, and identified the following BHC activities planned for 2010: tuberculosis (establish the U.S.-México TB Consortium; conduct the Binational TB Legal Issues Forum; sponsor the U.S.-México BorderModels of Excellence in Tuberculosis); diabetes/obesity (report on the U.S.-México status of diabetes;sponsor the U.S.-México Border Models of Excellence in Childhood Obesity); and conduct the FirstAnnual U.S.-México Binational Infectious Disease Conference. Other BHC priorities identified includedstrategic planning, access to care (sponsor the National Infant Immunization Week/Vaccination Week inthe Americas and Border Binational Health Week); and research, data collection, and academic alliances(conduct the Leaders across Borders leadership training program).National Rural Health AssociationGabriela Boscan, Program Services Manager, National Rural Health Association (NRHA), provided anoverview of NRHA and identified over 20,000 members.7

G. Boscan also provided an overview of the NRHA border health initiative, a four-year strategy focusedon rural health advocacy. This initiative, inaugurated in 2008, highlights best practices and policyrecommendations at the national level.Pan American Health OrganizationDr. Maria Teresa Cerqueira, Chief, U.S.-Mexico Border Office-PAHO, Regional Office of the WorldHealth Organization (WHO) presented on the U.S.-Mexico Border Technical Cooperation Strategies andthe PAHO-U.S.-Mexico Border Office 2010-2011 Biennial Work Plan, which included the following: 1)health analysis and surveillance for disease prevention and control; 2) family and community healthpromotion activities; 3) chronic disease prevention; 4) environmental health and sustainable development;5) knowledge management, communication, and research; and 6) building alliances for a healthier border.Dr. Cerqueira also identified the following current PAHO action items:• Congenital syphilis elimination and vertical transmission of STDs and HIV prevention programs• Health analysis and information systems to improve diagnostic and evaluation capacity, disasterpreparedness, violence, and injury prevention• Tobacco control and diabetes prevention programs• Center of Excellence to prevent chronic diseases• Chamizal El Paso obesity prevention with children and youth• Knowledge management, communication, and research• Alliance building with health entities, academia, philanthropic organizations, the community, andfederal and state government agenciesU.S. Health Resources and Services AdministrationFrank Cantu, Field Director, Office of Rural Health Policy, Border Health Division, Health Resources andServices Administration (HRSA), presented on the U.S.-approved health reform legislation and theopportunities for increasing rural health funding. He stated that border health is a priority for HRSA andits present involvement continues to increase supporting programs such as community health centers,migrant health centers, HIV-AIDS, homeless programs, maternal and child health, etc., reachingunderserved areas in the border.F. Cantu concluded by advising the COBINAS to take advantage of the recovery act and stimulus fundingand keep federal agencies, like HRSA, aware of the needs of the border.Binational Health Council PresentationsBrownsville / MatamorosCo-President Art Rodríguez, Public Health Director, City of Brownsville, and Leticia P. Harris,Matamoros Secretariat of Health, Tamaulipas Health Services, and representative for Co-President Dr.José Luis Robles López, presented the Brownsville/Matamoros COBINA operational plan. The planfocused on four priorities: obesity, dengue fever, tuberculosis, and HIV/AIDS. They identified that otherexisting programs require more resources for sustainment and expansion; however, current capacity fortuberculosis and dengue is sufficient.8

In response to unavailable epidemiological data on obesity prevalence in the border region, and nobinational prevention strategy, the Brownsville/Matamoros COBINA proposed a three-year pilot projectfocused on developing a prevalence of obesity study for the border region, as well as developingintervention activities in two schools per city, to include an assessment conducted at the end of the thirdyear. To develop this intervention, $ 11,000 was requested.In addition, a proposal was also presented to host the 2010 Border Binational Health Week (BBHW)inaugural events with a requested budget of $30,000.The total budget requested for both activities was $41,000.Hidalgo / ReynosaEduardo Olivarez, Chief Administrative Officer, Hidalgo County Health and Human Services, in HidalgoCounty, Texas, and Dr. Mario Alfonso Sáenz Salinas, Chief, Sanitary Jurisdiction IV, Reynosa Secretariatof Health de Salud in Reynosa, Tamaulipas, presented the Hidalgo/Reynosa COBINA three-yearoperational plan.The Hidalgo/Reynosa COBINA identified that 29 percent of the adult population is obese in HidalgoCounty and approximately only 10 percent of county residents are aware they have diabetes; in Reynosa,the prevalence of overweight and obesity in children 5-11 years is 39.7 percent.In response to these statistics, the Hidalgo/Reynosa COBINA developed a three-year pilot project to helpreduce obesity in two Reynosa elementary schools with the following milestones: the first year—developa survey examining the prevalence of overweight and obesity in school children ages 6-8 years; thesecond year—implement a project intervention with parent, teacher, student, and media participation; thethird year—develop an assessment.The total budget requested, including expenses for 2010 BBHW, was $15,340.SMAC (Starr County / Miguel Alemán / Camargo)Co-President Dr. Carmen Alice Peña Morales, City of Camargo Health Center, Health Jurisdiction V,Tamaulipas, México’s Secretariat of Health, and representative Edith DeLafuente, Program Specialist,Texas DSHS, Health Services Region 11, presented the Starr County-Miguel Alemán-Camargo COBINAoperational plan.In response to unavailable information regarding the incidence of obesity in school children ages 6-9, theSMAC COBINA developed an operational plan with the following milestones: the first year—develop asurvey for elementary school populations in three municipalities covered by the SMAC COBINA; thesecond year—develop a pilot project aimed to reduce obesity in 5 percent of participating studentsdiagnosed as obese based on survey results; the third year—assess the survey results and identifysuggestions for improvement.The total budget requested was $14,750.TNT (Laredo / Nuevo Laredo / Nuevo León)Co-Presidents Dr. Héctor F. González, Health Director, City of Laredo Health Department, and Dr. JaimeEmilio Gutiérrez Serrano, Chief, Sanitary Jurisdiction V, México’s Secretariat of Health, and Nuevo LeónRepresentative Dr. Abelardo García, Coordinator, BHC Outreach Office, presented the TNT COBINAoperational plan.9

In response to unavailable epidemiological data on the obesity prevalence of children ages 2 to 18 livingin the border region, the TNT COBINA identified the following milestones which focused onoverweight/obesity and nutrition: the first year—develop and integrate a database as well as datacollection and analysis for presentation to school directors participating in intervention activities, parents,and community leaders; the second year—develop a health promotion campaign focused on increasedphysical activity and healthier eating habits, followed by another collection of data; the third year—collect and analyze final data and develop recommendations for policy change.For BBHW, the TNT COBINA identified the following proposed activites—• Provide an obesity progress update• Provide glucose screenings• Develop a proclamation focused on obesity prevention and tuberculosis awareness• Conduct other health promotion activities such as flu vaccines and HIV screeningsThe total budget requested was $38,000.HOPE-K (Eagle Pass / Piedras Negras / Kickapoo Traditional Tribe) and AMISTAD (DelRio / Ciudad Acuña)Representative Kassie Rogers, Regional Manager, Texas DSHS, Public Health Region 8, presented theHOPE-K operational plan, and Co-President Héctor M. Guerra, Regional Coordinator, Office of BorderAffairs, Texas Health and Human Services Commission, presented the HOPE-K and AMISTADCOBINAS’ operational plan.The HOPE-K and AMISTAD COBINAS identified managing their own funds to strengthen theirorganizational capacity as a top priority, followed by obesity and diabetes prevention and tuberculosis.Tier II priorities included substance abuse, environmental health and dengue, and early warning infectiousdisease surveillance.To help reduce the high obesity and overweight percentage, as well as diabetes mortality, the COBINAS’activities focused on raising environmental awareness to facilitate increased physical activity, promotingimportance of proper nutrition, and increasing cancer and diabetes awareness and treatment.Both COBINAS also proposed developing binational activities and training sessions to support the newTB binational program.Regarding mental health and substance abuse, HOPE-K proposed developing a binational youthconference on addiction prevention and family violence, and AMISTAD proposed hosting the SeventhAnnual Binational Youth Conference on Addiction Prevention.The HOPE-K and AMISTAD COBINAS’ operational plans also included the Binational Conference onInfectious Diseases in November 2010. For environmental health and dengue, HOPE-K proposedsupporting the Kickapoo Ecological Club, meetings, and local border 2012 program activities, to includethe recycling event in Piedras Negras. AMISTAD proposed supporting the “Patio Limpio” program inCiudad Acuña and possibly in Del Rio. Continued support was also proposed for the Del Rio elementaryschool program “Henry the Hand" and possibly in Ciudad Acuña as well.The total budget requested was $48,000.10

Presidio / OjinagaOjinaga Co-President Dr. Manuel Jesús Acosta Muñóz, Chief, Sanitary Jurisdiction III, and NancyOlvera, Presidio Representative for Co-President Judge Jerry Agan, presented the Presidio/OjinagaCOBINA operational plan.The Presidio/Ojinaga COBINA identified focusing activities on obesity and diabetes to promote alliancesbetween the Presidio/Ojinaga public health sectors and awareness of educational methods targetingfamilies and health sector personnel.Objectives identified were as follows:• Establish Presidio/Ojinaga public health sector relationships and encourage Presidio/Ojinagacommunity leader involvement• Increase health sector staff capacity and cultural competency of family dynamics• Employ appropriate binational interventions to promote healthy lifestylesProposed activities included improving communication and continuing participation with health sectorleaders; establishing a binational diabetes/obesity committee to complete at least three culturalcompetencies and family dynamics training courses for health sector personnel; and adopting a binationaldiabetes/obesity curriculum for all participating sectors.The total budget requested was $110,000.El Paso / Ciudad Juárez / Las CrucesCo-Presidents Dr. Héctor Puertas Rincones, Director, Sanitary Jurisdiction II, Chihuahua Health Services;Angie Sánchez Corral, Community Development Coordinator, Office of Border Health, New MexicoDepartment of Health; and Bea Martínez, EWIDS Coordinator, Office of Border Health, TexasDepartment of State Health Services, presented the El Paso/Ciudad Juárez/Las Cruces COBINAoperational plan.The El Paso/Ciudad Juárez/Las Cruces COBINA operational plan focused on obesity and diabetesprevention and tuberculosis. Obesity and diabetes activities included promoting healthier habits,increasing community awareness, and creating safer environments for physical activity.The total budget requested was $606,400.Tuberculosis activities included increasing health promotion, improving treatment adherence, andimproving communication with the U.S. Immigration and Customs Enforcement officials to follow upwith binational and foreign-born patients.Proposed actions included participating in field activities organized by the Ciudad Juárez TuberculosisProgram and Project JUNTOS (a binational TB project); participating in health events, fairs, workshops,and conferences; and producing informative tuberculosis posters and its comorbidities for all physician,clinic, and hospital distribution.11

Columbus / Luna County / PalomasCo-Presidents Dr. Rafael Magaña, Epidemiologist, Sanitary Jurisdiction V, Nuevo Casas Grandes,Chihuahua, and Kathryn Ritterbusch, Administrator, Presbyterian Medical Services in Deming, NewMexico, presented the Columbus/Luna County/Palomas COBINA operational plan.Obesity/diabetes, tuberculosis, as well as substance abuse and teen pregnancy, were identified as priorityareas for the region.The Columbus/Luna County/Palomas COBINA identified the lack of physical activities and nutritioneducation in schools, as well as the lack of certified diabetes educators as the most important issues. Toaddress these issues, this COBINA proposed continuing to work with local schools to create a curriculumthat offers more outdoor physical activities, nutrition education, and films promoting obesity and diabetesawareness to schools and community health centers, as well as local organizations and agencies inColumbus-Luna County and Palomas, increasing the number of classes and support groups for WICclients with diabetes, and hiring certified diabetes educators.The total budget requested was $381,000.Another issue identified was tracking tuberculosis patients, most of whom are Mexican immigrants, forfollow-up treatment. To address this issue, activities proposed included improving binational patientinformation flow, increasing active case findings among the migrant population, increasing treatmentadherence efforts and patient follow up, as well as coordinating actions for crossing samples.The Columbus/Luna County/Palomas COBINA also identified substance abuse and teen pregnancy asimportant issues, noting that currently, 36 percent of pregnant teens in Luna County use alcohol, tobacco,and illicit or prescription drugs. In addition, limited recreational opportunities exist for youth.The total budget requested was $258,000.Northeast Sonora / Cochise CountyCo-Presidents Susie B. Peru, Border Binational Health Program Coordinator, Cochise County HealthDepartment, and Dr. Gerardo Benavides Duarte, Director, Hospital General in Agua Prieta, Sonora,presented the Northeast Sonora and Cochise County COBINA operational plan.Priorities identified were diabetes and obesity, EWIDS, and teen pregnancy.Proposed activities included establishing obesity/diabetes prevention programs/campaigns and increasingpublic awareness/education for diabetic and obese adolescents with funding provided by the ArizonaDepartment of Health Services.The Northeast Sonora/Cochise County COBINA also proposed establishing protocols for quality andtimely local bilateral information exchange regarding EWIDS. For teen pregnancy prevention, the planincluded developing an information media campaign to include programs like the “Teen Maze” duringBorder Binational Health Week.The total budget requested was $3,000.12

Ambos NogalesCo-Presidents, Jesus Kataura, M.B.A., Santa Cruz Council on Aging, Nogales, Arizona, and Dr. JoséSalvador Mercado Gutiérrez, Director of the Center for Urban Health of Nogales, Sonora, presented theAmbos Nogales COBINA operational plan.Priorities identified were diabetes, obesity, and hypertension; infectious disease surveillance; and teenpregnancy.Proposed activities included a Type II diabetes conference; a marathon during BBHW; the “TakingControl of Your Health” course; a medical service provider workshop organized by the EpidemiologySurveillance Sub-Committee; and teen pregnancy prevention workshops, such as the “Teen Maze.”The total budget requested was $19, 000.Peñasco / Sonoyta / Tohono O’odham NationCo-Presidents Andrew Lorentine, Assistant Manager, Community Health Division, Tohono O’odhamNation Department of Health and Human Services; Dr. Daniel Esquivel, Director, Hospital Integra; andDr. Naomi Valdés Castolo, Director, Health Center of Puerto Peñasco, assisted by Sara Gonzalez,COBINA member, presented the Peñasco/Sonoyta/Tohono O’odham Nation COBINA operational plan.The Peñasco /Sonoyta/Tohono O’odham Nation COBINA identified obesity and diabetes in the firstpriority group and infectious diseases emergency response in the second.This COBINA proposed evaluating a group of 20 patients with diabetes mellitus, who are also obese, tohelp improve lifestyle choices and also raise diabetes awareness, using resources from BBHW, the SonoraHealth Department, the Tohono O’odham Nation, and the Arizona Office of Border Health.Yuma County / San Luis Río ColoradoCo-Presidents Dr. Sergio Kelly Baraza, Director, San Luis Río Colorado General Hospital, and Dr. JoséL. Muñóz, Medical Director, St. Louis Walk-in Clinic, San Luis, Arizona, presented the Yuma County/San Luis Rio Colorado COBINA operational plan.Priorities identified were obesity, diabetes, tuberculosis, and adolescent health.Proposed objectives/activities included the following: increase awareness about obesity, nutrition, andphysical activity in children and adults, such as an Arizona Healthy Food initiative; promote diabetesmanagement educational activities; promote promotores tuberculosis training activities on tuberculosistreatment adherence and continuity; and facilitate the Teen Maze training.The total budget requested was $8,000.Baja California / CaliforniaThe BHC California Outreach Office requested Project Concern International (PCI) and the HealthInitiative of the Americas (HIA) identify health priorities in the San Diego-Tijuana and Imperial-Mexicaliregions, assess the interest level in reactivating both COBINAS, and obtaining recommendations on howthe BHC should support these efforts.13

Dr. Blanca Lomelí, Regional Director for North America, PCI, presented the results, together with Dr.Maria Remedios Lozada, HIV/AIDS and STD’s Coordinator, Institute of Health Services (ISESALUD)of Mexicali, Baja California. The survey was followed by two strategic meetings organized by PCI inTijuana and another in San Diego, three interviews (two in Mexicali and one in Imperial) with keyinformants, and a final binational meeting by HIA.The survey was provided to 46 participants, mostly to governmental and non-governmental or non-profitorganization officials. The most important public health issues identified at the California/Baja Californiaborder were obesity and diabetes, followed closely by infectious diseases such as tuberculosis andHIV/AIDS.The most important findings were identified as follows:• COBINAS in California and Baja California were active in the recent past, and interest still existsin reactivating them.• Challenges identified included extensive time spent crossing the border, activities dependentlargely on voluntary support, frequent changes in leadership, and little or no economic support.• Community interest exists in learning the COBINAS role and impact, to include leadershipopportunities.• Interest exists in the BHC facilitating communication and providing connections to fundingopportunities and logistical support; however, there was no interest in the BHC defining healthpriorities or COBINA activities.S UMMAR Y OF PR IOR ITY ISSUES AND OBJECTIVESThe majority of the COBINAS in Workshop II reaffirmed the priorities identified in Workshop I andchose to work primarily with Tier I priorities, i.e., overweight/obesity, diabetes, and tuberculosis. Tier IIpriorities were also included in several COBINAS’ operational plans. Of these, the three most frequentlyidentified priorities were EWIDS, family violence in connection with mental health and substance abuse,and teen pregnancy, especially in the Arizona/Sonora border region.Table 1 presents the consolidated list of COBINA priorities.14

Table 1 – Consolidated List of Identified COBINA Priority AreasIssue Total Baja CaliforniaCaliforniaObesity/NutritionDiabetesTuberculosisEWIDS/EpidemiologicSurveillanceYumaSL RíoColoradoPeñascoSonoytaTohonoO’dhamNortheastSonoraCochiseCountyColumbusLunaPalomasEl PasoJuárezLasCrucesPresidioOjinagaAmistad HOPE-K TNT SMAC HidalgoReynosa11 X X X X X X X X X X X6 X X X X X X6 X X X X X X4 X X X XBrownsvilleMatamorosDengue FeverStrengthen localCOBINASCapacityHIV/AIDS/STDsMentalHealth/SubstanceAbuse/DomesticViolenceTeen PregnancyTeen HealthOther3 X X X2 X X2 X X2 X X2 X X1 X015

S UMMAR Y OF R E C OMME NDATIONS AND NEXT STEPSThe COBINAS presented three-year plans with individual project costs, working primarily withTier I priorities (overweight/obesity, diabetes, and tuberculosis). Tier II priorities were alsoincluded in selected operational plans, with the three most frequently identified being EWIDS,family violence in connection with mental health and substance abuse, and teen pregnancy,especially in the Arizona/Sonora border region.Recommendations and agreements included the following:• The COBINAS are at different stages and levels as a local binational health group ofsister cities and/or county/health jurisdictions.• The COBINAS claim their autonomy as local binational public health organizations butalso recognize that common needs or strategic priorities can be shared by COBINASregionally or even borderwide and proposed the following basic guiding principles:ooooWhen developing activities, focus primarily on disease prevention.Jointly propose recommended changes in public health policies.Search for technical and financial resources as one group, avoiding competitionamong COBINAS for the same scarce resources.Recognize the importance of the 3Cs (communication, coordination, andcollaboration) among the COBINAS and with federal, state, and local healthauthorities.• The COBINAS develop an alliance.• The Binational Health Councils’ Strategic Planning Workshop should occur annually toupdate and evaluate their strategic and operational plans.16

AP PENDICESAppendix A: AgendaAGENDAWorkshop II – Operational PlanningUS-Mexico Binational Health Councils (COBINAS)Wyndham HotelEl Paso, Texas – April 19-20, 2010Workshop II Objectives:The results of all COBINAS operational (“vertical”) plans presentations will be synthesized into a border-wideoperational plan that lends itself to technical and financial support to be provided by state and federal healthauthorities (“horizontal”) of both the U.S. and Mexico. These efforts will be facilitated through communication,coordination, and collaboration (the 3 C’s) between the entities that have a mandate to address public healthissues and policies impacting the people of the US-Mexico border region.Day 17:30 – 8:30 Registration8:30 – 8:45Monday, April 19Inauguration and Opening RemarksDr. Ronald J. Dutton (Director, Office of Border Health, Texas Department of State HealthServices-DSHS), and Dra. Elisa Aguilar Jiménez (Coordinator Chihuahua Outreach Office,USMBHC)8:45 – 9:00 Sponsors Welcome – U. S.-Mexico Border Health Commission (USMBHC)Emma Torres, MSW (Arizona Commission Member), and Lic. Clemente Villalpando(Executive Secretary, México Section, USMBHC)9:00 – 9:15 Introductions9:15 – 9:30 Workshop I and Purpose of Workshop IIPaul Dulin, MA (Director, Office of Border Health, New Mexico Department of Health)9:30 -10:0010:00 -10:30Review of Available Local Data (border states, counties and municipios) for Tier IPriorities (obesity, diabetes, and tuberculosis)A. US Border Report:Dr. Allison Banicki (Epidemiologist, Office of Border Health, DSHS)B. Mexico Border Report:Dr. Francisco Javier Navarro Galvéz (Epidemiólogo Estatal, Secretaría de Salud deSonora)10:30 – 10:45 Break10:45 – 11:1011:10 – 11:30Update on Projects Related to Obesity, Diabetes and TuberculosisA. TB, diabetes and obesity in the border: Technical cooperation of PAHO/WHODr. Maria Teresa Cerqueira (Chief, U.S.-Mexico Border Office, Pan-American HealthOrganization-PAHO)B. TB, diabetes and obesity in the border: Technical cooperation of PAHO/WHODr. Maria Teresa Cerqueira (Chief, U.S.-Mexico Border Office, Pan-American HealthOrganization-PAHO)A-1

11:30 – 11:4511:45 – 12:00Update on Strategic and Operational Priorities of “Horizontal” OrganizationsA. Border Governors Conference – Health TableRobert Guerrero MBA ( Chief, Office of Border Health, Arizona Department of HealthServices)B. Border Legislative Conference (invited)Martha Castañeda, Director, Border Legislative Conference, Council of StateGovernments-WEST12:00 – 1:30 Lunch1:30 – 2:002:00 – 2:152:15 – 2:302:30 – 2:45Continued…Update on Strategic and Operational Priorities of “Horizontal”OrganizationsC. U.S.-México Border Health Commission (USMBHC)Emma Torres, MSW (Arizona Commission Member), and Lic. Clemente Villalpando(Executive Secretary, Mexico Section, USMBHC)D. National Rural Health Association (NRHA)Gabriela Boscan, MPH (Manager, Program Services, NHRA)E. Pan American Health Organization (PAHO/WHO)Dr. Maria Teresa Cerqueira (Chief, U.S.-Mexico Border Office, PAHO)F. U.S. DHHS Health Resources and Services Administration (HRSA)Mr. Frank Cantú (Field Director, Office of Rural Health Policy, Border Health ProgramHRSA)2:45 – 2:55 Break2:55 – 3:00 COBINAS (“Vertical”) Presentations – Review of MethodologyDr. Ronald J. Dutton / Dra. Elisa Aguilar Jiménez3:00 – 3:20 Brownsville / MatamorosArturo Rodríguez, MPH, and Dr. José Luis Robles López3:20 – 3:40 Hidalgo / ReynosaMr. Eduardo (Eddie) Olivares and Dr. Mario Alfonso Sáenz3:40 – 4:00 SMAC – Starr County / Miguel Alemán / CamargoDr. Juan Joel Barrientos Duque4:00 – 4:10 Break4:10 – 4:30 Laredo / Nuevo Laredo / Nuevo LeónDr. Héctor F. González, Dr. Jaime Emilio Gutiérrez Serrano, and Dr. Abelardo García4:30 – 4:50 HOPE-K – Eagle Pass / Piedras Negras / Kickapoo Traditional TribeLic. Calixto Seca, Dr. Arturo Botello Méndez, and Ms. Martha Salazar4:50 – 5:10 AMISTAD – Del Rio / Cd. AcuñaMr. Héctor Mario Guerra and Dr. Herbey Faz Rios5:10 – 5:30 Conclusion of Day 1 – DiscussionA-2

Appendix B: Bilingual List of Border Health OrganizationsEnglishSpanishBinational Health CouncilsConsejos Binacionales de Salud (COBINAS)Border Governors Conference (BGC)Conferencia de Gobernadores Fronterizos (CGF)Border Legislative Conference (BLC)Conferencia Legislativa FronterizaDepartment of State Health Services (DSHS)Departamento Estatal de Servicios de SaludNational Rural Health Association (NRHA)Asociación Nacional de Salud RuralOffice of Border Health (OBH)Oficina de Salud FronterizaPan American Health Organization (PAHO)Organización Panamericana de la Salud (OPS)Health Resources and Services Administration(HRSA), Border Health ProgramAdministración de Recursos y Servicios de Salud(HRSA), Programa de Salud FronterizaU.S.-México Border Health Commission (BHC)Comisión de Salud Fronteriza México- (CSF)BHC Outreach Office (ORO)Oficinas de Alcance de la CSFB-1

Appendix C: Map of U.S.–México Border COBINAS and Sister CitiesC-1

Appendix D: List of Invitees and Participants, Binational Health Councils’Strategic Planning Workshop IIInvitedName 4/19/10 4/20/101 Acosta Miuñóz, Dr. Jesús Manuel X X2 Acosta, Luis Mauricio X X3 Agan, Hon. Jerry4 Aguilar, Dra. Elisa X X5 Ambriz Irigoyen, Lorely X X6 Baena, Javier X X7 Baker, Duiona X X8 Banicki, Dr. Allison X X9 Barajas Keeler, Veronica X X10 Barrientos Duque, Dr. Juan Joel11 Benavides, Gerardo X X12 Botello-Méndez, Dr. Arturo13 Boscan, Gabriela X X14 Cano-Hays, Rosalinda X X15 Cantú, Frank X X16 Castro Gutiérrez, Liz X X17 Cerqueira, Dra. Maria Teresa X X18 Corona, Adriana X X19 DeLafuente, Edith X X20 Deckert, Myrna X X21 Díaz Garza, Umbert X X22 Doria, Dra. Gloria Leticia X X23 Dulin, Paul X X24 Dutton, Dr. R.J. X X25 Emrick, Gail E.26 Esquivel, Daniel X X27 Faz-Rios, Dr. Herbey28 Flores Durazo, Manuel Guillermo29 Gerónimo Castañón, Trinidad30 Gaines, Araceli X X31 Garcia Cantú, Dr. Abelardo X X32 González, Dr. Héctor X X33 González, Sara X X34 Guerra, Héctor Mario X X35 Guerrero, Robert X X36 Gutiérrez, Jaime Emilio X X37 Gutiérrez, Lizeth X X38 Harris, Leticia P. X X39 Hernández Rodríguez, Jorge Sebastián X X40 Herrera, Dyanne X X41 Hill, Michael X X42 Holguín, Mario X X43 Iturralde, Gustavo X XD-1

InvitedName 04/19/10 04/20/1044 Jiménez, Ricardo X X45 Kataura, Jesús X X46 Kelly G., Sergio X X47 Kline, Dr. Larry X X48 Kork, Marcelo X X49 Leiva, Mauricio X X50 Lomeli, Blanca X X51 López, Waldo X X52 Lorentine, Andrew X X53 Lozada, María Remedios X X54 Lozano, Claudia X X55 Magaña, Rafael X X56 Martin, Lisa X X57 Martínez, Bea X X58 Martínez, Kathie X X59 Mata, Lupita X X60 Maya, Ben X X61 McDonald, Jill X X62 Mercado, José Salvador X X63 Moreira, José X X64 Muñóz, José L. M.D. X X65 Navarrete, Lorraine X X66 Muñóz, José L. M.D. X X67 Navarrete, Lorraine X X68 Navarro, Francisco Javier X X69 Olivarez, Eddie X X70 Olvera, Nancy X X71 Palafox, Noé X X72 Peña, Carmen Alicia X X73 Perez Ortiz, Fermin X X74 Peru, Susan B. X X75 Plascencia, Lizette X X76 Puertas, Héctor X X77 Rangel Gómez, María Gudelia X X78 Reyna, Dan X X79 Ritterbusch, Kathryn X X80 Robles López, José Luis81 Rodríguez, Arturo X X82 Rogers, Kassie X X83 Salazar, Martha84 Sánchez Corral, Angie X X85 Seca, Calixto X X86 Southern, Luanne X X87 Suarez, Roberto X X88 Torres, Emma X X89 Villalpando Padilla, Clemente X X90 White, Sarah C. X XD-2

Appendix E: Glossary of U.S.–México Border Health OrganizationsBinational Health CouncilsThe binational health councils (more commonly referred do as COBINAS, the Spanish acronymfor Consejos Binacionales de Salud ) examine health needs, problems, and available programswith particular attention and concern to the council's geographical area and consider how itsmembers can promote joint actions in common benefit to the population of both sides of theborder.Currently, there are 15 COBINAS along the U.S.-México border, each generally correspondingwith their respective sister city combinations or border regions. The COBINAS typically meet ona regular schedule, usually rotating locations between the United States and México. Dependingupon the COBINA, meetings generally involve presentations of one or more speakers on aparticular topic (e.g., HIV/AIDS, tuberculosis, diabetes) or report on planned activities andupcoming events.The structure of each COBINA can vary, and in some cases within the same COBINA from yearto year depending on the membership makeup. The COBINAS are coordinated by the copresidentseither representing the health authority in each jurisdiction or elected by the COBINASmembership.U.S.-Mexico Border Governors Conference – Health Work TableThe BGC Health Work Table was created as a means of formalizing borderwide communicationamong the ten U.S. and México border states. Generally, a conference is held each year,alternating locations between the United States and México. Since 1980, the organization hasenhanced joint border efforts addressing agriculture, border crossings, education, economicdevelopment, energy, environment, health, tourism, and border security issues. Officialrecommendations focusing on these issues are presented in the form of a Joint Declaration, whichis signed by each of the ten participating governors at each conference.Pan American Health Organization – U.S.-Mexico Border OfficeEstablished in 1942, the Pan American Health Organization continues to facilitate and promoteborder collaboration with public and private binational institutions and entities involved inimproving the health and population at the border. The U.S.-Mexico Border Office developstechnical cooperation in close alliance with strategic institutions that also have a mandate acrossthe border, such as the United States-México Border Health Commission, the Border GovernorsConference, as well as other academic and research institutions and non-governmentalorganizations.U.S.-México Border Health CommissionThe U.S.-México Border Health Commission (BHC) is a binational health commission created toprovide international leadership to optimize health and quality of life along the U.S.-Méxicoborder. The BHC is comprised of the federal secretaries of health, the chief health officers of theten border-states and prominent community health professionals from both nations. The BHC hasthe unique opportunity to bring together the two countries and its border states to solve borderhealth problems and provides the necessary leadership to develop coordinated and binationalactions that can improve the health and quality of life of border residents.E-1

The BHC has 10 outreach offices (OROs) which are strategically located along the border in eachof the four U.S. and six Mexican states and serve as a binational resource for border communitiesin terms of binational public health activities, information dissemination, and critical links toother public and private partners, including promotores and related organizations. The U.S. andMéxico OROs are directly integrated with their respective state departments of health and otherpublic and private partners. In the United States, they operate under the auspices of the stateoffices of border health. The overall role of the OROs is to support and extend the BHC’s work atthe border.E-2

United States-MéxicoBorder Health Commission211 N. Florence, Suite 101El Paso, TX 79901Tel: (915) 532-1006Fax: (915) 532-1697Toll Free (866) 785-9867www.borderhealth.orgComisión de Salud FronterizaMéxico-Estados UnidosAvenida Durango No. 247, 4o pisoCol. Roma Norte, DelegaciónCuauhtémocC.P. 06700 México, D.F.Tel./Fax (01152-55) 3611-0765www.saludfronteriza.org.mx