United States-Mexico 

Border Health Commission

B order Lives

Health Status in the United States- B 

MExico Border Region 

order Lives

Health Status in the 

United States-Mexico Border Region 
The mission of the United States-Mexico Border Health 

Commission (BHC) is to provide international leadershp to 

optmize health and quality of life along the 

United States-Mexico border.

Providing Leadership on Border Health Issues to—

Facilitate Identification, Study, and Research

Be a Catalyst to Raise Awareness

Promote Sustainable Partnerships for Action

Serve as an Information Portal

April 2010 

Note: This report contains information and data applicable only to the U.S. border area.
 

B order Lives

Health Status in the 

United States-Mexico Border Region 

United States-Mexico Border Health Commission

Editor’s note: The information, data, and views published in this report represent the work of 

the contributing authors and do not necessarily reflect those of the United States-Mexico Border 

Health Commission or the organizations whose contributors have made this report possible. 

The United States-Mexico border region is a unique and dynamic area 

where various cultures come together and interrelate across geopolitical 

boundaries. Though the residents may possess different economies and 

politics, they share a common culture, language, environment, and 

health disparities.

 —Border Health Research, National Latino 

 Research Center, 2004

 

 Contributers 

III 

Executive Summary..........................................................1

Contributors....................................................................3

Acknowledgements..........................................................9

Introduction...................................................................11

Chapter 1: The U.S. Population at the Border................27 

Chapter 2: The Healthcare Workforce............................51 

Chapter 3: Access To and Use of Health Care.................71

Chapter 4: Maternal, Infant, and Child Health.............109 

Chapter 5: Communicable Diseases..............................149

Chapter 6: Breast and Cervical Cancer..........................197

Chapter 7: Diabetes......................................................223

Chapter 8: Heart Disease and Stroke............................247 

Chapter 9: Injuries.......................................................273

Chapter 10: Mental Health..........................................301

Conclusion...................................................................319

Appendices...................................................................323

Further Reading...........................................................359

Table of Contents

iii 
ARIZONA

1. Cochise

2. Pima

3. Santa Cruz

4. Yuma

CALIFORNIA

1. Imperial 

2. San Diego

NEW MEXICO

1. Doña Ana

2. Grant

3. Hidalgo

4. Luna

5. Otero

6. Sierra

TEXAS

1. Brewster

2. Brooks 

3. Cameron

4. Crockett

5. Culberson

6. Dimmit

7. Duval

8. Edwards

9. El Paso

10. Frio

11. Hidalgo 

12. Hudspeth

13. Jeff Davis 

14. Jim Hogg 

15. Kenedy

16. Kinney

17. La Salle 

18. Maverick

19. McMullen

20. Pecos

21. Presidio

Border Area: Defined in P.L. 103-400 (22 U.S. Code, 290 n-5) and the La Paz Agreement of 

1983, as the area 100 kilometers (62 miles) north and south of the United States-Mexican border. 

This area includes 80 municipios in 6 Mexican States and 48 counties in 4 U.S. states. For the 

purposes of the Healthy Border 2010 initiative, the border definition is limited only to the 44 

U.S. border counties, excluding Maricopa, Pinal, and La Paz in Arizona and Riverside County in 

California. The terms “area” and “region” are used interchangeably. 

Border States: In the U.S. the states are Arizona, California, New Mexico, and Texas. In Mexico, 

the states are Baja California Norte, Chihuahua, Coahuila, Nuevo León, Sonora, and Tamaulipas.

22. Real

23. Reeves

24. Starr

25. Sutton

26. Terrell

27. Uvalde

28. Val Verde

29. Webb

30. Willacy

31. Zapata

32. Zavala

United States-Mexico Border Health Commission

Study Area

 iv 
1 

EXECUTIVE SUMMARY 

This report provides an overview of key health indicators affecting U.S. 

residents living in the U.S.-Mexico border region. The report uses the 

definition of the border region adopted by the U.S.-Mexico Border 

Health Commission, which designates the U.S. portion of the border region as 

the area extending 100 kilometers (62 miles) north of the U.S.-Mexico border. 

Because most health, demographic, and economic information is available on 

a county basis, the U.S. border area is defined to include 44 counties that are 

entirely or partly within the 62-mile zone in the four border states of California, 

Arizona, Texas, and New Mexico.

In 2003, the U.S.-Mexico Border Health Commission published Healthy Border 

2010: An Agenda for Improving Health on the U.S.-Mexico Border. That report was 

developed to identify key border health issues and to introduce Healthy Border 

2010. Those key issues are addressed in this document, with a focus on the specific 

objectives of Healthy Border 2010.

Data presented in this document provide critical information for the use of 

policy makers, public health professionals, researchers, community members, 

and all others working to improve the health of border residents. Health and 

related data from a wide range of sources were used as the basis for each chapter’s 

focus on a major challenge to the health of the border population. The datacentric approach of this report makes it the most comprehensive report available 

on the health status of U.S. border residents.

Key Findings

As data for this report were examined, several key themes emerged. Many of 

these themes cut across all chapters in this report, suggesting that achievement 

of Healthy Border 2010 objectives will require an integrated, systems-level 

approach. These themes are as follows:
Border Lives: Health Status in the United States-Mexico Border Region

2

•	 Despite high poverty rates, complex barriers to accessing health care, 

multiple socioeconomic, cultural, and environmental challenges, and a 

complex political and regulatory environment, the border population fares 

surprisingly well on several leading health indicators, including maternal, 

infant, and child health and heart disease and stroke. However, the border 

population is disproportionately affected by diabetes mellitus, cervical 

cancer, certain communicable diseases including tuberculosis, and certain 

unintentional injuries including unintentional poisonings.

•	 The rapid growth of the border population poses multiple challenges to 

development of a sufficient health workforce in the border region and access 

to primary, preventive, and specialty care.

•	 In the border region, socioeconomic factors, linguistic and cultural barriers, 

low population densities, and lack of health insurance combine to impede 

residents’ ability to access health care. Barriers to access are particularly acute 

for Hispanic border residents.

•	 There is a critical need for increased surveillance and tracking of 

communicable diseases, environmental factors, and other influences on 

health.

•	 There is a need for standardization of data to ensure compatibility with data 

being collected by border states on both sides of the U.S.-Mexico border, as 

well as by both nations.

•	 Public health infrastructure is sorely needed throughout the border region, 

including educational and research institutions that can train culturallycompetent health care providers.

•	 While many successful public health programs have been implemented in 

the border region, these programs are rarely replicated. In addition, lack of 

coordination between programs, funded from a variety of sources, presents 

challenges to public health professionals and the communities they serve.
3 

CONTRIBUTORS 

Juan R. Albertorio-Díaz, M.A.

Juan R. Albertorio-Díaz is a health statistician at the National Center for 

Health Statistics (NCHS), International Statistics Program (ISP), Office of the 

Center Director. Mr. Albertorio provides logistic and statistical support to all 

the projects conducted under the ISP. Before coming to NCHS, Mr. Albertorio 

spent three years as a fellow at the Partnership Program at the National Institute 

on Deafness and Communication Disorders, National Institutes of Health 

(NIH). At NIH, he conducted demographic, epidemiological, psychological, 

and genetic research in collaboration with the Gallaudet Research Institute and 

the Medical College of Virginia. He has an M.A. from the University of Puerto 

Rico, Río Piedras campus.

Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D. 

Dr. Correa is a cardiovascular pathologist trained at the National Heart, Lung, 

and Blood Institute. She is currently the Deputy Director of the Office on 

Disability. Prior to this position she served as the Director of the Office of the 

Americas Region in the Office of Global Health Affairs and the Secretary’s 

Delegate to the U.S. Mexico Border Health Commission. Dr. Correa successfully 

led a Secretarial priority initiative on health diplomacy in Central America which 

culminated in partnerships between the U.S. Department of Health and Human 

Services (HHS) and foreign Ministries of Health in that region. As the Agency 

for Healthcare Research and Quality’s former Director of Women’s Health and 

Gender-Based Research, Dr. Correa expanded the women’s health agenda to 

encompass a new field of inquiry – gender-based research – and received AHRQ 

Director’s Award of Excellence for introducing a gender-based approach to health 

services research. As AHRQ’s spokesperson in the Spanish language, she received 

AHRQ Director’s Award of Merit for ensuring prevention and quality messages
Border Lives: Health Status in the United States-Mexico Border Region

4

to educated professionals and Hispanic communities. As a biomedical and a 

health services researcher, Dr. Correa has numerous scientific publications in 

peer-reviewed journals, as well as chapters in pharmacology textbooks, and 

consumer products.

Paul Dulin, M.A.

Paul Dulin, who graduated in 1976 from East Carolina University with an M.A. 

in Environmental Geography, is a resident of Hatch, New Mexico. After carrying 

out various consulting assignments with the New Mexico Department of Health 

in the border region, he was appointed as the Director of the New Mexico Office 

of Border Health in October 2006. Mr. Dulin is a fluent Spanish speaker and has 

more than 30 years of professional experience spanning 28 countries, including 

the U.S.-Mexico border region and most of Latin America and the Caribbean, 

Somalia, and Bangladesh. Mr. Dulin has worked extensively in the design, 

management, and evaluation of social and environmental impact mitigation and 

management programs. He has been involved in numerous development projects 

that have included elements of environmental and public health, occupational 

safety and health, and infectious disease surveillance and prevention.

Ronald J. Dutton, Ph.D.

Dr. Dutton grew up in Potrerillos, Chile, and has worked for 20 years in 

international and public health after receiving graduate degrees in Environmental 

Engineering Sciences and Environmental Toxicology from the University of 

Florida. He served as Senior Scientist at the International Life Science Institute in 

Washington, D.C., and as Senior Toxicologist in the Community Health Branch 

at the Agency for Toxic Substances and Disease Registry and the Centers for 

Disease Control and Prevention in Atlanta, Georgia. Dr. Dutton currently serves 

as Director of the Office of Border Health, Texas Department of State Health 

Services, where he directs activities of about 20 staff members located in border 

field offices in Harlingen, Laredo, Eagle Pass, Uvalde, Presidio, and El Paso. Dr. 

Dutton also manages the U.S. Department of Health and Human Services public 

health preparedness funds along the Texas-Mexico border, known as the Early 

Warning Infectious Disease Surveillance program.

Antonio Furino, Ph.D.

Antonio Furino is a Professor of Economics in the Department of Epidemiology 

and Biostatistics, and Associate Director of the Center for Health Economics 

and Policy and the Regional Center for Health Workforce Studies at The 

University of Texas Health Science Center at San Antonio. He teaches medical 

and dental economics and directs health workforce and health service research 

with a focus on the impact of health policy on the health professions and atthe 
5 

Contributors 

the Innovation, Creativity, Capital (IC2) Institute of The University of 

Texas at Austin, where he has been engaged in studies of human resource 

productivity, technology transfer, community health planning, and grassroots 

entrepreneurship. His publications are interdisciplinary with emphasis on 

national economic and health policy and its impact on minorities and the 

Hispanic/Latino population.

Robert Guerrero, M.B.A.

Robert Guerrero serves as the Chief of the Office of Border Health for the 

Arizona Department of Health Services. Mr. Guerrero oversees border activities 

of the Early Warning Infectious Disease Surveillance program and the Border 

Infectious Disease Surveillance program in Arizona. In addition, Mr. Guerrero 

also oversees the activities of the U.S.-Mexico Border Health Commission’s 

(BHC) Arizona Outreach Office. Mr. Guerrero is the liaison between the 

Arizona Department of Health Services and the Secretaría de Salud Pública 

del Estado de Sonora and serves as ADHS Director’s delegate to the BHC, the 

Arizona-Mexico Commission’s Health Services Committee, and the U.S.-Mexico 

Border Governors Conference – Health Worktable.

Alma I. Martinez-Jimenez, M.S.

Alma Martinez-Jimenez is a Research Scientist with the Institute for 

Demographic and Socioeconomic Research at the University of Texas at San 

Antonio where she is engaged in the study of obesity and diabetes with a special 

interest in the impact of diabetes on the U.S. workforce. From 2004 to 2007 she 

was the Technical Project Manager at the Regional Center for Health Workforce 

Studies at The University of Texas Health Science Center at San Antonio.

Francis C. (Sam) Notzon, Ph.D.

Dr. Notzon is the Director of the International Statistics Program at the 

National Center for Health Statistics, CDC. He holds a Ph.D. in Population 

Dynamics from Johns Hopkins University (1989). Dr. Notzon has worked 

in the area of international health statistics for more than 25 years, dealing 

with both developed and developing countries, as well as multi-national 

organizations. Dr. Notzon was the lead U.S. participant in the preparation 

of the “Sister Communities Health Profiles, 1989-91,” published by the Pan 

American Health Organization (PAHO) Field Office in 1994 and was the 

lead U.S. participant in the preparation of the “Mortality Profiles of the Sister 

Communities, 1995-97” published by PAHO in 2000. He was the lead U.S. 

author of the “Healthy Border 2010” report published by the U.S.-Mexico 

Border Health Commission in 2003. He was born and raised on the U.S.-

Mexico border in Laredo, Texas.
Border Lives: Health Status in the United States-Mexico Border Region

6

Victoria D. Ojeda, Ph.D., M.P.H.

Dr. Ojeda is Assistant Professor at the University of California, San Diego, 

Department of Family and Preventive Medicine. For more than ten years, her 

research has focused on the health of underserved and vulnerable populations, 

including immigrants, Latinos, women, and children. Dr. Ojeda has published 

on health services issues including access to health insurance coverage, utilization 

of health and mental health services, and the financing of health care. Dr. Ojeda 

is now pursuing new research focusing on substance abuse and mental health 

comorbidities in immigrant communities. Dr. Ojeda previously worked as a 

Social Epidemiologist at the California Department of Public Health, Office of 

Binational Border Health.

Alfonso Rodriguez-Lainz, Ph.D., D.V.M., M.P.V.M.

Dr. Alfonso Rodriguez-Lainz holds a Ph.D. in Epidemiology from the University 

of California, Davis. He was formerly the Chief Scientist for the Office of 

Binational Border Health, California Department of Public Health. In his current 

position, he provides technical support to state, federal, and local agencies on 

border and migrant health issues. Dr. Rodriguez-Lainz also coordinates health data 

monitoring and implementation of projects and works to enhance collaboration 

between Californian and Mexican officials to address common health issues.

Kerstin Müller Reinschmidt, Ph.D., M.P.H.

Dr. Reinschmidt has worked with multi-ethnic populations in the United States 

and Mexico since 1997. Since 2002, she has worked at the Canyon Ranch 

Center for Prevention and Health Promotion (CRCPHP) (previously known as 

the Southwest Center for Community Health Promotion). As co-investigator 

of CRCPHP, Dr. Reinschmidt has been working with behavioral and policy 

interventions, focusing on understanding and addressing depression and other 

mental health issues among community members in general and among people 

with diabetes and their family members in particular. In collaboration with 

community and university partners, she has developed SONRISA, a bilingual 

curriculum toolbox for promotores/community health workers on depression 

and other mental health issues associated with diabetes. Dr. Reinschmidt has 

also been co-principal investigator for a pilot study that investigated depression 

symptoms in Hispanic and non-Hispanic patients with and without diabetes/

chronic diseases. 

Kasslane Rogers, M.S.

Ms. Rogers grew up in the hill country of Texas. After receiving her M.S. in 

Biology in Texas and completing three years of graduate studies at Virginia Tech 

in the field of Plant Taxonomy, she taught Freshman Biology at Blinn College 
7 

Contributors 

in Brenham, Texas, for six years. She entered the field of public health in 1987 

as Chief Sanitarian for Henry County, Indiana, then moved back to Texas in 

1989 to work for the then Texas Department of Health as the Regional Septic 

Inspector for the San Antonio/Uvalde Region. It was during this time that she 

became familiar with water, wastewater, and solid waste problems in the colonia 

areas of the Texas-Mexico border. She also worked in the Immunization and 

Zoonosis Divisions before coming to work for the Office of Border Health in 

1994. She holds current certifications as a Registered Sanitarian.

Cecilia Rosales, M.D., M.S.

Cecilia Rosales is an Associate Professor in the Community, Environmental and 

Policy division at the University of Arizona Mel and Enid Zuckerman College of 

Public Health. Dr. Rosales has worked in the health arena for more than twenty 

years and in the field of public health for fifteen years. She served as Director 

of the Office of Border Health for the Arizona Department of Health Services 

for five years prior to accepting her current position as an Associate Professor 

at the University of Arizona. Dr. Rosales has expertise in the areas of program 

development and implementation, public health administration, and policy and 

health disparities research related to the Southwest. She has worked with the 

U.S.-Mexico Border Health Commission, the Arizona-Mexico Commission, the 

Border Governors, and the State Health Departments in Arizona and Sonora to 

develop strategies for strengthening the public health infrastructure in the border 

region. Most recently Dr. Rosales was appointed by President George W. Bush to 

serve on the U.S.-Mexico Border Health Commission representing Arizona.

Graciela E. Silva, Ph.D., M.P.H., M.T.

Graciela Silva is an Associate Professor in the College of Nursing and Healthcare 

Innovation at Arizona State University in Phoenix, Arizona. Dr. Silva earned her 

doctorate in Epidemiology and a Master of Public Health from the University 

of Arizona, 2004. She was awarded a National Institutes of Health (NIH)/

National Heart, Lung, and Blood Institute (NHLBI) Minority Fellowship to 

perform a longitudinal study of relationships between asthma as a risk factor for 

the development of chronic obstructive pulmonary disease. Subsequently, Dr. 

Silva was awarded an NIH/NHLBI Research Supplement to Promote Diversity 

in Health-Related Research Postdoctoral Fellowship to investigate associations 

between sleep disordered breathing in pre-adolescent children and their 

neurocognitive performance. Her work also includes disease surveillance along 

the U.S.-Mexico border.

9 

ACKNOWLEDGEMENTS

 

The United States-Mexico Border Health Commission (BHC) wishes to thank Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D., Deputy Director, 

Office on Disability, Office of the Secretary, U.S. Department of Health and 

Human Services (HHS) for her overall review and coordination during the 

latter stages of the report development and writing; Francis C. (Sam) Notzon, 

Ph.D., Director, International Statistics Program, National Center for Health 

Statistics, who brought reality to the vision for this report and for his long-term 

coordination and marshalling of the report writing team; Renée T. Despres, 

Ph.D., for her consultant editorial review of the initial versions of this report; 

Leah Hsu, M.P.H., International Health Analyst, and Julia S. Goldberg, 

M.P.H., International Health Analyst, Office of Global Health Affairs, HHS, 

for their support in editing early drafts of the report; and Daniel M. Reyna, 

M.S.S., M.P.A., General Manager, U.S. Section, U.S.-Mexico Border Health 

Commission, for his overall coordination of the completion of the report. 

We would also like to acknowledge the long-term contributions of many of our 

partners, including Ronald J. Dutton, Ph.D., Director, Texas Office of Border 

Health, Texas Department of State Health Services; Paul Dulin, M.A., Director, 

New Mexico Office of Border Health, New Mexico Department of Health; Robert 

Guerrero, M.A., Director, Arizona Office of Border Health, Arizona Department 

of Health Services; and Maura Mack, Ph.D., former Director, California Office of 

Binational Border Health, California Department of Public Health.

We are also indebted to the members of the U.S. Section who were most 

encouraging and supportive throughout the period of work on this report.

The BHC also wishes to recognize the efforts of the following U.S. Section 

staff for their assistance in the completion of this project: Linda Willer, 

Communications Director; Lorraine Navarrete, Binational Coordinator; and 

Adriana Mota, Administrative Assistant.

11 

INTRODUCTION

BORDER LIVES 

The United States-Mexico border stretches 2,000 miles from the Gulf of 

Mexico to the Pacific Ocean. Defined in part by the Rio Grande river, 

the border has no other natural boundaries. Four U.S. states lie

to the north of the border, and six Mexican states lie to the south. The area 

immediately to the north of the border includes parts of Arizona, California, 

New Mexico, and Texas. According to the 2000 U.S. National Census, 

approximately 6.5 million people live in the area, and 49 percent of those 

residents are Hispanic, mostly of Mexican origin. They mix with people of other 

ethnic groups throughout the border region, including non-Hispanic whites, 

blacks, American Indians, Asian-Americans, and others.

The border region is a complex milieu of cultures, peoples, languages, and 

traditions. Almost 800,000 people crossed the U.S.-Mexico border daily in the 

year 2000 (DOT, 2008), and economic exchange between the two countries 

is growing rapidly. Yet characterizing the border is no simple matter. Wealth 

contrasts with poverty, and dense urban areas lie adjacent to vast stretches 

of rural desert landscape. Nor is it a homogenous area. The problems and 

issues of one area may be contradicted by the characteristics of another, often 

neighboring, part of this unique region of the United States.

This social, cultural, economic, and political context provides the backdrop 

for the health and well-being of U.S. border residents. Border lives are 

characterized by complex and sometimes seemingly contradictory factors. It 

may seem difficult to paint the true picture of the border from a public-health 

perspective. Is it a bustling area engaged in international business, enjoying a 

healthy environment and good health outcomes? Or is it a poor region with 

few prospects for economic growth, suffering from environmental health risks, 

plagued with violent crime, frustrated with poor access to health care, and 

burdened with a variety of health problems?
Border Lives: Health Status in the United States-Mexico Border Region

12

Paradoxically, the answer is, “both.” The border region is all of these things, a 

combination of the favorable and unfavorable that is difficult to summarize in a 

few words. The region is sorely lacking in health facilities and health workforce, 

and many border residents suffer from very poor access to health care. Border 

residents have high levels of obesity and diabetes, among other health problems. 

Nevertheless, the border population does well on other health measures including 

infant mortality, overall mortality, and deaths from the two leading causes, heart 

disease and cancer. Hispanics are the border residents who suffer the most from 

poverty and poor access to care, and in general have lower quality of health 

compared to non-Hispanics. However, they may do nearly as well and in some 

cases do better than their non-Hispanic neighbors on some health measures.

This report provides an overview of health issues in the border region, supported 

by health and related data from a wide range of sources. Each chapter considers 

a major challenge to the health of the border population. U.S. Public Law 

§103-400 defines the U.S. portion of the border region as the area extending 

100 kilometers (62 miles) north of the U.S.-Mexico border. Because most 

health, demographic, and economic information is available on a county basis, 

this report defines the U.S. border area to include 44 counties that are entirely 

or partly within the 62-mile zone. This relatively restrictive definition excludes 

the interaction between border communities and large metropolitan areas just 

outside the boundary, such as Los Angeles, California, Phoenix, Arizona, and 

San Antonio, Texas. On the other hand, this restriction focuses the current study 

on the region most exposed to the forces that make the border area unique, 

namely, the binational social and economic ties that result from the large daily 

interchange of population.

The data-centric approach used in this report differs substantially from many 

other border reports, most of which tend to rely on local studies or projects, 

observations and personal experience (Bruhn, 1997; Power, 1998). A data 

focus has its advantages, as borderwide data can provide insights that are not 

perceptible in any single locality. But caution should be used in interpreting 

summary statistics. For example, combining data across 44 border counties 

produces averages that inevitably mask some of the variability of life within the 

border region. Average values also can be affected by a small number of counties. 

A case in point is San Diego County, California, which represents nearly half of 

the border population but is unlike most other border counties in many ways, 

particularly in terms of wealth and education. In some cases, borderwide averages 

that include San Diego County may conceal the situation in the remaining border 

counties, for example, in terms of average income or years of schooling. For 

these instances, we have presented the averages in two ways: first with San Diego 

County data included, and then without San Diego County data.
Introduction 

13 

Providing detailed health data in terms of counties was especially challenging. In 

general, the largest array of health information is available at the national level, 

with the availability of data somewhat less for states, and even less information 

is available for individual counties. Ensuring that consistent definitions and data 

collection methods were used in all border counties further reduced the number 

of data sources. The small populations of many counties, and thus the small 

number of events (births, deaths, hospital discharges, etc.), made it difficult to 

provide statistically reliable data for each county. To provide the greatest level 

of geographic detail possible, we have included statistics for the entire border 

region and the border region of each state, in some instances combining several 

years of data to produce stable rates.

Healthy Border 2010

This report takes as its starting point a report published by the United StatesMexico Border Health Commission (BHC) in 2003, Healthy Border 2010: 

An Agenda for Improving Health on the U.S.-Mexico Border. While the report 

contained some health information for the border population, it was not 

intended to serve as an evaluation of health status in the border region; instead, 

it was developed to identify key border health issues and to introduce the BHC’s 

Healthy Border 2010.1

The Healthy Border 2010 report contained background information on the 

health of United States and Mexican border residents, and focused on the 

specific objectives of the Healthy Border 2010 initiative. These objectives 

represented the core of the BHC’s Healthy Border, which was established as the 

BHC’s binational agenda of health promotion and disease prevention for the 

decade. Healthy Border 2010 uses the U.S. Department of Health and Human 

Services’ Healthy People 2010 initiative as its framework. It also incorporates the 

United States’ Healthy Gente initiative (Arizona Office of Border Health, 2004) 

and Mexico’s Indicadores de Resultado/National Health Indicators (Secretariat of 

Health of Mexico, 2007).

The focus areas and objectives of Healthy Border 2010 are deliberately limited 

to a small number of variables for which data are currently available or are 

expected to be available in the near future. These are—

•	 Access to Care: Reduce the population lacking access to a primary health 

provider. 

•	 Cancer: Reduce breast cancer and cervical cancer mortality.

1 The BHC has published in July 2009 the Healthy Border 2010 Midterm Review U.S. Border Area, 

a review of Healthy Border 2010 at mid-decade.
Border Lives: Health Status in the United States-Mexico Border Region

14

•	 Diabetes Mellitus: Reduce both the mortality rate of diabetes and the need 

for hospitalization.

•	 Environmental Health: Improve household access to sewage disposal and 

reduce hospital admissions for acute pesticide poisoning.

•	 HIV/AIDS: Reduce the number of cases of HIV/AIDS.

•	 Immunization and Infectious Diseases: Expand immunization coverage for 

young children, as well as reduce the incidence of hepatitis and tuberculosis.

•	 Injury Prevention: Reduce mortality from motor vehicle crashes as well as 

childhood mortality from injuries.

•	 Maternal, Infant, and Child Health: Reduce overall infant mortality as well 

as infant deaths due to congenital defects, improve prenatal care, and reduce 

teenage pregnancy rates.

•	 Mental Health: Reduce suicide mortality.

•	 Oral Health: Improve access to oral health care.

•	 Respiratory Diseases: Reduce the rate of hospitalization for asthma.

In its 2003 report, the Commission recognized the need for additional 

information for both sides of the border and encouraged the Mexico and U.S. 

Sections of the Commission to produce more in-depth reports on health status 

during the decade. The Mexico Section of the Border Health Commission 

published the first such report, México: Frontera Norte Saludable, in 2002. The 

present report is intended as a companion volume for the U.S. border population.

The Evolving Field of Border Health

 

As a programmatic area of public health, border health has 

slowly evolved in the United States. The first programs 

specifically targeting residents of the U.S.-Mexico border region

began in the early 1940s. However, federal and state departments 

of health did not begin to focus on border health until the 1990s. 

Early interventions focused on the surveillance and prevention of 

communicable diseases, such as the prevention and treatment of 

sexually transmitted diseases. Border health programs now address 

a broad range of public health issues, including chronic diseases, 

Border health is a range of shared public health issues that 

span the international border and necessitates binational 

collaboration to be effectively addressed.

—Health on the U.S.-Mexico Border: Past, Present, & Future; 

 U.S. Department of Health and Human Services, July 2000
Introduction 

15 

environmental health, health emergency preparedness and response, 

and mental and behavioral health. Local, state, and federal government 

agencies and a host of advocacy organizations and universities are also 

involved in addressing the health needs of border residents. 

In many instances, health disparities among border populations are 

more pronounced than in other parts of both the United States and 

Mexico. The lack of a uniform epidemiological baseline relative to 

demographics and health conditions among the differing cohorts that 

comprise the border population also restricts an accurate analysis of 

health disparities among these groups, as well as the efficient targeting 

of public health resources. While research has been useful to characterize 

health conditions and disparities in specific geographic areas and cohorts 

(for example, the Mexican-American population), results have generally, 

to date, not translated into significant programmatic changes in health 

systems applied at the state or federal level. This situation is further 

exacerbated as population growth and the ever-increasing rolls of the 

poor and uninsured are outstripping the capacities of health systems to 

meet public health demands. 

Efforts to address health problems along the U.S.-Mexico border 

can be traced to 1942 when thousands of Mexican nationals were 

hired as temporary agricultural laborers to meet U.S. labor shortages 

during World War II (Collins-Dogrul, 2006). Under the Bracero 

Program, Mexican laborers wishing to work in the United States were 

required to complete a tuberculosis test as a condition to entering the 

country. Also in the early 1940s, the U.S. government first addressed 

sexually transmitted diseases in the border region. Soldiers from Fort 

Bliss in Texas and Camp Pendleton in California took many of their 

leaves in adjoining Mexican border towns, leading to high rates of 

sexually transmitted diseases. To avoid national sovereignty issues with 

Mexico, the U.S. Public Health Service requested that a transnational 

institution, the Pan American Health Organization (PAHO), open a 

U.S.-Mexico field office in El Paso, Texas. In effect, the PAHO Field 

Office was established and immediately initiated an education and 

testing program to reduce sexually transmitted diseases. The program 

included funds to establish diagnostic laboratories managed by 

Mexican health authorities in Nuevo Laredo, Juárez, and Mexicali, as 

well as staff training (Collins-Dogrul, 2006). These individual efforts 

soon led to the establishment of the first organizations dedicated to 

border health.
Border Lives: Health Status in the United States-Mexico Border Region

16

In 1943, PAHO held the first binational border health convention

in Juárez. At that meeting participants supported the creation of a 

binational professional organization. As a result, the U.S.-Mexico 

Border Health Association (USMBHA) was established and housed at 

the PAHO Border Field Office in El Paso. Both PAHO and USMBHA 

helped bring together public health professionals and policy makers to 

coalesce around border health issues. Through the two organizations, 

practitioners began to participate in binational committees, regional 

councils, and working groups to address public health problems 

affecting residents in sister cities and along the entire extent of the 

U.S.-Mexico border. 

Beginning in the late 1960s, economic and demographic pressures 

throughout Mexico, including the collapse of several Mexican states’ 

agricultural models, prompted millions of Mexican nationals to move 

north to the larger sister-city areas of the border to fill ever-growing 

labor needs emanating from the development of the maquiladora

(“twin-city” manufacturing and assemblage) industry and associated 

construction and service sectors. With the advent of the North 

American Free Trade Agreement (NAFTA) in 1994, trade between the 

United States and Mexico tripled and the total number of maquiladoras

increased to more than 3,000. Cross-border movement of goods and 

workers grew concomitantly, further exacerbating health access issues. 

While NAFTA included environmental side agreements to address 

expected impacts caused by economic growth and infrastructure, the 

agreement did not include any public health provisions. In December 

1994, shortly after NAFTA went into effect, the devaluation of the peso 

precipitated the 1995-1996 financial crisis in Mexico and collapse of 

the banking sector, leading to thousands of failed small and medium 

enterprises and enlarging the rolls of unemployed. 

The confluence of both of these processes encouraged migrations 

of Mexicans to the border in numbers that outstripped the capacity 

of Mexican state public health authorities. Consequently, health 

disparities among low-income families and the unemployed increased 

dramatically, including increases in rate of infectious disease (especially 

tuberculosis and sexually transmitted diseases). As thousands of 

migrants were unable to find employment opportunities in Mexico, 

they continued north, crossing the border illegally and adding to the 

burgeoning population of undocumented immigrants in the United 

States, now estimated to exceed 12 million people. With the increased 

movement of millions of people back and forth across the border every 

day, the demand for health services has also grown on the U.S. side of 

the border, requiring county, state, and federal health authorities to 
Introduction 

17 

respond to an ever-increasing number of uninsured, including the 

undocumented who are not eligible for many state and federallysponsored health-coverage programs.

In 1983, the U.S. and Mexican governments signed the La Paz 

Agreement on Cooperation for the Protection and Improvement of the 

Environment in the Border Area, and accepted a definition of the shared 

“border region” as the geographic area defined by 100 kilometers (62 

miles) north and south of the U.S.-Mexico border. While originally 

intended only to cover efforts at environmental protection and natural 

resources conservation in the border region, this definition was later 

adopted by other federal and state authorities for any planning and 

implementation of activities with a binational perspective, including 

public health.

The border states responded with the establishment of their respective 

offices of border health. The Texas, New Mexico, and California offices 

opened in 1993, and the Arizona office in 1994 (Collins-Dogrul, 

2006). State and county governments developed special legislation and 

appropriations to cover the costs of providing health care to indigents, 

including housing and health services. San Diego County and Imperial 

County opened their own border health offices in 1997 and 1998 

respectively, while other county governments established colonias task 

forces and programs to provide basic human services (especially water 

and wastewater) and health care in these communities. Initially, most 

of the programming in border health concentrated on the 15 sister-city 

pairs, where approximately 90 percent of the border population resides.

Public Law §103-400 (1994) also authorized the President of the 

United States to establish an agreement with Mexico to create a 

binational commission to address the serious health problems in the 

border region. At the federal level, the Health Resources and Services 

Administration (HRSA) initiated its Border Health Program in 1996 to 

address health access issues in the border region, and in 1997, Congress 

approved funding for a commission through the U.S. Department of 

Health and Human Services (HHS).

As a result, the U.S.-Mexico Border Health Commission (BHC) was 

established in July of 2000. The agreement went into effect for five 

years and is automatically extended for additional five-year periods 

unless either party gives notice of withdrawal. The BHC began to more 

formally and systematically address border health problems when it 

began operations at the offices of the U.S. Section in El Paso and the

Mexican Section within the Secretariat of Health Mexico City in 2001. 
Border Lives: Health Status in the United States-Mexico Border Region

18

The U.S. Section established outreach offices in each of the four state 

offices of border health, through which it funds border health activities. 

Similar offices now exist in each of the six Mexican border states.

Since the mid-1990s, numerous projects and programs have been 

implemented in the border region. The departments of health of the 

four U.S. border states have taken the lead in implementing most of the 

programs through their respective offices of border health, with financial 

and technical support from HHS.

As a result of these efforts, several models of excellence have emerged 

as innovative and effective approaches to addressing specific border 

health challenges, and coordination has improved among U.S. and 

Mexican federal health authorities. Cooperation in handling local and 

regional priority public health issues has been especially notable between 

individual border states and “sister cities.”

As public health systems continue to evolve and develop innovative 

approaches that recognize the unique multicultural and socioeconomic 

character and challenges of the border population, the evolving field of 

border health will continue to move forward and provide solutions to the 

benefit of all border residents along the U.S.-Mexico border region.

References

Collins-Dogrul, J. (2006). Managing U.S.-Mexico “border health”: An 

organizational field approach. Social Science and Medicine, 63, 3199-

3211.

Pan American Health Organization. History of the U.S.-Mexico border 

field office. Retrieved October 1, 2007, from http://www.fep.paho.org/

english/oficina/history.html

Texas Border & Mexican Affairs.(nd). Colonias FAQs. Retrieved 

October 15, 2007, from http://www.sos.state.tx.us/border/colonias/

faqs.shtml

U.S. Department of Housing and Human Development. (2007, 

September 21). Facts about farmworkers and colonias. Retrieved 

October 15, 2007, from http://www.hud.gov/groups/farmwkercolonia.

cfm
19 

Introduction 

Organization of the Report

Each chapter provides a comprehensive view of the impact of a particular issue 

on border health and considers how those challenges to border health might be 

addressed. 

The chapter on the U.S. border population documents the significant increase in 

border residents in recent years and projects that growth into the future; it also 

considers the ethnic composition of the border population. A number of other 

chapters discuss the impact of a rapidly growing border population on specific 

health issues. Likewise, the division of the border population into its two major 

ethnic groups, Hispanics and non-Hispanic whites, figures prominently in every 

chapter.

The large daily interchange of populations across the international border is 

a second common theme. Residents of both countries cross the border for a 

variety of reasons, including work, shopping, health care, visits with friends or 

relatives, and others. This cross-border traffic is essential to the economies of 

communities on both sides of the border. For communicable disease prevention 

however, border crossings present a major challenge to the identification and 

tracking of communicable disease cases, as well as ensuring that individuals 

under medical care complete the prescribed treatment regimens. Border 

residents from both countries frequently cross to “the other side” to seek health 

care, producing an impact on provision of care and patient workloads. The 

requirement that U.S. citizens will have to have a passport to gain reentry to 

the United States may reduce the level of border crossings. However, such 

reductions are unlikely to be major or permanent given the social and economic 

mandates of life in the border region. 

One surprising finding is addressed in several chapters: favorable health 

outcomes for border Hispanics, including low death rates from heart disease 

and some cancers, and low rates of low birthweight and infant mortality. These 

findings seem to confirm the “Hispanic paradox,” that is, good health outcomes 

despite poor access to care and low socioeconomic status (Scribner, 1996). 

Several chapters examine this issue and consider possible statistical explanations 

for this epidemiologic puzzle.

One of the most important issues for the border is ensuring access to health care 

for a rapidly growing population when a large portion of that population lacks 

health insurance and cannot afford to pay out-of-pocket expenses. Compounding 

this problem is the relatively slow growth of the border health workforce, which 

is not keeping up with the population increase. Both public and private health 

care systems will be challenged to deal with this very complex problem.
Border Lives: Health Status in the United States-Mexico Border Region

20

Chapter 1, “The U.S. Population at the Border,” provides data on income and 

employment levels for border residents and describes the small population and 

low population density of many border counties. The chapter examines the 

rapid rise in population in the border region and provides basic data on each 

group, including important differences in population growth rates, income and 

education levels, and country of birth. The border region often is described as 

an area of open spaces, wide vistas and unpopulated expanses, yet more than 90 

percent of the population live in urban areas – a higher rate than the U.S. average 

of 79 percent. The border population is rising rapidly, and this increase, combined 

with booming trade with Mexico – especially related to the maquiladoras or 

“twin plant” facilities in northern Mexico – have created an image of dynamic 

growth for the border region. At the same time, overall levels of poverty and 

unemployment are very high in the border area. Removing San Diego County, the 

wealthiest of the border counties, would make these poverty and unemployment 

measures even worse. The border population is characterized by the large 

proportion of Hispanics, most of Mexican origin, and a high percentage of 

foreign born residents. In terms of health issues, the Hispanic population are 

genetically predisposed to certain diseases. The high prevalence of diabetes in 

Hispanics is thought to be related to the American Indian contribution to their 

genetic profile (CDC, 1999). In addition, genetic predisposition, along with 

dietary deficiencies, might also explain the higher level of neural tube defects 

among Mexican-Americans (Suarez, 2000).

Chapter 2, “The Healthcare Workforce,” examines the health workforce in the 

border region. This chapter describes the shortage of border health professionals 

and the need to increase the training of new health workers to respond to the 

rapidly growing border population. It also discusses challenges to retain health 

workers within the border counties and proposes some possible solutions to the 

growing shortage of health workers on the border.

In Chapter 3, “Access To and Use of Health Care,” the lens turns to obstacles 

to health care access for border residents. This chapter documents the primary 

barriers to accessing health care using survey data on health insurance status 

of border residents, inability to pay for care out-of-pocket, and use of health 

care by border residents. Low income and lack of health insurance mean that 

Hispanics suffer disproportionately from a lack of access to health care, both 

in the border region and nationally. In addition, access to care is one of the 

important reasons for border crossings. U.S. residents seek less expensive health 

care and dental care, as well as traditional medicine or Spanish-speaking healthcare providers in Mexico. Mexican residents travel to the United States to obtain 

more specialized medical care than is available in Mexico for the treatment of 

chronic diseases and traumatic injuries, among others.
Introduction 

21 

Fertility rates and birth outcomes are examined in Chapter 4, “Maternal, Infant, 

and Child Health.” The data presented in this chapter indicate that, in the 

border region, Hispanics have much higher fertility than non-Hispanic whites. 

In addition, Hispanic birth outcomes such as birth weight and infant mortality

are very good considering the low income, low levels of education, and poor 

access to care of border Hispanics.

Data on infectious diseases in the border region are presented in Chapter 5, 

“Communicable Diseases.” The daily mixing of large numbers of U.S. and 

Mexican residents in border communities, along with poverty and other factors, 

contribute to high levels of communicable diseases in the border region. For 

example, the Border Counties Coalition reported in 2006 that if the 24 U.S. 

counties contiguous with the Mexican border were the 51st state, that state would 

rank second among the states in the incidence of tuberculosis. Yet, for many other 

communicable diseases, incidence rates in the border counties are lower than in 

the non-border areas of the four states and lower than national levels as well. The 

communicable disease chapter considers at length the impact of border crossings 

on disease transfer, along with the difficulties of identifying and tracking disease 

cases. Ensuring that individuals suffering from communicable diseases complete 

their prescribed regimen of treatment is another major concern. Several of the 

chapters focus on the need for improved access to care and screening, including 

the chapters on diabetes, cancer, heart disease, and mental health. Likewise, 

several chapters in this section discuss the possibility of genetic explanations for 

certain chronic diseases, such as diabetes.

Chapter 6, “Breast and Cervical Cancer,” provides an overview of the impact of 

breast and cervical cancers, as well as other cancers, on the population living in 

the border region. Cancer prevalence and death rates are thought to be highest in 

minority populations, yet while Hispanics suffer greater mortality from cervical 

cancer than non-Hispanic whites, their breast cancer mortality is lower than the 

non-Hispanic white rate. Nevertheless, cancer remains the second leading cause 

of death for border residents, both Hispanics and non-Hispanic whites. Low rates 

of screening and treatment often lead to cancer being diagnosed at later stages, 

when it is more aggressive. Limited access to health care services, along with 

language and cultural barriers, are important reasons for late diagnosis of cancer 

in border residents (Tsui, Saraiya, Thompson, et al., 2007).

Diabetes mellitus is a rapidly growing problem throughout the United States, 

and the border region is among the areas most affected by growing prevalence 

of this disease. Both Hispanics and Native Americans are more susceptible to 

type-2 diabetes mellitus. Chapter 7, “Diabetes,” examines the impact of diabetes 

on border residents and calls for additional research, support for collaborative 

efforts, and policies to emphasize diabetes prevention and education.
Border Lives: Health Status in the United States-Mexico Border Region

22

Chapter 8, “Heart Disease and Stroke,” reviews the available information 

on heart disease and stroke in the border region, including levels and trends, 

morbidity and mortality, and prevalence of risk factors. Although heart disease is 

the leading cause of death in both the United States and the U.S.-Mexico border 

region, the border mortality rate is significantly lower than the national rate. 

One surprising finding of this analysis was lower death rates due to heart disease 

and stroke among Hispanics than non-Hispanic whites, despite higher levels 

of certain risk factors for Hispanics, such as obesity, diabetes, and uncontrolled 

hypertension. While this finding seems to confirm the theory of the Hispanic 

paradox, the chapter also reviews several longitudinal cohort studies that raise 

questions about the Hispanic advantage in heart disease and stroke.

Newspaper articles and television reports highlight violent crime in border 

communities, especially events related to illegal drug traffic and human 

smuggling. Yet, as documented in Chapter 9, “Injuries,” the homicide rate in 

the border counties is substantially below the national level. Crime reports show 

increases in violent crime for some border counties in recent years but declines in 

others, including some of the largest counties (Bureau of Justice Statistics, 2007).

In addition, downward trends in violent crime for the four border states mirror 

the national decline in violent crime since 1990. The chapter summarizes 

available information on injury-related mortality in the border region. Among 

the key findings of the analysis were major differences between border Hispanics 

and non-Hispanic whites in mortality from various causes of injury, and 

significantly higher injury death rates in the border areas of Arizona and New 

Mexico as compared to the border counties of California and Texas.

Mental well-being is the foundation for overall health and the ability to function 

in society. Chapter 10, “Mental Health,” examines data on the prevalence of 

mental illness, illicit substance use, and patterns of utilization of mental health 

and substance use services in the U.S.-Mexico border region. While many 

similarities were found in mental health status across ethnic groups, important 

differences emerged when data were disaggregated by ethnicity. Nationally, a 

greater proportion of people born in the United States, both Hispanic and nonHispanic, reported psychological distress and major depression compared to their 

immigrant peers; although within the border region there was no significant 

difference between the native-born and immigrants for the same measures. 

Data on use of mental health services indicates that nationally and in the border 

region, Hispanics are particularly underserved by mental health providers.

The health problems of the border are numerous and complex and are unlikely 

to be solved in the near future. Border communities are searching for and 

developing innovative solutions to many of these problems. For instance, 

foreign-born border residents, especially those from developing countries, often 
Introduction 

23 

are poorly educated and have limited English language ability. Communicating

health promotion and health education to this group is challenging and requires 

imaginative solutions. One of the more successful techniques for health outreach 

to this group has been through promotoras, or lay health workers, an approach 

used successfully in many developing countries (Ford, 1998). This type of 

cross-fertilization between domestic and international programs may yield 

other innovative strategies in the future and needs to be supported by policy 

development and funding.

The chapters that follow provide information on the health status of the border 

population, including data on the extent and severity of many border health 

problems. It is our hope that the information provided in this report will assist 

policymakers, public health agencies, private foundations and others to improve 

the design and efficacy of health programs and projects for the population of the 

U.S.-Mexico border region.

References

Arizona Office of Border Health.(2004) Healthy Gente 2010. Tucson, 2004. 

Retrieved September 13, 2007 from www.azdhs.gov/phs/borderhealth/

healthy_gente.htm

Border Counties Coalition. (2006). At the Crossroads: U.S.-Mexico border 

counties in transition. El Paso. Retrieved August 16, 2007, from www.

bordercounties.org

Bruhn, J.G. & Brandon, J.E. (1997). Border health: Challenges for the United 

States and Mexico. New York, Garland Publishing.

Chan, L.S., McCandless, R., Portnoy, B., Stolp, C., Warner, D.C. (1987). 

Maternal and child health on the U.S.-Mexico border: Special project report. 

Austin, TX: University of Texas at Austin.

Centers for Disease Control. (1999). Self-reported prevalence of diabetes among 

Hispanics: United States, 1994-1997. Morbidity and Mortality Weekly 

Report, 48, 8-12.

Colonia Initiatives Program of the Office of Texas Secretary of State. (2006, 

December 1). Tracking the progress of state-funded projects that benefit 

colonias. Retrieved September 11, 2007, from http://www.sos.state.tx.us/

border/forms/sb827_111706.pdf
Border Lives: Health Status in the United States-Mexico Border Region

24

Department of Transportation, Bureau of Transportation Statistics, US-Mexico 

Border Crossing Data. Retrieved May 28, 2008, from http://www.bts.gov/

programs/international/border_crossing_entry_data/us_mexico/

Environmental Protection Agency. (1996). U.S.-Mexico Border XXI Program: 

Framework document. Washington, DC: Author.

Ford, L.A., Barnes, M.D., Crabtree, R.D., & Fairbanks, J. (1998). Boundary 

spanners: Las promotoras in the borderlands. In: J.G. Power & T. Byrd 

(Eds.), U.S.-Mexico border health: issues for regional and migrant populations. 

Thousand Oaks, CA: Sage Publications.

Pan American Health Organization. (1994). Sister Communities Health Profile, 

1989-91. U.S.-Mexico Border Field Office, El Paso, TX. Retrieved August 

16, 2007, from www.fep.paho.org

Power, J.G. & Byrd, T. (Eds.). (1998). U.S.-Mexico border health: Issues for 

regional and migrant populations. Thousand Oaks, CA: Sage Publications.

Scribner, R. (1996). Paradox as paradigm: the health outcomes of MexicanAmericans. American Journal of Public Health, 86, 303-305.

Secretariat of Health of Mexico, Direccion General de Evaluacion del 

Desempeno. (2007). Indicadores de resultado. Mexico City. Retrieved 

September 13, 2007, from http://evaluacion.salud.gob.mx/indicadores/

indicadores.htm

Suarez, L., Hendricks, K.A., Cooper, S.P., Sweeney, A.M., Hardy, R.J., & 

Larsen, R.D. (2000). Neural tube defects among Mexican Americans living 

on the U.S.-Mexico border: Effects of folic acid and dietary folate. American 

Journal of Epidemiology, 152, 1017-1023.

Tsui, J., Saraiya, M., Thompson, T., et al. (2007). Cervical cancer screening 

among foreign-born women by birthplace and duration in the United 

States. Journal of Women’s Health, 16, 1447-57.

U.S. Department of Commerce, Bureau of the Census. (2003). Summary File 1, 

2000 Census. Retrieved March 9, 2007 from www.census.gov/main/www/

cen2000.html

U.S. Department of Justice, Office of Justice Programs, Bureau of Justice 

Statistics. (2007). Crime and Victims Statistics, 2007. Retrieved August 16, 

2007 from www.ojp.usdoj.gov/bjs/cvict.htm.
Introduction 

25 

U.S.-Mexico Border Health Commission. (2003). Healthy Border 2010: An 

agenda for improving health on the United States-Mexico Border. El Paso, TX: 

Author.

U.S.-Mexico Border Health Commission, Mexico Section. (2002). México: 

Frontera norte saludable: Seccion de México. Mexico City: Author.

27 

CHAPTER 1

THE U.S. POPULATION AT THE BORDER

I

n most discussions of health status, population issues serve only as an 

introduction or background to health topics. But population issues have 

an important bearing on many aspects of health, including the ability to 

access and pay for health care, the likelihood of developing chronic disease, 

environmental exposures, diet and other risk factors. Population issues directly 

affect almost all Healthy Border 2010 objectives.

According to the 2000 U.S. Census, more than 6.5 million people reside in the 

44 U.S. counties within 100 kilometers of the Mexican border. Due to climate, 

terrain, the availability of water, and other issues, the border population is 

overwhelmingly urban and largely located close to the border with Mexico. The 

region experienced rapid population growth beginning in the 1980s (U.S.-

Mexico Border Health Commission [BHC], 2003). This growth was related in 

part to strengthened economic ties between the United States and Mexico under 

the North American Free Trade Agreement (NAFTA), which created work 

opportunities in urban areas along the U.S.-Mexico border. In fact, almost all of 

the U.S. border population lives in or near “sister cities” – the U.S. cities linked 

economically, socially and culturally to neighboring Mexican border cities. The 

interdependency between U.S. and Mexican border cities is underscored by the 

roughly one million northbound border crossings that occur each day for work, 

shopping, family visits and other reasons (Freeman, Gomez-Dantes, & Frenk, 

1995).

Methods

This chapter describes the population of the U.S. region near the border with 

Mexico, various characteristics of that population, and recent population 

trends. The population issues covered in this chapter include: population size, 

distribution, and growth; population distribution by age and race/ethnicity; 
Border Lives: Health Status in the United States-Mexico Border Region

28

socioeconomic status of the border population; English language ability of the 

border population; and the proportion of foreign-born residents among the 

border population.

Information presented in this chapter was obtained primarily from the 2000 

decennial census. For some topics, data from the 1990 census were added 

in order to provide trends (Census 2000 Gateway, 2007). Census Bureau 

population data for recent years allow respondents to claim more than one race, 

conforming to the 1997 Office of Management and Budget (OMB) standards 

for the collection of data on race and ethnicity (OMB, 1997). Because many 

U.S. states continue to request only a single race for birth and death registration, 

it was necessary to modify the census population counts and estimates for recent 

years to produce denominators needed to calculate vital rates. The modified 

census data, known as bridged-race estimates, were prepared by the National 

Center for Health Statistics in collaboration with the National Cancer Institute 

and the Census Bureau (Ingram, 2003). Bridged-race estimates also facilitate the 

presentation of race-specific data.

Population Distribution

The distribution of border residents within the 44-county area is far from even 

and this uneven distribution impacts these residents’ health, especially in terms 

of access to health care. California and Texas claim the largest proportions of the 

border population, with fewer residents in Arizona and only a small percentage 

in New Mexico. Table 1 shows the distribution of the population in the border 

region. With more than 91 percent of the population residing in urban areas, 

the border region is significantly more urbanized than the United States as a 

whole. Nationwide, 79 percent of the population lives in urban areas. The urban 

proportion of the border population increased slightly over the last decade of 

the twentieth century, from 88.5 percent in 1990 to 91.3 percent in 2000. In 

addition, a large proportion of the border population is located in just a few 

areas. San Diego County alone accounts for 43 percent of the total, with Pima 

and El Paso counties each claiming more than 10 percent of the total. The 

residents of these three counties represent almost two-thirds of the total border 

population.

The remainder of the U.S. border population is distributed among the 

remaining 41 counties, most of which cover very large geographic areas. Thus, 

despite a large and growing total population, the number of residents per square 

mile is extremely low in many border counties, particularly in New Mexico 

and Texas. Eighteen border counties have fewer than five residents per square 

mile and seven have less than one resident per square mile (see Figure 1). The 

Texas counties of Kenedy and McMullen each have fewer than 1,000 residents, 
 Chapter 1 - The U.S. Population at the Border

29 

comprising roughly 0.01 percent of the total border population. Kenedy County 

has 414 residents or less than 0.5 inhabitants per square mile.

The combination of high and low population density creates problems for health 

resources in both areas. In urban areas, high population density strains existing 

health-care resources and public health infrastructure. In rural and frontier 

areas, extremely low population densities translate into long distances to the 

nearest physician’s office or hospital. Several U.S. border counties do not have 

a single hospital, clinic, or physician’s office. For a detailed discussion of health 

workforce issues, see Chapter 2, “The Healthcare Workforce.”

Table 1: Population by various characteristics, U.S.-Mexico border, 2000

United States 281,421,906 13.2 100.0 79.0 21.0

Border States 61,673,146 18.8 100.0 89.3 10.7

Arizona 5,130,632 40.0 8.3 88.2 11.8

California 33,871,648 13.8 54.9 94.4 5.6

New Mexico 1,819,046 20.1 2.9 75.0 25.0

Texas 20,851,820 22.8 33.8 82.5 17.5

Border counties 6,553,766 20.0 100.0 91.3 8.7

Arizona border 1,159,908 28.4 17.7 87.6 12.4

Cochise 117,755 20.4 1.8 66.4 33.6

Pima 843,746 26.3 12.9 91.6 8.4

Santa Cruz 38,381 28.4 0.6 68.1 31.9

Yuma 160,026 48.6 2.4 86.9 13.1

California border 2,956,194 12.7 45.1 95.6 4.4

Imperial 142,361 28.3 2.2 85.5 14.5

San Diego 2,813,833 12.0 42.9 96.1 3.9

New Mexico border 312,200 25.5 4.8 72.9 27.1

Dona Ana 174,682 29.2 2.7 79.6 20.4

Otero 62,298 20.3 1.0 71.0 29.0

 - Other NM border 75,220 21.7 1.1 59.1 40.9

Texas border 2,125,464 26.1 32.4 90.0 10.0

Cameron 335,227 28.1 5.1 87.1 12.9

El Paso 679,622 14.0 10.4 96.9 3.1

Hidalgo 569,463 47.2 8.7 93.4 6.6

Maverick 47,297 35.6 0.7 88.4 11.6

Starr 53,597 31.1 0.8 78.7 21.3

Val Verde 44,856 16.3 0.7 89.9 10.1

Webb 193,117 43.6 2.9 95.6 4.4

 - Other TX border 202,285 5.4 3.1 59.8 40.2

 

Percent growth, 

Total 1990-2000

Percent 

Total

Percent 

Urban

Percent 

Rural
Border Lives: Health Status in the United States-Mexico Border Region

30

Population Growth

Rapid population growth also is straining health resources in the border region. 

The population in the 44 border counties has grown rapidly since 1970. 

Between 1970 and 2000, the border population more than doubled, from 3.1 

million to more than 6.5 million inhabitants. Table 1 shows the percent of 

population growth, and Figure 1 illustrates the population density throughout 

the border region. Although the growth rate slowed somewhat during the 1990s, 

the border population still grew by 20 percent from 1990 to 2000, while the 

total U.S. population grew by 13 percent. As Figure 2 illustrates, if growth 

trends of the 1990s continue, the U.S. border population will reach 8 million in 

2010 and 9.8 million by 2020.

Not all U.S. border counties grew at the same rate during the 1990s, and some 

counties even experienced negative population growth. Certain border counties 

grew rapidly over the decade, with increases of 40 percent or more in three 

counties: Yuma County, Arizona, and Hidalgo and Webb counties in Texas. 

Growth of 25 percent or more was recorded in seven other border counties. Two 

of the largest border counties — San Diego, California, and El Paso, Texas — 

reported much lower growth rates for the decade: 12 percent and 14 percent, 

respectively. Eleven of the smaller border counties lost population between 1990 

and 2000.

Population growth in the border region is fueled by a number of factors. 

Growing economic trade with Mexico is an important stimulus, but not the 

Figure 1: Population density, U.S.-Mexico border, 2000

Source: U.S. Census Bureau, 2000 Census, Summary File 1
 Chapter 1 - The U.S. Population at the Border

31 

only one. Favorable weather and a lower cost of living are a great attraction to 

migrants, including many U.S. retirees who have relocated to border counties. 

The elderly population of the border is growing faster than the total population. 

From 1990 to 2000, the population aged 65 years or more grew by 26 percent, 

compared to 12 percent for the nation and 19 percent for the four border 

states. Growth of the elderly population was especially rapid in the border areas 

of New Mexico (42 percent increase), Arizona (37 percent), and Texas (35 

percent). Because of greater use of health services by the elderly, continued rapid 

growth of this age group will place a heavy burden on border health resources. 

In addition, the aging population is likely to lead to a growing prevalence of 

chronic diseases in the region.

The high birth rate in many parts of the border region is another important 

contributor to population growth. Continued rapid population growth will 

strain many border resources, not least the supply of physicians, nurses, and 

other health personnel. Rapid population growth also will require substantial 

public and private investment to ensure adequate educational services, housing, 

safe water supplies, and other resources that provide the foundation for healthy 

communities.

Figure 2: Population trends, U.S.-Mexico border, 1970-2020

Source: 1970-2000: U.S. Census Bureau; 2010-2020: projection using 1990-2000 average 

annual percent growth rates
Border Lives: Health Status in the United States-Mexico Border Region

32

Age Distribution

Overall, the age distribution of the U.S. border population is younger than 

that of the total U.S. population, but the border age distribution is affected 

by three major trends. First, the movement of retirees to the region adds to 

the proportion of elderly. Second, the migration of individuals seeking work 

increases the working-age population. Third, the high birth rate in many border 

counties leads to a relatively high proportion of children. The impact of these 

trends on age distribution varies substantially by ethnic group.

Figure 3 and Figure 4 contain population pyramids that present the age and sex 

distributions on a percentage basis for the 44 border counties combined and the 

United States. The border pyramid shows a slightly younger population, with 

almost 32 percent of the population below 20 years of age, as compared to about 

29 percent for the United States. The proportion of elderly (age 65 years or 

more) is similar in both populations, at 11 percent for the border region and 12 

percent for the United States. The border regions of the four border states also 

have differing age distributions, with Arizona and California reporting about 

29 percent below age 20 while New Mexico and Texas have larger proportions 

in the young ages, at 33 percent and 37 percent respectively. Among the larger 

border counties, Webb County, Texas had the largest proportion of youth (39 

percent under age 20) and Yuma County, Arizona had the largest proportion of 

elderly (16.5 percent aged 65 or more).

Figure 3: Population pyramid,

U.S.-Mexico border, 2000

Figure 4: Population pyramid,

United States, 2000

Source: U.S. Census Bureau, Summary File 1, 2000
 Chapter 1 - The U.S. Population at the Border

33 

Race and Ethnicity

Race and ethnicity are also important contributors to overall health. The high 

proportion of Hispanics in the border region means that a substantial part of 

the population may be predisposed to certain diseases, such as diabetes mellitus. 

Many border Hispanics experience a lack of health insurance coverage, low 

levels of income and education, and poor English language skills, all of which 

represent barriers to adequate health care. Access to health care on the border 

will be covered in Chapter 3, “Access To and Use of Health Care.” Data on 

border income, education and language skills are presented later in this chapter. 

In addition, a notable proportion of border Hispanics are migrant or seasonal 

farm workers, a situation that presents its own unique challenges to ensuring 

continuity of care (Benavides-Vaello, 1998).

Procedures for determining the racial identity of the U.S. population underwent 

major change in the 2000 census, as mentioned in the Methods section above. 

In previous censuses respondents were asked to select the single racial category 

that best described them. Using the new racial identity standards, respondents 

in the 2000 census were permitted to select more than one race, from a total 

of 31 racial categories, to reflect their racial heritage more accurately. More 

than 97 percent of the U.S. population selected a single racial category, but the 

remaining population selected two, three, or more races from the 31 possible 

categories. Presenting this information concisely is a major challenge. To 

simplify the presentation of such data for the U.S. border region, single-race 

estimates of the 2000 population, known as bridged-race estimates, were used 

in Table 2 and Figures 5-7. The bridged-race estimates of the 2000 population 

provide single-race estimates of the population using the four racial categories 

defined for use in the United States prior to 1997 (Ingram, 2003). These same 

bridged-race population estimates were used to calculate vital rates.

Table 2 provides details on the racial and ethnic mix of the border area in the 

year 2000 using the bridged-race population estimates. The racial and ethnic 

distribution of residents in the border states, and in particular the 44 border 

counties, differs substantially from the national pattern. At the national level, 

blacks and Hispanics share roughly equal proportions of the population, 

about 13 percent. At the border state and border county levels, however, the 

proportion of Hispanics is much larger and the proportion of blacks is smaller. 

The border areas of California and Arizona have some black and Asian-American 

residents. In California, more than 15 percent of the border population is 

composed of black and Asian-American residents. However, if San Diego 

County is excluded, Hispanics and non-Hispanic whites represent more than 95 

percent of the remaining border population.
Border Lives: Health Status in the United States-Mexico Border Region

34

Table 2: Percent distribution of population by race and ethnicity, U.S.-Mexico 

border 2000

*Persons of Hispanic origin may be of any race.

**Excludes San Diego County

Source: NCHS website of U.S. census population with bridged-race categories,

www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge/htm

United States 81.7 70.0 13.0 1.1 4.2 12.6

Border states 81.8 51.1 8.5 1.8 8.0 32.1

Arizona 88.7 64.5 3.6 5.4 2.3 25.5

California 78.9 48.1 7.4 1.4 12.3 32.5

New Mexico 86.1 45.6 2.3 10.2 1.4 42.3

Texas 84.3 52.9 11.9 0.7 3.1 32.2

 

Border counties 89.1 41.6 4.2 1.5 5.3 49.0

Border counties** 94.5 30.3 2.4 1.7 1.4 65.6

Arizona border 91.0 58.2 3.5 3.2 2.3 34.4

Cochise 90.9 61.1 5.3 1.6 2.2 30.9

Pima 90.1 62.1 3.6 3.7 2.5 29.6

Santa Cruz 98.0 18.0 0.4 0.8 0.8 81.0

Yuma 94.0 44.9 2.6 2.0 1.4 50.8

California border 82.3 54.9 6.5 1.2 10.0 29.1

Imperial 90.8 20.8 4.3 2.3 2.6 72.6

San Diego 81.8 56.6 6.6 1.2 10.4 26.9

New Mexico border 94.0 41.9 2.3 2.7 1.1 53.7

Dona Ana 94.8 33.2 2.0 2.0 1.2 63.5

Otero 87.6 57.0 4.6 6.3 1.5 32.3

Other NM border 97.2 49.8 0.9 1.5 0.4 48.6

Texas border 96.7 14.0 1.6 0.8 0.9 83.9

Cameron 98.1 14.6 0.6 0.6 0.6 84.6

El Paso 94.1 17.3 3.4 1.1 1.4 78.5

Hidalgo 98.1 10.5 0.6 0.6 0.7 88.5

Maverick 97.4 3.6 0.4 1.4 0.8 95.2

Starr 99.0 2.1 0.2 0.3 0.5 97.6

Val Verde 96.7 22.0 1.8 0.8 0.7 75.8

Webb 98.3 5.0 0.5 0.7 0.6 94.4

Other TX border 97.1 24.6 1.7 0.7 0.5 73.5

White

Total

NonHispanic BlackAmerican 

Indian Asian HIspanic*
 Chapter 1 - The U.S. Population at the Border

35 

Figure 5 provides race and ethnicity information for the two most prevalent 

groups in the U.S. border region: Hispanics and non-Hispanic whites. While 

Hispanics constituted slightly more than 12 percent of the total U.S. population, 

they represented nearly one-third of the combined population of the four border 

states. Within the 44 border counties, Hispanics were nearly half the total 

population. The percent Hispanic followed a west-east gradient, ranging from 

29 percent in the California border counties, 34 percent in the Arizona border 

region, 54 percent in the New Mexico border area, to nearly 84 percent on the 

Texas border. 

There were major differences in the age structure of the Hispanic and non-Hispanic 

white groups in the border region, as depicted in Figure 6 and Figure 7. The 

population pyramid for the Hispanic border population displays the shape of a 

rapidly growing population, with large proportions in the youngest ages and a 

correspondingly small elderly population. The slightly smaller percentage in the 

0-4 age group may be the first sign of a decline in birth rate in border Hispanics. 

The non-Hispanic white pyramid is quite different, with a large proportion of the 

total in the 35-54 year age range (corresponding to the years of the post-World 

War II baby boom), and smaller proportions in the very young and elderly age 

groups. Overall, 40 percent of the Hispanic population was under 20 years of age 

compared to 22 percent of non-Hispanic whites; less than 7 percent of the Hispanic 

population was aged 65 years or more, compared to nearly 18 percent of nonHispanic whites.

Figure 5: Percent Hispanic, U.S.-Mexico border region, 2000

Source: NCHS website for U.S. Census population with bridged-race categories, 

www.cdc.gov/nchs/about/major/dvs/popbrige/popbridge/htm
Border Lives: Health Status in the United States-Mexico Border Region

36

Foreign-Born Population

On the basis of figures from the 2000 census, more than 1.4 million border 

residents, amounting to nearly 22 percent of the border population, were born 

outside the United States to parents who were not U.S. citizens (Table 3). The 

proportion of foreign-born residents in the border region was almost exactly 

twice the proportion of foreign-born residents in the total U.S. population. This 

finding was not surprising given the migration flow into the United States from 

Latin America. The proportion of foreign-born residents was only slightly lower 

for the four border states combined, about 20 percent. Over the past decade, the 

impact of foreign immigration has been felt at all levels in the United States, with 

substantial increases in the proportion of foreign-born residents for the nation as 

a whole, the four border states, and the border counties. Mexico is the source of 

a growing number of immigrants to the United States, accounting for 30 percent 

of all foreign-born residents for the United States and 72 percent of the foreignborn residents in the border region. The constant influx of foreign-born border 

residents, combined with the high level of daily border crossings, increases the 

probability of communicable disease transmission in the border region.

Figure 6: Population pyramid, U.S.- 

Mexico border. Hispanics, 2000 

Figure 7: Population pyramid, U.S.-

Mexico border. Non-Hispanic whites, 2000

Source: NCHS website for U.S. Census population with bridged-race categories, 

www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge/htm.
 Chapter 1 - The U.S. Population at the Border

37 

Language Ability

From a public health perspective, the ability to speak English is important in 

terms of understanding public health messages and communicating effectively 

with health personnel. Border state health departments have made great 

advances in providing translations into various languages of public health 

advertisements, brochures, and other materials, but an inability to speak English 

inevitably limits the ability of border residents to obtain health information.

According to the 2000 census, about four percent of the border population 

aged five years or more did not speak English at all, and an additional seven 

percent did not speak English well (Table 4). The proportion of non-English 

speakers was about two percent for the border areas of Arizona and California, 

four percent for the New Mexico border, and nine percent for the Texas border. 

For the entire border region, the percent that did not speak English at all rose 

from one percent for those aged 5-17 years to eight percent for those 65 years of 

age or more. Elderly Texas border residents represented the highest proportion 

of non-English speakers (18 percent). Health departments on the border must 

ensure that personnel are able to communicate with non-English speakers and 

that informational materials are translated into the appropriate languages.

Table 3: Foreign-born population and county of birth, U.S.-Mexico border, 2000

Source: U.S. Census Bureau, 2000 Census, Summary File 3

 Foreign born population Country of birth (percent distribution)

 Number Percent Mexico Other Other 

 Latin 

 America

United States 31,107,889 11.1 29.5 22.2 48.3

Border states 12,569,686 20.4 50.5 10.6 38.9

Arizona 656,183 12.8 66.4 5.0 28.5

California 8,864,255 26.2 44.3 11.3 44.4

New Mexico 149,606 8.2 71.7 5.1 23.2

Texas 2,899,642 13.9 64.8 10.1 25.1

Border counties 1,435,155 21.9 71.9 3.3 24.8

Arizona border 167,424 14.4 72.1 3.8 24.0

California border 652,037 22.1 51.5 4.5 44.0

New Mexico border 47,010 15.1 85.9 1.8 12.3

Texas border 568,684 26.8 94.1 1.8 4.1
Border Lives: Health Status in the United States-Mexico Border Region

38

Socioeconomic Status

The population of the U.S. border region is typically characterized as being of 

low socioeconomic status in terms of income, poverty status, level of education, 

and other measures. Socioeconomic status can be an important factor in 

determining diet, environmental exposures, and other health risk factors. While 

average socioeconomic measures for the border are substantially below the 

national averages, the border counties are not uniformly disadvantaged. Indeed, 

certain border communities are substantially better off than the national average 

in terms of income, poverty level, unemployment, or education. Two such 

border counties are San Diego County, California and Pima County, Arizona. 

Of the two, San Diego is the most important because it represents 43 percent 

of the total border population and so has a disproportionate effect on borderwide averages. To illustrate this effect, we have calculated border-wide averages 

for socioeconomic measures in two different ways: including San Diego and 

excluding San Diego. The average figures that exclude San Diego County provide 

a more accurate picture of socioeconomic levels for most areas of the border.

Low income limits access to health care, in particular for those border families 

whose income is above Medicaid income limits but who still cannot afford 

health insurance and are unable to pay out of pocket for health-care costs. 

Hospitals, clinics, and physicians are also less likely to locate in poor areas. 

Table 4: Percent distribution of population age 5+ by ability to speak English, 

U.S.-Mexico border, 2000

*Excludes San Diego County

Source: U.S. Census Bureau, 2000 Census, Summary File 3

United States 1.3 2.9 0.4 2.5 1.5 3.3 1.6 2.4

Border states 3.1 5.9 1.0 6.8 3.7 6.6 4.0 5.0

Border counties 4.4 6.7 1.2 12.9 4.9 7.0 7.7 7.0

Border counties* 6.2 7.9 1.5 20.0 7.0 8.1 11.1 8.5

Arizona border 2.2 4.1 0.9 5.5 2.6 4.5 2.4 2.9

California border 2.4 5.5 0.9 7.3 2.6 5.9 3.6 5.1

New Mexico border 3.6 5.4 1.3 9.7 4.1 5.6 5.3 4.9

Texas border 8.6 10.2 1.7 41.2 9.8 10.4 18.4 13.3

 Age 5+ Age 5-17 Age 18-64 Age 65+

Not 

at all

Not 

well

Not 

at all

Not 

well

Not 

at all

Not 

well

Not 

at all

Not 

well
 Chapter 1 - The U.S. Population at the Border

39 

Table 5 presents per capita income information for 1999 by race/ethnicity, as 

well as percent growth since 1989. Information on non-Hispanic whites was not 

available from the 1990 census, so trend data were only analyzed for the total 

and Hispanic populations. Starting with 1999 data for the total population, 

per capita income in 1999 for the entire border region was $17,771 or about 

82 percent of the national level ($21,587). If San Diego County is excluded, 

however, the per capita income level for the border drops to $13,892, less than 

two-thirds the national figure. In the border counties of three of the four states, 

per capita income is lower than the national level: Arizona (86 percent of the 

national average), New Mexico (64 percent), and Texas (53 percent). Per capita 

income in the California counties, on the other hand, was higher than the U.S. 

level, at $22,460. Only three border counties had per capita incomes above 

$15,000: San Diego County ($22,926), Pima County ($19,785) and Cochise 

County ($15,988). Starr County, Texas reported the lowest per capita income of 

any border county, $7,069 or less than one-third the national level. Within the 

border region, per capita income was lowest in Texas, highest in California, and 

in general rose from east to west.

Comparing per capita income figures by race/ethnicity showed striking 

differences in the border region between income levels of non-Hispanic whites 

and Hispanics (Table 5; Figure 8). For non-Hispanic whites in the border 

region, per capita income was more than twice Hispanic income ($27,411 

versus $9,928) and was actually higher than U.S. national per capita income. 

Figure 8: Per capita income by race/ethnicity, U.S.-Mexico border, 1999

*Excludes San Diego County
Border Lives: Health Status in the United States-Mexico Border Region

40

Table 5: Per capita income by race/ethnicity and percent change, U.S.-Mexico 

border region, 1989 and 1999

*1989-99 change is measured in constant 1999 dollars.

**Excludes San Diego County

Source: U.S. Census Bureau, 1990 and 2000 Census, Summary File 3

United States 21,587 24,819 12,111 11.4 7.3

Border states 21,302 28,888 11,314 6.4 8.1

Arizona 20,275 25,239 10,629 12.1 7.3

California 22,711 31,700 11,674 3.0 2.2

New Mexico 17,261 23,976 12,045 14.2 18.9

Texas 19,617 26,197 10,770 13.2 20.9

 

Border counties 17,771 27,411 9,928 5.8 14.0

Border counties** 13,892 23,575 9,372 10.8 18.3

Arizona border 18,497 23,929 10,528 10.6 11.3

Cochise 15,988 19,424 9,530 11.1 20.0

Pima 19,785 24,775 11,318 11.8 10.3

Santa Cruz 13,278 30,289 9,460 9.7 9.1

Yuma 14,802 21,649 8,964 5.7 14.2

California border 22,460 30,029 11,520 5.0 4.6

Imperial 13,239 23,497 9,927 7.0 18.0

San Diego 22,926 30,150 11,738 5.2 3.1

New Mexico bdr 13,918 19,975 9,350 9.4 14.0

Doña Ana 13,999 22,892 9,328 11.2 14.6

Otero 14,345 18,243 9,029 6.2 7.2

 - Other NM bdr 13,378 17,089 9,592 8.3 15.8

Texas border 11,419 24,359 9,085 11.1 22.6

Cameron 10,960 24,153 8,546 14.5 22.4

El Paso 13,421 26,926 10,273 9.2 22.3

Hidalgo 9,899 24,575 8,012 11.1 19.1

Maverick 8,758 18,135 8,457 25.7 41.7

Starr 7,069 14,995 6,912 26.7 27.6

Val Verde 12,096 20,795 9,402 13.9 29.5

Webb 10,759 24,694 9,966 18.3 21.1

 - Other TX bdr 11,983 19,269 9,294 18.4 33.3

1999 Percent change, 1989-99*

Total

Non-Hispanic 

white Hispanic Total Hispanic
 Chapter 1 - The U.S. Population at the Border

41 

Even with San Diego excluded, non-Hispanic white income in the border 

region was only slightly lower than the national figure. The largest difference 

in per capita income between the two race/ethnicity groups was in California, 

where non-Hispanic whites’ income was nearly three times Hispanics’ income 

($30,029 versus $11,520).

Between 1989 and 1999, the per capita income growth rate in the border 

region was only half the national growth rate (6 percent versus 11 percent), as 

shown in the two right-hand columns of Table 5. Income growth was highest 

in the Arizona and Texas border regions (11 percent in both), and lowest in 

the California border region (5 percent). Although Hispanic per capita income 

remained far lower than that for non-Hispanic whites in 2000, per capita 

income for Hispanics increased substantially during the 1990s. From 1989 to 

1999, per capita income for Hispanic border residents grew by 14 percent, or 

nearly triple the 5.8 percent growth for the total border population. Income 

growth for Hispanics was highest in the border areas of Texas (23 percent) and 

Arizona (11 percent). The smallest increase in Hispanic income during the 

decade was in San Diego County (3 percent).

Poverty Status

Poverty status measures illustrate the high level of poverty within the border 

region (Table 6). In 1999, the proportion of the border population below the 

poverty level was more than 50 percent higher than for the U.S. as a whole, 

20 percent versus 12 percent. However, when San Diego County data were 

removed from the calculation, the percent of the border population living below 

the poverty level increased to 25 percent, more than double the national rate. 

Of the border counties, the lowest percentage of poor was in San Diego (12 

percent) and the highest was in Starr County, Texas (51 percent). Information 

on the percent of children living in poverty showed similar results for the border 

region: 27 percent lived below the poverty level on the border, compared to 16 

percent nationwide. Hispanics in the border region were more than three times 

as likely as non-Hispanic whites to be living in poverty, 30 percent versus 8 

percent. The percentage of children living in poverty was four times higher for 

Hispanics than for non-Hispanic whites, 37 percent versus 9 percent.

There was only a small decrease in the border poverty rate during the 1990s, 

but among Hispanics the decline was much larger. From 1989 to 1999, the 

proportion of the border population living below the poverty level declined 

by one percentage point (from 21 percent to 20 percent), while for Hispanics 

the rate dropped 6 percentage points (from 36 percent to 30 percent). The 

poverty rate for the total population increased or remained unchanged 

during the decade in San Diego and several other border counties. Among 
Border Lives: Health Status in the United States-Mexico Border Region

42

Table 6: Population by poverty status and ethnicity, U.S.-Mexico border 1989 and 1999*Non-Hispanic white, **Excluding San Diego CountySource: U.S. Census Bureau, 1990 and 2000 Census, Summary File 3 
 Chapter 1 - The U.S. Population at the Border

43 

children, the poverty rate declined moderately during the decade, with a larger 

drop for Hispanic children. The childhood poverty rate fell 3 percentage points 

for all border children, from 30 percent to 27 percent, while for Hispanic 

children the rate declined 7 percentage points (44 percent to 37 percent). The 

greatest declines in poverty rates were in the Arizona and Texas border areas.

Unemployment Rates

Unemployment rates for the border are provided in Table 7. The level of 

unemployment as measured by the 2000 census was overstated, the result of 

problems with responses from individuals living in group quarters. In 2003, 

the Census Bureau produced more reliable unemployment rates by limiting 

this measure to respondents living in households (Column A in Table 7). The 

household-only unemployment data followed the same pattern as the income 

and poverty measures discussed above: The rates followed a west-east gradient, 

with the lowest rates in the border area of California and the highest rates in the 

border area of Texas. Pima County, Arizona had the lowest unemployment rate 

(5 percent) and Starr County, Texas had the highest rate (20.9 percent).

Information on race/ethnicity was not available for the household-only 

population, but unemployment rates for racial and ethnic groups were obtained 

for the total population (see columns B-D, Table 7). Even though these rates are 

overstated, they remain useful in illustrating differences in unemployment by 

race/ethnicity. The unemployment rate for border Hispanics was two or more 

times the rate for non-Hispanic whites at the national, border state, and border 

county levels. In the border counties, the race/ethnicity differential did not 

differ greatly across states. The lowest differential was in the California border 

region, where the unemployment rate for Hispanics was 1.9 times that for nonHispanic whites, and the highest was in Texas, where the unemployment rate for 

Hispanics was 2.4 times higher than the rate for non-Hispanic whites.

Education

Education is another important indicator of health status (Marmot, 2005; 

Smith, 2005). Individuals with higher education levels are more likely to seek 

health care, adopt healthy behaviors, and know both about the availability of 

health care and how and when to access it appropriately. The level of education 

for adults (aged 25 years or more) in the border region was considerably lower 

than for the United States as a whole, as depicted in Figure 9 and in Table 

8. Nearly 15 percent of border adults had completed less than nine years of 

education in 2000, double the proportion for the United States (7.5 percent). 
Border Lives: Health Status in the United States-Mexico Border Region

44

Table 7: Unemployment rate by ethnicity, U.S.-Mexico border region, 2000

*Excludes San Diego County

**Source: U.S. Census Bureau, 2000 Census, PHC-T28: Employment information for the 

population in households

***Source: U.S. Census Bureau, 2000 Census, Summary File 3

United States 5.2 5.8 4.3 9.3

Border states 6.2 6.6 4.6 9.5

 Arizona 5.4 5.6 4.1 8.1

 California 6.6 7.0 5.0 10.2

 New Mexico 7.0 7.3 4.6 8.8

 Texas 5.7 6.1 4.1 8.7

 

Border counties 7.3 7.7 4.7 10.8

Border counties*** 9.0 9.0 4.6 11.6

Arizona border 6.0 6.3 4.4 9.4

Cochise 6.5 6.7 5.3 10.5

Pima 5.0 5.3 4.2 7.0

Santa Cruz 7.8 7.7 3.2 9.2

Yuma 11.9 12.1 6.0 17.5

California border 5.7 6.2 4.7 9.0

Imperial 12.5 12.6 6.1 14.8

San Diego 5.4 5.9 4.6 8.4

New Mexico border 8.8 9.3 6.0 11.8

Dona Ana 8.3 9.2 5.4 11.3

Otero 8.0 8.1 6.2 10.6

- Other NM border counties 10.6 10.7 7.2 14.2

Texas border 10.7 10.9 5.0 12.0

Cameron 11.3 11.4 5.0 12.6

El Paso 9.2 9.5 5.3 10.6

Hidalgo 12.0 12.0 5.1 12.8

Maverick 17.5 17.6 3.5 18.0

Starr 20.9 20.9 7.9 21.3

Val Verde 11.2 11.3 3.6 13.7

Webb 9.2 9.3 5.0 9.6

- Other TX border counties 9.1 9.4 4.4 11.3

 

Total Population**

Area

Population in 

Households* 

(Col. A) 

All 

Races 

(Col. B)

non-Hispanic 

Whites* 

(Col. C) 

Hispanic 

(Col. D)
 Chapter 1 - The U.S. Population at the Border

45 

The percentage of border adults with less than nine years of education increased 

to 20 percent when San Diego County was excluded, nearly three times the 

national figure. Education data followed the same west-east pattern, with the 

lowest percent of adults with less than nine years of education in California (8.7 

percent) and the highest in Texas (28.3 percent). In two Texas border counties, 

Maverick and Starr, the percent of adults with less than nine years of education 

exceeded 40 percent.

Across the United States as a whole, educational achievement was significantly 

higher for non-Hispanic whites than for Hispanics. The differential was even 

greater at the border, as Figure 10 illustrates. Nationwide in 2000, 86 percent of 

non-Hispanic whites and 52 percent of Hispanics had completed a high school 

education or more. In the border region, the proportion of non-Hispanic whites 

completing high school or more was actually higher (91 percent) than for the 

United States, and the same was true for the border region without San Diego 

(89 percent). The percent of border Hispanics completing high school or better 

was similar to the U.S. Hispanic rate, about 50 percent.

Educational achievement improved from 1990 to 2000 for the United States as 

a whole and for the border region (Table 8). The proportion of the population 

with less than nine years of education fell in all areas during the 1990s, although 

Figure 9: Education level, U.S.-Mexico Border, 2000

*Excludes San Diego County

Source: U.S. Census Bureau, 2000 Census, Summary File 3
Border Lives: Health Status in the United States-Mexico Border Region

46

Figure 10: Percent high school graduate or more, U.S.-Mexico border, 2000

*Excludes San Diego County

Source: U.S. Census Bureau, 2000 Census, Summary File 3

Table 8: Percent distribution of population (age 25+) by education level, U.S.-

Mexico border region, 1990 and 2000

*Excludes San Diego County

Source: U.S. Census Bureau, 2000, Summary File 3
 Chapter 1 - The U.S. Population at the Border

47 

this proportion remained far higher in the Texas border counties (28 percent) 

than elsewhere. For the United States, the decade saw an increase of four 

percentage points in the proportion with a four-year college degree or more, 

from 20.3 to 24.4 percent. The proportion with a four-year college degree or 

more also increased in the border region, although the increase was smaller than 

for the nation as a whole (2.5 percentage point rise); the smallest gains were in 

the border areas of New Mexico and Texas (1.0 and 1.3 percentage point gains, 

respectively).

Conclusion

A variety of forces have affected the size and composition of the border 

population over time, and will continue to do so into the future. A combination 

of climate, terrain, and water availability has led to a highly urbanized 

population on both sides of the border, producing a string of city pairs known 

as sister cities. The population has grown rapidly in recent decades, and if the 

same pace continues will double by 2030. High birth rates, especially in the 

Hispanic population, is producing rapid growth in the number of children. 

Job opportunities attract working-age migrants, and a combination of climate 

and low cost of living draws many retirees to the area. A large proportion of the 

population is foreign born. The Hispanic proportion of the population is high, 

and that proportion increases from west to east along the border.

The border region does not fare well in terms of socioeconomic measures. The 

unemployment and poverty rates are substantially above the national average 

and per capita income is significantly below the national figure; these differences 

are much greater when San Diego is removed from the border averages. 

Educational achievement is also lower among the border population. These 

socioeconomic disadvantages are particularly marked among Hispanic border 

residents. Combined, these demographics present a number of challenges to 

improving health at the border. The rapidly growing border population presents 

a challenge to ensure an adequate future supply of health resources, including 

health personnel, equipment, and supplies. The sparse population of many U.S. 

border counties may limit access to care, as residents may live many miles from 

health facilities and specialized care. Low income levels also limit access to care, 

in part because individuals lack health insurance and are unable to pay out of 

pocket, but also because hospitals, clinics, and physicians are less likely to locate 

in poor areas. This is reflected by the fact that several U.S. border counties do 

not have a single hospital, clinic, or physician.

Socioeconomic status also can be an important factor in determining diet, 

environmental exposures, and other risk factors. The education level of the U.S. 

border population is relatively low, particularly in Texas and New Mexico, and 
Border Lives: Health Status in the United States-Mexico Border Region

48

this can play an important role in individuals’ willingness to seek health care, 

in the adoption of healthy behaviors, and in the knowledge of the availability 

of health care The aging of the population in the U.S. border region is likely to 

lead to a growing prevalence of chronic diseases, while the high proportion of 

Hispanics in the border region means that an important part of the population 

may be predisposed to certain diseases, such as diabetes mellitus. The high 

proportion of foreign-born residents and the large number of daily border 

crossings increase the probability of communicable disease transmission. 

A significant proportion of border residents speak no English, and a larger 

proportion does not speak English well. This limits their ability to obtain health 

information and to interact with health personnel. Border health department 

personnel must have foreign language skills to establish verbal and written 

communication with residents.

A growing and diverse border population presents a number of challenges to 

public and private health-care services in the border region. The following 

chapters examine these issues from the perspectives of access to care, health 

workforce development and retention, and mortality rates for leading diseases. 
 Chapter 1 - The U.S. Population at the Border

49 

References

Benavides-Vaello S., Seltzer H. (1998). Migrant and seasonal farmworkers. 

In J.G. Power, & T. Byrd (Eds.). U.S.-Mexico border health: Issues for 

regional and migrant populations. (pp. 224-249). Thousand Oaks, CA: Sage 

Publications.

Freeman, P., Gomez-Dantes, O., Frenk, J., (Eds.). (1995). Health Systems in 

an Era of Globalization: Challenges and opportunities for North America. 

Washington, DC: Institute of Medicine; and Mexico, DF: National 

Academy of Medicine.

Ingram D.D., Parker J.D., Schenker N., et al. (2003). United States Census 

2000 population with bridged race categories. Vital Health Statistics 2(135). 

Hyattsville, MD: National Center for Health Statistics.

Marmot M. (2005). Social determinants of health inequalities. Lancet, 

365,(9464), 1099-1104.

Office of Management and Budget. (1997, October 30). Revisions to the 

standards for the classification of Federal data on race and ethnicity, Federal 

Register (62FR58781-58790), Retrieved March 09, 2007, from http://www.

whitehouse.gov/omb/fedreg/ombdir15.html

Smith, J.P. (2005). The Impact of socioeconomic status on health over the 

life-course. Labor and Population Working Paper Series, No. WR-318. Santa 

Monica, CA: Rand Corporation.

U.S. Census Bureau. Census 2000 Gateway. Washington, U.S. Census Bureau. 

Retrieved 3/09/07 from http://www.census.gov/main/www/cen2000.html

U.S.-Mexico Border Health Commission. (2003). Healthy Border 2010: An 

agenda for improving health on the U.S.-Mexico border. El Paso, Texas.

51 

CHAPTER 2

THE HEALTHCARE WORKFORCE

The health workforce is a key contributor to the quality of life of the 

border population and a critical element in reaching Healthy Border 

2010 goals. Regrettably, primary care, dental, and mental health 

professional shortage areas – as defined by the Health Resources and Services 

Administration (HRSA) – are 25 percent to 49 percent more prevalent in the 

border region than in the rest of the nation. Community clinics located in 

border areas struggle to serve a growing population of patients who are poor, 

inadequately insured, or not insured.

There are many challenges to attracting, educating, and retaining a healthcare workforce capable of serving the diverse needs of the border population. 

These challenges include uneven demographic distribution, rapid population 

expansion, poor distribution of the health workforce, low health insurance rates, 

and socioeconomic barriers to access to care. This chapter briefly reviews these 

challenges. Then it partially illustrates them with descriptive data from a recent, 

unprecedented, yet still limited study of the border health workforce. It concludes 

with observations addressing urgent border health workforce policy issues.

Uneven demographic distribution affects the size and quality of sub-regional and 

small areas’ demand for health services. Therefore, delivering adequate care to the 

border communities will require customized strategies. As discussed in Chapter 1,

“The U.S. Population at the Border,” the population of the 44 border counties 

is growing in a geographically unequal pattern at an overall rate of about two 

percent per year. For example, almost half of the population of the U.S.-Mexico 

border region resides in two California counties that make up only seven percent 

of the region’s land area. In contrast, 32 Texas counties, stretching over 64 

percent of that frontier, are home to only one-third of total border residents.

Besides uneven distribution, other demographic factors pose unique challenges 

to health workforce development and retention. The most recent population 
Border Lives: Health Status in the United States-Mexico Border Region

52

projections by the U.S. Bureau of the Census (2004) have revived professional 

and public attention to the aging population. A parallel phenomenon, the 

aging health workforce, threatens its size and effectiveness. This is particularly 

true in the border region, where socioeconomic pressures often induce younger 

physicians to relocate to non-border areas.

The growth of minority groups is another major demographic change taking 

place throughout the U.S., and in greater relative magnitude in the border 

regions. Between 2000 and 2050, the minority population is expected to 

account for approximately 89 percent of total population growth, with 

Hispanics contributing nearly half of that increase (48.6 percent; Murdock, 

2005). The large Hispanic population of the U.S.-Mexico border region will 

lead to structural changes in the country’s demographic profile and, more than 

ever before, will require a culturally competent health workforce to adequately 

address its health-care needs.

Increasing diversity of the population does not in itself call for diversity in the 

health professions. However, researchers including Cohen, Gabriel, and Terrell 

(2002) have argued that “absent sufficient health and racial diversity, the healthcare workforce would be unable to fulfill its fundamental obligation to the 

public” (p. 91). Their argument is rooted in four observations.First, cultural 

competence – a combination of knowledge, skills, attitudes, and behavior – is a 

necessary tool for effective patient/doctor interaction with persons of different 

cultural background. Second, it has been well documented that minority health 

professionals are more likely to locate in underserved communities than their 

non-Hispanic white counterparts. Third, because many serious health problems 

disproportionately affect minorities, the research agenda must place a greater 

focus on minority health and more minority researchers must be recruited and 

encouraged. Finally, diversity is needed in the managerial and policy health 

sectors to find appropriate solutions for the pressing health problems of the 

future. These researchers concluded that diversity in the education of health 

professionals is the necessary condition to augment the pool of competent 

and influential decision makers in all of the above areas of professional activity 

(Cohen et al., 2002).

Large-scale ethnic diversification will significantly impact the mix of diseases 

in the U.S. population. In turn, changes in the type of health services and 

required health professional competencies will be needed to address shifting 

disease burdens in those regions with a high concentration of minorities. Ethnic 

diversification will also magnify the impact of socioeconomic disparities between 

ethnic groups. Poverty rates of Hispanics and blacks are two to three times those 

of non-Hispanic whites. This will increase the need for decentralized delivery 

systems capable of reaching out to isolated and underserved communities 

(Murdock, 2005).
 Chapter 2 - The Healthcare Workforce 

53 

In summary, different health strategies – ideally with decentralized and 

community-based delivery systems using a workforce of health professionals 

with special competencies – are needed to address the different factors that 

account for diseases and health disorders among the communities stretched 

over a 2,000-mile border characterized by varied geographic, demographic, and 

socioeconomic environments.

Often, the need for different strategies is not immediately apparent. Health 

conditions may be epidemiologically equivalent among different border 

communities but vary in causes, morbidity, and contributing environmental and 

socioeconomic factors. For example, in some communities the major barrier to 

access may be the driving distance to the closest clinic; in others, language and 

the absence of culturally competent providers may cause a nearby facility to be 

inaccessible to those who need it most. In other cases, a lack of specialists for 

prevailing morbidities may affect the health status of border neighborhoods. In 

yet other communities, urban enclaves of uninsured and underinsured workers 

remain isolated even when located near well-equipped health-care facilities.

This need for different strategies and types of providers makes their quantity 

and availability an even greater challenge for educational and service delivery 

institutions. Yet increasing the number and the types of health workers will not 

in itself improve the health status of border residents. Appropriate and growing 

economic activity is needed to attract and retain the health workforce which is, 

in turn, both a direct and an indirect contributor to economic development. 

Directly, the health workforce payroll and infrastructure trigger economic 

multipliers; indirectly, an adequate and skilled health workforce contributes 

to a healthier population and thus sustains socioeconomic progress. Without 

adequate economic infrastructure, adverse distribution of the health workforce 

is inevitable, and short tenure of providers where they are needed most will 

reduce or even neutralize the impact of programs aimed at increasing the health 

workforce.

Methods

This chapter uses data from the HRSA Border County Health Workforce 

Profiles (2007) to provide an overview of available information about the health 

workforce in the border region. The Evaluation and Analysis Branch of the 

Bureau of Health Professions, HRSA, developed Border County Health Workforce 

Profiles under a contract with the Regional Center for Health Workforce Studies 

(RCHWS) of The University of Texas Health Science Center at San Antonio1

.

1 The study is available in its entirety by individual state reports at the HRSA web site (http://bhpr.

hrsa.gov/healthworkforce/) and at the RCHWS/UTHSCSA web site (http://www.uthscsa.edu/rchws/projects.

htm).
Border Lives: Health Status in the United States-Mexico Border Region

54

This data-gathering project was the first systematic effort to assemble current 

information on the health workforce in the border region, relevant population 

characteristics, and basic health indicators in one consistent database. The 

study was designed to address the emerging health-care needs of the diverse and 

rapidly changing population of the U.S.-Mexico border region and the challenge 

of developing policy responses with the limited, usually highly aggregated, 

and non-comparable information on the health workforce available from state 

databases.

County-level data were obtained from state health agencies and health 

professions’ licensing boards and verified for comparability and consistency. 

These data were used to develop social and health indicators and estimate 

practitioner-to-population ratios. Healthy Border 2010 objectives guided the 

selection of health indicators. Border county values were then compared to 

values for each state – Arizona, California, New Mexico, Texas – as a whole, the 

total for the four border states, and the nation. These indicators help describe 

health status and health disparities in the U.S.-Mexico border region, as well 

as provide information on the number of practitioners available to address the 

health needs of the areas. Because Florida bears some similarity to the states that 

share a border with Mexico, being a port of entry and a place of settlement for 

immigrants entering the United States, it was added to the series as an additional 

independent study.

The health professions included in the study were physicians, dentists, registered 

nurses, physician assistants, and selected specialties of these professions. Vital 

statistics, hospital discharge data, and incidence data for selected diseases 

were gathered from state health departments. Prevalence data for select health 

conditions were retrieved from the Behavioral Risk Factor Surveillance System. 

County population estimates from the U.S. Census Bureau were used to 

calculate the rates reported here. Ratios of providers per 100,000 population 

were calculated as a first approximation of the health care available to the 

population living in the health workforce service area.

While the information in the profiles is a great improvement over existing and 

rarely comparable data, many limitations remain. Data on state sub-regions 

are only available at the county level for all the states. Thus, politically defined 

county boundaries were used as a unit of measurement, rather than the service 

areas within which health care is actually delivered. County averages may hide 

important differences among sub-regions. For example, concentrations of health

professionals in an urban area may overshadow the lack of health services in 

rural communities and produce inaccurate, better-than-average provider-topopulation ratios for the county as a whole.
 Chapter 2 - The Healthcare Workforce 

55 

Distribution of Health Professionals

The ratio of health providers per 100,000 population is commonly used as a 

rough indicator of the supply of health professionals relative to the demand 

for their services. In the border region, these ratios ranged from less than half 

of the national average (physicians in Texas) to values that were at par with it 

(physicians in California) or exceeded it (registered nurses in Arizona). Ratios 

for key members of medical teams are shown in Table 1.

Generally, ratios of health professionals to population in border states and the 

border region were well below those for the nation. However, ratios of nurse 

practitioners were close to or above the national average of 27.6. Since U.S. data 

were retrieved from the 2000 Census and state data were from 2003 and 2004 

databases, the differences between the border and the nation may be assumed 

to be greater than those shown in the table. The averaged values also do not 

reflect the hardship of underserved communities in inner cities and rural areas 

of the border, since health-care professionals are more likely to practice in more 

affluent urban and suburban centers. Also, adverse geographic distribution 

remains hidden in averages and aggregate statistics.

Maldistribution of physicians occurs throughout the border region. Statewide, 

only 12 percent of counties in California and three percent of counties in 

Arizona have concentrations of physicians comparable to or greater than the 

Sources: (1) Arizona: Arizona Medical Board (2004), and Arizona Board of Osteopathic Examiners in Medicine and Surgery (2004), and Arizona State Board of Nursing (2004); (2) California: 

California Department of Consumer Affairs (2004); (3) New Mexico: New Mexico Health Policy 

Commission (2003); (4) Texas: Texas State Board of Medical Examiners (2003) and Texas 

Board of Nurse Examiners (2003); and (5) U.S.: Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services (2000).

Table 1: Health professionals per 100,000 population
Border Lives: Health Status in the United States-Mexico Border Region

56

national average. The lowest ratios were found in rural counties. Figures 1 

and 2 show physician distribution for the states of California and Arizona 

and illustrate how the aggregate totals can mask differences within a region. 

In California, the number of physicians available in the border counties per 

100,000 population was similar to the number of physicians in the United 

States: 276 and 278, respectively. However, closer examination of the two

counties in the California border region reveals that San Diego County has 

a disproportionately larger number of physicians than neighboring Imperial 

County. A similar situation exists in Arizona where Pima County, which 

includes Tucson, has more physicians per 100,000 population than other border 

counties in the state.

Changes in the Health Workforce

Historical data for comparing health professional characteristics over time were 

available only for Texas. This data is summarized in Tables 2, 3 and 4. The 

Regional Center for Health Workforce Studies at the University of Texas Health 

Science Center at San Antonio and the Texas Department of State Health 

Services are the only repositories of health workforce data dating back to the 

1980s, at least for some professions. Most state agencies maintain only current 

licensure data, and no other research centers have systematically acquired 

licensure data every year, on the same month, to create a reliable source of 

historical information. The lack of historical data from other border states and 

the diversity of population, socioeconomic characteristics, and public health 

Figure 1: Physicians per 100,000

 population in California

Figure 2: Physicians per 100,000

 population in Arizona
 Chapter 2 - The Healthcare Workforce 

57 

structures among them suggest caution in generalizing the Texas experience to 

the region as a whole. At the time of writing, adequate information could not be 

found to support a comparative analysis.

Between 2000 and 2005, more physicians providing direct patient care started 

their practices in or moved their practices to Texas than stopped practicing in 

the state. Forty percent (4,310) of new physicians in Texas graduated from the 

state medical schools, 35 percent (3,843) from other U.S. medical schools, and 

25 percent (2,747) from foreign schools. Of those no longer practicing in the 

state, only half actually left Texas; the others left direct patient care to pursue 

research, teaching, or administrative positions.

Table 2: Changes in gender, age, and ethnicity among Texas direct patient 

care physicians, 2000-2005

Note: Includes active, direct patient care, non-federal physicians

Table 3: Profile of direct patient care physicians entering and leaving 

Texas, 2000-2005

Note: Includes active, direct patient care, non-federal physicians
Border Lives: Health Status in the United States-Mexico Border Region

58

Although the cohort of mature professionals 45 to 54 years of age still showed 

losses, these were partially compensated by young, female, and minority doctors. 

The percentage of female physicians increased from 19.6 percent in 2000 to 

nearly 25 percent in 2005. Of physicians who left the state, 80.5 percent were 

male and 19.5 percent were female. Under-represented minorities constituted 

almost half of direct-practice physicians who started their practices in or moved 

their practices to Texas. Less than one-fourth of those who left the state were 

members of minority groups. Nearly one-fourth (24.1 percent) of doctors who 

entered the state were under 35 years of age, while only 0.5 percent of those who 

exited the state fell in that age group.

Retention of Health Professionals

Health professional retention is a core challenge for the border area. Two major 

forces influence retention rates: the aging of the health workforce and the lack 

of socioeconomic incentives for health. Many health professionals who serve 

the border are growing older and retiring without being replaced by younger 

health workers, and low retention reduces the effectiveness of programs aimed at 

locating new health professionals in underserved areas. Although Texas welcomed 

small increases in younger, minority and female health professionals entering the 

workforce, this only partially compensated for the loss of health/human resources. 

While not systematically studied, the retention issue emerges informally in almost 

all gatherings of stakeholders discussing border health. However, lack of historical 

data allowed the compilation of a retention chart only for Texas.

Figure 3 illustrates the magnitude and urgency of the challenge of maintaining 

an adequate supply of health professionals in the border region. Among the 1993 

cohort of Texas doctors, more than half were no longer practicing in the border 

area 10 years after graduation. The largest numbers of relocations outside the 

border took place after the first and third years of practice.

Table 4: Profile of direct patient care physicians retained within 

Texas, 2000-2005 

Note: Includes active, direct patient care, non-federal physicians
 Chapter 2 - The Healthcare Workforce 

59 

Ethnic Distribution of Health Professionals

The ethnic distribution of the border workforce relative to the population 

is difficult to assess because data on ethnicity and race were not available 

for all border states. Texas, however, does collect ethnicity data for selected 

health professions2

. Data from 2003 show that 47 percent of Texas physicians 

providing direct patient care in the border areas were Hispanic and 35 percent 

were non-Hispanic whites. In comparison, 84 percent of the Texas border 

population was Hispanic and 13.6 percent was non-Hispanic white. While 

a larger proportion of physicians practicing in the Texas border area were 

Hispanic, a wide gap remained between the ethnic backgrounds of health 

providers and those of the populations in their service areas. Predictions of 

rapidly increasing diversity in the population, coupled with modest gains in the 

number of minority health professionals, suggest that the gap is likely to increase 

in the near future.

2 While information on race and ethnicity other than licensure-based data were available for other 

states, these were not comparable to the more current data maintained by the border states and used in the 

HRSA study. 

Figure 3: Physician Retention (1993 Cohort) Non-Border and 

43 Border Texas Counties*

This assessment was made using the definition of border counties adopted 

by the Texas Comptroller of Public Accounts, which includes 11 more counties 

than the 32 so defined by the U.S.-Mexico Border Health Commission.
Border Lives: Health Status in the United States-Mexico Border Region

60

Oral Health Providers

Statewide data from the 2002 Behavioral Risk Factor Surveillance System 

indicate that, with the exception of California and Arizona, the percentage of 

adult border residents visiting a dentist within a year was significantly below 

both the Healthy Border 2010 objective (75 percent) and the national average 

(70 percent).

Low utilization rates of oral health care are closely linked to low densities of oral 

health providers. Figure 4 shows the ratio of dentists per 100,000 population in 

the border region. In New Mexico and Texas, the ratio was approximately onehalf (29.8) and one-third (19.4), respectively, of the national rate of 60 dentists 

per 100,000 population. In 2003, approximately one-fifth (18 percent) of New 

Mexico and one-sixth (15 percent) of Texas border counties did not have a 

dentist.

In California and Arizona, apparently favorable averages conceal maldistribution 

of oral health providers (see Figure 5 and Figure 6). In 2004, only 57 percent 

of counties statewide were equal to or above the 2000 national average rate of 

dentists per 100,000 population. About one-tenth of them (9 percent) had 

rates that were less than half of the national mean. In Arizona, only Coconino 

County, a non-border county, compared favorably with the national average, 

and 40 percent of the state’s border counties had rates that were less than half of 

the national average. Dental shortages occurred mostly in rural areas, and some 

large rural sub-regions had no dentist at all.

Figure 4: Border Oral Health

Dentists per 100,000 Population

Counties Within 62 Miles of the Border Percent visited a dentist 

within past year:

Border Regions:

Arizona – 69.2

California – 74.7

New Mexico –60.9

Texas – 57.5

Total Border Area – 68.2

Border States – 66.3

U.S. – 69.5

Source: Behavioral Risk Factor 

Surveillance System (2002).

Sources: Arizona Medical Board (2004), and Arizona Board of Osteopathic Examiners 

in Medicine and Surgery (2004), New Mexico Health Policy Commission (2003, reflects 

MDs only), and Texas State Board of Medical Examiners (2003); U.S. from Bureau of 

Health Professions, Health Resources and Services Administration, U.S. Department of 

Health and Human Services (2000).
 Chapter 2 - The Healthcare Workforce 

61 

Maternal, Infant, and Child Health

Women living in border regions may not receive prenatal care for their unborn 

children, partly because obstetricians and gynecologists are in short supply3

. 

Figures 7 and 8 present data regarding the availability of gynecologists, 

obstetricians and nurse midwives in the border region. In 2002, the percentage 

of women receiving prenatal care during the first trimester of pregnancy in the 

border region was slightly less than the national average (82 percent and 84 

percent, respectively). For infants and children, health risks continue after birth 

because pediatricians are too few to monitor the physical and cognitive growth 

of all the children in need of their care. In New Mexico and Texas, which have 

the highest fertility rates of the border states, problems associated with lack of 

access to prenatal and pediatric care are likely to increase in intensity.

Chronic Disease Care

Provider-to-population ratios indicate that both primary care physicians and 

specialists are scarce in the border region. Specialty care physicians and other 

health professionals play a key role in helping people manage chronic diseases. 

For instance, diabetes, which is addressed at length in Chapter 7 of this report, 

is a chronic disease disproportionately affecting the border region. Many 

3 County data on the number of physicians by specialty were not available for California at the time 

of writing.

Figure 6: Dentists per 100,000 

 population in Arizona 

Figure 5: Dentists per 100,000 

 population in California 
Border Lives: Health Status in the United States-Mexico Border Region

62

Figure 7: Women’s and Children’s Health 

Sources: Arizona Medical Board (2004) and Arizona Board of Osteopathic Examiners in 

Medicine and Surgery (2004); California Department of Consumer Affairs for nurse midwives 

(2004); New Mexico Health Policy Commission, reflects MDs only (and New Mexico 

Department of Health for nurse midwives) (2003); and Texas State Board of Medical 

Examiners (2003); U.S. from Bureau of Health Professions, Health Resources and Services 

Administration, U.S. Department of Health and Human Services (2000) for physicians and 

The Registered Nurse Population: Findings from the National Sample Survey of Registered 

Nurses, 2001, for nurses.

Sources: Arizona Dept of Health 

Services (2002), California Dept 

of Health Services (2002), New 

Mexico Dept of Health (2002), 

Texas Dept of Health (2002), 

and Births: Final Data for 2002 

(U.S.).

Percent beginning prenatal 

care during first trimester:

Border Regions:

Arizona – 71.6

California – 84.7

New Mexico – 67.1

Texas – 74.7

Total Border Area – 77.8

Border States – 82.4

U.S. – 83.7

Texas – 74.7

Total Border Area – 77.8

Border States – 82.4

U.S. – 83.7

Obstetricians/Gynecologists and Nurse Midwives per 100,000 

Females (Ages 15-44)

Counties Within 62 Miles of the Border

Figure 8: Children’s Care

Pediatricians per 100,000 Children (Ages 0-17)

Counties Within 62 Miles of the Border

General fertility rates:

Border Regions:

Arizona – 72.9

California – 69.6

New Mexico – 74.4

Texas – 104.0

Total Border Area – 81.8

Border States – 72.5

U.S. – 64.8

Sources: Arizona Dept of Health 

Services (2002), California Dept 

of Health Services (2002), New 

Mexico Dept of Health (2002), 

Texas Dept of Health (2002), and 

Births: Final Data for 2002 (U.S.).

Sources: Arizona Medical Board (2004), and Arizona Board of Osteopathic Examiners in 

Medicine and Surgery (2004), New Mexico Health Policy Commission (2003, reflects MDs 

only), and Texas State Board of Medical Examiners (2003); U.S. from Bureau of Health 

Professions, Health Resources and Services Administration, U.S. Department of Health and 

Human Services (2000).
 Chapter 2 - The Healthcare Workforce 

63 

health professionals are involved in the care of a diabetic patient. Primary care 

physicians help monitor patients’ blood glucose levels and their overall health 

status; ophthalmologists assist in the evaluation and treatment of glaucoma and 

other vision problems; and orthopedic surgeons are needed in complications 

calling for amputation of extremities. Other specialists such as endocrinologists, 

cardiologists, and mental health professionals may also be involved in the care of 

the diabetes patient.

Table 5 shows ratios of primary care and selected specialty care physicians 

involved in diabetes treatment in the border region per 100,000 population. 

While the average border ratio was only one-fourth less than the national 

average, large discrepancies existed between counties in different states. In the 

Arizona border counties, the ratio (89.6) was actually higher than the national 

average (85.0). California border counties fared less well, with a ratio of 62.7. In 

New Mexico (47.7) and Texas (48.9), ratios were only a few percentage points 

above half of the national average. It is not surprising that in New Mexico 

and Texas, the mortality rates for diabetes are 36 and 40 deaths per 100,000 

population, respectively, notably higher than the national rate of 25.

Mental Health Professionals

Border communities need mental health professionals to effectively address 

mental health conditions, which may heighten the individually and socially 

damaging effects of low wages, low productivity, and unemployment. Shortages 

of mental health professionals have a substantial negative impact on these 

Age-adjusted 

mortality rates

for diabetes:

Border Regions:

Arizona – 20.7

California – 18.6

New Mexico – 36.3

Texas – 40.3

Total Border Area – 26.1

Border States – 25.7

U.S. – 25.4

Sources: Arizona Dept of Health 

Services (2002), California Dept 

of Health Services (2002), New 

Mexico Dept of Health (2002), 

Texas Dept of Health (2002), and 

Births: Final Data for 2002 (U.S.).

Sources: (1) Arizona: Arizona Medical Board (2004), and Arizona Board of Osteopathic 

Examiners in Medicine and Surgery (2004); (2) The Practice of Medicine in California: A 

Profile of the Physician Workforce. San Francisco CA: California Workforce Initiative at the 

UCSF Center for the Health Professions. February 2001, for primary care physicians; (3) 

New Mexico: New Mexico Health Policy Commission (2003), reflects MDs only; (4) Texas: 

Texas State Board of Medical Examiners (2003); and, (5) U.S.:: American Medical Association 

Masterfile (2006) with 2005 estimates for population as 2006 were not available.

Table 5: Medical Care for Chronic Diseases: The Case of Diabetes 
Border Lives: Health Status in the United States-Mexico Border Region

64

communities’ quality of life. In each state, the psychiatrists available to address 

mental health issues in the border regions were below the national average of 

12.7 psychiatrists per 100,000 population (Figure 9). California, New Mexico, 

and Texas face the greatest shortages with only 7.4, 4.7, and 3.0 psychiatrists per 

100,000 population, respectively.

Health Workforce Training

Most educators, health administrators, and policy makers who are engaged 

in health professional workforce development in the border region agree 

that training health professionals where they are needed is a key strategy for 

encouraging graduates to practice in border communities. Historically, health 

professional training has been accomplished in large urban centers far from 

the border, and recent efforts to change this state of affairs have not yet been 

evaluated. Also, no scientific study on the border workforce has been undertaken 

to prove a link between training location and choice of practice location, 

and the evidence so far is at best indirect. However, many unpublished and 

informal surveys, reports to funding agencies, and informal investigations by 

administrators of educational institutions suggest that those students who were 

trained in underserved areas or were recruited from those areas were more likely 

to return to those locations to practice.

In a related area of research, studies (Rabinowitz et al., 2001; Rosenthal, 2000) 

have been conducted on workforce shortages in rural areas and on the positive 

impact of medical training that includes exposure to rural medicine on practice 

Figure 9: Mental Health

Pediatricians per 100,000 Population

Counties Within 62 Miles of the Border Years of potential life lost/

mortality rate due to suicide: 

Border Regions:

Arizona – 336.9 / 15.5

California – 227.8 / 10.6

New Mexico – 445.9 / 20.0

Texas – 143.3 / 6.5

Total Border Area – 

229.0 / 10.7

Border States – 237.0 / 10.9

U.S. – 261.6 / 10.9

Sources: Arizona Dept of Health 

Services (2002), California Dept 

of Health Services (2002), New 

Mexico Dept of Health (2002), 

Texas Dept of Health (2002), 

and National Center for Injury 

Prevention and Control, WISQARS 

Years of Potential Life Lost 

Reports (2001).

Sources: Arizona Medical Board (2004), and Arizona Board of Osteopathic 

Examiners in Medicine and Surgery (2004); The Center for Health Professions, 

University of California, San Francisco (2003), reflects 2000 data; New Mexico 

Health Policy Commission (2003, reflects MDs only); and Texas State Board of 

Medical Examiners (2003); U.S. from American Medical Association Masterfile 

(2006), where 2005 population estimates used as 2006 were not available.
 Chapter 2 - The Healthcare Workforce 

65 

location decisions. These studies provide strong evidence that a combination 

of factors, such as the selection of matriculates with appropriate background 

and career goals, and offering training that includes clinical experiences in rural 

medicine, increase the number of practitioners locating in rural underserved areas. 

The research is convincing and useful for guiding educational programs even if 

not successful in isolating the factors as independent predictors of rural practice 

(Ranmuthugala et al., 2007). In addition, several studies have demonstrated 

that health professionals who are members of minority groups are more likely to 

practice in underserved areas (Cohen, et al., 2002; Kington, et al., 2001).

The accumulation of this informal and formal knowledge has motivated HRSA’s 

Bureau of Health Professions to support the development of a guidebook for 

increasing the number of disadvantaged and minority students entering the 

health professions, with the ultimate goal of increasing the health status of the 

border. A consortium of the U.S.-Mexico Border Centers of Excellence will 

develop the guidebook4.

Some federal programs are specifically aimed at addressing health workforce issues 

of underserved areas and offer great potential for an effective Border workforce 

policy. However, their impact on Border health professionals has not been 

adequately evaluated. Notable among them are the special J-1visa for foreign 

physicians, the H1-B visa for foreign-born employees without residence privileges, 

and the National Health Service Corps (NHSC) program5. In 1998, Baer, 

Ricketts, Konrad and Mick reported that international medical graduates 

accounted for a greater proportion of primary care physicians in rural areas with 

physician shortages. It is estimated that the NHSC loan repayments and other 

assistance programs will support 3,400 clinicians in the HRSA FY 2009 proposal, 

with half of them to be assigned to serve in HRSA-supported health centers.

Community Health Workers

Given persistent health workforce shortages, successfully addressing 

communities’ different needs may require innovative strategies such as adding 

promotores/promotoras and other community health workers (CHWs) to the 

health-care team. As defined by the Community Health Worker National 

Workforce Study (2007):

Community health workers are lay members of communities who work 

either for pay or as volunteers in association with the local healthcare system in both urban and rural environments and usually share 

4 More information about the guidebook project is available at the website of the University of Texas 

Health Science Center at San Antonio, Medical Hispanic Center of Excellence, 

www.uthscsa.edu/hcoe/consortium.asp.

5 http://nhsc.bhp.hrsa.gov/
Border Lives: Health Status in the United States-Mexico Border Region

66

ethnicity, language, socioeconomic status and life experiences with 

the community members they serve. CHWs offer interpretation and 

translation services, provide culturally appropriate health education and 

information, assist people in receiving the care they need, give informal 

counseling and guidance on health behaviors, advocate for individual 

and community health needs, and provide some direct services such as 

first aid and blood pressure screening.

In other words, community health workers work in the gap between social 

services and health systems. They are employed under many job titles, including 

peer health educator, outreach worker, community health advocate, and in 

Mexico, Latin America, and Hispanic communities in the United States, are 

referred to as promotores and promotoras6.

A Community Health Worker National Workforce Study (2007) has collected 

detailed data on this emerging workforce nationwide and in the border region7. 

In the four border states combined, nearly 16,000 community health workers, 

both paid and volunteer, provided services in their communities – about 

26 per 100,000 population. It is unknown how many were working in the 

border region. Nationally, there were an estimated 85,879 community health 

workers in 2000 – about 31 per 100,000 population. Evidence regarding the 

effectiveness of community health workers in complementing medical teams to 

improve health outcomes is accumulating and research on this sector of the 

workforce is just now beginning to produce acceptable results (HRSA, 2007).

Conclusion and Recommendations

The following conclusions are an attempt to link the border workforce issues 

listed at the beginning of the chapter with the findings of the data-gathering 

project sponsored by HRSA. The comments deliberately go beyond the details 

of the data to draw, in a few bullet statements, the larger and complex picture of 

challenges facing the border health workforce, Hispanic health, and health policy.

6 More specifically, the terms are used to describe advocates of the welfare of their own communities 

who have the vocation, time, dedication, and experience to assist fellow community members in improving 

their health status and quality of life. Recently the terms have been interchangeably, despite some opposition, 

with the term community health workers.

7 The two-year study was conducted by the University of Texas Health Science Center at San 

Antonio Regional Center for Health Workforce Studies under a contract with the HRSA Bureau of Health 

Professions, Evaluation and Analysis Branch, The research, accomplished in collaboration with several national 

and state organizations, chronicles for the first time, in all the 50 states, the involvement of community health 

workers in the delivery of health services, summarizes the legislative process relative to their integration in the 

U.S. health-care system, describes the skills required by employers and provides national and state workforce 

estimates. Completed in 2007, the study is available in its entirety at the HRSA web site (http://bhpr.rsa.gov/

healthworkforce/) and at the RCHWS/UTHSCSA website (http://www.uthscsa.edu/rchws/projects.htm).
 Chapter 2 - The Healthcare Workforce 

67 

In 1989, the first National Action Forum on Health Policy and the Hispanic 

was sponsored in San Antonio, Texas by the Robert Wood Johnson Foundation. 

It attracted an unprecedented group of scholars, health researchers, public 

figures, educators, administrators of health programs, and health professionals 

(Furino, 1992). The results were so powerful in their vision of a better future for 

the underserved and so terse in their message of what was needed to successfully 

address the problems that they produced another unprecedented event: the first 

issue of the Journal of the American Medical Association to be totally dedicated 

to Hispanic health (JAMA, 1991; Furino & Munoz, 1991). The Hispanic health 

issues addressed in that volume, published 18 years ago, are strikingly similar 

to the border problems of today. The challenges are complex and – despite 

increased public recognition of the urgency of the problems, the goodwill 

of many dedicated individuals, organizations, and public entities, and some 

progress – the problems linger. These problems need the strongest resolve of 

private and public organizations, and the public at large, for their solution.

This chapter provides a summary of the available data on the health workforce 

in border state sub-regions. Collecting, verifying, and organizing these data 

represent an important first step that should be followed by additional research 

and analyses linking the data to the available relevant literature. The health and 

workforce indicators vary greatly among the border states and the regions and 

counties within them. They also vary between rural, urban and suburban areas. 

But these differences are often hidden in the aggregate data and averages used 

to make policy and to design intervention programs. Therefore, a key objective 

for stakeholders in the public and private sectors should be the development 

of reliable community-level data. Without this data, it is difficult to make 

appropriate policy decisions and develop effective intervention programs. 

Finally, border health workforce problems are the result of multiple factors and 

therefore require multiple, decentralized, and simultaneous interventions.

The following recommendations suggest some of the challenges that must be 

addressed in creating an adequate health workforce for the border. Although 

it may appear overly ambitious, the list is far from comprehensive. Still, even 

modest modification, enhancement, or better funding of existing programs 

could achieve many improvements in all of the recommended action items.

•	 Programs aimed at producing more health professionals need to be 

complemented by appropriate regional and local economic development 

programs to support retention of providers and access by the underserved. 

Most importantly, evidence-based interventions need to be developed 

in accordance with logical rationale provided by solid research and datacollection strategies.

•	 National and international partnerships are needed to create a data 

infrastructure on both sides of the border. This infrastructure must be 
Border Lives: Health Status in the United States-Mexico Border Region

68

capable of producing information that is timely, accurate, longitudinal, and 

comparable over time and space.

•	 Better information is needed on workforce size, characteristics, practice 

location, training, and full-time-equivalent (FTE) measures of health 

services for specific population groups. The productivity of the health 

workforce is a better indicator that its size of the available supply of health 

services. An inadequate health workforce data infrastructure leaves policy 

makers uninformed and produces a vicious circle of data shortage and 

inaction where interventions are needed most.

•	 An adequate data infrastructure needs to be coupled with community-based 

research endeavors that include community members in their planning and 

implementation. The health problems of the border region are generated 

in diverse border communities and must be solved with interventions that 

reach those many communities and are sensitive to their differences.

•	 Workforce shortage data, now available mostly at the county level, need to 

be computed from reliable and current addresses on practice location that 

would allow smaller area indicators. Those data need to be complemented by 

estimates of true service areas, with the actual FTE services delivered to the 

underserved, and with data on the capacity of practices and clinical facilities, 

as well as their distances from providers and neighborhoods. In addition, 

periodic assessments of the mobility of providers need to be conducted.

•	 Reliable estimates are needed of the size and location of the uninsured and 

underserved populations receiving care, and of those needing care but not 

qualifying for public assistance.

•	 Better understanding of and better data on cross-border health-care activity 

are needed to estimate total demand for health care. Currently, only a few 

local studies (Chacón-Sosa & Otalora-Soler, 1988; Landeck & Garza, 

2002; Macias & Morales, 2001; Tabet & Wiese, 1990) provide information 

on border residents who seek services in Mexico, and these do not allow 

generalizations to the rest of the border population.
 Chapter 2 - The Healthcare Workforce 

69 

References

Baer, L.D., Ricketts, T.C., Konrad, T.R., & Mick, S.S. (1998). Do international 

medical graduates reduce rural physician shortages? Medical Care, 36, 

1534-44.

Chacón-Sosa, F., & Otalora-Soler, M. (1988). Utilization of health services in 

Hermosillo, Sonora by United States residents. Border Health 4(2), 19-

25.

Cohen, J.J., Gabriel, B.A., & Terrell, C. (2002). “The Case for Diversity in the 

Health Care Workforce.” Health Affairs 21(5), 90-102.

Furino A. (Ed.). (1992). Health Policy and the Hispanic, Boulder, CO: Westview 

Press 

Furino, A., & Muñoz, E. (1991). Health status among Hispanics: Major themes 

and new priorities. Journal of the American Medical Association, 265(16), 

2064-2065.

Kington, R., Tisnado, D. & Carlisle, D.M. (2001). Increasing racial and 

ethnic diversity among physicians: An intervention to address health 

disparities?” In H. W. Nickens & B. D. Smedley (Eds.), The right thing 

to do, the smart thing to do: enhancing diversity in the health professions: 

summary of the Symposium on Diversity in Health Professions in honor 

of Herbert W. Nickens, M.D. (pp. 57-90). Washington, D.C.: National 

Academy Press.

Landeck, M., & Garza, C. (2002). Utilization of physician health care services 

in Mexico by U.S. Hispanic border residents. Health Marketing 

Quarterly 20(1), 3-16.

Macias, E.P., & Morales, L.S. (2001). Crossing the border for health care. 

Journal of Health Care for the Poor and Underserved 12(1), 77-87.

Murdock, S.H., Hoque, M.N., & McGehee, M. (2005). Population change in 

the United States: Implications of an aging and diversifying population 

for health care in the 21st century. In T. Miles & A. Furino (Eds.). 

Annual Review of Gerontology and Geriatrics: Aging Health-Care 

Workforce Issues (Vol.25). (pp. 19-63). New York: Springer Publishing.
Border Lives: Health Status in the United States-Mexico Border Region

70

Rabinowitz, H.K., Diamond, J.J., Markham, F.W., & Paynter, N.P. (2001). 

Critical factors for designing programs to increase the supply and 

retention of rural primary care physicians. Journal of the American 

Medical Association, 286, 1041-1048.

Ranmuthugala, G., Humphreys, J., Solarsh, B., Walters, L., Worley, P., 

Wakerman, J., et al. (2007). Where is the evidence that rural exposure 

increases uptake of medical practice? Australian Journal of Rural Health, 

15, 285-288.

Rosenthal, T.C. (2000). Outcomes of rural training tracks: a review. Journal of 

Rural Health, 16, 213-216.

Tabet, S.R., & Wiese, W.H. (1990). Medications obtained in Mexico by 

patients in southern New Mexico. Southern Medical Journal 83(3), 271-

273.

U.S. Bureau of the Census. (2004). U.S. interim projections by age, sex, race, and 

Hispanic origin. [Data file]. Available from U.S. Census Bureau Web 

site, http://www.census.gov/ipc/www/usinterimproj/

U.S. Department of Health and Human Services, Health Resources and 

Services Administration. (2007). Border County Health Workforce 

Profiles, 2007. [Data file]. Available from Health Resources and Services 

Administration Web site http://bhpr.hrsa.gov/healthworkforce/

U.S. Department of Health and Human Services, Health Resources and Services 

Administration. (2007, March). Community health worker national 

workforce study. Retrieved March 30, 2007, from http://bhpr.hrsa.gov/

healthworkforce/chw/

U.S. Department of Health and Human Services, Health Resources and Services 

Administration. National Health Service Corps. Retrieved [date] from 

http://nhsc.bhpr.hrsa.gov/

U.S. Department of Health and Human Services, Health Resources and Services 

Administration, Office of Rural Health Policy (2005). 2005 Annual 

report. Retrieved [date] from http://ruralhealth.hrsa.gov/overview/

ORHP2005AnnualReport.asp#workforce
71 

Adequate access to health care and related health services can increase 

appropriate use of the health care system, increase quality and years 

of healthy life, and in due course improve health outcomes (HHS, 

2000). Appropriate use of health care services can also help control health-care 

spending and ultimately reduce or eliminate health disparities (Starfield 1996, 

1998; Starfield & Simpson, 1993).

Healthy Border 2010 recognizes the role played by access to health care in 

improving overall health status. Two of the 25 Healthy Border indicators 

directly address access to health care provider: “Reduce by 25 percent the 

population lacking access to a primary health care;” and “Raise preparation 

of population using oral care to 75 percent annually” (Healthy Border 2010, 

2003, p.71). However, improved access to health care can also have a direct 

and positive impact on rates of cancer, chronic disease, infectious disease, and 

immunization. Oral health, chronic disease management, and health-related 

behaviors all improve with access to health care.

Yet those who live in the U.S.-Mexico border region face multiple barriers to 

accessing health care and related services. These barriers include lack of health 

insurance coverage, health care costs, lack of health care infrastructure, health 

care workforce shortages, language, cultural attitudes, and logistical issues such 

as transportation and child care.

Of these barriers, the most salient is lack of health insurance coverage. Health 

insurance coverage is the most important predictor of gaining access to health 

care (Centers for Disease Control [CDC], 2004; Cohen, Hao, & Coriaty, 2004; 

Institute of Medicine [IOM], 1993; Parchman, 2001). Most national surveys 

that measure access to health care use health insurance status as a primary 

metric, based on the rationale that “measurement of lack of health insurance 

coverage for a lengthy period of time is associated with persistent lack of access 

CHAPTER 3

ACCESS TO AND USE OF HEALTH CARE
Border Lives: Health Status in the United States-Mexico Border Region

72

to health care in individuals who may be at high risk of not obtaining preventive 

services as well as care for illness and injury” (Cohen 2004; IOM, 1993; 

Sambamoorthi & McAlpine, 2003, pp.478 ).

The number of U.S. residents without health insurance is increasing rapidly. Data 

from the Current Population Survey (CPS) indicate that in 2003, 16 percent of 

the U.S. population, or 45 million people, were without any health insurance 

(Denavas-Walt, Proctor, & Mills, 2004). Data used in this chapter show that the 

border region, as well, is severely affected by this troubling fact.

This chapter provides an analysis of access to health care for the population 

along the U.S.-Mexico border based on health insurance status and use of 

selected health services. Section one provides an assessment of access to health 

care based on health insurance coverage. Section two assesses use of selected 

health services as a function of health insurance coverage status.

Methods

This study uses the National Health Interview Survey (NHIS) definitions of 

private and government health insurance coverage. Private health insurance is 

coverage by a plan provided through an employer or union or purchased by an 

individual from a private company. Government health insurance includes the 

federal programs Medicare, Medicaid, and military health care; State Children’s 

Health Insurance Programs (SCHIP); and individual state health plans. The 

NHIS does not classify types of insurance as mutually exclusive, and people can 

be covered by more than one plan during the year (Cohen & Martinez, 2004).

For this study, data for four years (2000-2003) from the in-house version of 

the NHIS were merged and analyzed. The NHIS is a household, multistage 

probability sample survey conducted annually by the National Center for 

Health Statistics at the Centers for Disease Control and Prevention (CDC). 

Each year, NHIS collects data from approximately 100,000 individuals across 

the nation. The NHIS monitors the health of the U.S. population through the 

collection and analysis of data on a broad range of health topics. The NHIS 

was justified for use in this study because it includes a well-constructed health 

insurance module that historically reported low non-response rates. NHIS staff 

performs extensive cognitive testing of the questions used. Most importantly, 

specific health insurance information obtained through the NHIS is derived 

directly from the health-plan card of the individual1

.

Percentages and adjusted standard errors of the variables under study were 

1 Detailed information about the NHIS and the methodology used in this study can be found in the 

Appendix to Chapter 3. 
 Chapter 3 - Access To and Use of Health Care 

73 

stratified by ethnicity (Hispanic2 versus non-Hispanic3) and by region of 

residence (border counties, non-border counties in the border states, four 

border states combined, and the United States). The analysis focused on the 

insured versus non-insured populations, using health insurance status definitions 

provided in the NHIS documentation4

. For most variables, data are limited to 

the adult population (18 years of age or more) although information for both 

adults and children is available for selected variables.

I: Access to Health Care Based on Health Insurance Status

Health Insurance among Hispanics

National surveys consistently show disproportionately low rates of health 

insurance among Hispanics. The CPS reports that, among ethnic groups, 

Hispanics disproportionately lacked health insurance compared to any other 

groups (Denavas-Walt et al., 2004; see Figure 1). Likewise, the 2004 NHIS 

found that Hispanics were four times more likely than non-Hispanic whites and 

2.5 times more likely than non-Hispanic Blacks to be uninsured for more than 

one year (Cohen et al., 2004).

2 Hispanic persons may be of any race, including persons of Mexican, Puerto Rican, Cuban, Central 

and South American, or Spanish origin. 

3 Non-Hispanic of any race.

4 A person was defined as uninsured if he or she did not have any private health insurance, Medicare, 

Medicaid, SCHIP, state-sponsored or other government-sponsored, or military health plan at the time of the 

interview. A person was also defined as uninsured if he or she had only Indian Health Service coverage or had 

only a private plan that paid for one type of services such as accidents or dental care. 

Figure 1: Percent of population without health insurance coverage by 

ethnicity, United States, 2003

Source: DeNavas-Walt, C. Proctor, B., & Mills, R. Income, Poverty, and Health Insurance 

Coverage in the United States: 2003. U.S. Census Bureau, Current Population Survey, (2004)
Border Lives: Health Status in the United States-Mexico Border Region

74

These results were mirrored by those of the Behavioral Risk Factor Surveillance 

System (BRFSS), a national telephone survey conducted by the CDC. 

Data from the 2001-2002 BRFSS showed that Hispanic respondents were 

significantly less likely than non-Hispanic respondents to have health insurance 

(76.2 percent versus 90.6 percent); to have less than one regular personal healthcare provider (68.5 percent versus 84.1 percent); and to have less regular access 

to a place for care (93.4 percent versus 96.2 percent; CDC, 2004). On the basis 

of the overwhelming historical survey data available, Valdez and colleagues 

(1993) concluded that “Latinos have the worst health insurance coverage of 

any ethnicity group in the country” (p. 889). These data, as well as the data 

presented in this report, suggest that health insurance coverage for Hispanics has 

been inadequate for many years.

Other literature suggests that lack of health insurance coverage and consequent 

delay and limited access to health care among Hispanics contribute to their 

age-adjusted potential for life lost before age 75 (CDC, 2004), poor health 

status in general, and high rates of morbidity and mortality (Lieu, Newacheck, 

& McManus,1993). This problem is heightened for Hispanics who live in the 

U.S.-Mexico border region. Hispanics living in the border region are more likely 

to experience barriers to access to and use of health care services than any other 

Hispanic group in the United States. The southwest region of the nation, which 

includes states with higher concentrations of residents of Mexican descent, 

consistently displays the highest rate of uninsured population in the nation 

(Cohen et al., 2004; Parchman & Byrd, 2001).

Health Insurance Coverage along the Border

Lack of health insurance coverage and consequent lack of access to health care is 

more prevalent in counties and states that lie along the U.S.-Mexico border. As 

shown in Figure 2, the border states of Texas and New Mexico have historically 

reported two of the highest uninsured rates in the nation.

Two studies offer additional perspectives on barriers to health care access in 

the border region. In 1997, Parchman and Bird used the BRFSS to investigate 

lack of access to health care in El Paso, Texas, the largest U.S. city directly 

on the U.S.-Mexico border. The researchers found that approximately two 

of every five residents in El Paso were uninsured. As in the rest of the United 

States, having health insurance was one of the most important predictors of 

realized access to health care in terms of regular check-ups and access to regular 

sources of care. The investigators also found that respondents who spoke only 

Spanish reported more limited access to health care than those who spoke both 

Spanish and English. Similarly, Landeck and Garza (2000) found substantial 

inequities in access to health care in Mexican-American communities in the 
 Chapter 3 - Access To and Use of Health Care 

75 

border city of Laredo, Texas. With support of the Laredo Health Department, 

the researchers randomly performed more than 1,000 interviews in Laredo’s 

nineteen statistical census tracts. In addition to finding a significant number 

of uninsured individuals, Landeck and Garza also found problems in access to 

and availability of preventive health care services for a considerable segment of 

Laredo’s population.

These studies suggest that residents of El Paso and Laredo have inadequate access 

to health care, largely due to lack of health insurance. The findings also suggest 

that lack of health insurance coverage severely limits access to health care, not 

only in El Paso and Laredo but throughout the U.S.-Mexico border region, 

where population characteristics, socio-economic status, health care resources, 

and health insurance coverage rates are analogous. The problem is likely to grow 

in magnitude because of the rapid population growth and low socio-economic 

status of the area (Parchman & Bird, 2001; Warner, 1991).

However, both studies also documented the use of an alternative route to 

accessing health care. Hispanic residents of both cities said they regularly crossed 

the U.S.-Mexico border into Mexico to seek health care services. In this respect, 

both studies echoed the findings of other published reports on health care access 

Figure 2: Percent of the population without health insurance coverage by 

state, 2001-2003

Source: Denavas-Walt et al., 2004, Income, Poverty, and Health Insurance Coverage in the 

United States: 2003. U.S. Census Bureau, Current Population Survey, 2003
Border Lives: Health Status in the United States-Mexico Border Region

76

in the border region (Hunter et al., 2003; Landeck & Garza, 2002; Macias & 

Morales, 2001; & Seid, Castañala, Mize, Zivkovic, & Varni, 2003).

Lack of Health Insurance Coverage by Type

To maintain consistency with previous work, three NHIS definitions of lack 

of health insurance were adopted in this analysis: current, short-term, and 

long-term. Because the terms are not mutually exclusive, an individual may be 

counted in more than one of the three measures.

As Cohen and Martinez (2004) point out, these definitions allow identification 

of different policy-relevant perspectives pertinent to the population under 

study. For example, current lack of health insurance coverage (CLHIC) helps 

to identify the segment of the population that may experience barriers to 

obtaining needed health care services and for whom access to care is perceived as 

extremely limited. On the other hand, the categories of short or long-term lack 

of health insurance coverage help to reveal obstacles to accessing care, including 

preventive health services and prolonged care for major illnesses.

Current lack of health insurance coverage

CHLIC is defined as not having health insurance at the time of the interview. 

Because of the relevance of this topic, estimates of lack of health insurance 

coverage were calculated for the total population instead of the adult population. 

Analysis of prevalence of individuals in the CLHIC group provides an overview 

of the population that may experience barriers to obtaining needed health care. 

In 2000-2003, the CLHIC for the border5

 was significantly higher than the 

CLHIC for the United States (22.9 percent versus 14.7 percent)6

. The border 

rate was 56 percent higher than the national rate, as illustrated in Figure 3.

CLHIC in relation to ethnicity differed substantially between the border and the 

United States (see Figure 4). Hispanics at the border were three times more

 likely than non-Hispanics who lived in the same region to be without health 

insurance at the time of the interview (38.2 percent versus 12.0 percent). In 

comparison, 32.7 percent of Hispanics nationwide reported not having health

5 The cluster of U.S. counties along the U.S.-Mexico border were identified as one epidemiological 

unit and compared to the United States in several fashions. Additional comparisons among the border counties, versus the cluster of non-border counties, and the four border states combined (Arizona, California, New 

Mexico, and Texas) can also be accomplished by using the detailed tables provided in the Appendix to Chapter 3.

6 Statistical tests for measuring significance of differences between two point estimates were performed using a two-tail Z test at the 0.05 level, assuming independence. For multiple comparisons, statistical 

significance was assessed by judging the overlap of 95 percent confidence intervals for calculated rates. Overlapping confidence intervals represent non-statistically significant relationship. Lack of comments regarding 

the difference between two estimates does not necessarily imply that the difference was tested and found to be 

not significant.
 Chapter 3 - Access To and Use of Health Care 

77 

Figure 3: Current lack of health insurance coverage, United States versus 

U.S.-Mexico border region, 2000-2003 

Source: Data retrieved in 2005 from the 2000-2003 NHIS in-house data file 

Figure 4: Percent of the population without health insurance coverage at time 

of interview (current lack of health insurance coverage), by ethnicity, 2000-

2003

Source: Data retrieved in 2005 from the 2000-2003 NHIS in-house data file 
Border Lives: Health Status in the United States-Mexico Border Region

78

insurance at the time of the interview. Thus, the CLHIC rate for border-area 

Hispanics was 17 percent higher than for U.S. Hispanics. In contrast, rates of 

CLHIC for non-Hispanics in the border area were comparable to CLHIC rates 

in the United States as a whole.

CLHIC status presents a clear picture of the disparity in insurance coverage 

between ethnic groups in the border region as well as in the United States. 

The border population had the highest percentage of Hispanics without health 

insurance coverage at the time of the interview. However, a parallel trend is 

identifiable at the border-state level and in non-border counties (see Table 17

).

This finding supports previous work by Cohen and others, who found that 

CLHIC was concentrated in the southwest region (Cohen et al. 2004; Cohen & 

Martinez, 2004; DeNavas et al. 2004).

Short and long-term lack of health insurance

Short-term lack of health insurance coverage (STLHIC) is defined as not having 

any type of insurance coverage for at least part of the 12 months prior to the 

interview. Long-term lack of health insurance coverage (LTLHIC) defines 

the group of individuals who report spending more than 12 months without 

insurance coverage. As Figure 5 shows, 27.2 percent of the uninsured U.S. 

population was in the STLHIC group. In contrast, only 17.9 percent of the total 

border population was classified as STLHIC. Individuals who were uninsured 

and lived in the border region were more likely to experience LTLHIC than the 

rest of the U.S. population (82.1 percent versus 72.8 percent).

7 All tables are found in the Appendix to Chapter 3.

Figure 5: Percent distribution of uninsured population by time without 

insurance, 2000-2003

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
 Chapter 3 - Access To and Use of Health Care 

79 

Figure 6 displays STLHIC and LTLHIC estimates by ethnicity for the 

uninsured United States and border populations. Uninsured border Hispanics 

were significantly more likely than any other group to be classified as LTLHIC 

(86.9 percent). Estimated LTLHIC for uninsured border Hispanics was 27 

percent higher than for the uninsured non-Hispanic community in the same 

region (68.6 percent) and five percent higher than the national estimates for 

uninsured Hispanics (82.5 percent). At both border and national levels, ethnic 

disparities were noticeable (see Table 2). In general, almost 8 of every 10 

uninsured Hispanics spent more than a year without health insurance, compared 

to 7 of every 10 uninsured non-Hispanics. These rates were similar for the both 

United States and border regions.

Inability to Afford General Health Care, Oral, or Behavioral Health Services

Although health insurance status is a critical determinant of access to health 

care, even those with health insurance coverage may not be able to afford needed 

health care because of alarmingly high out-of-pocket costs for deductibles or copayments. During the period 2000-2003, approximately 4.8 percent of the U.S. 

adult population (18 years and over) who needed medical care did not receive it 

because they could not afford it. Similarly, in the border region, almost 1 out of 20 

adults did not receive health care because they could not afford it (see Table 3).

Figure 6: Percent distribution of uninsured population by ethnicity and time 

without insurance, 2000-2003

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
Border Lives: Health Status in the United States-Mexico Border Region

80

Inability to afford health care and ethnicity

Inability to obtain health care due to cost was associated with ethnicity. Overall, 

Hispanic adults were more likely to report inability to afford medical care 

than were non-Hispanics, as shown in Figure 7. The percentage of Hispanics 

residing in the border region who could not afford needed medical services was 

40 percent greater than that of border non-Hispanics (6.0 percent versus 4.3 

percent). At the national level, the percentage of Hispanics who were unable 

to afford needed care was 16 percent higher than that of non-Hispanics (5.4 

percent versus 4.7 percent). In both regions, the disparity by ethnicity was 

statistically significant.

Health insurance plays a pivotal role in a person’s ability to afford health care 

services. In 2000-2003, about 3 out of every 100 insured individuals reported 

that they had not received needed medical services in the past year because they 

could not afford them. Figure 8 shows this relationship. This finding was true 

for both Hispanics and non-Hispanics. No statistical difference was identified 

between the two groups. However, another picture emerged for the uninsured

Figure 7: Percent of the adult population who needed medical care but did not 

get it because they could not afford it, by ethnicity, 2000-2003

(Results are based on answers to the following question: “During the past 12 months, was 

there any time when [name of individual] needed medical care, but did not get it because [name 

of individual] could not afford it?”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
 Chapter 3 - Access To and Use of Health Care 

81 

population. Uninsured non-Hispanics were much more likely to report that 

they could not afford medical services than were uninsured Hispanics. In all 

geographic regions under study, uninsured non-Hispanics reported the highest 

percent of inability to afford health-care services.

The percentage of uninsured border Hispanics who reported that they could not 

afford medical services (11.3 percent) was more than three times greater than 

that of insured border Hispanics (2.7 percent). This trend was mirrored at the 

national level, where the difference between Hispanics with or without health 

insurance was noteworthy. In both regions, the disparity between insured and 

uninsured populations was statistically significant.

Inability to afford oral health care for the past year

Adults living in the border region were on average more likely to report the 

inability to afford oral health care than were adults in the United States (11.5 

percent versus 9.4 percent). Although the proportion of adults who could not 

afford oral health services at the border differed statistically from the national 

estimate, the difference between the border and the rest of the Southwest region 

was not statistically significant (see Table 4).

Figure 8: Percent of the population who needed medical care but did not get it 

because they could not afford it, by ethnicity and insurance status, 2000-2003 

(Results are based on answers to the following question: “During the past 12 months, was 

there any time when [name of individual] needed medical care, but did not get it because [name 

of individual] could not afford it?”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
Border Lives: Health Status in the United States-Mexico Border Region

82

Hispanics were more likely than non-Hispanics to report the inability to afford 

oral health services. This disparity was particularly apparent in the border region, 

where the percentage of Hispanics who could not afford oral health services 

was more than double that of non-Hispanics (16.8 percent versus 8.1 percent). 

Geography was also a key factor in determining ability to afford oral health 

services. The percentage of Hispanics in the border region who could not afford 

oral health services was 46 percent greater than the estimate for the adult U.S. 

Hispanic population.

People who did not have health insurance were less likely to be able to afford 

oral health care than were people who had insurance. As Figure 9 shows, this 

was true for both Hispanics and non-Hispanics. The proportion of uninsured 

border adult Hispanics who were unable to afford oral health care was more 

than twice that of insured border Hispanics (27.0 percent versus 8.5 percent). 

Disparity in the ability to afford oral health care based on health insurance status 

was exhibited in every region (see Table 4). Nationally, uninsured Hispanics 

were less likely to be able to afford oral health care than were uninsured nonHispanics. However, ethnicity did not make a difference between uninsured 

populations at the border.

Figure 9: Percent of the adult population who could not afford oral health care 

for previous 12 months, by ethnicity and insurance status, 2000-2003

(Results are based on answers to the following question: “During the past 12 months, was 

there any time when you needed any of the following (dental care including check-ups) but 

didn’t get it because you couldn’t afford it?”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file 
 Chapter 3 - Access To and Use of Health Care 

83 

Inability to afford mental health services for the past year

In 2000-2003, adults in the border region who needed mental health services were 

more likely to report inability to afford those services than were adults in the United 

States as a whole (2.7 percent versus 1.9 percent; see Table 5). Hispanics who lived 

along the border were more likely to report the inability to afford behavioral health 

services than any other ethnic group, as shown in Figure 10. The percentage of 

adult Hispanics in the border region who reported inability to afford behavioral 

health services was 147 percent higher than adult non-Hispanics in the same region 

(4.2 percent versus 1.7 percent) and almost two times that of U.S. Hispanics.

Both Hispanic and non-Hispanic groups were more likely to report inability 

to afford mental health services if they did not have health insurance. For 

the insured population, point estimates were found to be alike (see Table 5). 

However, within the uninsured adult population, ethnicity affected the ability 

to afford behavioral health services at the national, but not at the border level. 

Nationally, uninsured adult non-Hispanics were more likely to report inability 

to afford mental health services than were uninsured Hispanics (6.6 percent 

Figure 10: Percent of the adult population who could not afford mental health 

services for the previous 12 months, by ethnicity, 2000-2003 

(Results are based on answers to the following question: “During the past 12 months, was 

there any time when you needed mental health counseling but did not get it because you could 

not afford it?”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
Border Lives: Health Status in the United States-Mexico Border Region

84

versus 4.2 percent). Although uninsured Hispanics in the border region reported 

the highest percentage of all (7.7 percent), the ethnic disparity for uninsured 

Hispanics versus non-Hispanics at the border was not statistically significant8

.

II: Use of Health Services

Analysis of use of health services provides a general picture of whether the adult 

population was able to access the types of health services generally sought when 

an injury or illness occurs. Public health literature suggests that the use of health 

services is heavily influenced by socio-demographic factors such as cost, location, 

health insurance coverage, and ethnicity (Lieu, Newacheck, & McManus, 1993; 

Macias & Morales, 2001; Valdez et al. 1993). All of these factors come into play 

as well for people who reside along the U.S.-Mexico border. However, health 

insurance status and ethnicity were consistently two of the most important 

measurable influences on the use of health services in this region.

This section provides an overview of the effect of health insurance status and 

ethnicity on the use of selected health services in the border region. It is divided 

into three topics: access to health services, accessibility to health professionals, 

and immunization practices.

Access to Health Services

Having a place to go when you are sick

In 2000-2003, almost one of every five adults living near the border did not have 

adequate access to health care when they were sick or needed medical advice. The 

percent of the border population without a place to go when they were sick (18.6 

percent) was 36 percent higher than the national estimate (13.6 percent).

Having no place to go to receive health services was related to ethnicity. 

Hispanics who lived in the border area were more than three times more likely 

than non-Hispanics living in the same region not to have a place to go (31.9 

percent versus 10.0 percent). In addition, Hispanics who lived at the border 

were more likely than the average U.S. Hispanic not to have access to health care 

when they were ill (31.9 percent versus 28.4 percent). In both regions (national 

and border), the disparity between Hispanic and non-Hispanic adults was 

statistically significant (see Table 6).

8 The border point estimates for insured Hispanics and insured non-Hispanics are unreliable. 

Reported relative standard errors (RSE) are higher than 30.
 Chapter 3 - Access To and Use of Health Care 

85 

Having a place to go when sick was heavily influenced by both ethnicity and

health insurance status, as Figure 11 shows. Approximately 11 percent of 

insured adult Hispanics who lived near the border indicated that they usually 

did not have access to health care when they were sick or needed advice about 

health issues. Although this percentage was comparatively low, ethnicity as a 

factor, no matter the health insurance status. Among the insured population in 

the border region, Hispanics were more likely than non-Hispanics not to have 

a place to go when they needed medical care (11.2 percent versus 4.8 percent). 

This disparity was consistent with national data, which show insured Hispanics 

were more likely than insured non-Hispanics not to have a place to go when 

they were sick (10.6 percent versus 7.5 percent).

Among the uninsured U.S. adult population, more than half of Hispanics (57.4 

percent) did not have a place to go to access health services when they were 

sick, compared to 40.8 percent of the non-Hispanic population. In the border 

region, more than half of the uninsured adult population did not have a place to 

go when they were sick, regardless of ethnicity (Hispanics 57.1 percent, nonHispanics 52.4 percent). The percentage of uninsured Hispanics in the border 

region without a place to go for medical care was 9 percent higher than that of 

uninsured non-Hispanics in the same area. However, due to limited sample size, 

there was insufficient evidence to demonstrate a statistically significant difference.

Figure 11: Percent of the adult population who do not have a usual place to go 

when they are sick, by ethnicity and insurance status, 2000-2003

(Results are based on answers to the following question: “Is there any place that you usually go 

to when you are sick or need advice about your health?”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file Percent
Border Lives: Health Status in the United States-Mexico Border Region

86

A noticeable gap between ethnic groups that differed in health insurance status 

is visible. Hispanics who lived in the border region and did not have health 

insurance were more likely not to have a place to go when sick than were 

insured Hispanics living in the same region (57.1 percent versus 11.2 percent). 

Both nationally and in the border region, considerable disparity was observed in 

having a place to go when sick based on insurance status and ethnicity.

Where do people go to receive health-care services?

Identification of places where people received health-care services provides a 

general picture of health services utilization. In 2000-2003, 79.7 percent of U.S. 

adults had visited a doctor’s office or health management organization (HMO) 

facility. Approximately one out of every five individuals had used clinics, health 

centers, emergency rooms, or outpatient services. In general, point estimates 

between the United States and the border were roughly equivalent (see Table 7).

Non-Hispanics were more likely than Hispanics to use doctors’ offices or HMO 

services. On the other hand, Hispanics were more likely than non-Hispanics to use 

other health services to address their health needs, as shown in Figure 12. Hispanic 

adults were more likely to report the use of emergency room or outpatient facilities 

Figure 12: Percent and places that the adult population reported having gone 

when they were sick or needed advice about their own health, by ethnicity

(Results are based on answers to the following question: “Is there any place that you usually go 

to when you are sick or need advice about your health?”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file

Clinic/

Health Center

Dr. Office/

HMO

Hospital ER 

Outpatient

Othr place/ 

No place

Clinic/

Health Center

Dr. Office/

HMO

Hospital ER 

Outpatient 

Othr place/

No place
 Chapter 3 - Access To and Use of Health Care 

87 

than were non-Hispanics (7.3 percent versus 3.9 percent). This national trend was 

similar at the border, where Hispanics were more likely than non-Hispanics to use 

outpatient facilities (5.7 percent versus 3.3 percent).

Selection of places to receive health care was deeply influenced by both ethnicity 

and health insurance status. Even among the insured population, noteworthy 

differences were observed. The average U.S. adult Hispanic was less likely to 

frequent doctors’ offices and HMOs than the average U.S. adult non-Hispanic 

(77.0 percent versus 83.0 percent). On the other hand, Hispanics with health 

insurance were substantially more likely to visit doctors’ offices or HMOs than were 

Hispanics who did not have health insurance (77.0 percent versus 37.7 percent).

At the border, Hispanics who did not have health insurance were less likely to 

visit doctor’s offices or HMO facilities than were Hispanics who had health 

insurance (46.2 percent versus 79.8 percent). Both nationally and in the border 

region, the disparity between insured and uninsured adult Hispanics was 

notable. Our results paralleled Cohen’s findings: Both nationally and at the 

border, the adult population with no health insurance displayed the highest 

percent of emergency room use compared to their insured counterparts (Cohen 

2005). At the border, use of emergency room or outpatient facilities was four 

times greater among Hispanics who did not have health insurance than among 

Hispanics who had health insurance (12.9 percent versus 2.9 percent). The 

disparity was slightly less at the national level, where the percentage of uninsured 

Hispanics who used emergency room services was not quite four times greater 

than that of the insured Hispanic population (17.2 percent versus 4.5 percent).

Emergency room use

Emergency rooms are widely conceived as gateways to medical services for 

those who have an illness or injury that cannot wait for a regular doctor’s visit, 

specifically if the problem is life-threatening. But some literature suggests 

that emergency room use is noticeably changing. An increasing proportion 

of emergency room visits are for conditions more appropriately cared for in 

primary care than urgent care settings. Researchers at the Seton Healthcare 

Network in Texas9

 note that current emergency room use in that state is due to 

two main sources: a) the increasing number of uninsured individuals and b) a 

growing number of insured individuals whose health problems are less pressing 

but who believe that they need urgent medical attention (Care for All, 2002).

Misuse of emergency rooms creates three main problems for health systems as 

well as for the frequent emergency room user. First, the emergency room is not 

a satisfactory environment for treating routine health problems. Emergency 

9 The Seton Healthcare Network is considered the leading provider of health-care services in Central 

Texas. More information about the network is available at www.seton.net.
Border Lives: Health Status in the United States-Mexico Border Region

88

room protocols generally do not allow for continuum of care once the individual 

is discharged. Second, the extra demands made on emergency room services 

by people with non-emergent conditions force emergency rooms to provide 

limited or low-quality health services to others who do need care for emergent 

conditions (Care for All, 2002). Third, treatment of minor ailments in the 

emergency room setting is documented to be significantly more expensive than 

the use of other health-care options, such as a visit or telephone consultation 

with a primary care provider.

Of the population that reported emergency room use during the previous year, 

the border adult population was less likely to use emergency room services 

than were adult populations in any other region under study (see Table 8). 

Emergency room services were used by 14.7 percent of adults living in the 

border region. This was 27 percent less than the estimate for the four border 

states combined (17.8 percent) and 20 percent less than for the non-border 

region (18.4 percent).

Ethnicity also affected the likelihood that a person had used emergency room 

services in the previous year. Nationwide, the average adult Hispanic was nearly 

14 percent less likely to report the use of emergency room services than was the 

average adult non-Hispanic (17.5 percent versus 20.4 percent). This difference 

was reflected in all the regions under study, although in some instances 

differences were not statistically significant (see Table 8). At the border, 

emergency room utilization was similar for Hispanics and non-Hispanics (13.1 

percent versus 15.7 percent).

Adult Hispanics in the border region were about one-quarter less likely to 

use emergency room services than were Hispanics nationwide, a statistically 

significant difference. This finding may be explained, at least in part, by the 

proximity of less costly health-care services in Mexico. In their 2001 study of 

health-care utilization in the border region, Macias and Morales (2001) found 

that many Hispanics were willing to travel to Mexico to find health services 

despite the significant burden of cost and travel. The authors reported that U.S. 

residents living in the border region often sought care in Mexico because health 

services cost much less there than in the United States, and because they could 

receive health services in their native language.

Health insurance status was an important determinant of emergency room 

utilization, as shown in Figure 13. In general, adults who had health insurance 

were more likely to report using emergency room services in the previous year 

than were those who did not have health insurance. In both the border region 

and the United States as a whole, point estimates for emergency room use were 

equivalent for the insured population. This finding suggests that having health 

insurance makes the cost of emergency room services affordable, regardless 
 Chapter 3 - Access To and Use of Health Care 

89 

of ethnicity. However, the difference in emergency room use between adult 

Hispanics and non-Hispanics who did not have health insurance was striking. 

Hispanics in the border region who did not have health insurance were less 

likely to report emergency room use than were Hispanics in the same region 

who did have health insurance (9.4 percent versus 16.0 percent). Nationally, 

uninsured Hispanics were 40 percent less likely to use emergency room services 

than were uninsured non-Hispanics (13.1 percent versus 22.0 percent).

Results shown in Figure 13 are based on answers to the following question: 

“During the past 12 months, how many times have you gone to a hospital 

emergency room about your own health?” This includes emergency room 

visits that resulted in hospital admissions. This question referred specifically to 

the frequency of emergency room use in a year period. It differs substantially 

from the question about home sites that are sought for health services, which 

measures the frequency of medical homes – i.e., a single place where care is 

coordinated. Thus, the questions are not compatible in concept and scope.

Figure 13: Percent of the adult population who had used emergency room 

services during the previous 12 months, by ethnicity and insurance status, 

2000-2003

(Results are based on answers to the following question: “During the past 12 months, how 

many times have you gone to a hospital emergency room about your own health?” This includes emergency room visits that resulted in hospital admissions.)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
Border Lives: Health Status in the United States-Mexico Border Region

90

Overnight hospital stay

Reported overnight hospital stay is a way to measure the potential effect of 

cost on the ability of populations to use inpatient health care services. For the 

purpose of this section, “overnight hospital stay” is defined as the affirmation 

by the survey respondent of at least one overnight stay in an inpatient hospital 

facility. Due to the wording of the NHIS survey question, overnight hospital 

stay reflects the estimate for the total population instead of the adult population. 

In 2000-2003, the total population of the border was less likely to spend a night 

in a hospital than the population of the United States as a whole (7.9 percent 

versus 8.5 percent). Border residents were 7 percent less likely to stay overnight 

in a hospital than were people in the United States as a whole (see Table 9).

Evidence of ethnic disparity concerning an overnight hospital stay was found 

exclusively at the national level, where Hispanics were less likely than nonHispanics to spend at least one night in a hospital setting (7.4 percent versus 

8.7 percent). At the border (Table 9), the difference in overnight hospital stay 

between Hispanics and non-Hispanics was not statistically significant (7.6 

percent versus 8.2 percent).

A notable discrepancy in overnight hospital stay was found among populations 

who differed by health insurance status. In all regions, people with health 

insurance were more likely to stay overnight in a hospital than were those 

without health insurance as indicated in Figure 14 and Table 9. In the border 

region, Hispanics who had health insurance were more than twice as likely to 

spend a night in a hospital as were those who did not have health insurance (9.5 

percent versus 4.5 percent). A similar trend was seen in the border non-Hispanic 

population. The proportion of non-Hispanics who resided in the border region, 

had health insurance, and who reported at least an overnight hospital stay 

was more than twice the proportion of uninsured non-Hispanics (8.8 percent 

versus 4.0 percent). At the border, there was no difference by ethnicity among 

those who shared the same insurance status. This evidence suggests that health 

insurance plays an important role in determining whether a person is able to 

afford an overnight hospital stay when needed.

Accessibility to Health Professionals

Contact with health professionals, either through a face-to-face visit or by 

telephone consultation, is a conventional way to deal with an ailment outside 

the hospital inpatient setting. In this fashion, as opposed to an inpatient hospital 

facility, the individual who suffers from a condition can receive follow-up services 

over a long interval of time. The following section summarizes findings regarding 

the accessibility of the population to a selected group of health professionals.
 Chapter 3 - Access To and Use of Health Care 

91 

See or talk to a general doctor in the previous 12 months

For the purposes of this section, contact with a general doctor was defined as 

getting in contact with a health professional who specializes in treating a variety 

of illnesses during the previous year10. Both face-to-face and telephone contacts 

were counted. In 2000-2003, the adult population at the border was less likely 

than the average United States resident to have seen or talked to a general doctor 

in the previous year (56.7 percent versus 68.2 percent). Residents of the border 

region were less likely to get in touch with a general doctor than were residents 

of any other region (see Table 10).

There was demonstrable ethnic inequality in contact with a general doctor in all 

regions. Generally, adult Hispanics were less likely to have contact with a general 

doctor than were non-Hispanics. This trend was heightened at the border, 

where the percentage of Hispanics who had seen or talked to a doctor during 

the previous year (45.2 percent) was 30 percent less than that reported by the 

non-Hispanic population (64.2 percent) and 20 percent less than the percentage 

reported for the whole border population (56.7 percent).

10 Based on previous work done by Robin Cohen and others (2004), a time frame of a year is used as 

a gold standard to quantify the affirmation and frequency of contact with health professionals. For comparison 

purposes, the following sections contain estimates of contacts with selected health professionals based on the 

same interval of time.

Figure 14: Percent of the total population who spent at least one night in a 

hospital, by ethnicity and insurance status

(Results are based on answers to the following question: “During the past 12 months, was 

[name of individual] a patient in a hospital overnight?” Overnight stays in an emergency room 

were not included. However, overnight stays for mothers and neonates were included.)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file 
Border Lives: Health Status in the United States-Mexico Border Region

92

Health insurance plays a pivotal role in determining ability to see or talk to a 

general doctor. In the border region, Hispanics and non-Hispanics who had 

health insurance were more likely to have had contact with a general doctor than 

were their uninsured counterparts (57.1 percent and 68.2 percent, respectively, 

versus 30.4 percent and 32.2 percent, respectively). But an ethnic gap was seen 

even for those with health insurance, as shown in Figure 15. At the border, 

insured adult Hispanics were less likely to see or talk to a doctor than were 

insured non-Hispanics living in the same region. The point estimate for insured 

Hispanics in the border region was more than 15 percent less than for the nonHispanic population.

Not having health insurance severely limits access to health care professionals. 

This limitation was noticeable at the border where the estimates for uninsured 

adult Hispanics and non-Hispanics were equivalent. Nationally, the average 

uninsured Hispanic was less likely than the average uninsured non-Hispanic to 

have had contact with a general doctor during the previous year (34.5 percent 

versus 45.3 percent).

See or talk to a medical specialist doctor during the previous 12 months

The adult border population also faced obstacles in accessing care from 

specialized health professionals. In comparison with all people in the United 

States, people living in the border region were less likely to have seen or talked

to a medical specialist during the previous year (19.9 percent versus 25.7 

percent; see Table 11).

Analysis of ethnic differences shows that Hispanics in general were less likely to 

have seen or talked to a medical specialist during the previous year than were 

non-Hispanics. Hispanics living in the border region were notably less likely to 

report contact with a medical specialist than were non-Hispanics in the same 

region (11.7 percent versus 25.2 percent). Hispanics living in the border region 

were also less likely to see or talk to a specialist than were Hispanics in the 

United States as a whole (11.7 percent versus 15.1 percent).

Limits in access to a medical specialist were linked directly to having health 

insurance, as well as to ethnicity. At the border, Hispanic adults who did not 

have health insurance were less likely to have seen or talked to a specialist than 

were uninsured non-Hispanics (5.0 percent versus 11.9 percent). But ethnic 

disparity was also evident, even among those without health insurance. As Figure 

16 illustrates, Hispanics who lived in the border region and had health insurance 

were still less likely to have had contact with a medical specialist than were 

insured non-Hispanics in the same region (17.2 percent versus 26.7 percent). 

This finding was replicated both nationally and throughout the southwest area. 

In all regions, statistically significant differences were easily identified.
 Chapter 3 - Access To and Use of Health Care 

93 

See or talk to an obstetrician/gynecologist during the previous 12 months

Regular visits to an obstetrician and gynecologist (OB/GYN) are of critical 

importance during pregnancies and deliveries. In addition, OB/GYNs can help 

the female population avoid or prevent health complications from happening, 

identify internal biological abnormalities at an early stage, and help to control 

them. Preventive health measures provided by OB/GYNs include breast exams, 

pelvic exams, and Pap tests. Many physicians consider OB/GYN visits to be 

the ideal forum for discussion of sexual health practices such as birth control 

and prevention of sexually transmitted infections and diseases. Experts in the 

women’s health field strongly suggest that annual visits to an OB/GYN begin 

as early as age 13 as a means to initiate successful preventive health measures 

(American College of Obstetricians and Gynecologists [ACOG]).

Data presented here are limited to the female population 18 years and older. 

Analysis shows that the overall adult female population along the border reported 

limited access to OB/GYN care in comparison to the rest of the United States. 

Adult women who resided in the border area were less likely to report visits to an 

Figure 15: Percent of the adult population who had seen or talked to a general 

doctor during the previous 12 months, by ethnicity and insurance status

(Results are based on answers to the following question: “During the past 12 months, have you 

seen or talked to any of the following health care providers about your own health? A general 

doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal 

medicine).”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
Border Lives: Health Status in the United States-Mexico Border Region

94

OB/GYN than any other female group (see Table 12). Female adults living in 

the border region were almost 11 percent less likely to have visited an OB/GYN 

during the previous year than were women nationwide (40.8 percent versus 45.6 

percent). For Hispanic women in the border area, the joint effect of ethnicity and 

region of residence was to decrease the likelihood that they reported contact with 

an OB/GYN during the previous year. At the border, the percentage of adult 

Hispanic females who had visited an OB/GYN was more than 20 percent less 

than non-Hispanic females (35.1 percent versus 44.5 percent).

Health insurance status had considerable influence over women’s ability to 

access OB/GYN services, as illustrated in Figure 17. Nationally, Hispanic 

women who had health insurance were more likely to have visited an OB/GYN 

than were insured non-Hispanic women (50.1 percent versus 47.3 percent). In 

every region under study, Hispanic women who had health insurance reported 

equal or higher use of OB/GYN services than did their insured non-Hispanic 

counterparts. In the border area, Hispanic women who did not have health 

insurance were dramatically less likely to report access to an OB/GYN than were 

insured Hispanic women in the same region (27.5 percent versus 40.7 percent). 

Uninsured Hispanic females living in the border region were least likely to 

Figure 16: Percent of the adult population who had seen or talked with a medical 

specialist during the previous 12 months, by ethnicity and insurance status

(Results based on answers to the following question: “During the past 12 months, have you 

seen or talked to any of the following health-care providers about your own health? A doctor 

who specializes in particular medical disease.”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
 Chapter 3 - Access To and Use of Health Care 

95 

report having seen or talked to an OB/GYN during the previous year. However, 

their level of access to OB/GYN care was not significantly different from that of 

uninsured Hispanic females throughout the southwest.

Access to Oral Health Care

Oral health is traditionally maintained by regular visits to the dentist (at least 

two per year) and practice of good oral hygiene. This analysis was limited to 

the portion of the adult population 18 and older who reported not having seen 

a dentist for more than a year. Estimates for those who visited a dentist more 

frequently can be found in Table 13, which contains estimates based on answers11.

Geographic region was an important determinant of access to oral health care. 

People in the border region were more likely than the average United States 

resident not to have seen or had any contact with a dentist for more than a year 

(39.8 percent versus 36.2 percent).

11 Table 13 contains estimates based on answers to the question: “When was the last time you visited 

a dentist?” Six months or less, more than six months, but not more than a year, and more than a year.

Figure 17: Percent of the adult female population who had seen or talked with 

an obstetrician/gynecologist during the previous 12 months, by ethnicity and 

insurance status

(Results are based on answers to the following question: “During the past 12 months, have you 

seen or talked to any of the following health-care providers about your own health? A doctor 

who specializes in women’s health (an obstetrician/gynecologist).”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
Border Lives: Health Status in the United States-Mexico Border Region

96

Analysis of data on ethnicity and use of oral health care services showed that 

adult Hispanics were substantially less likely than non-Hispanics to have 

had any contact with a dentist in more than a year. In the border region, the 

proportion of Hispanics who had not seen or talked to a dentist was greater 

than that reported by the non-Hispanic community (56.2 percent versus 

29.8 percent). This pattern was replicated nationally; across the United States, 

Hispanics were more likely to report lack of access to oral health services than 

were non-Hispanics (48.6 percent versus 34.7 percent). In comparison with 

other regions, Hispanics who lived in the border area were also more likely 

than any other Hispanic or non-Hispanic group to have not seen or talked to a 

dentist in more than a year.

Regardless of ethnicity status, access to oral health services was also greatly 

influenced by health insurance status. In 2000-2003, adult Hispanics who lived 

in the border area and did not have health insurance were more likely to report 

not having seen or talked to a dentist for more than a year. Of this population, 

71 percent reported no contact with a dentist for 12 months or more. Similarly, 

65 percent of uninsured non-Hispanics who lived in the border region reported 

lack of access to oral health services for more than a year.

When oral health care use was compared between equivalent ethnic groups with 

different health insurance status, a striking disparity emerged. The percent of 

uninsured Hispanics in the border region who had not seen a dentist for more 

than a year was 57 percent greater than that of insured Hispanics in the same 

region (70.8 percent versus 45.1 percent). A similar trend was found across the 

United States. Nationwide, uninsured Hispanics were more likely than insured 

Hispanics to have not seen or talked with a dentist for more than a year (65.8 

percent versus 39.0 percent).

Ethnic disparities were also found even among groups of equivalent insurance 

status, as shown in Figure 18. Of the insured population, Hispanics who lived 

in the border area were more likely than non-Hispanics to be unable to access 

oral health services (45.1 percent versus 25.5 percent). This tendency was 

reflected nationally, where insured Hispanics were more likely to report inability 

to access oral health services than were insured non-Hispanics (39.0 percent 

versus 31.1 percent).
 Chapter 3 - Access To and Use of Health Care 

97 

Access to Mental Health Services

Access to mental health services is essential for treatment of mental disorders 

such as anxiety, depression, substance abuse, suicide, and other behavioral or 

psychological conditions. Consulting with a mental health professional is the 

most effective way to identify behavioral health disorders, provide preventive 

and therapeutic psychological services, and avoid inpatient hospitalizations for 

mental disorders.

Strong evidence suggests that the proportion of mental disorders and alcohol 

abuse is similar among Hispanics and non-Hispanics (U.S. Department of 

Health and Human Services [HHS], 1999, 2000, 2002). Nationally, the number 

of bilingual mental health professionals who serve Spanish-speaking clients 

is inadequate to serve the growing Hispanic population. The 1990 Surgeon 

General’s mental health report documented only 29 Hispanic mental health 

professionals for every 100,000 Hispanics, compared to 173 non-Hispanic 

providers per 100,000 U.S. residents. This health care workforce shortage 

is amplified in the border region, where Spanish speakers are common and 

inadequate access to mental health services continues to be observed.

Figure 18: Percent of the adult population who had not seen or talked to a 

dentist in more than a year

(Results are based on answers to the following question: “About how long has it been since you 

last saw a dentist? Include all types of dentists, such as orthodontists, oral surgeons, and all 

other dental specialists as well as dental hygienists.”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
Border Lives: Health Status in the United States-Mexico Border Region

98

In 2000-2003, adults in the border area reported that they were less likely to 

have sought mental health services during the previous year than the average 

person in the United States (4.7 percent versus 6.2 percent). A similar difference 

was found for the southwest region versus the United States, as documented in 

Table 14. Overall, Hispanics were less likely to have seen or talked to a mental 

health professional than were non-Hispanics. Figure 19 shows the difference 

by ethnicity for both the border area and nation. Nationally, the proportion of 

Hispanics who sought mental health services during the previous year was 41 

percent lower than that of non-Hispanics (3.8 percent versus 6.5 percent). In 

the border region, the percentage of Hispanic adults who sought mental health 

services during the previous year was less than half that of non-Hispanic (2.7 

percent versus 6.0 percent). Evidence of ethnic disparity in seeking mental health 

services was reflected in other regions as well (see Table 14).

As in access to all other types of health care, insurance and ethnicity played 

important roles in determining access to mental health services across the United 

States. Nationwide, uninsured Hispanics were less likely to seek mental health 

services than were insured Hispanics (1.4 percent versus 5.3 percent). But even 

those Hispanics with health insurance experienced disparity in access to mental 

health services. Among the insured population of the United States, Hispanics

were less likely than non-Hispanics to seek mental health services (5.3 percent 

versus 6.5 percent). However, in the border region, differences in access to mental 

health care services by ethnicity and insurance were not statistically significant12.

Immunization

Immunizations for influenza (flu) and pneumonia are available for both adults 

and children and historically have dramatically reduced the impact of these 

diseases in the United States. Yet the impact of these diseases is still enormous. 

According to the CDC, influenza causes illness in 5 to 20 percent of the 

population each year, more than 200,000 hospitalizations, and about 36,000 

deaths. Influenza is also closely related to pneumonia, a bacterial infection of the 

lungs. Lungs weakened by the flu virus are especially susceptible to infection. In 

2002, pneumonia accounted for 64,954 deaths in the United States. Combined, 

flu and pneumonia would rank as the seventh leading cause of death in the 

United States (Anderson, 2005). According to estimates from the National 

Heart Lung and Blood Institute (2004), the cost for dealing with both diseases 

is about $37.7 billion per year. Of this sum, $31.9 billion (84.6 percent) is

attributable to direct costs, while $5.8 billion (15.4 percent) is due to indirect 

mortality.

12 The percentage of uninsured Hispanic population is unreliable. RSE <30.
 Chapter 3 - Access To and Use of Health Care 

99 

Analysis of influenza and pneumonia immunization rates among adults reveals 

disparities based on geographic region, ethnicity, and health insurance status. 

Such analysis can help identify possible causes of low immunization rates.

Influenza

The CDC recommends seasonal flu vaccine for anyone who wishes to avoid the 

flu, but especially for young children, pregnant women, persons aged 50 and 

older, people with chronic diseases, those living in nursing homes or chronic 

care facilities, and people who are likely to be exposed to the flu such as healthcare workers. Flu vaccination must be repeated yearly to provide protection 

because the virus changes rapidly.

For immunization practices to be successful, a strong and continuous 

vaccination campaign has to be carried out. Unfortunately, this practice is not 

consistent across the United States. Comparison of flu immunization practices 

between the border and the United States as a whole shows disparities in access 

Figure 19: Percent of the adult population who had not seen or talked to a 

mental health professional during the previous 12 months, by ethnicity

(Results are based on answers to the following question: “During the past 12 months, have you 

seen or talked to any of the following health-care providers about your own health? A mental 

health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social 

worker.”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file 
Border Lives: Health Status in the United States-Mexico Border Region

100

Figure 20: Percent of the adult population who had received a flu shot in the 

previous 12 months, by ethnicity and insurance status, 2000-2003

(Results are based on answers to the following question: “During the past 12 months, have you 

had a flu shot or flu vaccine sprayed in your nose by a doctor or any other health professional? 

A health professional may have let you spray it. This vaccine is usually given in the fall and 

protects against influenza in the flu season.”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file

to and use of the vaccine (see Table 15). In 2000-2003, adults living in the 

border region were less likely to report having received flu vaccination during 

the past year than were people in the United States as a whole (24.2 percent 

versus 27.9 percent).

Ethnicity strongly affected the likelihood that a person had received flu 

vaccination. Hispanics were less likely to receive flu vaccination than were 

non-Hispanics, no matter where they lived. In the border region, 16.5 percent 

of adult Hispanics reported having received flu vaccination, compared to 29.2 

percent of non-Hispanics, a ratio of almost one to two. Nationally, 40 percent 

fewer Hispanics than non-Hispanics received a flu shot (17.4 percent versus 29.2 

percent). In contrast, there was no difference in immunization rates between 

non-Hispanics living in the border region and non-Hispanics nationwide.

Health insurance status also had a tremendous impact on the likelihood of 

receiving flu vaccination, as illustrated in Figure 20. In 2000-2003, people 

who had health insurance were more likely to report having received flu 

vaccination, no matter what their ethnic group or geographic region, than were 

those without health insurance. In the border region, uninsured Hispanics were 
 Chapter 3 - Access To and Use of Health Care 

101 

notably less likely to have received flu vaccination than were insured Hispanics 

(7.7 percent versus 23.6 percent). Nationally, insured Hispanics were 28 percent 

less likely to receive a flu shot than were insured Non-Hispanics (23.0 percent 

versus 31.8 percent).

Although health insurance was the major determinant of flu immunization rates, 

ethnicity was also an important factor. Among those insured, Hispanics were less 

likely to report flu immunization. This ethnic disparity was more pronounced in 

the border region, where 25 percent fewer insured Hispanics than insured nonHispanics received flu vaccination (23.6 percent versus 31.6 percent).

Pneumonia

The CDC recommends a single pneumonia vaccination for people who are older 

than 65 years of age, chronically ill, and other vulnerable populations. Yet the 

immunization rate for pneumonia is low across the United States, even among 

these targeted populations. In 2000-2003, only 15.6 percent of the United States 

adult population reported having received a pneumonia shot. The estimated 

percentage at the border was 14.9 percent, not significantly different from the 

national rate. Pneumonia immunization was slightly higher in the border area 

than in the southwest region as a whole. Table 16 documents these differences.

In the border region, ethnicity strongly impacted the likelihood of receiving 

pneumonia vaccination. Only 6.2 percent of Hispanics reported immunization 

against pneumonia, compared to 20.6 percent of non-Hispanics. Nor was ethnic 

disparity exclusive to the border region. Inequality in pneumonia immunization 

based on ethnicity was reported in all other regions (see Table 16).

Health insurance status was a less important predictor of pneumonia 

immunization than was ethnicity. Non-Hispanics with health insurance were 

more likely to have ever received pneumonia vaccination than were Hispanics 

with health insurance. Among people who had health insurance in the 

border region, the percentage of Hispanics who had ever received pneumonia 

immunization was 60 percent less than the estimate for non-Hispanics (9.1 

percent versus 22.6 percent). A similar disparity was found at the national 

level, where the percentage of insured Hispanics who had received the vaccine 

was 48 percent lower than that of insured non-Hispanics (18.2 percent versus 

9.4 percent). Among uninsured populations, non-Hispanics reported higher 

pneumonia immunization rates than did Hispanics.
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102

III. Conclusion and Recommendations

This chapter provides a comprehensive description of access to health care and 

health care consumption along the U.S.-Mexico border, as well as comparisons 

to the nation as a whole and to other relevant geographic regions. The results 

demonstrate that insurance status and ethnicity are important determinants of a 

person’s ability to access health care services.

In comparison to the United States, the population living in the border region 

was more likely to report significant inability to access and afford health care, 

including having contact with a primary care physician, medical specialist, 

dentist, or mental health professional. People who lived in the border area were 

also less likely to report compliance with standard immunization practice. They 

were more likely to be uninsured and to spend more than a year without having 

any kind of health insurance coverage.

Analysis of these data consistently shows ethnic disparity in access to health 

care between Hispanic and non-Hispanic adults. In most areas examined, this 

Figure 21: Percent of the adult population who had ever received a pneumonia 

shot, by ethnicity, 2000-2003

(Results are based on answers to the following question: “Have you ever had a pneumonia 

vaccination, sometimes called a pneumonia shot? This shot is usually given only once in a 

person’s lifetime and is different from the flu shot.”)

Data retrieved in 2005 from the 2000-2003 NHIS in-house data file
 Chapter 3 - Access To and Use of Health Care 

103 

disparity was found even among the insured population. However, people who 

had insurance were more prone to report adequate access to health care than 

those who did not. This tendency was seen at the border, but also at the state, 

regional, and national levels. Most literature that examines access to health care 

uses health insurance coverage as the main measure of access. But data from this 

report show that even with insurance, a noteworthy disparity in access to health 

services is related to ethnicity. Our work suggests that, compared to uninsured 

non-Hispanics living in the border region, uninsured Hispanics are (a) less likely 

to access direct medical care through a doctor’s visit or specialist; (b) often do 

not have a place to go when they are sick or need health advice; (c) do not seek 

specialty medical care; (d) do not have an adequate immunization practice, and 

(e) are more likely to report inability to afford extended inpatient care.

These findings provide a comprehensive picture of the limits on access to health 

care in the border region, especially for the portion of the population that is 

currently uninsured. Future work on this topic should go beyond the mere 

quantification of health-care accessibility and health insurance status. For future 

research, we suggest the application of a novel and integrated approach to 

measure access to health care, based on different health insurance coverage types. 

This exercise would deepen comprehension of how the use and consumption 

of health care services by the border population can be better described and 

consequently improved.

The findings of this report suggest that two areas need to be addressed in order 

to improve access to health care in the U.S.-Mexico border. First, health care 

providers must be given the necessary infrastructure and resources to provide 

affordable, high-quality health care services to those who currently cannot afford 

care. Second, the general population must be provided with the resources and 

information they need to effectively access health care at all levels. Public health 

professionals have the responsibility to be the liaison between these two worlds. 

Public health professionals, health care providers, and government need to work 

together to ensure that these two issues are addressed. Without this collaboration, 

access to health care in the border region will continue to stagnate.
Border Lives: Health Status in the United States-Mexico Border Region

104

References

American College of Obstetricians and Gynecologists (ACOG). (2006, May 9). 

ACOG recommends first OB/GYN visit in early teens. Press Release. 

Retrieved May 20, 2006 from http://www.acog.org/from_home/

publications/press_releases/nr05-09-06-2.cfm

American Lung Association. (n.d). Pneumonia. Retrieved June 11, 2007, from 

http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34

706&ct=3052571#prevention

Anderson, R.N., & Smith B.L. (2005). Deaths: leading causes for 2002. 

National Vital Statistics Reports. 53(17). National Center for Health 

Statistics. U.S. Centers for Disease Control and Prevention. Hyattsville, 

Maryland.

Care for All. (2002). Out of the emergency room: communicating healthcare 

options to low-income Texans. Retrieved August 30, 2006 from 

www.careforall.net/AccesstoHealthCAre/HospitalERUse71/

OutoftheEmergencyRo095C.asp

Centers for Disease Control. (2004). Access to health-care and preventive 

services among Hispanics and non-Hispanics, United States, 2001-

2002. Morbidity and Mortality Weekly Report. 53(40): 937-41.

Centers for Disease Control. (n.d.) “Key Facts About Influenza and the 

Influenza Virus.” http://www.cdc.gov/flu/keyfacts.htm. Accessed 

6/11/2007.

Centers for Disease Control. (n.d.) “Pneumococcal Disease – In Short.” http://

www.cdc.gov/vaccines/vpd-vac/pneumo/in-short-both.htm#who

Cohen, R.A., & Bloom, B. (2005). Trends in health insurance access to medical 

care for children under age 19 years: United States, 1998-2003. Advance 

Data from Vital Health Statistics, 355. 1-12. National Center for Health 

Statistics. U.S. Centers for Disease Control and Prevention.Hyattsville, 

MD: Author.

Cohen R.A., Hao, C., & Nelson, Z. (2005 January 28). Health insurance 

coverage: estimates from the National Health Interview Survey, JanuaryJune 2004. Morbidity and Mortality Weekly Report, 54(03); 75. Atlanta, 

GA: U.S. Centers for Disease Control.
 Chapter 3 - Access To and Use of Health Care 

105 

Cohen, R.A. & Martinez, M.E. (2004). Health insurance coverage: estimates 

from the National Health Interview Survey, 2004. (Early release of 

health insurance estimates based on data from the 2004 National 

Health Interview Survey). Retrieved October 26, 2006 from http://

www.cdc.gov/nchs/data/nhis/earlyrelease/insur200506.pdf. National 

Center for Health Statistics, Centers for Disease Control and 

Prevention.

DeNavas-Walt, C., Proctor, B., & Mills, R. (2004). Income, poverty, and health 

insurance coverage in the United States: 2003. (U.S. Census Bureau, 

Current Population Reports, P60-266). Washington,

DC: U.S. Government Printing Office.

Healthy Border 2010 (2003). An Agenda for Improving Health on the 

United States-Mexico Border. United States-Mexico Border Health 

Commission. October, 2003. El Paso, Texas.

Hunter, J., Derman C., Monada E., Papenfuss M., Wallace D., & Giuliano, A. 

(2003). Health care access and utilization among women 40 and older 

at the U.S.-Mexico border: predictors of routine check-ups. Journal of 

Community Health, 28(5), 317-333.

Landeck, M., & Garza, C. (2002). Utilization of physician health care services 

in Mexico by United States Hispanic border residents. Health Marketing 

Quarterly, 20(1), 3-16.

Lieu, T., Newacheck, P., & McManus, M.. (1993). Race, ethnicity and access 

to ambulatory care among U.S. adolescents. American Journal of Public 

Health, 83, 960-5.

Macias, E.P. & Morales, L.S. (2001). Crossing the border for health care. Journal 

of Health Care for the Poor and Underserved, 12(4), 77-87.

National Heart, Lung and Blood Institute. (2004). Morbidity and mortality: 

2004 chartbook on cardiovascular, lung and blood diseases. Washington, 

DC: U.S. Government Printing Office.

Parchman, M., Bird T. (2001). Access to and use of ambulatory health care by a 

vulnerable Mexican-American population on the U.S.-Mexico border. 

Journal of Health Care for the Poor and Underserved, 12(4), 404-414.

Sambamoorthi U., DD McAlpine. (2003). Racial, ethnic, socioeconomic, 

and access disparities in the use of preventive services among women. 

Preventive Medicine. 37: 475-484.
Border Lives: Health Status in the United States-Mexico Border Region

106

SPSS Complex Sample 13.0. (2004). Chicago, IL.

Seid M, C. D., Mize R, Zivkovic M, and Varni J. (2003). Crossing the border 

for health care: access to primary care characteristics for young children 

of Latino farm workers along the U.S.-Mexico border. Ambulatory 

Pediatrics, 3, 121-130.

Starfield B., S. L. (1993). Primary care as part of United States health services 

reform. Journal of the American Medical Association, 269, 3136-3139

Starfield, B. (1998). Primary care: Balancing health needs, services and technology. 

New York: Oxford University Press.

Starfield, B. (1996). Public health and primary care: A framework for proposed 

linkages. American Journal of Public Health, 86, 1365-1369.

U.S. Committee on Monitoring Access to Personal Health Care Services, 

Institute of Medicine. (1993). Access to health care in America, 

Washington, DC: National Academy Press.

U.S. Department of Health and Human Services. (2000). Healthy People 2010. 

(Vol. 1, 3-12). (Second ed.) Washington, DC: U.S. Government 

Printing Office.

U.S. Department of Health and Human Services, Office of the Surgeon 

General, Substance Abuse and Mental Health Services Administration. 

(1999). Mental health: a report of the Surgeon General. Retrieved 

December 20, 2006, from http://www.mentalhealth.samhsa.gov/cmhs/

surgeongeneral/surgeongeneralrpt.asp

U.S. Department of Health and Human Services. Substance Abuse and Mental 

Health Services Administration. Center for Mental Health Services. 

(2001). Mental health, United States, 2000. Retrieved September 18, 

2005 from http://www.mentalhealth.samhsa.gov/publications/allpubs/

SMA01-3537/default.asp

U.S. Department of Health and Human Services, Substance Abuse and Mental 

Health Services Administration, Center for Mental Health Services. 

(2004). Mental health, United States, 2002. Retrieved September 18, 

2005 from http://www.mentalhealth.samhsa.gov/publications/allpubs/

SMA04-3938/default.asp
 Chapter 3 - Access To and Use of Health Care 

107 

Valdez R, M. H., Brown R, Wyn R, Wang C, and Cumberland W. (1993). 

Insuring Latinos against the cost of illness. Journal of the American 

Medical Association, 269(7), 889-894.

Warner, D. (1991). Health issues at the U.S.-Mexican border. Journal of the 

American Medical Association, 265(2), 242-247.

109 

Introduction

Assuring the health of mothers, infants and children in the border region 

is critical for the continued growth and good health of this population. 

The health of mothers before and during pregnancy is important for 

good birth outcomes; ensuring that mothers survive and remain healthy after 

pregnancy is necessary for the growth and development of their children. Access 

to care is essential if infants and children are to receive routine physical exams, 

screening, and childhood vaccinations, as well as for monitoring of their growth 

and development. Parents and schools both play an important part in providing 

children with a healthy diet and lifestyle, including appropriate physical activity. 

Thus, health-care professionals, parents, educators, mentors, and others all need 

to be involved in ensuring that border youth enter adulthood in good physical 

and mental health.

The U.S.-Mexico border is home to a young and rapidly growing population. 

Providing the public and private health care services required by this population 

will call for substantial investment, now and into the future. Hispanic 

border residents in particular suffer from many disadvantages including low 

socioeconomic status, limited access to health care, and various risk factors. Yet 

they manage to have good health outcomes, particularly regarding maternal, 

infant and child health. This phenomenon of good health status for Hispanics, 

despite a variety of socioeconomic and other disadvantages was described as an 

“epidemiological paradox” (Markides, & Coreil, 1986). More recently it has 

become known as the “Hispanic paradox” (Hunt et al., 2002).

This chapter draws on available information from national and state-level 

datasets to describe the health status of mothers, infants and children living in 

the border region. Information regarding health behaviors and other factors 

associated with key indicators and outcomes are examined. The accuracy of 

CHAPTER 4

MATERNAL, INFANT, AND CHILD HEALTH
Border Lives: Health Status in the United States-Mexico Border Region

110

the “Hispanic paradox” as it applies to maternal, infant, and child health of 

Hispanics on the U.S.-Mexico border also is assessed.

Maternal-Child Health and Healthy Border 2010

The importance of maternal, infant, and child health in the border region is 

reflected in the fact that six of the 20 objectives of Healthy Border 2010 are 

directly related to maternal, infant and child health (U.S.-Mexico Border Health 

Commission, 2003). The objectives that relate to maternal, infant, and child 

health and their 2010 targets are:

•	 Infant mortality: Reduce the infant mortality rate by 15 percent;

•	 Congenital anomalies: Reduce infant mortality from congenital anomalies 

by 30 percent;

•	 Prenatal care: Increase the proportion of mothers initiating prenatal care in 

the first trimester to 85 percent;

•	 Early teen births: Reduce the pregnancy rate in adolescents 15-17 years of 

age by 33 percent;

•	 Immunization coverage: Raise immunization coverage among children 19-35 

months of age to 90 percent;

•	 Childhood injuries: Reduce the childhood injury death rate by 30 percent.

Two additional Healthy Border objectives – reducing motor vehicle crash deaths 

and asthma hospitalization – also address two important causes of morbidity 

and mortality among border youth.

Methods

This chapter presents information on current maternal, infant, and child health 

status in the border region, defined as the 44 counties on or near the U.S.-

Mexico border. A major challenge for any health study involving counties, 

particularly those with small populations, is locating accurate and relevant health 

data. Most surveys are designed to produce national or state-level estimates, 

and few counties have the resources to collect their own health data. As a 

result, most of the statistics used in this report are based on administrative data, 

principally information from birth and death certificates. Some information 

on hospital stays is derived from state-based hospital discharge data systems. 

State-level information on vaccination coverage levels comes from the National 

Immunization Survey (Centers for Disease Control [CDC], 2006a).

Natality and mortality information for the border region presented in this 
 Chapter 4 - Maternal, Infant, and Child Health

111 

chapter is based on all births and deaths occurring in the United States to 

residents of the 44 border counties. This information is used to compare and 

contrast various measures for the border region, border states, and the United 

States. Within the border region, the same measures are compared across the 

combined border counties of each state. Because of substantial differences in 

birth and death outcomes for Hispanics and non-Hispanic whites, many birth 

and death measures are presented separately for these two ethnic groups.

The most recent national natality and mortality data available at the time this 

report was prepared were based on births and deaths occurring in 2004. Every 

effort has been made to present the most recent data available, but in numerous 

cases it was necessary to combine birth or death data for several years in order 

to present statistically reliable measures. This was particularly necessary to make 

reliable comparisons across states, by ethnicity, sex, and/or age group.

Natality data were used to measure a variety of maternal health characteristics 

including maternal medical risk factors; complications of pregnancy, labor, and 

delivery; maternal race, ethnicity and age at delivery; and maternal access to 

prenatal care. Natality data also were used to measure birth outcomes, including 

gestational age, birthweight, multiple births, and method of delivery, as well as 

other characteristics such as attendant at birth and place of delivery. Natality 

data also provided the denominators for infant mortality rates. Mortality data 

provided information on the decedent’s age, sex, race and ethnicity, as well as the 

cause of death.

Population: Women of Childbearing Age and Children

During the 1990s the number of women of childbearing age (15-44 years) in 

the border region grew rapidly, as did the number of children. The number of 

women 15-44 years of age rose by more than 12 percent over the decade, more 

than double the national growth rate of 4.8 percent. The number of children 

0-14 years of age increased by nearly 19 percent, compared to an 11 percent rise 

for the nation. Within the border region the largest increases were in the Texas 

border counties, both for women of childbearing age (20 percent) and children 

(24 percent). The rapid growth in both the number of women of childbearing 

age and children sets the stage for sustained rapid growth of the border 

population into the future.

Growth patterns were markedly different for the two major border ethnic 

groups, Hispanics and non-Hispanic whites. Population growth was especially 

strong among Hispanics, with an increase of 35 percent or more over the decade 

for both women of childbearing age and children. Population growth among 

non-Hispanic whites was almost the mirror image of the Hispanic trends: the 
Border Lives: Health Status in the United States-Mexico Border Region

112

number of childbearing women fell by 11 percent and the number of children 

dropped by 8 percent over the decade. As large and striking as the border 

Hispanic increases were, they were surpassed by Hispanic population growth 

at the border state and national levels. The female childbearing population 

grew by 43 percent in the border states and by 52 percent at the national level 

over the same period. Growth of the 0-14 year age group was slightly higher 

— 46 percent for the border states and 57 percent for the nation. However, as 

discussed later in this chapter, Hispanic birth rates in the border counties are 

higher than or equal to Hispanic fertility for the border states or for the United 

States as a whole. Thus the higher Hispanic childhood growth rates in nonborder areas are likely due in part to Hispanic migration into non-border areas 

of the United States.

Natality

Number of births

More than 125,000 births took place in the border region in 2004, a slight 

increase from the year 2000. Although the California border counties had the 

largest total population on the border, the largest number of births took place 

in the border counties of Texas. The majority of border births were to Hispanic 

mothers, for all 44 border counties and for the border counties of each state. 

Nationally, Hispanic births were slightly less than one-quarter of the U.S. total.

Recent trends in the number of births are somewhat different than the trends 

in the number of women of childbearing age or of children. As Figure 1 shows, 

between 2000 and 2004 the percent increase in births in border counties was 

about four percent overall and similar across each border state; the national 

increase was much lower (1.3 percent). Among Hispanics, births in the border 

counties grew by 7 percent, less than the 10 percent increase in the border states 

and less than the 16 percent rise in Hispanic births for the United States as a 

whole. Among non-Hispanic whites the number of births fell from 2000 to 

2004. The number of non-Hispanic white births declined by more than nine 

percent in the border counties, while the percentage decline was smaller at the 

border state and national levels. In the border area of Texas the number of births 

to non-Hispanic whites fell by more than 30 percent.

Border birth rates

Birth rates, as opposed to the number of births, provide a better understanding 

of the fertility behavior of a population. The crude birth rate measures the 

number of births per 1000 population, providing a measure of fertility that 

is independent of population size. The fertility rate measures the number of 
 Chapter 4 - Maternal, Infant, and Child Health

113 

births per 1000 women of childbearing age, thus taking account of the effects 

of both population size and composition on the number of births. The total 

fertility rate estimates the total number of births that each woman could have 

over her reproductive lifetime. The total fertility rate assumes that each woman’s 

reproductive behavior over her lifetime will follow the current age pattern of 

childbearing in the total population. For example, the total fertility rate for U.S. 

women in 2004 was 2.0. This means that women in the United States could 

expect an average of 2.0 births over their lifetime if their childbearing matched 

the birth rates reported by each five-year age group of U.S. women during the 

year 2004.

All three measures come to the same conclusions regarding the reproductive 

behavior of women on the border. Figure 1 presents fertility rates for the 

United States, border states and border counties in 2004. Overall, fertility 

rates for the total population and for Hispanics were significantly higher in the 

border region than for the nation, and also higher than the four border states 

combined. Within the border region, Texas border counties had the highest level 

of childbearing (103.4 per 1,000 women 15-44 years versus 84.0 in the region 

as a whole), due mostly to higher rates among Hispanics. Hispanic fertility 

rates in the border region were nearly double the rates for non-Hispanic whites, 

although the disparity was reduced in the New Mexico border counties, where 

the Hispanic rate was 50 percent higher than the white non-Hispanic rate.

Figure 1: Fertility rates, USA and US-Mexico border, 2004

Source: National natality data, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

114

Age-specific fertility

For demographers, the age pattern of fertility is important in describing the 

reproductive behavior of women, in analyzing current fertility trends, and in 

preparing population projections for future years. In terms of public health, 

age-specific fertility data are most useful in providing information on births to 

high-risk mothers, that is, women in their early teens and those aged 35 years or 

more. Birth data by age of mother are also useful in understanding differences in 

the reproductive behavior of different population groups.

The age-pattern of childbearing illustrates the differences in reproductive behavior 

between the border and the nation as a whole, as shown in Figure 2. Age-specific 

birth rates measure the number of births per 1000 women of a particular age 

group. The border birth rate for all ethnicities was substantially higher than the 

U.S. national rate among teens (15-19 years of age) and among women in their 

twenties. The border rate exceeded the national rate by 50 percent for teen births, 

and by 33 percent for births to women aged 20-24 years. The U.S. and border 

rates converged for women in their 30s and older, although the border rate never 

fell below the national rate.

The two major ethnic groups living in the border region displayed significantly 

different patterns of childbearing by age: The border Hispanic birth rate for 

teens 15-19 years of age was more than four times the birth rate for nonHispanic white teens (88 versus 20), and the Hispanic birth rate was double 

Figure 2: Birth rates by age and ethnicity, USA and US-Mexico border, 2004

Source: National natality data, NCHS/CDC
 Chapter 4 - Maternal, Infant, and Child Health

115 

the non-Hispanic white birth rate for women in their twenties (170 versus 76). 

For women aged 40 years or more, birth rates were roughly the same for border 

Hispanics and non-Hispanic whites. Overall, there was a much higher rate of 

childbearing among Hispanic women. In 2004, the total fertility rate (number 

of births expected over their lifetime) was 3.0 children for Hispanic border 

women, as compared to 1.7 among non-Hispanic white border women, and 2.0 

among women of all ethnicities nationwide.

Hispanic fertility is unusual not only because of its very high level but also 

because of the very high birth rates among very young women and somewhat 

higher rates among older women. Disaggregating the border Hispanic birth rate 

into women born in the United States versus those born abroad may help to 

explain this unusual fertility behavior, as the fertility behavior of immigrants may 

differ from that of Hispanic women born in the United States. It was not possible 

at the time of this writing to compare birth rates for these two groups because 

population data on mother’s country of birth are not available by sex or age, but 

it was possible to compare the percent distribution of births by mother’s age.

Among U.S.-born border Hispanics in 2004, the proportion of births to teenage 

mothers was much larger than for foreign-born teens, 20 percent versus 13 

percent, as depicted in Figure 3. In contrast, the proportion of births to foreignborn border women aged 35 years or more was nearly double the proportion for 

U.S.-born women (13 percent versus 7 percent). Thus the relatively high levels 

Figure 3: Percent distribution of births, border Hispanic women by age and 

place of birth, 2004

Source: National natality data, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

116

of fertility at both ends of the childbearing years for border Hispanic women 

may be due to the behavior of two different groups: U.S.-born Hispanic women 

for teenage childbearing; and foreign-born Hispanic women for births to older 

mothers. Confirmation of this observation through birth rates will have to await 

the availability of denominators, that is, the number of women by sex, age, and 

country of birth.

Risk Factors

Socioeconomic status

Social and economic status have long been considered important factors in 

fertility and maternal and infant health (Chandra, Martinez,, Mosher, Abma, 

& Jones, 2006; Dye, 2005; Martin et al., 2006). The relationship between 

socioeconomic status and these outcomes is complex and is believed to be 

mediated via a number of other factors, including behavioral issues such as 

maternal smoking, maternal health before pregnancy, nutritional factors, access 

to health care, and others (Institute of Medicine, 1985). In general, higher levels 

of income and parental education are associated with lower levels of unfavorable 

outcomes, such as low birthweight (LBW) and infant mortality. This inverse 

relationship has been found not only in the United States but in other developed 

countries as well (National Center for Health Statistics, 1992). Most studies 

of this relationship, however, find that racial and ethnic disparities in birth 

outcomes are not fully explained by socioeconomic differences (Bilheimer, 1992; 

CDC, 2002; Kleinman & Kessel, 1987).

Some information on socioeconomic status in relation to births for the border 

region is available from birth certificate data. The birth certificate requests 

information on both mother’s and father’s education, but paternal education 

data are incomplete, in particular for Hispanic births. Figure 4 illustrates large 

differences in the educational achievement of Hispanic and non-Hispanic 

white women in 2004. Although Hispanic and non-Hispanic white mothers 

are slightly more educated in the border region than at the national level, the 

disparity between them is greater on the border. The proportion of mothers 

with less than 12 years of education was six times higher among Hispanics 

than among non-Hispanic whites (42 percent versus 7 percent). Nationally, 

the Hispanic proportion with less than 12 years of education was 4.5 times the 

proportion for non-Hispanic white mothers (48 percent versus 11 percent). In 

addition, a substantial proportion of Hispanic mothers had completed less than 

seven years of education. This proportion was about 8 percent in the border 

region and 15 percent nationally, as compared to about 0.2 percent for nonHispanic white mothers (data not shown).
 Chapter 4 - Maternal, Infant, and Child Health

117 

Figure 4: Proportion of mothers with less than 12 years of education by 

ethnicity, USA and border counties, 2004

USA figures do not include data for Florida, Idaho, Kentucky, New Hampshire, New York State 

(excluding New York City), Pennsylvania, South Carolina, Tennessee, and Washington.

Source: National natality data, NCHS/CDC

Births to early teens and older women 

Childbirth during adolescence or at older ages is a risk factor for both infant 

survival and maternal health. Infant mortality has a number of risk factors, 

but the risk of infant death is clearly higher for births to women in their early 

teens (less than 18 years of age) and those aged 35 years or more (Mathews, & 

MacDorman, 2007). Ectopic pregnancy, an important risk factor for maternal 

death, is much more common among women aged 35 or above (CDC, 1995). 

Complications of labor and delivery are also more common for both younger 

and older mothers (Martin, Hamilton, Ventura, Menacker, & Park,, 2002; 

Notzon et al., 1994).

The number of early teen births decreased by about three percent in the border 

region from 2000 to 2004. The decline occurred among women aged 15-17 

years and those under age 15. Most of the decline took place in the California 

and Arizona border counties, primarily San Diego County, California and Pima 

County, Arizona. In addition, the birth rate for border women under 18 years 

of age fell by almost eight percent in the same interval, from 43.3 to 39.9, or 24 

percent of the Healthy Border target for the year 2010. While this decrease was 

notable, it was much less than the national decline in the early teen birth rate, 

which fell by 18 percent. Reductions in the birth rate for border women under 
Border Lives: Health Status in the United States-Mexico Border Region

118

18 years varied widely by ethnicity. The Hispanic rate declined by about four 

percent, while among non-Hispanic whites the rate fell by more than one-third.

Childbearing among older women has increased substantially in recent years 

at the national and border county levels. From 2000 to 2004 the number of 

births to border women 35 years of age or more increased by eight percent, 

and births to border women aged 40 years or more increased even faster (10 

percent rise). These increases were somewhat less than national trends. In terms 

of the birth rate for women aged 35 years or more, the rate for border women in 

2004 was significantly higher than the U.S. national rate: 31.6 births per 1000 

women versus 26.5 for the United States. Since 2000 the border birth rate for 

older women has risen at roughly the same pace as for the nation as a whole. 

The border birth rate for older non-Hispanic white women was less than the 

Hispanic rate, 27.8 versus 32.3 in 2004.

Tobacco and alcohol use during pregnancy 

Maternal smoking and drinking during pregnancy are well-established risk 

factors for a variety of poor outcomes. Tobacco use has been associated with 

LBW, spontaneous abortion, preterm delivery, and infant death; alcohol use 

has been linked to fetal alcohol syndrome and preterm delivery (Jones, 1986; 

Kleinman & Madans, 1985; Lundsberg, Bracken, & Saftlas, 1997; Pollack, 

2001; Zuckerman, 1998). In 1995, costs of complicated births that could be 

attributed to smoking were estimated at $1.4 to $2.0 billion (CDC, 1997).

Although there may be some underreporting of maternal smoking on the 

birth certificate, in part because of the stigma associated with tobacco use and 

poor birth outcomes, variations in smoking among population subgroups are 

generally consistent with other data sources. For example, the U.S. National 

Survey of Family Growth in 2002 reported a smoking rate during pregnancy of 

5.1 percent for Hispanics versus 17.1 percent for non-Hispanic whites (Chandra 

et al., 2006). CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) 

found that 4 percent of Hispanic women smoked during the third trimester of 

pregnancy as compared to 16.8 percent of non-Hispanic whites, although this 

study was limited to 27 states, only one of which (New Mexico) borders Mexico 

(McDonald, Suellentrop, Paulozzi, & Morrow, 2007). Differences in maternal 

smoking rates by ethnic group have also been found in other studies (Barnett, 

1995; Ebrahim, Floyd, Merritt, Decoufle, & Holtzman, 2000).).

Maternal smoking rates have declined since 1990 in the United States as well 

as in the border region. At the national level, the percent of mothers smoking 

during pregnancy fell from 18.4 percent in 1990 to 10.2 percent in 2004. 

Similar declines have been reported for Hispanics and non-Hispanic whites. 

Smoking rates differ substantially by ethnicity, however. For the United States as 
 Chapter 4 - Maternal, Infant, and Child Health

119 

a whole in 2004, only 2.6 percent of Hispanic mothers reported smoking during 

pregnancy, versus 13.8 percent of non-Hispanic whites. Maternal smoking rates 

were lower on the border, with an overall border rate of 2.2 percent in 2004, 

only 1.0 percent for Hispanic mothers and 8.9 percent for non-Hispanic whites.

Because smoking data were not available for some states with traditionally 

higher smoking rates during pregnancy, these smoking rates may be 

underestimated. The border rates may be even more underestimated than the 

national rates, however. California does not collect information on smoking 

on the birth certificate, and the other three border states continue to use the 

1989 smoking question which tends to underestimate the true level of maternal 

smoking. The 1989 smoking question asks a simple yes/no question on tobacco 

use during pregnancy, while the revised smoking questions on the 2003 standard 

birth certificate ask for tobacco use during each trimester of pregnancy. The 

revised smoking questions have resulted in increases in reported smoking rates 

in the seven states that have adopted the new standard certificate (Martin, & 

Ventura, 2006). Nevertheless, large ethnic differences in maternal smoking rates 

are expected to remain.

Birth certificate information on maternal alcohol consumption during 

pregnancy is considered unreliable because of severe underreporting. Maternal 

drinking rates based on birth certificate data are only one-tenth the level 

reported by other sources, such as the BRFSS, 1.5 percent versus 15 percent 

(Ebrahim et al., 1998). Underreporting of maternal drinking on the birth 

certificate may be due to questions that do not encourage reporting of very light 

alcohol use, along with the well-known association of maternal drinking with 

poor birth outcomes. As a result, no birth certificate data on maternal alcohol 

consumption is provided in this discussion.

Data for 27 states from the PRAMS System indicate a much lower proportion 

of Hispanic mothers reporting alcohol consumption before pregnancy than nonHispanic whites (26.8 percent versus 57.6 percent) (McDonald et al., 2007). 

During the last three months of pregnancy these proportions were much lower 

for both groups and not significantly different (4.7 percent for Hispanics, 6.5 

percent for non-Hispanic whites). Similar data are not available for the border 

region. Data from National Health Interview Survey indicate large differences 

in alcohol consumption between Hispanic and non-Hispanic white women 

18-44 years of age: 48 percent of Hispanic women are lifetime abstainers versus 

18 percent for non-Hispanic whites; 27 percent of Hispanic women are current 

drinkers versus 54 percent of non-Hispanic whites (Lucas, Schiller,& Benson, 

2004). Given these differences, alcohol consumption among pregnant women in 

the border region is likely to be low, in particular for Hispanic mothers.
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120

Prenatal Care

Access to medical care is a major issue in the U.S.-Mexico border region, as 

Chapter 3, “Access To and Use of Health Care,” has made clear. Pregnant 

women face barriers to prenatal care similar to the barriers confronting the 

general population, including lack of health insurance coverage, low income, 

inadequate supply of health personnel, and lengthy distance to health facilities. 

For this reason, access to timely prenatal care was selected as a Healthy Border 

objective, with a 2010 target of 85 percent of women initiating prenatal care 

during the first trimester of pregnancy.

Access to prenatal care has improved significantly since the beginning of the 

decade. While initiation of prenatal care in the first trimester has shown little 

progress at the national level since 2000, the proportion of border women with 

timely prenatal care rose from 73.2 percent in 2000 to 77.7 percent in 2004, 

or 38 percent of the 2010 goal of 85 percent. Figure 5 and Figure 6 show this 

trend. Access to prenatal care improved from 2000 to 2004 in the border areas 

of California and Texas, but deteriorated in the border counties of Arizona and 

New Mexico. In the California border area, access improved from 82.8 percent 

to 87 percent, while in the Arizona border region access fell from 70.2 percent 

in 2000 to 67.5 percent in 2004.

Figure 5: Percent of females with prenatal care in first trimester, USA and USMexico border counties, 2000 and 2004

Source: National natality data, NCHS/CDC
 Chapter 4 - Maternal, Infant, and Child Health

121 

Data on access to prenatal care by ethnicity shows progress for both major 

ethnic groups, though the groups were beginning from quite different levels. For 

non-Hispanic whites in the border region, initiation of prenatal care in the first 

trimester was already above the 2010 target in 2000, at 86.1 percent, and rose 

to nearly 88 percent in 2004. For Hispanics, the 2000 baseline rate was much 

lower (68 percent) but prenatal care access rose to nearly 74 percent by 2004.

Access to prenatal care rose substantially from 2000 to 2004 for California and 

Texas border Hispanic residents but declined substantially for Hispanics in the 

Arizona and New Mexico border counties (data not shown).

Prenatal care is important not only for health reasons but also for the 

opportunity to educate and encourage healthy behavior among women and 

infants. This need is particularly important for young, first-time mothers. 

Figure 7 provides data on the percent of teen mothers (less than 20 years of age) 

with either late or no prenatal care in 2004. Hispanic teens were significantly 

more likely than non-Hispanic white teens to receive late or no prenatal care 

at the national level and in the border counties. The proportion of Hispanic 

mothers with inadequate prenatal care was especially high in the Arizona border 

counties (20.2 percent) but was also very high in the New Mexico and Texas 

border areas (14.8 and 13.0 percent, respectively). There were too few nonHispanic white teen mothers with inadequate prenatal care in the New Mexico 

and Texas border counties to produce reliable measures.

Figure 6: Percent of females with prenatal care in first trimester, by ethnicity, 

USA and US-Mexico border counties, 2000 and 2004

Source: National natality data, NCHS/CDC
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122

Pregnancy, Labor, and Delivery

Complications of pregnancy, along with problems of labor and delivery, are 

associated with unfavorable birth outcomes (Buchanan, 1995; Danforth, 

1999; Sibai et al., 1998). Diabetes, hypertension and eclampsia during 

pregnancy, as well as complications of labor and delivery such as premature 

rupture of membranes, abruptio placenta, placenta previa, fetal distress, breech 

presentation, and prolonged or dysfunctional labor all can negatively impact the 

health of the newborn and may affect maternal health as well.

Along with pregnancy-associated hypertension, diabetes is one of the most 

frequently reported complications of pregnancy in the United States, affecting 

two to three percent of pregnancies in recent years. The true proportion of 

pregnancies complicated by diabetes is uncertain as this condition is likely 

underreported on birth certificates (Piper et al., 1993).

Maternal diabetes is composed of two different forms: preexisting or 

pregestational diabetes, and gestational diabetes. Preexisting diabetes represents 

only about 10 percent of all maternal diabetes, but can give rise to serious 

Figure 7: Percent of teen mothers with late or no prenatal care by ethnicity, USA 

and US-Mexico border counties, 2004

(Figure does not meet standards for reliability or precision.)

Source: National natality data, NCHS/CDC
 Chapter 4 - Maternal, Infant, and Child Health

123 

maternal and fetal complications (Buchanan, 1995). Overall, the risk of 

perinatal death is 1.5-2.0 times greater for pregnancies with preexisting diabetes, 

primarily the result of birth defects and maternal hypertension. Between 10 

and 33 percent of these infants will be macrosomic (excessive birthweight). 

Macrosomia can be an indication for cesarean section delivery, it increases the 

risk of birth trauma, and it is associated with a long-term risk of obesity for the 

child. Preexisting microvascular conditions such as retinopathy or neuropathy – 

two common complications of diabetes – frequently worsen during pregnancy.

Gestational diabetes, or diabetes that develops during pregnancy, accounts for 

most of the complications of pregnancy due to diabetes that are reported on 

birth certificates. Gestational diabetes may increase the risk of perinatal death or 

morbidity, and mothers are clearly at increased risk for subsequent development 

of diabetes (Coustan, 1995).

The proportion of mothers with diabetes was low at the national level, but 

lower still for the border counties (2.9 percent and 1.9 percent, respectively). 

The border diabetes prevalence was significantly higher for Hispanics than for 

non-Hispanic whites (1.9 percent versus 1.5 percent). For pregnancy-related 

hypertension, the border rate again was lower than the national rate, but among 

border residents the rate was higher for non-Hispanic whites than for Hispanics. 

For most of the reported medical complications of pregnancy, the national 

prevalence was significantly higher than in the border counties. As noted earlier, 

medical complications are likely to be underreported on the birth certificate. 

The level of underreporting may be greater in the border counties than at the 

national level in part because border birth certificates have higher levels of nonresponse than national data for many variables.

Method of delivery

The cesarean section delivery rate (that is, the percent of live births delivered 

by cesarean section), has increased substantially in recent years for both the 

United States and for all parts of the border region. Cesarean delivery rates had 

declined through the mid-1990s, partly because of an emphasis on trial of labor 

for women with a previous cesarean delivery. The national cesarean rate has risen 

consistently since 1996, the result of several trends. First, the rate of vaginal 

birth after cesarean (VBAC) has fallen dramatically since 1996, in part because 

of studies describing the risks associated with VBAC delivery (Lydon-Rochelle, 

Holt, Easterling, & Martin, 2001). In addition, the primary cesarean rate, that 

is the cesarean rate for women without a previous cesarean, rose significantly 

after 1997, a trend resulting from a variety of factors (Martin et al., 2006).

Across the United States, the cesarean section rate increased by more than 

one-quarter between 2000 and 2004, as shown in Figure 8. Nationally, 29 
Border Lives: Health Status in the United States-Mexico Border Region

124

percent of deliveries were by cesarean section in 2004, up from 23 percent in 

2000. The border cesarean rate in 2004 was even higher at slightly more than 

31 percent, rising from the 2000 rate of 25 percent. There were important 

regional differences within the border area. The Texas border region had a 

cesarean rate of nearly 37 percent in 2004, while the New Mexico and Arizona 

border counties had much lower rates (25 percent and 23 percent, respectively). 

Among individual counties, the highest rate in 2004 was in Starr County, Texas 

(46 percent) and the lowest was in Cochise County, Arizona (21 percent; data 

not shown). The cesarean rate for border Hispanics was somewhat higher than 

for non-Hispanic whites (33 percent versus 29 percent), but the same strong 

regional differences prevailed (data not shown).

Place of birth and birth attendant

The overwhelming majority of births take place in hospitals, and more than 9 

out of 10 deliveries are attended by physicians, both nationally and in the border 

region. In 2004, slightly more than 99 percent of births in the United States 

occurred in hospitals; in the border region the proportion was 99 percent as 

well, with slightly more Hispanic births in hospitals (99 percent) as compared to 

non-Hispanic whites (98 percent). Since 1990 the proportion of Hispanic births 

in hospitals has risen from 94 percent, while for non-Hispanic whites there has 

been little change since 1990. The major change in place of delivery has been in 

Figure 8: Cesarean section rates, USA and US-Mexico border counties, 2000 

and 2004 

Source: National natality data, NCHS/CDC
 Chapter 4 - Maternal, Infant, and Child Health

125 

Figure 9: Percent of deliveries in birthing centers, US-Mexico border, 1990, 

2000 and 2004

Source: National natality data, NCHS/CDC

the use of birthing centers: As shown in Figure 9, the use of these centers in the 

border region declined from 2.6 percent of all births in 1990 to less than one 

percent in 2004; in the Texas border counties the birthing center share fell from 

7.1 percent to one percent of all births. Birthing centers are designed for low-risk 

pregnancies and offer fewer routine medical interventions. Some of the decline in 

use of birthing centers is related to studies of adverse outcomes of vaginal birth 

after cesarean (VBAC), leading many providers and professional organizations 

to advise that VBAC only be attempted in facilities with immediate access to 

emergency delivery (Lieberman, Ernst, Rooks, Stapleton, & Flamm, 2004).

Birth attendants are most commonly physicians, although midwives are attending 

an increasing number of births. About 90 percent of border deliveries are attended 

by physicians for both Hispanics and non-Hispanic whites. The trend since 1990, 

however, has been largely toward increasing use of midwives, particularly certified 

nurse midwives (CNM). Figure 10 shows the percent of births attended by 

CNMs in 1990, 2000, and 2004. In the border region, the proportion of births 

attended by CNMs more than doubled from 1990 to 2000, from 5 percent to 

11 percent, although the level fell slightly in 2004. Large increases in the use of 

CNMs occurred in the border counties of Arizona, California, and New Mexico. 

In the Texas border area the 1990-2000 increase was smaller, and by 2004 the use 

of CNMs had receded to below the 1990 level. The use of other midwives also 

declined in Texas border counties (data not shown).
Border Lives: Health Status in the United States-Mexico Border Region

126

Figure 10: Percent of deliveries by certified nurse midwife, US-Mexico border, 

1990, 2000 and 2004

Source: National natality data, NCHS/CDC

Birth Outcomes

Preterm delivery

Infants born preterm, that is, at less than 37 completed weeks of gestation, 

are at greater risk of morbidity or death than are term births, and the risk of 

infant death is particularly high among the very preterm (less than 32 weeks of 

gestation). Preterm infants that do survive are more likely to be neurologically 

impaired, for example due to cerebral palsy (Mathews, & MacDorman, 2007). 

Despite numerous controlled trials of various intervention strategies over the 

past few decades, no successful prevention techniques or therapies that would 

affect substantial reductions in preterm births have been identified (Goldenberg, 

& Rouse, 1998). Until the causes of preterm delivery are better elucidated, such 

reductions are unlikely to occur. The increasing proportion of preterm deliveries 

in recent years has been associated with increasing trends in interventions 

(induction of labor, cesarean delivery), older maternal age at delivery, and 

increases in multiple births, among other factors (Martin et al., 2006).

The proportion of infants born preterm has risen steadily in the United States, 

increasing from 10.6 percent in 1990 to 11.6 percent in 2000 and 12.5 percent 

in 2004. Figure 11 illustrates this trend. In the border region the increase has 

been similar, rising from 10.2 percent in 1990 to 12.4 percent in 2004. Preterm 
 Chapter 4 - Maternal, Infant, and Child Health

127 

rates increased very little in the California border counties and the 2004 rate of 

10.7 percent was significantly lower than that in the border regions of the other 

three states. The preterm rate was especially high in the Texas border region, 

reaching 14 percent in 2004 (data not shown). Preterm rates were consistently 

higher for Hispanics than for non-Hispanic whites, both nationally and in the 

border region. In 2004, the preterm rate for border Hispanics was 12.4 percent 

versus 11.0 percent for non-Hispanic whites.

These figures are based on the conventional measure of preterm delivery, the 

interval between the first day of the mother’s last menstrual period (LMP) and 

the infant’s date of birth. However, the LMP-based gestational age is subject 

to a number of errors, including recall error and important levels of nonreporting of LMP. Three of the four border states (Arizona, New Mexico, and 

Texas) also collect physician estimates of gestational age. These estimates of 

preterm delivery are 20-40 percent lower than the LMP-based rates, as shown 

in Figure 12. While the physician estimates of preterm delivery also show 

an increase from 1990 to 2004, the physician-based preterm rates for border 

Hispanics were lower than or equal to the rates for non-Hispanic whites. In 

2004, the physician-based preterm rate for border Hispanics was 9.9 percent, 

while for non-Hispanic whites the rate was 10.5 percent. Nevertheless, physician 

estimates of gestational age are also subject to error, and the exact measurement 

of gestational age remains uncertain (Qin, Hsia, Berg, 2008).

Figure 11: Percent preterm births based on date of last menstrual period, USMexico border counties 1990, 2000 and 2004

Source: National natality data, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

128

An alternative approach is to consider combinations of gestational age and 

birthweight. An earlier analysis comparing U.S. Mexican-American births to 

non-Hispanic white births found many instances of implausible combinations, 

such as infants weighing more than 3000 grams (6.6 pounds) born at 28 weeks 

of gestation. These combinations were especially common among MexicanAmericans (Buekens, Notzon, Kotelchuck, & Wilcox, 2000). Repeating this 

analysis for border counties produced similar results. As shown in Figure 13, the 

Hispanic birthweight distributions were asymmetric and skewed toward heavy 

birthweights for all gestational ages below 37 weeks. The Hispanic excess for 

these implausible combinations was especially marked for gestational ages 28-31 

weeks and 32-35 weeks. If we exclude all normal birthweight infants (2,500 

grams or more) from the preterm deliveries to eliminate potentially misclassified 

preterm births, the preterm rate for border Hispanics was lower than for nonHispanic whites (4.2 percent versus 4.4 percent).

Figure 12: Percent preterm births based on physician estimate, by ethnicity, USMexico border counties, 1990, 2000 and 2004

*Border counties of Arizona, New Mexico and Texas only 

Source: National natality data, NCHS/CDC
 Chapter 4 - Maternal, Infant, and Child Health

129 

Birthweight

Low birthweight, or weight below 2500 grams, is highly associated with the risk 

of infant death. Infants weighing less than 1500 grams, or very low birthweight 

(VLBW), are nearly 100 times more likely to die in the first year of life than 

are infants above 2500 grams. The risk of death for infants weighing 1500-

2499 grams is nearly five times that of normal birthweight infants (Mathews, 

& MacDorman, 2007). An infant’s birthweight is related to both the length of 

gestation and the fetal growth rate in utero. Maternal smoking during pregnancy 

is an important contributor to LBW, primarily through intrauterine growth 

retardation (Kleinman, & Madans, 1985), although maternal weight before 

pregnancy and maternal weight gain during pregnancy are also important. 

VLBW is more closely associated with preterm delivery and its associated 

causes. A major advantage of birthweight data is that it is much more accurately 

reported than is gestational age (David, 1980). As with preterm births, some of 

the increase in LBW in recent years may be related to obstetrical interventions, 

as well as older maternal age at childbearing and increased numbers of multiple 

births (Branum & Schoendorf, 2002; Helmerhorst, Perquin, Donker, & Keirse 

2004; Zhang, Yancey, & Henderson, 2002).

Figure 13: Hispanic and non-Hispanic white births by birth weight at <28, 28-31, 

32-35 and 36 weeks of gestation, US-Mexico border counties, 2002-04

Source: National natality data, NCHS/CDC
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130

The LBW rate has risen slowly but consistently in the United States in recent 

years, increasing from 7 percent in 1990 to 8.1 percent in 2004 (see Figure 14). 

The LBW rate is trending upward both nationally and on the border, and for 

both Hispanics and Non-Hispanic whites, as depicted in Figure 14. In contrast, 

the VLBW rate has risen very little in recent years. Nationally, the VLBW rate 

increased from 1.3 percent in 1990 to 1.5 percent in 2004; in the border region 

the rate remained at about one percent over the same interval. The VLBW rate 

for Hispanics and non-Hispanic whites also changed very little over time; in 

2004 the VLBW rate was 1.1 percent for both groups.

The border LBW rate was significantly lower than the national rate in 2004: 7 

percent versus 8.1 percent. In addition, the percent LBW for border Hispanic 

births was approximately equal to the rate for border non-Hispanic whites: 6.8 

and 6.9 percent respectively. The low proportion of births under 2500 grams in 

the border region, despite high levels of poverty and limited access to medical 

care, is an important part of the puzzle that is known as the Hispanic paradox 

(Fuentes-Afflick, & Lurie, 1997; Scribner, 1996; Zambrana, Scrimshaw, 

Collins, & Dunkel-Schetter, 1997). It has been demonstrated that an important 

part of the good birthweight performance of Hispanics, who are the majority 

population on the border, is related to their low preterm delivery rate (once 

erroneous LMP dates are corrected; Buekens et al., 2000). The low proportion 

of preterm deliveries among border Hispanics is reflected in the low VLBWrate, 

Figure 14: Low birthweight and very low birthweight by ethnicity, US-Mexico 

border counties, 1990, 2000 and 2004

Source: National natality data, NCHS/CDC
 Chapter 4 - Maternal, Infant, and Child Health

131 

which, as noted above, is equivalent to the VLBW rate of border non-Hispanic 

whites (1.1 percent for both groups in 2004).

Multiple births

The rate of multiple births, that is, the number of twins, triplets, and higherorder births per 1,000 live births, has increased steadily since 1990 in the United 

States and in the border region. Increases in multiple births are the result of two 

trends. First, assisted reproduction therapies have had a major impact on the 

proportion of twin and especially triplet and higher-order births (Wilcox, Kiely, 

Melvin, & Martin,1996). Second, the increase in childbearing among older 

women also has raised the number of multiple births since the multiple birth 

rate is higher for older women regardless of other factors (Martin, MacDorman, 

& Mathew, 1997). An increase in the multiple birth rate is important because 

pregnancies involving multiple fetuses increase the likelihood of maternal 

complications of pregnancy, obstetrical interventions such as cesarean delivery, 

very preterm delivery, VLBW, and infant morbidity and mortality (Blondel, et 

al., 2002; Martin et al., 2006; Mathews, & MacDorman, 2007). Several of these 

outcomes, in particular very preterm delivery and VLBW, are important risk 

factors for developmental disabilities and infant death.

The multiple birth rate in the border region increased from 20 per 1000 live 

births in 1990 to 25 in 2000 and 28 by 2004, an overall increase of 40 percent. 

Nationally, the multiple rate rose from 23 in 1990 to 34 in 2004. The multiple 

birth rate was lower among Hispanics, both nationally and in the border region. 

In 2004, the Hispanic multiple rate was 22 nationally and 23 in the border 

counties. The multiple rate was much higher among non-Hispanic whites, 

growing from 24 in 1990 to 39 in 2004 both nationally and in the border 

region, an increase of 60 percent.

Maternal, Infant, and Child Mortality

Maternal mortality

Although less common now than in the past, maternal deaths remain an 

important indicator of women’s health. Furthermore, these deaths also are 

significant because they are highly preventable and because of the impact 

of maternal deaths on families. The major causes of maternal death are 

hemorrhage, pregnancy-induced hypertension, infection, and ectopic pregnancy 

(MacKay, Berg, Duran, Chang, & Rosenberg, 2005). Many of these causes 

of death were discussed above in the section concerning complications of 

pregnancy, labor, and delivery.
Border Lives: Health Status in the United States-Mexico Border Region

132

As defined by the World Health Organization (1992), maternal death is the 

death of a woman while pregnant or within 42 days of termination of pregnancy, 

regardless of the duration or location of the pregnancy, from any cause related to 

or aggravated by the pregnancy or its management, but not from accidental or 

incidental causes. Death certificates alone underestimate the number of maternal 

deaths, in part because of limitations in the death certificate itself and lack of 

linkage of birth and fetal death records to adult death records. A comparison 

of maternal deaths identified by death certificate data and via the Pregnancy 

Mortality Surveillance System (PMSS) found 35 percent more maternal deaths 

from the PMSS (MacKay et al., 2005). Another study estimated that maternal 

death reporting based on the death certificate underreported maternal deaths by 

more than 50 percent (Jocums, Mitchel, Entman, & Piper,1995).

In 2004, the maternal mortality rate for the United States was 13.1 deaths per 

100,000 live births, a 33 percent increase from the 2000 rate of 9.8. Whether 

this increase in the reporting of maternal deaths is due to improvements in 

reporting alone, or to an actual rise in the number of maternal deaths is unclear. 

Some of the increase is the result of improved reporting, including changes 

in coding practices under ICD-10 and the growing number of states adding 

a death certificate question on pregnancy status (Hoyert, Heron, Murphy, & 

Kung, 2006). Continued vigilance is called for in the form of careful monitoring 

of maternal death reports over the next decade.

In the 44 counties along the U.S.-Mexico border there were fewer than 10 

maternal deaths in 2004, too few to produce a statistically reliable rate. Even 

combining data from several years did not yield sufficient numbers of maternal 

deaths to produce statistically reliable rates for the border, so it is not possible to 

detect either an increase or decrease in the maternal mortality rate since 1990. 

Border states and localities could obtain additional information on maternal 

deaths by establishing maternal mortality review boards.

Infant mortality

Infant mortality is often used as an indicator of the general health status of a 

population. It is affected by the level of maternal health as well as by access 

to prenatal care for the mother and primary health care for the infant. Infant 

mortality also has a disproportionate effect on life expectancy because infant 

deaths represent the largest deductions from the expected number of years lived 

by a population.

The infant mortality rate is commonly divided into the neonatal mortality rate 

(deaths in the first 28 days of life) and the postneonatal mortality rate (deaths 

in the remainder of the first year of life). Neonatal deaths are more likely to 

be caused by problems related to pregnancy and fetal development, such as 
 Chapter 4 - Maternal, Infant, and Child Health

133 

congenital anomalies, LBW and prematurity, and complications of pregnancy. 

The causes of postneonatal death are more reflective of post-pregnancy 

experiences, such as sudden infant death syndrome (SIDS) and injuries.

In developing countries most infant deaths typically occur in the postneonatal 

period. This same pattern prevailed in developed countries a century or more 

ago. Improvements in health care, nutrition, and other aspects of modern life 

have disproportionately reduced postneonatal deaths in developed countries, 

including the United States, so that about two-thirds of all infant deaths in these 

countries now occur in the neonatal period. Postneonatal mortality has

declined in a similar fashion in the border region, so that by 2004 the border 

neonatal mortality rate was 3.3 per 1000 live births while the postneonatal rate 

was 1.6.

The most important cause of neonatal death on the border in 2004 was 

congenital anomalies (28 percent), followed by disorders related to preterm 

birth and LBW (17 percent); complications of pregnancy, labor, and delivery 

(15 percent); and respiratory distress and other respiratory problems of the 

perinatal period (13 percent). Nationally, the distribution of leading causes of 

neonatal deaths was roughly the same. The leading causes of postneonatal death 

in the border region in 2004 were: SIDS (28 percent), congenital anomalies (19 

percent), accidents (11 percent), conditions originating in the perinatal period 

(5 percent), and circulatory illnesses (5 percent).

The infant mortality rate on the border was significantly lower than the national 

rate in 2004: 4.9 versus 6.8 deaths per 1000 live births (see Figure 15). 

Infant mortality on the border was also significantly lower than the U.S. rate 

for all ethnicities and for Hispanics. The infant mortality rate for Hispanics, 

particularly those living near the border, is remarkable given the low income 

and poor access to care of many border Hispanics – another illustration of 

the Hispanic paradox. The reasons for the lower rate on the border are much 

debated, ranging from the good birthweights of Hispanic infants, to the better 

health of migrants, to arguments concerning data quality. A particular concern 

involves non-U.S. residents who claim to be U.S. residents, give birth on the 

U.S. side of the border and then depart the United States. Any deaths among 

these infants after they leave the country are not included in U.S. mortality data, 

thus understating infant mortality for border residents (Becerra, Hogue, Atrash, 

& Perez, 1991; Chan, McCandless, Portnoy, Stolp, & Warner, 1987; FuentesAfflick, Hessol, & Perez-Stable, 1999; Markides, & Coreil, 1986).

There is no consensus that non-resident births are an important part of the 

reason for the very favorable infant mortality rates on the border, and a recent 

study finds lower early neonatal death rates for the children of Hispanic 

immigrant mothers in the United States and some areas of the U.S.-Mexico 
Border Lives: Health Status in the United States-Mexico Border Region

134

border (Hummer, 2007). However, several studies, in particular the articles 

by Becerra, et al. (1991) and Chan et al. (1987), provide indirect evidence 

that infant mortality among Mexican-Americans giving birth on the border is 

underreported. Although dated, Chan et al.’s analysis of infant deaths in the 

sister cities of Laredo, Texas and Nuevo Laredo, Tamaulipas provides particularly 

compelling evidence of underreporting of deaths to infants born on the U.S. 

side of the border. Nevertheless, even if the Hispanic infant mortality rate for 

the border were adjusted upward by 50 percent, the adjusted rate would remain 

remarkably good for such a disadvantaged population.

Whatever the reasons for the low rate, infant mortality in the border region has 

continued to fall in recent years, declining from 5.4 in 2000 to 4.9 in 2004, 

or 62 percent of the Healthy Border target for the year 2010. Because of the 

small number of infant deaths in border counties this decline is not statistically 

significant. However, grouping infant deaths into three-year periods (1999-

2001 and 2002-2004) yields a significant decline in infant mortality between 

the two periods. These results are depicted in Figure 16. The decline appears 

to be confined to border Hispanics, as there was no significant change in infant 

mortality among non-Hispanic whites in the border region. During the same 

time periods, the overall U.S. infant mortality rate remained unchanged at 6.9.

Figure 15: Infant mortality rates by ethnicity, USA and US-Mexico border 

counties, 2004

Source: National natality data, NCHS/CDC
 Chapter 4 - Maternal, Infant, and Child Health

135 

Figure 16: Infant mortality rates by ethnicity, USA and US-Mexico border 

counties, 1999-2001 and 2002-200

Source: National natality data, NCHS/CDC

Congenital anomalies

Congenital anomalies are a leading cause of infant death in the United States 

and in the border region. They are also a cause of physical defects, metabolic 

disorders and disabilities (Stoll, & Kliegman, 2000). Neural tube defects such 

as spina bifida and anencephaly, which occur when the fetal neural tube fails to 

fully close, can lead to fetal loss, infant death, or severe disability. Half or more 

of neural tube defects may be prevented through consumption of adequate 

amounts of folic acid in the month prior to conception and the first trimester 

of pregnancy, although the protective effect of folic acid may be less among 

Hispanics (Werler, Shapiro, & Mitchell,1993; Shaw, Schaffer, Velie, Morland, 

& Harris,1995). Fortification of all grain products with folic acid was made 

mandatory in 1998 (U.S. Food and Drug Administration, 1996), and women 

were advised to consume folate-rich foods and take folic acid supplements. 

Iron deficiency has also been implicated as a possible contributing cause of 

neural tube defects in births among border women, but a statistically significant 

relationship was not demonstrated (Felkner, Suarez, Brender, Scaife, & 

Hendricks, 2005).

A cluster of deaths due to neural tube defects in the lower Rio Grande valley 

of Texas in the early 1990s led to an extensive investigation of possible causes 

and an intensive focus on the incidence of neural tube defects along the U.S.-
Border Lives: Health Status in the United States-Mexico Border Region

136

Mexico border (Suarez et al., 2000). Although investigations failed to find any 

explanation for the Texas cluster of deaths due to neural tube defects, subsequent 

investigations determined that neural tube defect rates among MexicanAmericans were 50 to 200 percent higher than for non-Hispanic whites, 

nationally as well as in the border region (Harris, & Shaw, 1995; Hendricks, 

Simpson, & Larsen, 1999). Neural tube defects are responsible for only one 

to two percent of infant deaths both nationally and on the border, but these 

studies, along with reports of environmental contaminants, led to increased 

concern about congenital anomalies of all types in the border region.

Two major challenges stood in the way of developing a Healthy Border objective 

concerning congenital anomalies. First, congenital anomalies are not well 

reported on birth certificates (CDC, 2000; Watkins, Edmonds, McClearn, 

Mullins, Mulinare, & Khoury,1996) and birth defects registries have only 

recently been established in several of the border states. Second, many congenital 

anomalies, including neural tube defects, are relatively rare, and the small 

numbers of births and infant deaths along the border make it difficult to provide 

reliable data to use in measuring trends. For this reason, the Healthy Border 

objective concerning congenital anomalies was based on infant deaths due to all 

congenital anomalies combined.

The Healthy Border objective calls for a 50 percent reduction in infant deaths 

due to all types of congenital anomalies by 2010. The baseline infant death 

rate from congenital anomalies in 2000 was 1.5 per 1,000 live births; thus the 

corresponding target for the year 2010 is an infant death rate of 0.75. In 2004 the 

infant death rate due to congenital anomalies had fallen to 1.2, meaning that 40 

percent of the 2010 target had been attained. However, this decline in the infant 

death rate was not statistically significant, even when multiple years of data were 

combined to reduce statistical variability. The border rate also was not significantly 

different from the corresponding rate for the United States (1.4 in 2000).

Childhood and young adult morbidity

Border children suffer from the usual childhood diseases and a variety of 

injuries, but are affected by some chronic diseases as well. Public health 

measures, in particular immunizations, have greatly reduced the burden of 

many communicable diseases. Injury prevention also has played a role in 

reducing the number of injuries and in limiting the severity of those that occur. 

The prevalence of some chronic diseases has increased, however, as a result of 

increased exposure to certain risk factors.

Hospital discharge data provide some information on childhood morbidity 

in the border counties. The most important cause of hospital stays among 

children was respiratory illnesses: the hospital discharge rate for acute bronchitis, 
 Chapter 4 - Maternal, Infant, and Child Health

137 

pneumonia, and asthma combined was nearly 80 per 10,000 population, far 

higher than the rate for any other major illness. Hospitalization for asthma 

has increased rapidly for border children, similar to the nationwide increase 

and coincident with the general rise in childhood asthma prevalence (English, 

Von Behren, Harnly, & Neutra, 1998). Increasing levels of atmospheric ozone 

and particulate matter are thought to be part of the explanation for the rise in 

asthma prevalence on the border, but incomplete air quality monitoring in the 

region prevents a definitive conclusion. 

The discharge rate for diabetes among border children is relatively low, but data 

from a number of registry studies in various parts of the United States document 

increases in type 2 diabetes in recent years (American Diabetes Association, 

2000). Much of this increase is thought to be related to the rapid rise in 

recent years of overweight and obesity in children. Childhood obesity data are 

not available for the border, but national data show sharp increases in these 

measures, in particular for Mexican-American youth (Ogden et al., 2006). In 

addition to dietary changes in recent years, increases in consumption of fats and 

carbohydrates, childhood overweight and obesity can be linked to a decline in 

daily exercise, for example the discontinuation of daily school physical education 

classes (CDC, 2004).

Some of the remaining important causes of hospitalization are two chronic 

diseases – malignant neoplasms and heart disease – and injuries. The discharge 

rates for these chronic diseases are relatively low, but these diseases are especially 

deadly as they are among the leading causes of childhood death. Injury diagnoses 

- fractures and poisonings - account for a discharge rate of about 15 per 100,000. 

Poisonings are the cause of very few childhood deaths in the border region, but 

exposure to poisons is all too common among children. The National Association 

of Poison Control Centers reports that in the United States in 2005, there were 

1.4 million exposures to poisons among children ages 0-13 and an additional 

170,000 exposures among teens 13-19 years of age (Lai et al., 2006).

Less important causes of hospitalization in the border region are communicable 

diseases. This is in large part due to the success of immunization in reducing 

the incidence of these diseases. Immunization coverage rates have increased 

gradually, both nationally and in the border region, but still remain far from the 

goal of 90 percent or more coverage for children aged 19-35 months. In 2005 

the coverage rate for the 4:3:1:3 series1 was 82.4 percent for the United States 

and near 80 percent for each of the border states (CDC, 2006a).

1 The 4:3:1:3 vaccination series includes diphtheria, tetanus and pertussis; polio; measles, mumps 

and rubella; and Haemophilus influenzae.
Border Lives: Health Status in the United States-Mexico Border Region

138

Immunization with hepatitis A vaccine has successfully reduced levels of 

hepatitis A in the border region. Previously, hepatitis A prevalence was high in 

the border states, particularly in areas where drinking water was contaminated. 

Colonias (unincorporated subdivisions lacking infrastructure such as municipal 

sewage and water service) had particularly high levels of hepatitis A in children 

(Leach, Koo, Hilsenbeck, & Jenson, 1999). Beginning in 1999, hepatitis A 

vaccination was recommended in 11 states with elevated rates, mostly in the 

western United States. Since that time the incidence of hepatitis A in those states 

has declined to the national average (CDC, 2006b). Within border counties 

the incidence of hepatitis A for the total population has fallen dramatically, 

declining from a rate of 25 per 100,000 population in 1998 to less than 5 in 

2003 (see Chapter 5, “Communicable Diseases”).

Childhood and young adult mortality

Mortality among young persons living in border counties is similar to or lower 

than national death rates. Although the death rates for ages 1-4 and 15-24 years 

were lower for border Hispanics ere lower than for non-Hispanic whites between 

2002 and 2004, the differences were not statistically significant. For border 

children 5-14 years of age the non-Hispanic white death rate was lower than the 

Hispanic rate, but again the difference was not statistically significant.

One issue that is consistent across all of these age groups, as well as for both 

sexes and the two major ethnic groups, is the importance of external causes of 

death for young people. As discussed in Chapter 9, “Injuries,” motor vehicle 

crashes are the leading cause of death for all three age groups, males and females, 

Hispanics and non-Hispanic whites. Other external causes of death, both 

unintentional and intentional, add to the impact of external causes on the young 

population of the border. For this reason, data for the most important causes of 

unintentional injury death are presented separately, rather than combined into a 

single cause as is done in conventional ranking of the leading causes of death.

Border youth 1-4 years of age: External causes of death accounted for nearly 40 

percent of all deaths in this age group in 2002-2004. In addition to motor 

vehicle crashes, drownings were an important cause of death for this group, 

as were homicides. Congenital anomalies were the second leading cause of 

death, although much less important than during the first year of life. The most 

important of these were congenital malformations of the heart and circulatory 

system (data not shown). Malignant neoplasms and diseases of the heart, the 

leading causes of death among adults, were much less important for young 

children, ranking third and sixth among the leading causes of death. There was 

little difference in the ranking of causes of death by sex or by ethnic group.
 Chapter 4 - Maternal, Infant, and Child Health

139 

Border youth 5-14 years of age: External causes of death become even more 

important in this age group, accounting for slightly more than 40 percent of all 

deaths. Motor vehicle crashes alone were responsible for 24 percent of border 

deaths for this age group in the period 2002-2004. Malignant neoplasms were 

the second leading cause, with an increase in both the number of deaths and the 

death rate as compared to the 1-4 year age interval. The most important sites for 

cancers for these children were lymphoid and haematopoietic tissue, including 

Hodgkin’s disease and non-Hodgkin’s lymphoma (data not shown). Again there 

was little difference in the ranking of causes of death by sex or ethnicity.

Border youth 15-24 years of age: External causes of death reach their peak in this 

age group, accounting for more than three-fourths of all deaths. External causes 

are important not only because of their relative share of all deaths in this age 

group, but also because of the absolute number of deaths and the death rate due 

to external causes. From 2002-2004, the death rate due to motor vehicle crashes 

for this age group was seven times the rate for border youths 5-14 years of age. 

There were similar large increases in the death rates for homicides, suicides, and 

unintentional poisoning.

Malignant neoplasms dropped to fourth place among the leading causes, despite 

a 50 percent increase in the cancer death rate, because of the overall increase 

in mortality in this age group. Death rates for most of these causes of death 

are similar for Hispanics and non-Hispanic whites, with a few exceptions. 

Among 15-24 year olds, the number of homicides was 50 percent greater than 

the number of suicides, while for non-Hispanic whites the number of suicides 

was more than double the number of homicides. Similarly, the death rate due 

to unintentional poisoning for non-Hispanic whites was almost twice the rate 

among Hispanics.

Conclusions and Recommendations

Maternal, infant, and child health status is surprisingly good in the U.S.-Mexico 

border region, especially considering the low income and poor access to care of a 

large part of the population. Hispanic border residents have good birth outcomes 

in terms of birthweight and the proportion of preterm births, and their infant 

and childhood death rates are lower than or equal to the average for the total 

U.S. population. Fertility is very high and increasing, the result of growth in 

the number of women of childbearing age and high rates of childbirth. Fertility 

rates are especially high for Hispanic border teens. The high teen birth rate for 

Hispanic women raises both health and quality of life concerns.

Continued vigilance is required, however, to maintain or reduce current levels 

of unhealthy behaviors and other risks. Education campaigns are required to 
Border Lives: Health Status in the United States-Mexico Border Region

140

continue reductions in the level of early teen pregnancies, to discourage women 

from smoking or drinking during pregnancy, and to encourage an improved diet 

including consumption of adequate levels of folates.

Continued enhancements in access to health care are necessary to maintain the 

increasing trend in access to timely prenatal care. For infants, a regular schedule 

of well-baby checkups and immunizations is essential. Poor access to prenatal 

care for Hispanic border teens is particularly troubling and should be addressed. 

The very high cesarean section delivery rates for certain parts of the border 

region are also a cause for concern. As pointed out in Chapter 2 of this volume,

“The Healthcare Workforce,” population growth in the border region is 

outstripping the supply of health personnel. Thus, some of this improved 

access to care in the future may have to come from non-physicians such as 

certified nurse-midwives, physician assistants, and nurse practitioners, as well as 

laypersons such as community health workers.

Continued efforts are called for to address a number of risk factors for border 

children and young adults. Rapid increases in childhood overweight and obesity 

have already increased the level of childhood diabetes and may increase it 

further. Programs to improve childhood nutrition and increase physical activity 

are urgently needed. Environmental efforts to reduce certain exposures, such 

as to atmospheric ozone and particulate matter, are essential to slow or reduce 

the recent large increases in asthma among border youth. Injury prevention 

programs, such as requiring bicycle helmets for children and graduated driving 

programs and alcohol control programs for teens, could do much to reduce 

injury deaths, which remain the leading cause of death in children. Teen 

smoking and illegal drug use continue to be important problems in the border 

region and continued education is called for on these topics. Special efforts 

are needed to reduce the level of teen suicides and suicide attempts, including 

access to counseling and to mental health care. Access to health care for border 

children and young adults should include both routine health-care visits and 

required immunizations.
 Chapter 4 - Maternal, Infant, and Child Health

141 

References

American Diabetes Association. (2000). Type 2 diabetes in children and 

adolescents. Pediatrics, 105, 671-680.

Barnett, E. (1995). Race differences in the proportion of low birth weight 

attributable to maternal smoking in a low-income population. American 

Journal of Health Promotion, 10(2):105-110.

Becerra, J.E., Hogue, C.J., Atrash, H.K., & Perez, N. (1991). Infant mortality 

among Hispanics: a portrait of heterogeneity. Journal of the American 

Medical Association, 265, 217-221.

Bilheimer, L. (1992). Factors contributing to the infant mortality ranking 

of the United States. CBO Staff Memorandum. Washington, DC: 

Congressional Budget Office.

Blondel, B., Kogan, M.D., Alexander, G.R., Dattani N., Kramer M.S., 

Macfarlane A., et al. (2002). The impact of the increasing number of 

multiple births on the rates of preterm birth and low birthweight: An 

international study. American Journal of Public Health, 92,:1323-1330.

Buekens, P., Notzon, F., Kotelchuck, M., & Wilcox, A. (2000). Why do 

Mexican-Americans give birth to few low-birth-weight infants? 

American Journal of Epidemiology, 152, 347-351.

Centers for Disease Control and Prevention. (1997). Medical-care expenditures 

attributable to cigarette smoking during pregnancy – United States, 

1995. Morbidity and Mortality Weekly Report, 46(44):1048-1050.

Centers for Disease Control and Prevention. (1995). Ectopic pregnancy in 

the United States, 1990-92. Morbidity and Mortality Weekly Report, 

47(19):46-48.

Centers for Disease Control and Prevention. (2000). Neural tube defect 

surveillance and folic acid intervention, Texas-Mexico border, 1993-

1996. Morbidity and Mortality Weekly Report, 49(1):1-4.

Centers for Disease Control and Prevention. (2002). Racial and ethnic 

disparities in infant mortality rates – 60 largest U.S. cities, 1995-1998. 

Morbidity and Mortality Weekly Report, 51(15):329-332.
Border Lives: Health Status in the United States-Mexico Border Region

142

Centers for Disease Control and Prevention. (2004). Assessing health risk 

behaviors among young people: Youth Risk Behavior Surveillance 

System at a glance 2004. Retrieved August 10, 2007, from http://www.

cdc.gov/nccdphp/publications/aag/yrgss.htm.

Centers for Disease Control and Prevention. (2006). Surveillance for certain 

health behaviors among states and selected local areas --- Behavioral 

Risk Factor Surveillance System, United States, 2004. Morbidity and 

Mortality Weekly Report, 55(SS-07).

Centers for Disease Control and Prevention. (2006a) National, state and urban 

area vaccination coverage among children aged 19-35 months – United 

States, 2005. Morbidity and Mortality Weekly Report, 55(36):988-993.

Centers for Disease Control and Prevention. (2006b). Summary of notifiable 

diseases – United States, 2004. Morbidity and Mortality Weekly Report, 

53(53):1-81.

Chan, L.S., McCandless, R., Portnoy, B., Stolp, C., & Warner, D.C. (1987). 

Maternal and Child Health on the U.S.-Mexico Border: Special Project 

Report. Austin, TX: University of Texas at Austin.

Chandra, A., Martinez, G.M., Mosher, W.D., Abma, J.C., & Jones, J. (2006). 

Fertility, family planning, and reproductive health of U.S. women: 

Data from the 2002 National Survey of Family Growth. Vital and 

Health Statistics, 23(25). Hyattsville, MD: National Center for Health 

Statistics.

Coustan, D.R. (1995). Gestational diabetes. In Diabetes in America, 2nd 

Edition (pp. 703-718). (NIH Publication No. 95-1468). Bethesda, 

MD: National Institutes of Health, National Institute of Diabetes and 

Digestive and Kidney Diseases, National Diabetes Data Group.

Danforth, D.N., & Scott, J.R. (1999). Danforth’s obstetrics and gynecology. 

Philadelphia, PA: Lippincott Williams & Wilkins.

David, R.J. (1980). The quality and completeness of birthweight and gestational 

age data in computerized birth files. American Journal of Public Health, 

70(9):964-973.

Dye, J.L. (2005) Fertility of American women: June 2004. Current Population 

Reports, P20-555. Washington: U.S. Census Bureau.
 Chapter 4 - Maternal, Infant, and Child Health

143 

Ebrahim, S.H., Floyd, R.L., Merritt, R.K., Decoufle, P., & Holtzman, D. 

(2000). Trends in pregnancy-related smoking rates in the United States, 

1987-1996. Journal of the American Medical Association, 283(3):361-366.

Ebrahim, S.H., Luman, E.T., Floyd, R.L., Murphy, C.C., Bennett, E.M., & 

Boyle, C.A. (1998). Alcohol consumption by pregnant women in the 

United States during 1988-1995. Obstetrics and Gynecology, 92(2):187-

192.

English, P.B., Von Behren, J., Harnly, M., & Neutra, R.R. (1998). Childhood 

asthma along the United States/Mexico border: hospitalizations and 

air quality in two California counties. Pan American Journal of Public 

Health, 3: 392-399.

Felkner, M.M., Suarez, L., Brender, J., Scaife, B., & Hendricks K. (2005). 

Iron status indicators in women with prior neural tube defect-affected 

pregnancies. Maternal and Child Health Journal, 9(4):421-428. 

Fuentes-Afflick, E., Hessol, N.A., & Perez-Stable, E.J. (1999). Testing the 

epidemiologic paradox of low birth weight in Latinos. Archives of 

Pediatric and Adolescent Medicine, 153, 147-153. 

Fuentes-Afflick, E., & Lurie P. (1997). Low birth weight and Latino ethnicity. 

Examining the epidemiologic paradox. Archives of Pediatric and 

Adolescent Medicine, 151, 665-674.

Goldenberg, R.L., & Rouse, D.J. (1998). Prevention of premature birth. New 

England Journal of Medicine, 339(5):313-320.

Harris, J.A., & Shaw, G.M. (1995). Neural tube defects – why are rates 

high among populations of Mexican descent? Environmental Health 

Perspectives, 103(Suppl 6), 163-164.

Helmerhorst, F.M., Perquin, D.A.M., Donker, D., & Keirse, J.N.C. (2004). 

Perinatal outcome of singletons and twins after assisted conception: A 

systematic review of controlled studies. British Medical Journal, 328, 1-5.

Hendricks, K.A., Simpson, J.S., & Larsen, R.D. (1999). Neural tube defects 

along the Texas–Mexico border 1993-1995. American Journal of 

Epidemiology, 149, 1119-1127.

Hoyert, D.L., Heron, M.P., Murphy, S.L., & Kung, H. (2006). Deaths: Final 

data for 2003. National Vital Statistics Reports, 54(13). Hyattsville, MD: 

National Center for Health Statistics.
Border Lives: Health Status in the United States-Mexico Border Region

144

Hunt, K.J., Williams, K., Resendez, R.G., Hazuda, H.P., Haffner, S.M., & Stern 

M.P. (2002). All-cause and cardiovascular mortality among diabetic 

participants in the San Antonio Heart Study: Evidence against the 

“Hispanic paradox.” Diabetes Care, 26, 1557-1563.

Institute of Medicine. (1985). Preventing Low Birthweight. Washington, DC: 

National Academy Press.

Jocums, S., Mitchel, E.F., Entman, S.S., & Piper, J.M. (1995). Monitoring 

maternal mortality using vital records linkage. American Journal of 

Preventive Medicine, 11:75-78.

Jones, K.L. (1986). Fetal alcohol syndrome. Pediatric Review, 8, 122-126.

Kleinman, J.C., & Kessel, S.S. (1987). Racial differences in low birthweight. 

New England Journal of Medicine, 317:749-753.

Kleinman, J.C., & Madans, J.H. (1985). The effects of maternal smoking, 

physical stature, and educational attainment on the incidence of low 

birth weight. American Journal of Epidemiology, 121(6):843-855.

Lai, M.W., Klein-Schwartz, W., Rodgers, G.C., Abrams, J.Y., Haber, D.A., 

Bronstein, A.C., et al. (2006). 2005 annual report of the American 

Association of Poison Control Centers’ National Poisoning and 

Exposure Database. Clinical Toxicology, 44, 803-932.

Leach, C.T., Koo, F.C., Hilsenbeck, S.G., & Jenson, H.B. (1999). The 

epidemiology of viral hepatitis in children in South Texas: Increased 

prevalence of hepatitis A along the Texas-Mexico border. Journal of 

Infectious Diseases, 180, 509-513.

Lieberman, E., Ernst, E.K., Rooks, J.P., Stapleton, S., & Flamm, B. (2004). 

Results of the national study of vaginal birth after cesarean in birth 

centers. Obstetrics and Gynecology, 104, 933-42.

Lucas, J.W., Schiller, J.S., & Benson, V. (2004). Summary health statistics for 

U.S. adults: National Health Interview Survey, 2001. National Center 

for Health Statistics. Vital and Health Statistics 10(218).

Lundsberg, L.S., Bracken, M.B., & Saftlas, A.F. (1997). Low-to-moderate 

gestational alcohol use and intrauterine growth retardation, low birth 

weight, and preterm delivery. Annals of Epidemiology, 7, 498-508.
 Chapter 4 - Maternal, Infant, and Child Health

145 

Lydon-Rochelle, M., Holt, V.L., Easterling, T.R., & Martin, D.P. (2001). Risk 

of uterine rupture during labor among women with a prior cesarean 

delivery. New England Journal of Medicine, 345, 54-55.

MacKay, A.P., Berg, C.J., Duran, C., Chang, J., & Rosenberg, H. (2005). 

An assessment of pregnancy-related mortality in the United States. 

Paediatric and Perinatal Epidemiology, 19(3), 206-214.

Markides, K.S., & Coreil, J. (1986). The health of Hispanics in the 

Southwestern United States: an epidemiologic paradox. Public Health 

Reports, 101(3), 253-265.

Martin, J.A., Hamilton, B.E., Ventura, S.J., Menacker, F., & Park, M.M.. 

(2002). Births: Final data for 2000. National Vital Statistics Reports, 

50(5). Hyattsville, MD: National Center for Health Statistics.

Martin, J.A., Hamilton, B.E., Sutton, P.D., Ventura, S.J., Menacker, F., & 

Kirmeyer, S. (2006). Births: Final data for 2004. National Vital Statistics 

Reports, 55(1). Hyattsville, MD: National Center for Health Statistics.

Martin, J.A., MacDorman, M.F., & Mathew, T.J. (1997). Triplet births: Trends 

and outcomes, 1971-1994. Vital Health Statistics, 21(55). Hyattsville, 

MD: National Center for Health Statistics.

Martin, J.A., & Ventura, S.J. (2006, June 8). Braving the new world: Challenges 

and rewards of the revised birth data. Paper presented at the annual 

meeting of the National Association for Public Health Statistics and 

Information Systems, San Diego, CA..

Mathews, T.J., & MacDorman, M.F. (2007). Infant mortality statistics from the 

2004 period linked birth/infant death data set. National Vital Statistics 

Reports, 55(14). Hyattsville, MD: National Center for Health Statistics.

McDonald, J.A., Suellentrop, K., Paulozzi L.J., & Morrow B. (2007). 

Reproductive health of the rapidly growing Hispanic population: data 

from the Pregnancy Risk Assessment Monitoring System, 2002. Matern 

Child Health J, (EPUB ahead of print June 26)

National Center for Health Statistics. (1992) Proceedings of the International 

Collaborative Effort on Perinatal and Infant Mortality, Vol. III. 

Hyattsville, MD: Author.
Border Lives: Health Status in the United States-Mexico Border Region

146

Notzon, F.C., Cnattingius, S., Bergsjo, P., Cole, S., Taffel, S., Irgens, L., 

& Daltveit, A.K. (1994). Cesarean section delivery in the 1980s: 

International comparison by indication. American Journal of Obstetrics 

and Gynecology, 170, 495-504.

Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & 

Flegal, K.M. (2006). Prevalence of overweight and obesity in the United 

States, 1999-2004. Journal of the American Medical Association, 295, 

1549-1555.

Piper, J.M., Mitchel, E.F., Snowden, M., Hall, C., Adams, M., & Taylor, P. 

(1993). Validation of 1989 Tennessee birth records using maternal and 

newborn hospital records. American Journal of Epidemiology, 137,:758-

768.

Pollack, H.A. (2001). Sudden infant death syndrome, maternal smoking during 

pregnancy, and the cost-effectiveness of smoking cessation intervention. 

American Journal of Public Health, 91,:432-436.

Qin, C., Hsia, J., Berg, C.J. (2008). Variation between last-menstrual-period 

and clinical estimates of gestational age in vital records. American 

Journal of Epidemiology, 167(6):646-652.

Scribner, R. (1996). Paradox as paradigm – The health outcomes of MexicanAmericans. American Journal of Public Health, 86, 303-305.

Shaw, G.M., Schaffer, D., Velie, E.M, Morland, K., & Harris, J. (1995). 

Periconceptual vitamin use, dietary folate, and the occurrence of neural 

tube defects. Epidemiology, 6, 219-226.

Sibai, B.M., Lindheimer, M., Hauth, J., Critis, S., VanDorsten, P., Klebanoff, 

M., et al. (1998). Risk factors for preeclampsia, abruptio placentae, and 

adverse neonatal outcome among women with chronic hipertensión. 

New England Journal of Medicine, 339, 667-671.

Stoll, B.J., & Kliegman, R. (2000). The fetus and neonatal newborn. In R.E. 

Behrman, R.M. Kliegman, H.B. Jenson (Eds.), Nelson Textbook of 

Pediatrics (4th ed.). Philadelphia: W.B. Saunders Company.

Suarez, L., & Hendricks, K.A., Cooper, S.P., Sweeney, A.M., Hardy, R.J., & 

Larsen, R.D. (2000). Neural tube defects among Mexican Americans 

living on the U.S.-Mexico border: Effects of folic acid and dietary 

folate. American Journal of Epidemiology, 152, 1017-1023.
 Chapter 4 - Maternal, Infant, and Child Health

147 

U.S. Food and Drug Administration. (1996). Food standards: amendment of 

standards of identity for enriched grain products to require addition of 

folic acid. Federal Register, 61, 8781-8807.

U.S.-Mexico Border Health Commission. (2003). Healthy Border 2010: An 

agenda for improving health on the United States-Mexico Border. El 

Paso, TX: Author.

Watkins, M.L., Edmonds, L., McClearn, A., Mullins, L., Mulinare, J., & 

Khoury, M. (1996). The surveillance of birth defects: The usefulness of 

the revised U.S. standard birth certificate. American Journal of Public 

Health, 86, 731-734.

Werler,. M.M., Shapiro, S., & Mitchell, A.A. (1993). Periconceptional folic 

acid exposure and risk of occurrent neural tube defects. Journal of the 

American Medical Association, 269, 1257-1261.

Wilcox, L.S., Kiely, J.L., Melvin, C.L., & Martin, M.C. (1996). Assisted 

reproductive technologies: Estimates of their contribution to multiple 

births and newborn hospital days in the United States. Fertility and 

Sterility, 65, 361-366.

World Health Organization. (1992). International statistical classification of 

diseases and related health problems. [10th Revision]. Geneva: Author.

Zambrana, R., Scrimshaw, S., Collins, N., & Dunkel-Schetter, C. (1997). 

Prenatal health risk behaviors and psychosocial risk factors in pregnant 

women of Mexican origin: the role of acculturation. American Journal of 

Public Health, 87, 1022-1026.

Zhang, J., Yancey, M.K., & Henderson, C.E. (2002). U.S. national trends in 

labor induction, 1989-98. Journal of Reproductive Medicine, 47, 120-

124.

Zuckerman, B. (1988). Marijuana and cigarette smoking during pregnancy: 

Neonatal effects. In: I. Chasnoff, (Ed.). Drugs, alcohol, pregnancy, and 

parenting. Boston, MA: Kluwer Academic Publishers.

149 

I

nfectious disease surveillance is a core public health activity that is 

conducted with the aims of assessing the incidence (i.e., emergence of new 

cases) and prevalence (i.e., the total number of existing cases) of infectious 

disease cases. Surveillance activities permit individual states and the nation to 

implement efforts that may reduce the burden of illness across populations, 

especially for diseases that can be contained or treated effectively. In addition, 

monitoring trends in infectious diseases that are deemed notifiable allows for 

targeted research activities, including development of effective interventions. 

Prevention and control of infectious diseases also represent important 

components of federal, state, and local health department activities. This is 

because infectious diseases can result in significant human and fiscal impacts, 

such as death, disability and other consequences for individuals, families, 

communities, health systems, employers and the nation.

Several conditions facilitate the transmission of infectious diseases, including 

poverty, migration, tourism, food processing and distribution mechanisms, 

changes to natural habitats, an increased number of individuals with weakened 

immune systems and others. Factors that affect efforts to control infectious 

diseases include drug resistance, lack of effective treatments to cure infected 

persons or to prevent transmission, emergence of new diseases, and factors 

that facilitate the transmission of disease (Centers for Disease Control [CDC], 

1998). Several of these conditions, including poverty, intense human flows, and 

drug resistance, are characteristic of the U.S.-Mexico border region.

This chapter describes the incidence of infectious diseases and their rates in U.S.-

Mexico border states and border counties in 2003. Three classes of infectious 

diseases are reviewed in this chapter: (a) foodborne and waterborne diseases, 

(b) other infectious diseases, and (c) sexually transmitted infections. We report 

on the most recent year of data available, 2003, for foodborne and waterborne 

diseases and other infectious diseases including for all sexually transmitted

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diseases, except HIV/AIDS for which we report 2004 data. All rates in this 

chapter are crude rates obtained by dividing the number of cases by the total 

population regardless of age. Rates are per 100,000 population.

Data for this report were obtained primarily from the Centers for Disease 

Control and Prevention (CDC). Tuberculosis data, as well as HIV/AIDS and 

other sexually transmitted infection data, were provided by each border state. 

Surveillance practices, resources, and priorities vary from state to state. With the 

exception of AIDS case reports, race and ethnicity data were not analyzed for 

this report because of high levels of non-reporting. While extensive efforts were 

made to ensure the quality and accuracy of data, discrepancies may occur with 

published data since the CDC’s databases are updated regularly. 

The chapter is organized in the following manner. For each of the most common 

conditions, a brief introduction is provided, which includes a summary of the 

etiology, symptoms, at-risk populations and long-term consequences. Where 

Healthy Border 2010 (U.S.-Mexico Border Health Commission [BHC], 2003a) 

objectives are available, they are included. For each border state, disease rates were 

calculated for its combined border counties. Disease rates for 2003 were compared 

between individual border states, border counties for each state, and the national 

level. Following the CDC’s data-reporting guidelines, geographic-specific rates 

were suppressed for many conditions because there were insufficient cases to meet 

criteria for report-ability.

Significance of Infectious Diseases in the Border Region

The large-scale movement of people, closeness of social interactions, large 

volume of trade, limitations of public health infrastructure, and environmental 

conditions are all factors that facilitate transmission of infectious diseases among 

residents of the U.S.-Mexico border region. From the standpoint of infectious 

disease monitoring, prevention and control, the border population should be 

considered as one rather than two separate populations (Weinberg et al., 2003). 

Binational collaboration on infectious disease issues is challenging since both 

countries have separate and distinct surveillance and public health systems, 

with great disparities in available resources, and sometimes different priorities 

and strategies to address infectious disease issues (Bruhn & Brandon, 1997). 

Of special public health concern are infectious disease cases or events that 

have some type of cross-border implication (i.e., binational cases). “Binational 

infectious disease cases” have been defined as suspected or confirmed cases 

that traveled or lived in the neighboring country during the incubation period 

for the disease, or had contact with persons who had been in the neighboring 

country during the incubation period, or for which binational cooperation 

is needed for case investigation and/or management (Weinberg et al., 2003). 
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Binational cases present unique challenges for diagnosis, treatment, and public 

health follow-up. Close communication and collaboration between Mexican and 

U.S. health officials is necessary to efficiently monitor and respond to binational 

infectious disease events in the border region.

Few comprehensive studies of infectious diseases have been performed in the 

border region. An analysis of 1990-1998 U.S. data showed that, compared to 

non-border regions, the U.S. border region had a significantly higher incidence 

of many infectious diseases. Specifically, the border had higher rates of hepatitis 

A, diphtheria, some childhood vaccine-preventable diseases, salmonellosis and 

shigellosis, among others. However, disease rates were lower in the border region 

for malaria, meningococcal disease, invasive Haemophilus influenza and trichinosis 

(Doyle & Bryan, 2000). Although this study did not analyze tuberculosis, HIV/

AIDS or STD data, it has been reported that those issues also pose a serious 

binational health problem for communities in the U.S.-Mexico border region 

(U.S. Department of Health and Human Services [HHS], 2000).

The U.S.-Mexico border can also be considered a high risk area for a 

bioterrorism event. (BHC, 2003b). Because of the incubation period of 

infectious agents, it would be easy for a terrorist to release agents on the U.S. 

side and cross the border long before cases of illness were detected. A release of a 

biological agent in one border city would almost certainly spread to persons on 

both sides of the border. For those reasons, binational coordinated bioterrorism 

preparedness and response strategies are needed.

Foodborne and Waterborne Diseases

Foodborne and waterborne illnesses are caused by a variety of bacteria, viruses, 

and parasites and they impose a heavy burden on society. Waterborne diseases 

are spread by unsanitary conditions or lack of water treatment facilities. 

Water pollution is a growing concern in the border regions of both countries 

(International Boundary and Water Commission, 1998). Rapid population 

growth has overwhelmed water and sewer systems and water treatment facilities 

in many communities across the U.S.-Mexico border. The very young, the 

elderly, and persons with immune system problems experience more serious 

foodborne illnesses (CDC, 2001). This section addresses some of the most 

common foodborne and waterborne diseases evident in the U.S.-Mexico border 

region in 2003.

Recent years have seen a tremendous expansion of international food trade, 

especially between the United States and Mexico. Globalization in food trade is 

beneficial for consumers because of the increased availability of varied products 

year-round, and because of lower prices. There is no reason to assume that food 
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imports are more prone to safety problems than domestic products (Buzby, 

2003). However, because of the great volume of products and diversity of 

countries of origin, the increased movement of food products across borders also 

creates more opportunities for food safety risks to materialize, especially with 

fresh produce. In the United States, sporadic reports of foodborne outbreaks 

have been associated with some imported products, including some originating 

from Mexico (Anderson et al., 2002; Dentinger et al. 2001; Hutin et al., 1999; 

Weinberg et al., 2004).

In addition to commercially imported products, a large volume of food products 

are transported by people traveling from Mexico to the United States. Some 

foods are for personal use, but others are imported for illegal resale in the United 

States. Those products, for example Mexican-style fresh cheese made with 

unpasteurized milk, mostly escape regulatory inspection, have been associated 

with foodborne outbreaks in the United States, and represent a serious public 

health risk (Janowski, Ginsberg, Torok, & Gunn, 2005; Kinde et al., 2007).

Inadequate sanitation infrastructure, including sewage and storm drainage 

systems in some areas of the U.S.-Mexico border region, increases the risk to 

resident communities of infectious diseases from exposure to contaminated 

drinking water or human and solid wastes (e.g., release of untreated sewage into 

rivers or the ocean; HHS, 2000). 

Cryptosporidiosis

Cryptosporidiosis is a diarrheal disease caused by microscopic parasites of the 

genus Cryptosporidium. The parasites can be found in soil, food, water and 

surfaces that have been contaminated with infected human or animal feces. 

Consumption of the parasite (for example, drinking infected water in swimming 

spaces, eating contaminated uncooked foods, or swallowing items that have 

come into contact with infected spaces) results in infection. Watery diarrhea is 

the most common symptom of cryptosporidiosis and may develop 2 to 10 days 

after infection. Other symptoms include dehydration, weight loss, stomach 

cramps or pain, fever, nausea and vomiting. Some persons may not experience 

these symptoms. The parasite lives in the intestine of the infected person or 

animal and may be shed in the feces. An outer shell allows the parasite to survive 

for extended periods of time in the natural environment; the shell also makes 

the parasite highly resistant to chlorine-based disinfectants. Persons with severely 

weakened immune system are at risk for more serious or prolonged disease. 

Cryptosporidiosis may be diagnosed by laboratory analyses of stool samples, 

although multiple samples may be needed to confirm a diagnosis. Treatment 

is available. Persons with healthy immune systems usually fully recover, even 

without antifungal treatment. The effectiveness of certain treatments in 

immunosuppressed individuals is variable.
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Figure 1 shows Cryptosporidiosis incidence rates by region. In 2003, 

Cryptosporidiosis infection was observed to be a low prevalence condition in 

the United States. The national rate was 1.21 per 100,000. Border states showed 

even lower incidence rates (0.81 in California and 0.36 in Texas). Rates were not 

reported for Arizona and New Mexico.

E Coli 0157:H7

Escherichia coli (E. coli) 0157:H7 is one strain of the bacterium Escherichia 

coli. Unlike other strains, E. coli 0157:H7 produces a deadly toxin that can 

cause severe bloody diarrhea and abdominal cramps. In children younger 

than five years and the elderly, complications may include hemolytic uremic 

syndrome, which is characterized by the destruction of red blood cells and 

kidney failure. Consumers of undercooked ground beef and other food products 

(e.g., sprouts, lettuce, and unpasteurized milk) can become infected with E. 

Coli. Inadequate hand-washing techniques may facilitate transmission of the 

bacteria and persons may also become infected by drinking or swimming 

in sewage-contaminated water. Symptoms often resolve within 5 to 10 days 

without antibiotics or other treatments. Yet persons who have developed 

hemolytic uremic syndrome may experience long-term repercussions such as 

abnormal kidney function, high blood pressure, seizures, blindness, paralysis, 

and others. Infection can be prevented by thoroughly cooking ground meat 

products and washing hands, utensils, and spaces in contact with raw meat with 

Figure 1: Crude rates of Cryptosporidiosis (per 100,000) by 

region, 2003
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soapy water. Consuming pasteurized products and thoroughly washing fruits 

and vegetables are recommended. Persons with diarrheal illnesses should avoid 

swimming in public spaces to reduce contamination.

In 2003, E. Coli 0157:H7 was a low prevalence condition, both nationally and 

in border states, as shown in Figure 2. The national rate was 0.92 per 100,000. 

Of border states, Texas exhibited the lowest rate (0.25 per 100,000). Rates of E. 

Coli 0157:H7 for Arizona and California appeared to be similar to the national 

rate, given their wide confidence intervals.

Hepatitis A Virus, Acute

Hepatitis A is caused by the hepatitis A virus. Symptoms of hepatitis A infection 

include jaundice, fatigue, abdominal pain, loss of appetite, nausea, diarrhea, or 

fever and occur most frequently in adults. There is no chronic infection and it 

cannot recur. Nevertheless, about 15 percent of people infected with hepatitis A 

will have prolonged or relapsing symptoms over a six to nine month period. The 

hepatitis A virus is typically spread when a person places into his or her mouth an 

item that has become contaminated through contact with the stool of an infected 

person. Persons at risk for infection are household contacts and sexual partners 

of infected persons, persons residing or traveling to high prevalence areas, men 

who have sex with men, and injecting and non-injecting drug users. A hepatitis 

A vaccine is available. Routine vaccination for all children starting at age one year 

is now recommended in the United States. Currently, the Advisory Committee 

on Immunization Practices recommends that people traveling to an area with 

Figure 2: Crude rates of E. Coli 0157:H7 (per 100,000) by region, 

2003
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155 

intermediate or high rates of hepatitis A receive one dose of single-antigen 

hepatitis A vaccine administered at any time before departure (CDC, 2007).

The Healthy Border 2010 objective for the United States for hepatitis A is 

to reduce the incidence rate by 50 percent, from 11.0 to 5.5 per 100,000 

inhabitants (BHC, 2003a). The combined 44 border counties have already 

surpassed the 2010 objective, as data for 2003 indicate a border rate of 4.6 per 

100,000 population (116 percent of the objective).

Figure 3 shows crude rates of hepatitis A. In 2003, the national crude rate of 

hepatitis A was 2.63 per 100,000 persons. Rates of hepatitis A varied among 

border states: Arizona had the highest crude rate of all border states (5.02), 

followed by California (3.23). In contrast, New Mexico exhibited the lowest 

crude rate of hepatitis A (1.33).

Hepatitis A infection rates in the border counties were similar to border state 

rates. Figure 4 shows hepatitis A rates in the 44 border counties. Arizona border 

counties reported the highest crude rate of the condition, followed by California 

(7.19 and 4.89 per 100,000).

Figure 3: Crude rates of Hepatitis A. v Acute (per 100,000) by 

region, 2003
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Giardiasis

Giardiasis is caused by Giardia intestinalis, a one-celled microscopic parasite 

that lives in the intestines and stools of infected individuals. Giardiasis can 

result when the parasite is consumed by drinking contaminated water, infected 

foods, or through surface contact with infected areas. Persons may experience a 

variety of symptoms one to two weeks after infection, including diarrhea, gas, 

greasy stools, stomach cramps, upset stomach, or nausea. Treatment is available 

through various prescription drugs. Giardiasis is highly contagious. Infected 

persons should take measures to prevent spreading the infection through use 

of appropriate hand-washing techniques, especially if eating or preparing 

foods, and by avoiding public water spaces during and for two weeks after the 

resolution of diarrheal symptoms.

As Figure 5 shows, rates of giardiasis were below 10 per 100,000 for all regions. 

Of border states, Arizona (4.59) and New Mexico (2.93) both exhibited rates 

below the national rate (6.78), while Texas reported no cases in 2003. Rates 

of giardiasis for California in 2003 were not significantly different from the 

national rate. Border county data were available only for Arizona and California; 

in both cases, rates did not differ from state rates (Figure 6). 

Figure 4: Crude rates of Hepatitis A. v Acute (per 100,000) by 

border county, 2003
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Figure 5: Crude rates of Giardiasis (per 100,000) by region, 2003

Figure 6: Crude rates of Giardiasis (per 100,000) by border county, 

2003
Border Lives: Health Status in the United States-Mexico Border Region

158

Listeriosis

Listeriosis is caused by the bacterium Listeria monocytogenes. Persons may become 

infected by eating contaminated foods. Typical sources are vegetables, raw meats, 

cold cuts, unpasteurized food products and some ready-to-eat items. Symptoms 

include fever, muscle aches, or gastrointestinal symptoms (e.g., nausea or diarrhea). 

If infection has spread to the nervous system, individuals may experience 

headache, stiff neck, confusion, loss of balance or convulsions. Pregnant women 

may experience symptoms similar to a mild, flu-like illness; miscarriage, stillbirth, 

premature delivery, or infection of the newborn may result. Some populations 

(e.g., elderly, immunocompromised persons, pregnant women, newborns) are 

at higher risk for infection. Application of proper food handling techniques can 

prevent listeriosis.

A blood or spinal fluid test (to cultivate the bacteria) can detect listeria bacteria 

in pregnant women, though consultation with a health care provider is 

critical. Infected pregnant women and infants may be treated with antibiotics. 

Consumption of unpasteurized soft cheeses has been associated with listeriosis 

outbreaks among Mexican-origin population in border states and across the United 

States (Linnan et al., 1998; Kinde et al., 2007; MacDonald et al., 2005).

Data show that, in 2003, listeriosis was a low prevalence condition nationally and 

in all border states. Furthermore, there was no difference between the national 

rate and those of California and Texas (all below 1 per 100,000). Figure 7 shows 

listeriosis rates in the United States and border states.

Figure 7: Crude rates of Listerosis (per 100,000) by region, 2003
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Salmonellosis

Salmonellosis is an infection caused by a type of bacteria called Salmonella. 

Symptoms include diarrhea, fever, and abdominal cramps 12 to 72 hours after 

infection. Symptoms may last four to seven days; most persons recover without 

treatment. If the infection has spread from the intestines to the blood stream 

or other body sites, death may result unless the person is treated promptly 

with antibiotics. The elderly, infants, and those with impaired immune systems 

are more likely to experience severe illness. Analyses of stools can identify 

salmonellosis. A small number of infected persons may develop Reiter’s 

Syndrome, which is characterized by joint pain, irritation of the eyes and painful 

urination. Reiter’s Syndrome may last for months or years and can lead to 

chronic arthritis.

Consuming contaminated foods, which are often of animal origin (e.g., beef, 

poultry, milk, or eggs) may result in salmonellosis; however, all foods may 

become contaminated. Food may also become contaminated by the unwashed 

hands of an infected food handler. Salmonella may be found in the feces of some 

pets, especially reptiles. People can become infected if they do not wash their 

hands after contact with infected feces. To prevent salmonellosis, people should 

avoid consuming raw or undercooked eggs, poultry, or meat, and produce 

should be thoroughly washed before it is consumed. Thorough cooking kills 

Salmonella. Cross-contamination of foods should be avoided. Hands, cutting 

boards, counters, knives, and other utensils should be washed thoroughly after 

handling uncooked foods. Hands should be washed before handling any food 

and between handling different food items. People who have salmonellosis 

should not prepare food or pour water for others until they have been shown to 

no longer be carrying the Salmonella bacterium.

In 2003, rates of salmonellosis were fairly similar throughout the border states 

and to the national rate (15.01 per 100,000), as depicted in Figure 8. Only 

California displayed a significantly lower rate (11.64 per 100,000).

Figure 9 shows rates of salmonellosis incidence in the border counties. 

California border counties appeared to have a rate of salmonellosis above the 

state rate (15.03 vs. 11.64 per 100,000). New Mexico border counties also had a 

lower rate than the overall state rate (11.30 vs. 16.18 per 100,000).
Border Lives: Health Status in the United States-Mexico Border Region

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Shigellosis

Shigellosis is caused by a group of bacteria called Shigella. Symptoms of shigellosis 

include (bloody) diarrhea, fever, and stomach cramps. Shigellosis usually resolves 

in five to seven days. Young children and the elderly with severe diarrhea may be 

hospitalized. Children less than two years of age with high fever may experience 

Figure 8: Rates of Salmonellosis by region, 2003

Figure 9: Rates of Salmonellosis, border counties, 2003
 Chapter 5 - Communicable Diseases

161 

seizures. Some infected persons may lack symptoms but may nevertheless transmit 

Shigella bacteria. A laboratory analysis of stool samples can determine whether 

a person has been infected. Antibiotic treatments can also be administered 

depending on the type of Shigella, though some bacteria have become antibiotic 

resistant. Persons with mild infections often recover quickly without antibiotic 

treatment. When many persons in a community are infected, antibiotics may be 

used selectively to treat only the more severe cases. Antidiarrheal medications, 

such as antimotility drugs, may make the illness worse and should be avoided.

Persons who experience diarrhea due to Shigella infection usually recover 

completely, although it may be several months before their bowel habits are 

entirely normal. About three percent of persons who are infected with Shigella 

flexneri may develop Reiter’s Syndrome, which is characterized by joint pain, 

irritation of the eyes, and painful urination. Reiter’s Syndrome may last for 

months or years and can lead to chronic arthritis. Infected persons are unlikely to 

become reinfected with that specific type of Shigella for at least several years.

No vaccine can prevent shigellosis, though its transmission can be stopped by 

frequent and careful handwashing with soap. Infected individuals should not 

prepare food or pour water for others until they have been shown to no longer 

be carrying the Shigella bacterium. Basic food safety precautions and regular 

drinking water treatment prevents shigellosis. At swimming beaches, having a 

sufficient number of bathrooms near the swimming area helps keep the water 

from becoming contaminated.

As Figure 10 shows, the 2003 national crude rate of shigellosis was 8.11 per 

Figure 10: Crude rates of Shigellosis (per 100,000) by region, 2003
Border Lives: Health Status in the United States-Mexico Border Region

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100,000 persons. Arizona (10.25), New Mexico (15.22), and Texas (19.95) all 

had higher crude rates of the condition. California had a lower rate than the 

national average (6.38 versus 8.11).

Figure 11 depicts data for border counties, which indicate that New Mexico 

and Texas experienced high rates of shigellosis in 2003 (23.86 and 18.82 per 

100,000 persons, respectively.

Typhoid fever

Typhoid fever is caused by the bacterium Salmonella Typhi (S. Typhi), which 

lives only in humans and may be fatal. About 400 cases of typhoid fever occur 

each year in the United States; approximately 75 percent of infections are 

acquired while traveling internationally, especially in developing countries. 

Typhoid fever is more common in areas where hand-washing is less frequent and 

water is likely to be contaminated with sewage. Vaccinations against typhoid are 

available to persons traveling to areas where it is prevalent.

Infection may occur after consuming food that has been contaminated by 

an individual who is actively shedding S. Typhi. Once S. Typhi bacteria are 

consumed, they multiply and spread into the bloodstream. Upon infection, 

symptoms include a sustained high fever (up to 103° to 104° F, or 39° to 40° C), 

weakness, stomach pains, headache, loss of appetite and, less commonly, a rash 

of flat, rose-colored spots. Infection is confirmed by laboratory analyses of stool 

or blood samples.

Figure 11: Crude rates of Shigellosis (per 100,000) by border 

county, 2003
 Chapter 5 - Communicable Diseases

163 

Persons with typhoid fever carry the bacteria in their bloodstream and intestinal 

tract. Some people become “carriers,” that is, they recover from the illness but 

continue to carry the bacteria. The illness may recur in carriers and carriers can 

also transmit S. Typhi to others. Both ill persons and carriers shed S. Typhi 

in their feces. Infected persons may be barred from working, especially if they 

are employed in food-handling or child-care positions, until the infection has 

resolved.

In 2003, typhoid fever was observed to be a low prevalence condition nationally 

(rate: 0.12 per 100,000). Figure 12 shows crude rates of typhoid fever by region 

during that year. Of border states, California displayed the highest rate (0.26 per 

100,000); it was significantly higher than the national rate for typhoid.

Other Infectious Diseases

Many infectious diseases are neither foodborne or waterborne, nor sexually 

transmitted. Some infections are blood-borne, while others are airborne and 

may stem from environmental or human vectors. Some of the conditions 

reported on in this section include meningococcal disease, streptococcal disease 

and tuberculosis (TB).

Even among infectious diseases, TB represents a grave concern. Converging 

factors contribute to elevated TB incidence and complicate TB control efforts 

along the U.S.-Mexico border. Mexico exhibits a higher TB rate than does the 

United States, and the migratory flow across the border results in elevated TB 

Figure 12: Crude rates of Typhoid (per 100,000) by region, 2003
Border Lives: Health Status in the United States-Mexico Border Region

164

incidence in the geographic areas most affected by cross-border migration flows. 

Low socioeconomic status, crowded living conditions, and limited access to 

health care increase the risk for TB transmission on both sides of the border.

An analysis of tuberculosis case reports in the United States from 1993-2001 

found that the TB rates for Mexican-born patients were five times or more 

higher than for U.S.-born persons. This was true both in border states and 

non-border states. TB rates were higher for Mexican-and U.S.-born patients 

residing in the 23 counties contiguous to the U.S.-Mexico border (Schneider, 

Laserson, Wells, & Moore, 2004). The high cross-border mobility of TB patients 

in the border region is a barrier for public health follow-up and completion of 

treatment and is one important factor associated with increasing drug resistance. 

Both multi-drug resistant and extensively-drug resistant TB have been diagnosed 

in the border region.

Coccidiodomycosis

Coccidiodomycosis is caused by inhalation of the fungus Coccidioides immitis, 

which is found in the soil. This condition is also commonly known as valley 

fever. The disease is endemic only in regions of the Western Hemisphere. In 

the United States, affected areas include southern Arizona, central California, 

southern New Mexico, and west Texas. Outbreaks may occur following dust 

storms, earthquakes, earth excavation, and other activities that disperse the 

fungus. An acute respiratory infection occurs 7 to 21 days after exposure and 

typically resolves rapidly. Infected persons may experience a flu-like illness with 

fever, cough, headaches, rash and myalgias. Some patients may develop chronic 

pulmonary infection or widespread disseminated infection that affects the 

meninges, soft tissues, joints and bones. Severe pulmonary disease may develop 

in HIV-infected persons and persons with other immunocompromising medical 

conditions. Infected persons may develop meningitis, and some may develop 

permanent neurological damage.

In both the United States (rate: 1.67 per 100,000) and most of the border 

states, Coccidioides immitis infection was a low prevalence condition in 

2003. As expected, Arizona experienced the highest rate of the illness (48.30 

per 100,000), followed by California (5.90 per 100,000). Figure 13 shows 

Coccidioides immitis infection rates by region.

As Figure 14 shows, Arizona and California border counties fared slightly 

better than their respective states: they had lower rates of Coccidioides immitis 

infection (38.33 and 1.86 per 100,000, respectively).
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Haemophilus Influenzae

Haemophilus influenzae is a small, gram-negative bacterium. Several subtypes 

of H influenzae cause infections in humans. Of those subtypes, H influenzae 

serotype b is the most virulent. H influenzae serotype b causes about 95 percent 

of H influenzae invasive diseases in children, and more than half of invasive 

Figure 13: Crude rates of Coccidioidomycosis (per 100,000) by 

region, 2003

Figure 14: Crude rates of Coccidioidomycosis (per 100,000) by 

border county, 2003
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diseases in adults (Bisgard, Bath, Srivastava, & Cortese, 2002). Infection 

can occur when individuals come into direct contact with droplets from 

nasopharyngeal carriers or case patients. Prior to the development of the H 

influenzae b conjugate vaccine, more than one-half of infected persons presented 

as meningitis with fever, headache, and stiff neck; others presented as cellulitis, 

arthritis, or sepsis. Between three and six percent of cases are fatal, and up to 20 

percent of surviving patients have permanent hearing loss or other long-term 

health effects.

Regular use of the vaccine in the United States has lowered the incidence of this 

condition. In 2003, the national crude rate of H influenzae infections was 0.69 

per 100,000 (see Figure 15). The crude rate of this condition for California 

was significantly lower (0.17) than the national rate, while Arizona appeared to 

have a significantly higher rate (1.67). The rate for New Mexico appeared to be 

higher than the national rate, though not significantly different (1.28).

Hepatitis B. v Acute

Hepatitis B is caused by the hepatitis B virus. About 30 percent of infected persons 

have no signs or symptoms of infection. Adults are more likely than children to 

present symptoms such as jaundice, fatigue, abdominal pain, loss of appetite, 

nausea, vomiting or joint pain. Persons who acquire infection perinatally or in 

childhood are more likely to develop chronic infection. Long-term consequences of 

hepatitis B infection include cirrhosis of the liver, liver cancer, liver failure or death. 

Hepatitis B-infected persons should be evaluated by their doctor for liver disease.

Figure 15: Crude rates of Haemophilus influenzae (Per 100,000) 

by region, 2003
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The virus is transmitted when blood from an infected person enters the body 

of an uninfected person. Activities that raise the risk of exposure include sexual 

intercourse without a condom, sharing of drugs or needles, or obtaining tattoos 

or body piercings from a vendor who does not follow appropriate sterilization 

or safe blood/body fluid practices. The virus can also pass from mother to infant 

during childbirth. Health care providers are also at risk via needlesticks or sharps 

exposures.

The hepatitis B vaccine is available to protect against the virus and can reduce 

hepatitis B transmission and related liver disease. Children in the United States 

are vaccinated against hepatitis B virus as part of routine childhood vaccinations. 

Vaccinations against both hepatitis A and B are recommended, especially for 

health-care and safety workers. Correct use of latex condoms during each sexual 

activity by persons with multiple sex partners is important. Pregnant women 

should get tested for the virus. Infants born to infected women should be 

vaccinated against the virus within 12 hours after birth. Drug users who share 

needles, syringes, or water are at high risk of contracting the virus. Sharing 

personal items that may have blood on them, such as razors or toothbrushes, 

is another risky practice. Persons who have ever been infected with hepatitis B 

should not donate blood, organs, or tissues.

The Healthy Border 2010 objective for the United States for hepatitis B 

is to reduce the incidence rate by 50 percent from 2.2 to 1.1 per 100,000 

inhabitants (BHC, 2003a). The borderwide hepatitis B incidence rate in 2003 

was 1.6, equivalent to 60 percent of the 2010 objective. The national crude 

rate of hepatitis B in 2003 was 2.59, as shown in Figure 16. Of border states, 

Figure 16: Crude rates of Hepatitis B. v Acute (per 100,000) by 

region, 2003
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168

Arizona (5.07) and Texas (4.37) reported the highest crude rates while rates for 

California(1.85) and New Mexico (1.92) were lower than the national rate and 

those of Arizona and Texas.

Figure 17 shows hepatitis B rates in border counties. Arizona border counties 

displayed the highest crude rate (4.33). This rate was notably higher than both 

national and border-wide rates. In contrast, the Texas border counties’ rate of 

hepatitis B was 1.63 per 100,000 — significantly lower than the state rate (4.37; 

Figure 16) and was near the Healthy Border 2010 objective.

Hepatitis C. v Acute

Hepatitis C is caused by the hepatitis C virus. Approximately 80 percent of 

infected persons do not show signs or symptoms of infection. When signs and 

symptoms do appear, they may include jaundice, fatigue, dark urine, abdominal 

pain, loss of appetite and nausea. The hepatitis C virus causes chronic infection 

and chronic liver disease. Some infected persons may die as a result of chronic 

liver disease.

As with hepatitis B, the hepatitis C virus may be spread when blood of an 

infected person enters the body of an uninfected person, such as in activities 

that involve sharing needles, during childbirth, and in needlesticks among 

health-care professionals. Persons at risk for hepatitis C infection may also be at 

risk for infection with hepatitis B virus and HIV. Testing for hepatitis C virus 

is recommended for persons at risk for the infection, including injection drug 

Figure 17: Crude rates of Hepatitis B. v Acute (per 100,000) by 

border county, 2003
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169 

users, some recipients of blood or solid organs, infants of infected mothers, 

health care and public safety workers and others. 

No vaccine is currently available to prevent hepatitis C infection. Infected 

persons may be treated with certain drugs. Treatment may slow or stop the 

progression of disease but does not eliminate the virus. However, several 

precautions can be taken to prevent infection. Abstention from injection drug 

use is a primary precaution. Drug users should not share needles, syringes, or 

water. Vaccination against hepatitis A and B is recommended. Personal items 

that may have blood, such as razors or toothbrushes, should not be shared. 

Blood and body fluid safety practices of tattoo or body piercing artists should be 

considered. Persons who are infected with hepatitis C should not donate blood, 

organs, or tissue.

As Figure 18 shows, crude rates of hepatitis C in 2003 were low, below 1 per 

100,000, nationally and in border states. Of border states, Texas displayed the 

highest rate at 0.23 per 100,000.

Meningococcal disease

Meningococcal disease, also known as meningitis or spinal meningitis, is 

an infection of the fluid of a person’s spinal cord and the fluid surrounding 

the brain. The condition may be caused by a viral or bacterial infection. 

Distinguishing between the two sources is important, because the source affects 

Figure 18: Crude rates of Hepatitis C. v Acute (per 100,000) by 

region, 2003
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170

the severity of the illness and treatment options. Viral meningitis may resolve 

without specific treatment, whereas bacterial meningitis is more severe and 

may result in brain damage, hearing loss and learning disabilities. In addition, 

the bacteria type should be identified because some antibiotic treatments may 

reduce transmission. Prior to the 1990s, Haemophilus influenzae type b was the 

leading cause of bacterial meningitis. Today, most cases of bacterial meningitis 

are caused by Streptococcus pneumoniae and Neisseria meningitidis. Signs and 

symptoms include high fever, headache, stiff neck, nausea, vomiting, discomfort 

looking into bright lights, confusion, and sleepiness in persons ages two and 

older. They may develop over several hours, or they may take one to two days to 

develop. In newborns and small infants, the classic symptoms of fever, headache, 

and neck stiffness may be absent or difficult to detect. The infant may appear 

slow or inactive, irritated, and be vomiting or feeding poorly. As the disease 

progresses, patients of any age may have seizures.

Early diagnosis and treatment of meningitis are very important, and a 

physician should be consulted immediately if meningitis is suspected. The 

diagnosis is usually made by growing bacteria from a sample of spinal fluid 

obtained during a spinal tap. Bacterial meningitis can be treated with a number 

of effective antibiotics. Treatment should begin early in the course of the 

disease. Some forms of bacterial meningitis are contagious, and bacteria may 

be transmitted through the exchange of respiratory and throat secretions (for 

example, coughing or kissing). People who are in close contact with a person 

who has meningitis caused by Neisseria meningitidis should receive antibiotics 

to prevent acquisition of the disease. Safe and highly effective vaccines are 

available against Hemophilus influenzae b, some serogroups of Neisseria 

meningitides, and many types of Streptococcus pneumoniae. Vaccination against 

H. influenzae and N. meningitides is part of routine childhood vaccination 

in the United States. Overseas travelers should check to see if meningococcal 

vaccine is recommended for their destination and should receive the vaccine at 

least one week before departure, if possible.

In 2003, the crude rate for meningococcal disease was below 1 per 100,000 in 

the United States and in all border states (Figure 19).
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Pertussis

Pertussis is caused by the Bordetella pertussis bacterium. It is a highly 

communicable, vaccine-preventable disease lasting many weeks. Children 

typically present with paroxysmal spasms of severe coughing, whooping, 

and posttussive vomiting. Major complications are most common among 

infants and young children and include hypoxia, apnea, pneumonia, seizures, 

encephalopathy, malnutrition and death. Most deaths occur among the 

unvaccinated or children too young to be vaccinated. Infection occurs through 

direct contact with discharges from respiratory mucous membranes of infected 

persons. Children who are too young to be fully vaccinated and those who have 

not completed the primary vaccination series are at highest risk for severe illness.

Figure 20 depicts national and border state crude rates for pertussis in 2003. 

The national crude rate for pertussis was 4.01 per 100,000. Though there was 

variation, border states did not appear to differ significantly from this rate.

Figure 21 shows crude rates of pertussis in the border region. California border 

counties’ crude rate of pertussis appeared higher than the state rate (5.15 per 

100,000 versus 3.54, respectively). In contrast, Texas border counties’ rate was 

lower than the state rate (2.29 per 100,000 versus 3.03, respectively).

Figure 19: Crude rates of Meningococcal Disease (per 100,000) by 

region, 2003
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172

Streptococcal Disease, Invasive Group A

Group A Streptococcus (GAS) is a bacterium often found in the throat or on the 

skin. The bacteria are transmitted through direct contact with mucus from the 

nose or throat of infected persons or through contact with infected wounds or 

sores on the skin. People may carry the bacterium without showing symptoms. 

Figure 20: Crude rates of Pertussis (per 100,000) by region, 2003

Figure 21: Crude rates of Pertussis (per 100,000) by border 

county, 2003
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173 

Most GAS infections result in mild illnesses such as “strep throat” or impetigo. 

Severe or life-threatening diseases such as necrotizing fasciitis or streptococcal 

toxic shock syndrome emerge less frequently. Appropriate antibiotic treatments 

generally eliminate transmission of the bacteria. Although healthy individuals 

can get invasive GAS disease, people with chronic illnesses like cancer, diabetes, 

and kidney dialysis, and those who use medications such as steroids, are at 

higher risk of infection and complications. Early treatment may reduce the 

risk of death from invasive GAS, though it may not always be preventable. 

Individuals with very severe illness may require intensive care. Individuals with 

necrotizing fasciitis may require surgery to remove damaged tissue. Transmission 

of GAS infection can be reduced by thorough hand washing, especially after 

coughing and sneezing and before preparing foods or eating.

Persons with sore throats should be evaluated to determine whether the illness 

is strep throat. Persons with strep throat should stay home from work, school, 

or day care until 24 hours after starting antibiotic treatment. All wounds should 

be kept clean and monitored for signs of infection such as redness, swelling, 

drainage, and pain at the wound site. Individuals with signs of an infected 

wound, especially fevers, should seek medical care.

Nationally, the crude rate of GAS infection was 2.02 per 100,000 persons in 

2003 (Figure 22); higher crude rates were evident in Arizona and New Mexico 

(4.64 and 6.76, respectively) whereas California’s and Texas’ crude rates were 

below the national rate (1.21 and 0.94, respectively).

Figure 22: Crude rates of Streptococcal Disease, Inv. Group A (per 

100,000) by region, 2003
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174

Of border counties, California had a crude rate (5.41) above the state and 

national rates, as shown in Figure 23. The crude rate for Arizona border counties 

(4.25) exceeded the national rate but was similar to the Arizona state rate.

Streptococcus Pneumoniae, Invasive Disease

Streptococcus pneumoniae is caused by a bacterium, of which more than 

90 serotypes exist. Streptococcus pneumoniae is transmitted from person to 

person. Death occurs in 14 percent of hospitalized adults with invasive disease. 

Neurological sequelae and/or learning disabilities can occur in meningitis 

patients. Hearing impairment can result from recurrent otitis media. Persons at 

higher risk for infection are the elderly, children less than two years old, blacks, 

American Indians and Alaska Natives, children who attend group day care 

centers, and persons with underlying medical conditions (such as HIV infection 

or sickle-cell disease). Although a vaccine is available, supplies of pneumococcal 

conjugate vaccine are inadequate and the 23-valent polysaccharide vaccine is 

underused. Sensitive, rapid diagnostic tests are not available for many types of 

pneumococcal infections, although a new urinary antigen test may be useful 

in adults. Widespread overuse of antibiotics contributes to emerging drug 

resistance.

Figure 24 shows that Streptococcus pneumoniae had a low national crude rate in 

2003 of 0.88 per 100,000. However, New Mexico displayed a high rate at 9.79.

Figure 23: Crude rates of Streptococcal Disease, Inv. Group A (per 

100,000) by border county, 2003
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175 

Tuberculosis

Tuberculosis (TB) is an airborne infection caused by mycobacterium 

tuberculosis. TB typically affects the lungs, though other areas may also 

be affected (for example, brain, kidneys or spine). Symptoms of infection 

include feeling sick or weak, weight loss, fever, night sweats, coughing, chest 

pain and coughing up blood. Other symptoms depend on the body part 

affected. Tuberculosis is transmitted when the bacteria are airborne (because 

of coughing, sneezing, speaking, or singing). Persons who inhale the bacteria 

may become infected and may have a latent TB infection. That is, they may be 

infected but do not show symptoms because the bacteria are not active. Their 

risk of transmitting the bacteria to others is low. Nevertheless, persons with a 

latent infection may be prescribed an appropriate treatment to prevent them 

from developing active TB disease. Individuals with active TB can transmit 

the bacteria to others, especially family or coworkers, and should be treated 

promptly and appropriately.

Individuals who have been exposed to TB should get tested by their physician 

or local health department to determine infection and they should be treated as 

necessary. Treatment for TB involves a multi-drug regimen, typically lasting six 

months. It is important to adhere to the treatment guidelines and to complete 

the regimen, as failure to do so may result in drug resistance, a situation which 

is more difficult and costly to treat. Rates of drug resistance have been shown to 

be high among Mexican-born pulmonary tuberculosis patients residing in the 

border states (Schneider et al., 2004). Although hampered by limited resources, 

Figure 24: Crude rates of Streptococcus Pneumoniae, Inv. 

Disease (per 100,000) by region, 2003
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176

several U.S. programs in the border region successfully collaborate with Mexican 

agencies in TB case-finding, follow-up, and continuity of care, focusing on 

patients traveling across the border.

The Healthy Border 2010 objective for the United States for TB is to reduce the 

incidence rate by 50 percent from 10.0 to 5.0 per 100,000 inhabitants (BHC, 

2003a). However, since the year 2000 the border incidence rate for TB has not 

changed significantly. The incidence rate in 2003 was 10.3.

Figure 25 illustrates national and border-state crude rates of TB incidence in 

2003. Nationally, the crude rate of TB was 5.12 per 100,00 in 2003. This rate 

was exceeded by Arizona (26.81), California (9.10) and Texas (7.30). Notably, 

New Mexico’s crude rate of TB was 2.61, below the national rate and that of 

other border states.

Figure 26 shows crude rates of TB incidence in the U.S.-Mexico border region. 

In 2003, California and Texas border counties had high rates of TB (11.12 and 

12.87, respectively).

Figure 25: Rates of Tuberculosis by region, 2003
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Sexually Transmitted Diseases (STDs)

Like other infectious diseases, sexually transmitted diseases (STDs) have 

important physical, psychological, and economic costs for infected persons, 

families, and payers of medical services. The burden of STDs is especially high 

for younger persons (ages 15-24 years). All too often, STDs are undiagnosed 

(Centers for Disease Control [CDC], 2006). Populations that lack health 

insurance or are otherwise marginalized because of their immigration or 

economic status may not receive timely or adequate attention. Factors that 

increase the risk of acquiring a sexually transmitted disease include engaging in 

unprotected sex, having multiple partners, and increased drug and alcohol use. 

All of these risk factors have been identified in Mexican migrant populations 

(Sanchez et al., 2004).

STDs also pose a health risk to pregnant women and their fetuses (CDC, 2004). 

Potential consequences of STD infection in pregnant women include early onset 

of labor, rupture of the membranes surrounding the baby in the uterus, and 

uterine infection after delivery. STDs may result in a stillbirth, low-birth weight 

infant, eye or respiratory infections, or other neurological effects. The infant 

may also become infected during childbirth. Therefore, it is recommended that 

women receive regular prenatal care and screening for any STDs (CDC, 2004). 

This section examines border states’ and counties’ experiences with chlamydia, 

gonorrhea, and syphilis as well as HIV/AIDS.

Figure 26: Crude rates of Tuberculosis (per 100,000) by region, 

2003
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178

Although the Joint United Nations Program on HIV/AIDS categorizes both 

Mexico and the United States as “low prevalence” countries for HIV/AIDS, 

aggregate national figures mask the epidemics of HIV/AIDS and STDs in the 

U.S.-Mexico border region. Dense social networks, characterized by high-risk 

sexual behaviors and relationships between individuals, straddle both sides of 

the border and fuel the emergence of these epidemics. These networks include 

the commercial sex industry in major urban border areas, supported by clients 

from the United States and Mexico who also have sex with their primary or 

regular partners on either side of the border (Brouwer et al., 2006; Rangel et al., 

2006). Clients include Mexican and other Latin-American migrants who are not 

necessarily disease carriers, but whose migration conditions and experiences (e.g., 

social isolation, limited health care access, etc.) increase their vulnerability to HIV 

and STDs (Fosados, Cabellero-Hoyos, Torres-Lopex, & Valente, 2006; Hirsch, 

Higgens, Bentley, & Nathanson, 2002). For example, STD transmission is 

associated with high rates of unprotected sex with casual partners among Mexican 

migrant men in the San Diego/Tijuana border area (Rangel et al., 2006).

The overlap of sexual and injection drug use networks has exacerbated the 

HIV and STD epidemics in the U.S.-Mexico border region. The commercial 

sex industry involves some workers who are injection drug users and have sex 

for money and/or supplies to support their drug consumption. This is part of 

the market created by the “spillover” of drug trafficking from Latin America 

to the United States via the border region (Brouwer et al., 2006; Frost et al., 

2006; Saavedra, 2007). For example, in one study in the El Paso/Ciudad Juárez 

border area, more than half of female sex workers interviewed reported injecting 

drugs (Frost et al., 2006). The high prevalence of syphilis among injection drug 

users in both the San Diego/Tijuana and El Paso/Ciudad Juárez border areas 

(Frost et al., 2006) may have introduced the infection into sexual networks. 

Because syphilis is a co-factor of HIV transmission, this introduction may have 

contributed to the increase of HIV seroprevalence among pregnant women in 

Tijuana, from 0.3 percent in 1998 to 1.1 percent in 2003. All new HIV cases 

were linked to injection drug use (Saavedra, 2007).

Despite difficulties caused by such factors as the stigma of HIV and STDs 

— and the challenges of reaching border sub-populations such as migrants, 

injection drug users, and others — academic research has complemented 

public health surveillance to determine the extent of the epidemics and the 

importance of observed risk factors. Intensified and related efforts to reduce 

stigma, provide universal access to HIV/STD services (especially testing and case 

management), and promote uniform binational surveillance practices will 

enhance the evidence base to inform appropriate disease prevention and control 

policies in the U.S.-Mexico border region.
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179 

Chlamydia

Chlamydia is caused by the bacterium Chlamydium trachomatis and spread 

through vaginal, anal, or oral sex. Chlamydia may also be transmitted by 

mothers to infants during vaginal childbirth. In women, the bacteria may infect 

the cervix, urethra, fallopian tubes, or rectum. Some infected women may not 

experience signs or symptoms. Others may experience symptoms such as lower 

abdominal pain, low back pain, nausea, fever, or painful intercourse. In men, 

the penis may be affected and symptoms may include penile discharge, burning 

sensations during urination, or other symptoms. Infected women who are 

untreated or undertreated may develop Pelvic Inflammatory Disease (PID), an 

infection of the reproductive organs. In turn, PID may lead to infertility. Women 

with chlamydia are also more likely to become infected with HIV if exposed.

Sexually active persons and pregnant women should be tested for this STD. 

In 1998, a urine-based test for chlamydia was introduced which made testing 

for chlamydia easier (CDC, 2002). Chlamydia can be treated and cured with 

antibiotics. However, underreporting of chlamydia by infected persons is 

pervasive since symptoms may be mild or absent. This disease has grown more 

prevalent since reporting was initiated in the early 1990s.

Chlamydia rates exhibit regional variation. In 2003, the crude rate for the 

nation was 368.54 per 100,000. Among border states, New Mexico exhibited 

the highest rate (454.92) followed by California (377.39). Figure 27 shows 

crude rates of chlamydia for the United States and border states. Arizona had the 

lowest overall crude rate of the four border states (288.53) in 2003.

Figure 27: Crude rates of Chlamydia (per 100,000) by region, 2003
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180

Analyses of border county data indicated that all border counties’ rates of 

chlamydia were slightly below the national rate as well as those of their 

respective states, as depicted in Figure 28. California border counties stood out 

as having the highest crude rate of chlamydia (347.81), while Arizona border 

counties’ rate was well below the state rate (239.88 vs. 288.53, respectively).

Gonorrhea

The bacterium Neisseria gonorrhoeae can be transmitted through contact with 

the penis, vagina, mouth, or anus. Infants may become infected during vaginal 

childbirth. Symptoms of gonorrhea in women include painful or burning 

sensation during urination, increased vaginal discharge, or vaginal bleeding 

between menstrual cycles. Symptoms may be mild and may be mistaken for a 

bladder or vaginal infection.

Infected men may experience painful or swollen testicles and a burning 

sensation while urinating. The penis may discharge a white, yellow, or green 

substance. Rectal infection is also possible. In these cases, symptoms include 

discharge, anal itching, soreness, bleeding, or painful bowel movements. Women 

whose condition is untreated may experience PID and consequent infertility, 

and their risk of ectopic pregnancy is higher. In men, the infection may lead 

to epididymitis, a testicular condition that can result in infertility if untreated. 

Infected individuals may also contract HIV more easily if exposed.

Figure 28: Crude rates of Chlamydia (per 100,000) by border county, 

2003
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181 

Like other STDs, gonorrhea is frequently underreported. Generally, gonorrhea 

can be treated and cured by the use of antibiotics. However, the spread of drugresistant strains is making the treatment and cure of gonorrhea difficult.

Figure 29 shows crude rates of gonorrhea both nationally and in the border 

states. The national crude rate of gonorrhea in the United States was 132.18 per 

100,000 persons. Of the border states, only Texas exhibited a crude rate similar 

to the national rate (128.02); other border states had significantly lower rates of 

gonorrhea.

Notably, border counties also displayed rates of gonorrhea that were well below 

the national rate, and more significantly, the state rate.

Primary and Secondary Syphilis 

Syphilis is caused by the bacterium Treponema pallidum; symptoms are often 

indistinguishable from those of many other diseases. Syphilis can be transmitted 

through direct contact with a syphilis sore, such as through sexual contact. Sores 

are found most frequently on the external genitals, vagina, anus, rectum, lips or 

mouth. Pregnant women may transmit syphilis to the fetus. Primary syphilis is 

the first stage of the disease and is characterized by the chancre lesion. Secondary 

syphilis follows and is characterized by the appearance of a rash in at least one 

area, such as on the palms of the hands or soles of the feet. Other symptoms 

include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, 

weight loss, muscle aches, and fatigue. Many infected people do not have any 

Figure 29: Crude rates of Gonorrhea (per 100,000) by region, 2003
Border Lives: Health Status in the United States-Mexico Border Region

182

symptoms for years and remain at risk for late complications if untreated. 

Infected persons in the late stages of syphilis may experience damage to internal 

organs (i.e., brain, nerves, eyes, heart, blood vessels, liver, bones, joints), and 

other symptoms include paralysis, numbness, dementia, or gradual blindness; in 

some cases death occurs.

Although transmission appears to occur from persons with sores who are in 

the primary or secondary stage, many syphilis-caused sores are unrecognized. 

Thus, most transmission is from persons who are unaware of their infection. 

The likelihood of HIV infection or transmission is greater among infected 

persons with genital sores. In its early stages, syphilis can be cured through 

the application of antibiotics; persons in later stages require a longer term 

application of antibiotics. Screening at-risk persons for syphilis is important 

given the availability of effective treatments. Primary and secondary syphilis has 

been declining in women but increasing among men, especially men who have 

sex with men (MSM).

Figure 30 shows crude rates of primary and secondary syphilis in the United 

States and four border states. The national crude rate of primary and secondary 

syphilis in 2003 was 3.44 per 100,000 persons. Of border states, Arizona (4.45) 

and California (5.70) displayed crude rates above the national rate.

Border county data were available for Arizona and California only and are 

depicted in Figure 31. Arizona data displayed a wide confidence interval, 

suggesting that there may be no statistical difference between the state and 

Figure 30: Crude rates of Primary and Secondary Syphilis (per 

100,000) by region, 2003
 Chapter 5 - Communicable Diseases

183 

border county rates, whereas California border counties appear to have a crude 

rate below the state rate (3.65 per 100,000).

Congenital Syphilis

Congenital syphilis is caused by the spirochete Treponema pallidum, which can 

be transmitted by the mother to the fetus during development or childbirth. 

Pregnant women infected with syphilis may have a stillbirth or the infant may 

die soon after birth — particularly if untreated — due to complications (e.g., 

seizures, failure to thrive, saddle nose, bone pain, sores, and others). In older 

children syphilis may produce brain damage, blindness and other developmental 

delays. Treatment options depend on factors such as identification of syphilis in 

the mother, adequacy of maternal treatment, presence of clinical, laboratory, or 

radiographic evidence of syphilis in the infant, and comparison of maternal and 

infant notreponemal serologic titers at delivery. Children presenting with syphilis 

should be evaluated to determine whether it is congenital or acquired (i.e., 

primary and secondary syphilis, latent syphilis, due to sexual assault or abuse).

In 2003, the national crude rate for congenital syphilis was 11.42 per 100,000 

live births, as depicted in Figure 32. Arizona displayed the highest crude 

rate (35.18) of all border states, although with a wide confidence interval 

because of the small number of cases reported. Texas was the border state with 

the second highest rate of congenital syphilis (21.99). Data for border counties 

were unavailable.

Figure 31: Crude rates of Primary and Secondary Syphilis (per 

100,000) by border county, 2003
Border Lives: Health Status in the United States-Mexico Border Region

184

HIV/AIDS

HIV is the acronym for human immunodeficiency virus, which causes acquired 

immunodeficiency syndrome (AIDS). HIV attacks the immune system by 

finding and destroying a type of white blood cell (i.e., T cells or CD4 cells) 

needed to fight diseases and infections. AIDS is the final stage of HIV infection 

and may develop after many years of infection with HIV. The immune system 

of persons diagnosed with AIDS is extremely fragile and they have difficulty 

fighting infections.

Because HIV cannot survive long outside the body, the virus is not transmitted 

through day-to-day activities (e.g., shaking hands, touching a doorknob, 

hugging, sitting on a toilet seat, drinking from a drinking fountain, etc). 

However, HIV is transmitted via the blood, semen, or vaginal fluids of an 

infected person. A person’s risk of becoming infected with HIV increases 

dramatically when they have sex (anal, vaginal, or oral) with someone infected 

with HIV or share needles and syringes with someone infected with HIV. 

Offspring of HIV-positive women may become infected before or during birth 

or through breast feeding.

HIV-positive persons may not realize they are infected until months or even years 

after exposure. The only way to confirm an HIV-positive diagnosis is to be tested 

for the virus. Thus, any exposure to blood, semen, or vaginal fluids of another 

person is considered risky. Factors that may increase the risk for infection include 

sharing injection drug equipment (e.g., needles, syringes, cotton, water); having 

Figure 32: Crude rates of Congenital Syphilis (per 100,000) by 

region, 2003
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185 

unprotected (i.e. without a condom) vaginal, anal, or oral sex with men who 

have sex with men, multiple partners, or anonymous partners; exchanging sex 

for drugs or money; having been diagnosed or treated for hepatitis, tuberculosis, 

or other sexually transmitted infections; or having unprotected sex with a person 

with any of these risk factors.

Treatment for HIV is available and may reduce the virus to undetectable 

levels, but current treatment regimens do not eliminate the virus from the 

body. Infected patients still need to take antiretroviral drugs and may pass the 

infection on to others even if treatment is effective.

The Healthy Border 2010 objective for the United States for HIV/AIDS is 

to reduce HIV-positive incidence rate by 50 percent (BHC, 2003a). Because 

California only began reporting HIV cases in mid-2002, it is not possible to 

calculate HIV incidence trends since 2000 for the entire border area. Based on 

HIV reporting for the border areas of Arizona, New Mexico, and Texas, the HIV 

incidence rate has fallen by 48 percent, from 7.9 in 2000 to 4.1 in 2004. Future 

reviews of HIV incidence in the border region will include data from California.

The data presented in this section refer to new HIV and AIDS cases reported by 

each border state for 2004. The accompanying graphics provide the number and 

percentage of cases for each mode of exposure. The text further contextualizes 

the data by characterizing each source of exposure as a percent of total cases for 

the regions under consideration.

Definitions

In men, HIV has four major sources of transmission: men having sex with men 

(MSM), injection drug use (IDU), men having sex with men who also use 

injection drugs (MSM/IDU), and heterosexual contact. There is also an “other” 

category that includes transmission modes such as hemophiliacs, those who 

received transfusion of blood or blood components/transplant, adults with 

confirmed other risks, adults who cannot be classified, and all pediatrics modes.

In women, transmission of HIV is limited to two major sources: IDU and 

heterosexual contact. A residual “other” category encompasses hemophiliacs, 

those who received transfusion of blood or blood components/transplant, adults 

with confirmed other risk, adults who cannot be classified, and all pediatrics 

modes.
Border Lives: Health Status in the United States-Mexico Border Region

186

Males and HIV

Figure 33 shows the percent and number of new male HIV cases reported 

in 2004 by border state and mode of transmission. These numbers varied 

considerably. California reported the greatest number of new HIV cases (7,398), 

and Texas reported the second most (2,975). Arizona reported 390 cases and 

New Mexico reported 92. Across border states, at least one-half of new cases in 

2004 were contracted through an MSM transmission. Nearly three-fourths (74 

percent) of cases in California and more than half (61 percent) of cases in Texas 

were among MSM. Injection drug users accounted for about one in every nine 

cases in Arizona, New Mexico, and Texas. Other modes of transmission account 

for a lower proportion of cases, though in New Mexico about one-fifth of cases 

were MSM/IDU.

Table 1 shows male HIV rates by border state and mode of transmission. Rates 

of HIV among males varied by mode of transmission throughout the border 

states. For example, the rate of infection among MSM for California was 30.70 

per 100,000; the next highest rate was observed in Texas (16.12 per 100,000). 

The rate of infection among IDU was highest in Texas (2.90 per 100,000).

Figure 33: Percent and number of new male HIV cases by border 

state and mode of transmission, 2004
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187 

Females and HIV

Figure 34 shows the incidence of HIV infection in women in the border states. 

California reported the greatest number of new cases of HIV in women in 

2004 (1176), followed by Texas (930), Arizona (77) and New Mexico (22). 

The data for 2004 indicate that heterosexual contact was the primary source 

of exposure for women in Arizona (73 percent of all state cases), California 

(38 percent of all state cases) and Texas (50 percent of all state cases). Women 

in New Mexico were equally affected by heterosexual contact and other 

sources (45 percent for each). Injection drug use accounted for 21 percent 

of all women’s HIV cases in 2004 in both Arizona and California and 16 

Figure 34: Percent and number of new female HIV cases by border 

state and mode of transmission, 2004

Table 1: Male HIV rates by border state and mode of transportation, 

2004
Border Lives: Health Status in the United States-Mexico Border Region

188

percent of all female HIV cases in Texas. Data were insufficient to assess 

injection drug use as an exposure source in New Mexico. 

Rates of HIV among women varied by mode of transmission and state, as 

depicted in Table 2. Heterosexual contact accounted for the highest rates 

of transmission among women in Texas (4.14 per 100,000), while rates in 

California (2.46) and Arizona were similar (1.95).

Males and AIDS

Figure 35 shows the total number of new AIDS cases in 2004 among males by 

border state and mode of transmission. Incidence of AIDS among males differed 

across border states. California had the greatest number of total cases (3941), 

followed by Texas (2386), Arizona (219), and New Mexico (131). For each state, 

MSM represented the group with the greatest number and proportion of cases. 

At least 50 percent of all cases in each state were among MSM. In addition,

injection drug use represented another important mode of transmission for 

all states. The number of cases further increased when injection drug use was 

coupled with MSM. While heterosexual sex was also a notable mechanism of 

transmission, it accounted for no more than 11 percent of cases in any state.

Figure 36 shows the percent and number of new male AIDS cases in 2004 by 

border counties and mode of transmission. Of border counties, California (455) 

and Texas (144) reported the greatest number of new male AIDS cases in 2004, 

followed by Arizona (39) and New Mexico (12). The distribution of AIDS cases 

by transmission source in border counties was comparable to state-level patterns. 

For example, in Arizona and California border counties, about three-fourths of 

new AIDS cases were attributable to MSM. In Texas, 77 cases (53 percent of 

Table 2: Women’s HIV rates by border state and mode of 

transmission, 2004
 Chapter 5 - Communicable Diseases

189 

all new cases) were among MSM. Injection drug use contributed 6 new cases 

(15 percent) in Arizona border counties, 40 (9 percent) in California, and 16 

(11 percent) in Texas. Heterosexual contact was another important source of 

exposure for men in California border counties (30 or 7 percent of all new cases) 

and Texas (20 or 14 percent of all new cases).

Figure 35: Percent and number of new male AIDS cases by border 

state and mode of transmission, 2004

Figure 36: Percent and number of new male AIDS cases by border 

counties and mode of transmission, 2004
Border Lives: Health Status in the United States-Mexico Border Region

190

Table 3 summarizes male AIDS incidence rates by border state and mode of 

transmission. Of the border states, California exhibited the highest rate of MSM 

(15.14 per 100,000), followed by Texas (11.70). While lower than these, rates 

for New Mexico (7.58) and Arizona (5.57) were also elevated. Rates of IDU 

were substantially lower (below 2.50 per 100,000 for all states).

Females and AIDS

Figure 37 provides information on new AIDS cases among women by their 

home state and mode of transmission. Of the four border states, Texas (735) 

and California (524) reported the greatest number of AIDS cases in women in 

2004. In all states, heterosexual contact represented the most common mode of 

transmission, both numerically and proportionally, ranging from 49 percent of 

all new cases in Texas and California to 85 percent of all new cases in Arizona.

Table 4 summarizes data regarding female AIDS rates by border state and 

mode of transmission. Female AIDS rates associated with IDU were highest in 

Texas (1.45 per 100,000) and California (0.71). The rate of female AIDS cases 

associated with heterosexual contact was 3.16 in Texas, the highest rate among 

states reporting these data. Rates were lower in Arizona (1.39) and California 

(1.44).

Table 3: Male AIDS rates by border state and mode of transmission, 

2004
 Chapter 5 - Communicable Diseases

191 

Conclusion

The data presented in this chapter represent an initial attempt to document the 

incidence of infectious diseases in the four border states of Arizona, California, 

New Mexico, and Texas and the 44 border counties that lie north of the U.S.-

Mexico border. The conditions reported upon here vary in their etiologies, 

symptoms, and modes of transmission, as well as severity and long-term 

consequences.

The data demonstrate much diversity among the border states and border 

counties with respect to the number and rates of new cases reported for each 

Table 4: Female AIDS rates by border state and mode of 

transmission, 2004

Figure 37: Percent and number of newfemale AIDS cases by border 

state and mode of transmission, 2004
Border Lives: Health Status in the United States-Mexico Border Region

192

condition. Some diseases, such as TB and hepatitis A, disproportionately affect 

border states and counties compared to overall U.S. rates.

However, the picture was much more complex for many infectious diseases, 

including haemophilus influenza, hepatitis B acute, salmonellosis, shigellosis, 

streptococcal disease and typhoid. Rates of disease for some of these conditions 

were higher in border states than across the United States; for other conditions, 

border state rates were lower than national rates. Discrepancies were also 

found when border counties’ rates were compared to disease rates in their 

corresponding border states. For example, data on salmonellosis showed that 

California and Arizona fared better than the nation as a whole and had lower 

crude rates of cases compared to the national rate. While New Mexico and 

Texas had higher rates than the nation, New Mexico and Texas border counties 

reported lower crude rates of salmonellosis than their states, while Arizona and 

California border counties had higher rates.

This analysis also identified several infectious diseases for which rates in border 

states were lower than the national rate, including E. coli, giardiasis, hepatitis C. 

acute, listeriosis and pertussis. Diseases were also identified that had lower rates 

in border counties than in those counties’ respective states (e.g., giardiasis).

Rates were suppressed for many conditions because there were insufficient cases 

to meet criteria for reportability. In addition, the low number of cases often did 

not permit identification of geographic variation in disease rates. Nevertheless, 

findings revealed variations in disease incidence across geographic regions for 

many diseases.

These findings have various implications. Significantly, the data indicate that 

assumptions regarding the incidence and prevalence of infectious diseases in 

border states and counties must be examined systematically, using the best 

available data. By adopting this approach, public health and policy interventions 

will be well-guided and will match the needs of the population. Additionally, 

federal health agencies and state health departments must consider the special 

needs of their border counties. The unique sociodemographic and geographic 

characteristics of the region, especially the pervasiveness of cross-border traffic, 

may facilitate the transmission of infectious diseases. More in-depth research 

studies are needed to understand the many factors affecting disease rates in the 

border region. Finally, the presence of a large and diverse Hispanic population in 

all border states and counties calls for public health interventions that can reduce 

the burden of infectious diseases and that are culturally and linguistically sensitive. 

Such interventions must take into account important differences in generational 

status, language, and ethnic subgroup compositions. Efficient prevention and 

control of infectious diseases in the border region frequently requires close 

collaboration between health agencies from the United States and Mexico.
 Chapter 5 - Communicable Diseases

193 

References

Anderson, J.S. Stenzel, K., Smith, B., Labus, P., Rowley, S., Shoenfeld, L., et al. 

(2002). Multistate outbreaks of salmonella serotype poona infections 

associated with eating cantaloupe from Mexico—United States and 

Canada, 2000-2002. Morbidity and Mortality Weekly Report, 51(46), 

1044-1047.

Bisgard K.M., Bath S., Srivastava P., & Cortese M. (2002). Haemophilus 

influenzae type b invasive disease. In M. Wharton, H. Hughes, & M. 

Reilly, (Eds.), Manual for the surveillance of vaccine preventable diseases, 

(3rd ed). (pp. 2-1 – 2-11). Atlanta, GA.: Centers for Disease Control 

and Prevention.

Brouwer K.C., Strathdee S.A., Magis-Rodríguez C., Bravo-García E., Gayet C., 

Patterson T.L., et al. (2006). Estimated numbers of men and women 

infected with HIV/AIDS in Tijuana, Mexico. Journal of Urban Health, 

83(2):299-307.

Bruhn, J.G. (1997). Introduction. In J.G Bruhn and J.E. Brandon (Eds.) Border 

Health Challenges for the United States and Mexico (pp. xiii-xviii). New 

York, N.Y.: Garland Publishing Inc.

Buzby, J.C. (Ed.). (2003, November). International trade and food safety: 

Economic theory and case studies. (Agricultural Economic Report 

No. AER828). Washington, DC: U.S. Department of Agriculture, 

Economic Research Service. Retrieved February 4, 2008, from http://

www.ers.usda.gov/Publications/AER828

Centers for Disease Control and Prevention. (1998). Preventing emerging 

infectious diseases: A strategy for the 21st century overview of the 

updated CDC plan. Morbidity and Mortality Weekly Reports 47(RR15), 

1-14. Retrieved March 7, 2007, from http://www.cdc.gov/mmwr/

preview/mmwrhtml/00054779.htm

Centers for Disease Control and Prevention (2001). Diagnosis and management 

of foodborne illnesses: A primer for physicians. Morbidity and Mortality 

Weekly Reports: Recommendations and Reports, 50(RR02),1-69.

Centers for Disease Control and Prevention (2002). Screening tests to detect 

Chlamydia trachomatis and Neisseria gonorrhoeae infections – 2002. 

Morbidity and Mortality Weekly Reports: Recommendations and Reports, 

51(RR15), 1-27.
Border Lives: Health Status in the United States-Mexico Border Region

194

Centers for Disease Control and Prevention. (2004). STDs & pregnancy. 

Retrieved May 14, 2007, from http://www.cdc.gov/std/std_pregnancy.pdf

Centers for Disease Control and Prevention. (2006). Trends in reportable 

sexually transmitted diseases in the United States, 2006. Retrieved May 

14, 2007, from http://www.cdc.gov/std/stats/pdf/trends2006.pdf

Centers for Disease Control and Prevention (2007). Update: Prevention of 

Hepatitis A after exposure to Hepatitis A virus and in international 

travelers. Updated recommendations of the Advisory Committee on 

Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 

56, 1080-1084.

Dentinger C.M., Bower W.A., Nainan O.V., Cotter S.M., Myers G., Dubusky 

L.M., et al. (2001). An outbreak of hepatitis A associated with green 

onions. Journal of Infectious Disease, 183, 1273 –1276.

Doyle T. & Bryan R. (2000). Infectious disease morbidity in the U.S. region 

bordering Mexico. Journal of Infectious Disease, 182, 1503-10. Epub 

2000 September 27.

Fosados R., Caballero-Hoyos R., Torres-López T., & Valente, T.W. (2006). Uso de 

condón y migración en una muestra de migrantes mexicanos: potencial 

para la transmisión de VIH/ITS. Salud Pública Mex, 48, 57-61.

Frost S.D., Brouwer K.C., Firestone Cruz M.A., Ramos R., Ramos M.E., 

Lozada R.M., et al. (2006). Respondent-driven sampling of injection 

drug users in two U.S.-Mexico border cities: recruitment dynamics and 

impact on estimates of HIV and syphilis prevalence. Journal of Urban 

Health, 83(6 Suppl):i83-97.

Hirsch J.S., Higgens J., Bentley M.E., & Nathanson, C.A. (2002). The social 

constructions of sexuality: marital infidelity and sexually transmitted 

disease—HIV risk in a Mexican migrant community. American Journal 

of Public Health, 92, 1227-1237.

Hutin Y.J., Pool V., Cramer E.H., Nainan O.V., Weth J., Williams I.T., et al. 

(1999). A multistate, foodborne outbreak of Hepatitis A. New England 

Journal of Medicine, 340, :595-602.

International Boundary and Water Commission. (1998). Second phase of the 

binational study regarding the presence of toxic substances in the Rio 

Grande/Rio Bravo and its tributaries along the boundary portion between 

the United States and Mexico, Vols. 1 and 2. El Paso, TX: Author.
 Chapter 5 - Communicable Diseases

195 

Janowski M.C., Ginsberg M.M., Torok T.J., & Gunn, R.A. (2005). Outbreak 

of Salmonella Typhimurium related to consumption of Mexican-style 

soft cheese purchased from unregulated sources, San Diego, California 

2004. Paper presented at the 43rd Annual Meeting of the Infectious 

Diseases Society of America, San Francisco, CA. Retrieved September 

11 2006, from http://www.idsociety.org/template.cfm?Section_Progr

am2&CONTENTID_14111&TEMPLATE_/ContentManagement/

ContentDisplay.cfm

Kinde H., Mikolon A., Rodriguez-Lainz A., Adams C., Walker R.L., et 

al. (2007). Recovery of Salmonella, Listeria monocytogenes, and 

Mycobacterium bovis from cheese entering the United States through 

a noncommercial land port of entry. (2007). Journal of Food Protection

70(1), 47–52.

Linnan M.J., Mascola L., Lou X.D., Goulet V., May S., Salminen C., et al. 

(1988). Epidemic listeriosis associated with Mexican-style cheese. New 

England Journal of Medicine, 319, 823-828.

MacDonald, P.D., Whitwam, R.E., Boggs, J.D., MacCormack, J.N., Anderson, 

K.L., Reardon, J.W., et al. (2005). Outbreak of listeriosis among 

Mexican immigrants as a result of consumption of illicitly produced 

Mexican-style cheese. Clinical Infectious Diseases, 40, 677-82.

Rangel, M.G., Martínez-Donate, A.P., Hovell, M.F., Santibáñez, J., Sipan, C.L., 

& Izazola-Licea, J.A. (2006). Prevalencia de factores de riesgo para la 

infección por VIH entre migrantes mexicanos: encuesta probabilística 

en la frontera norte de México. Salud Pública Mex 48, 3-12.

Saavedra, J. (2007, June 1-2). Update on HIV/AIDS in Mexico. Paper presented 

at Management of TB, STDs, HIV, Hepatitis C, and Substance Abuse 

at the Border: Focus on Testing, Holtville, CA.

Sanchez, M.A., Lemp, G.F., Magis-Rodriguez C., Bravo-Garcia E., Carter S., 

Ruiz J.D. (2004). The epidemiology of HIV among Mexican migrants 

and recent immigrants in California and Mexico. Journal of Acquired 

Immune Deficiency Syndromes, 37, S204–S214.

Schneider E., Laserson K.F., Wells C.D., Moore M. (2004). Tuberculosis along 

the United States-Mexico border, 1993-2001. Rev Panam Salud Publica. 

16(1), 23-34.
Border Lives: Health Status in the United States-Mexico Border Region

196

U.S. Department of Health and Human Services (2000). Health on the U.S.-

Mexico border: past, present and future: a preparatory report on the 

future United States-Mexico Border Health Commission. Washington, 

DC: Author.

U.S.-Mexico Border Health Commission (2003a). Healthy Border 2010: An Agenda 

for Improving Health on the United States-Mexico Border. El Paso, TX.

U.S.-Mexico Border Health Commission (2003b), Terrorism and Emergency 

Response Preparedness Initiative: Strategic Actions and Bilateral 

Cooperation for Health Security Efforts along the United States–

Mexico Border, In Partnership with U.S.–Mexico Border State Health 

Directors.

Weinberg M., Waterman S., Lucas C.A., Falcon V.C., Morales P.K., Lopez L.A., 

et al. (2003). The U.S.-Mexico Border Infectious Disease Surveillance 

Project: Establishing binational border surveillance. [Electronic version]. 

Emerging Infectious Diseases, 9, 97-102.

Weinberg M., Hopkins J., Farrington L., Gresham L., Ginsberg M., & Bell B.P. 

(2004). Hepatitis A in Hispanic children who live along the United 

States–Mexico border: The role of international travel and food-borne 

exposures Pediatrics, 114, e68-e73.
197 

Introduction

Cancer is a major public health problem, the second most common cause 

of death and an important cause of morbidity in both the United States 

and the U.S.-Mexico border region. Cancer is expected to become the 

leading cause of death in the United States in the next decade (Stewart, 2004), 

and it is likely that cancer deaths among residents of the U.S.-Mexico border 

region will follow a similar trend. It is estimated that more than 1.4 million new 

cancer cases will be diagnosed in the United States in 2008, with about 286,000 

occurring in the border states of Arizona, California, New Mexico and Texas 

(Jemal, 2008).

Cancer contributes significantly to the cost of health care in the United States. 

The National Institutes of Health (NIH) estimated the overall costs for cancer 

to be $206.3 billion in 2006. This figure includes $78.2 billion for direct costs, 

$17.9 billion for indirect costs, and $110.2 billion in loss of productivity due to 

premature death (American Cancer Society [ACS], 2008).

Breast cancer is of significant concern, both nationwide and on the border. 

Among women in the United States, breast cancer is the most frequently 

diagnosed cancer and causes more deaths than any other cancer except lung 

cancer. In the border region, breast cancer is the leading cause of female cancer 

deaths. Nationwide, approximately 180,000 new cases of invasive breast cancer 

will be diagnosed in 2008, and about 40,000 women will die of this disease 

(Jemal, 2008). Almost 37,000 new cases of breast cancer will be diagnosed in 

2008 in the four border states.

Cervical cancer is ranked thirteenth nationally in terms of incidence rates for women 

in 2003 but is the sixth leading cancer site for Hispanic women (Howe, 2006). In 

addition, death rates for cervical cancer in the United States and in the border region 

CHAPTER 6

BREAST AND CERVICAL CANCER
Border Lives: Health Status in the United States-Mexico Border Region

198

are higher among Hispanics than non-Hispanic whites (Giuliano, 2001).

Screening is especially important for early detection and treatment for both 

cervical and breast cancer (Frisell, 1991; Chan, 2003). Low rates of screening 

and treatment often lead to cancer being diagnosed at later stages, when it 

is more aggressive. Limited access to health-care services and prior screening 

history are the primary reasons for ethnic disparities in cancer screening 

(Zembrana, 1999; Gorin, 2005; Ramirez, 2005).

Cancer is a major focus area of the Healthy Border 2010 program. Two Healthy 

Border 2010 objectives directly focus on cancer: reducing the female breast 

cancer death rate by 20 percent, from 27.2 to 21.8 per 100,000 women; and 

reducing the cervical cancer death rate by 30 percent, from 3.7 to 2.6 per 

100,000 women. Other Healthy Border 2010 objectives also include several of 

the most important risk factors for cancer of all types. These include increasing 

access to primary care or basic health services, and reducing the number of 

hospital admissions for acute pesticide poisoning. Improvements in these areas 

also will reduce cancer incidence and mortality.

The aim of this chapter is to provide an overview of cancer morbidity and 

mortality for residents of the U.S.-Mexico border region. Special emphasis is 

placed on two cancer types, female breast and cervical cancers.

Understanding Cancer

Cancer is a group of diseases characterized by uncontrolled growth and spread of 

abnormal cells. Cancer cells develop when the genetic material that directs cells’ 

activities, called deoxyribonucleic acid (DNA), is damaged. Normally, the body 

is able to repair damaged DNA. In cancer cells, however, damaged DNA is not 

repaired. Unlike normal cells, which divide only to replace worn-out or dying 

cells and to repair injuries, cancer cells continue to grow and divide, forming 

more abnormal cells. In most types of cancer, the cells form tumors. Cancer cells 

can also travel to other parts of the body in a process called metastasis. The type 

of cancer is based on the place it began. For instance, breast cancer that spreads 

to the brain is still called breast cancer (ACS, 2008).

Cancer risk factors include environmental (radiation, second-hand smoke, some 

viral agents, others), behavioral (diet, alcohol abuse, tobacco use), and hereditary 

factors among others. They may act singly or synergistically. Behavioral risk 

factors can be modified to significantly reduce the occurrence of cancer. It is 

estimated that cancers related to smoking and alcohol consumption can be 

completely prevented by eliminating these risk factors, and that those related to 

overweight, physical activity, nutrition, and sun exposure can be significantly 

reduced or prevented by reducing weight, eating healthier diets, increasing 

exercise, and using sun blockers (ACS, 2008).
 Chapter 6 - Breast and Cervical Cancer

199 

Methods

This summary of cancer incidence and mortality for the U.S.-Mexico border 

region draws on a variety of data sources. Incidence data in this chapter are 

from state and regional cancer registries, including those participating in 

the National Cancer Institute’s (NCI) Surveillance, Epidemiology and End 

Results (SEER) Program, and the Center for Disease Control and Prevention’s 

(CDC) National Program of Cancer Registries (NPCR). Combined, the SEER 

and NPCR registries cover 98 percent of the U.S. population (U.S. Cancer 

Statistics Working Group [USCSWG], 2007). Incidence estimates for 2008 

were produced by the American Cancer Society (ACS) (Jemal, 2008). Data are 

presented for cancers of all sites combined, by sex and ethnicity, as well as for 

selected cancer sites.

Hispanic ethnicity is not always reported on cancer registries. To improve the 

identification of Hispanics, the North American Association of Central Cancer 

Registries (NAACCR) has developed an algorithm based on a number of items 

including surname and maiden name (Howe, 2006). This algorithm is used 

by the SEER and NPCR registries and is the basis for the Hispanic cancer 

incidence data that appear in this chapter.

Mortality data used in this chapter are from the national vital statistics data 

system of the National Center for Health Statistics (NCHS). Death rates due 

to malignant neoplasms are presented for the border region, with state and 

national comparisons where appropriate. Within the border region, comparisons 

are made across the combined border counties of each border state. In many 

cases data are presented separately for the two major population groups on the 

border, Hispanics and non-Hispanic whites. Hispanic ethnicity also is thought 

to be underreported on death certificates; this is attributed in part to the fact 

that funeral directors are responsible for completing this item (Rosenberg, 

1999). The most recent mortality information available when this chapter was 

written was from 2004. Every attempt was made to use the most recent data, 

but in some cases it was necessary to combine multiple years of mortality data to 

present statistically reliable measures.

Information on risk factors and cancer screening are from the Behavioral Risk 

Factor Surveillance System (BRFSS) for the United States and the four border 

states. BRFSS data also are available for the 32 counties that form the border 

region in Texas.

Rates and all other results are age-adjusted to the U.S. 2000 standard population 

and are per 100,000 population. Cancer incidence rates are age-adjusted to 

the U.S. 2000 standard population using 19 age intervals, while death rates are 

age-adjusted using 11 age intervals. Ninety-five percent confidence intervals 
Border Lives: Health Status in the United States-Mexico Border Region

200

are provided for most estimates. Differences between two rates are considered 

statistically significant only if their confidence intervals do not overlap.

Longer-term trends in cancer incidence are measured by joinpoint analysis 

and are based on delay-adjusted data that have been modified to account for 

delayed submissions of cancer diagnoses (Kim, 2000). The data adjustment uses 

reporting-delay models developed with 1981-2004 SEER registry data (Howe, 

2006). Because these models are not appropriate for more recent fixed time 

intervals, incidence trends for fixed-time intervals are based on unadjusted data. 

Levels and Trends in Cancer Incidence and Mortality

Cancer incidence

In 2004, an estimated 1.37 million cancer cases of all sites were diagnosed in the 

United States (Jemal, 2008). In the same year, more than 250,000 cancer cases 

of all sites were diagnosed in the four border states (USCSWG, 2007). Within 

the next 50 years, it is estimated that the combined effects of population growth 

and aging will double the annual number of Americans diagnosed with cancer 

(Espy, 2007).

Table 1 provides 2004 incidence rates for cancers of all sites in the United States 

and border states, by sex and ethnicity. The national incidence rate for all sites 

(458.2 per 100,000) was significantly higher than the rates in all four of the 

border states. For all ethnicities combined, male incidence rates were 25 percent 

or more above female rates at the national and border state levels; the same 

sex disparity existed for Hispanics. Incidence rates for Hispanics (both sexes 

combined) were also 25 percent or more below the all ethnicities rate for the 

U.S. and for all border states except New Mexico, where the differential was 15 

percent.

Figures 1a and 1b provide 2004 national cancer incidence rates for the five 

leading sites by ethnicity and sex. Cancer of the prostate was the leading 

incident cancer among men, for all ethnicities combined and for Hispanics; 

breast cancer was the leading cancer site for women in both groups. Incidence 

rates for every leading site were lower for Hispanics than for all ethnicities 

combined, among both men and women. Incidence rates for lung and bronchus 

cancer were much lower for Hispanics than for all ethnicities combined, 41 

percent lower among men and 51 percent lower among women. The leading 

sites and their ranking were the same for males of all ethnicities and Hispanic 

males. Among women, the ranking of the leading sites differed slightly by 

ethnicity: Lung and bronchus were the second leading sites for all ethnicities, 

while colon and rectum were the second leading sites among Hispanic females.
 Chapter 6 - Breast and Cervical Cancer

201 

In the border states, age-adjusted cancer incidence rates for the leading sites 

were generally the same or lower than the national rates by sex and ethnicity, 

although there were some differences. The Arizona rates for most of the leading 

cancer sites were significantly lower than the national rates. Hispanic males 

in Arizona had lower incidence rates for prostate cancer and Hispanic women 

had lower breast and colon cancer rates than the national Hispanic rates. Male 

cancer incidence in California was significantly above the national rate for 

prostate cancer, while the lung and colon rates were lower. Site-specific cancer 

rates for females in California were similar to national rates. Most incidence 

rates in New Mexico were not significantly different from national rates by sex 

or ethnicity. Incidence rates in Texas were significantly lower for prostate and 

breast cancers (all ethnicities and Hispanics) and similar to national rates for 

most of the other leading sites.

Table 1: Invasive cancer incidence rates, all sites, USA and border states, 2004

Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2004 

Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention and National Cancer Institute; 2007. 

* 95% confidence interval

Rates are per 100,000 population, age-adjusted to the US 2000 standard population.

USA Arizona California New Mexico Texas

All ethnicities, both sexes

Rate 458.2 383.3 435.0 409.0 442.2

C.I.* 457.4, 459.0 378.2, 388.4 432.7, 437.3 400.0, 418.2 439.2, 445.2

All ethnicities, males

Rate 537.6 435.0 509.8 469.3 530.9

C.I.* 536.3, 538.8 427.0, 443.1 506.1, 513.6 454.9, 484.2 525.9, 535.9

All ethnicities, females

Rate 403.1 345.3 382.7 363.9 380.4

C.I.* 402.1, 404.1 338.7, 352.0 379.8, 385.6 352.3, 375.8 376.7, 384.1

Hispanics, both sexes

Rate 356.5 308.0 346.7 352.6 343.5

C.I.* 353.9, 359.1 294.6, 321.9 341.8, 351.7 337.9, 367.8 337.7, 349.4

Hispanics, males

Rate 415.5 358.6 410.1 409.7 402.0

C.I.* 411.1, 420.0 335.5, 382.7 401.7, 418.6 385.7, 434.7 392.2, 412.0

Hispanics, females

Rate 318.6 277.5 306.1 310.7 306.2

C.I.* 315.4, 321.8 260.9, 294.7 300.2, 312.2 292.2, 329.9 299.0, 313.5
Border Lives: Health Status in the United States-Mexico Border Region

202

Although Hispanics had lower incidence rates for all cancers combined and for 

the five leading sites, they had higher incidence rates for several cancers. At the 

national and border state levels, cancer incidence rates for Hispanics were 50 to 

100 percent higher for liver, stomach, and cervical cancers (USCSWC, 2007). 

Infections are an important cause of all three of these cancers. Chronic bacterial 

infections with Helicobacter pylori (H pylori) can cause stomach ulcers, which 

are a significant source of stomach cancers (Peto, 2001). Infections with Human 

Figure 1a: Age-adjusted cancer incidence rates for 5 leading sites, USA 

males 2004

Figure 1b: Age-adjusted cancer incidence rates for 5 leading sites, USA 

females 2004

Source: UCSWG, 2007

Rates are per 100,000 population, age-adjusted to US 2000 population.

*Not otherwise specified

0 25 50 75 100 125 150 175

Non-Hodgkin Lymphoma

Corpus and uterus, NOS*

Colon and rectum

Lung and bronchus

Breast

Rate per 100,000

A ll et hnicit ies Hispanic

0 25 50 75 100 125 150 175

Non-Hodgkin Lymphoma 

Urinary bladder

Colon and rectum

Lung and bronchus

Prostate

Rate per 100,000

A ll et hnicit ies Hispanic
 Chapter 6 - Breast and Cervical Cancer

203 

papillomavirus (HPV) are a major cause of cervical cancer (Walboomers, 1999), 

and infections with hepatitis-B and hepatitis-C viruses account for the large 

majority of liver cancer cases worldwide (Donato, 1998).

Helicobacter pylori infections are higher in lower socioeconomic groups, in 

particular in groups living in crowded conditions (Brown, 2000). MexicanAmerican women born in Mexico have a higher prevalence of HPV infection 

than other Hispanic groups (ACS, 2008). Age-adjusted seroprevalence rates for 

Mexican-Americans as compared to non-Hispanic whites were 2.2 times higher 

for H pylori (63.0 percent versus 28.4 percent), 1.8 times higher for hepatitis-B 

(5.3 versus 3.0), and 1.7 times higher for hepatitis-C (3.4 versus 2.0).

Trends

Trends in cancer incidence rates can be affected by a number of factors. 

First, changes in screening, including the introduction or discontinuation 

of a diagnostic test, can have a significant impact on the number of cancers 

diagnosed. For example, the rapid rise and then decline in the prostate cancer 

incidence rate is thought to be related to changes in the use of prostate-specific 

antigen testing (Jemal, 2004a). In addition, trends that use the most recent 

year of data may be misleading, because the most recent year submissions 

are approximately two percent below the total number of cancers that will 

eventually be submitted for that year (Ries, 2008). Trends described below are 

adjusted for delayed reporting, as described in the Methods section.

In the United States, the age-adjusted incidence rate for all cancer sites for males 

and females combined slowly decreased from 1992 through 2004, declining by 

0.3 percent per year (Espy, 2007). This decline was only statistically significant 

when rates for both sexes were combined. The male incidence rate was stable 

from 1995 to 2004 while the female rate rose from 1987 through 1999 and 

remained stable thereafter. Incidence trends for specific sites, by sex, are provided 

in Table 2. Lung cancer incidence in men has declined by nearly 2 percent per 

year, beginning in 1991; colon and rectum cancer incidence has declined even 

faster (2.6 percent per year) beginning in 1998. Trends for other male cancer 

sites have been stable in recent years.

Since 2001, breast cancer incidence in women has fallen at an even faster pace, 

with a decrease of 3.5 percent per year, while colon and rectum cancer incidence 

in women has declined at an annual rate of 2.2 percent in recent years. However, 

the incidence of non-Hodgkin lymphoma among women has been rising at 1.4 

percent per year since 1988.

The significant declines in incidence rates for several of the most important 

cancers are due to a number of factors. Reducing exposure to risk factors, such 
Border Lives: Health Status in the United States-Mexico Border Region

204

as tobacco use, has been a major contributor to the prevention of lung cancer. 

Improved screening and treatment of precancerous lesions has had a major 

impact on the incidence of colon and cervical cancers. Eradication of infections 

can play a major role in eliminating certain cancers, such as cervical, stomach, 

and liver cancer.

Incidence of breast cancer

Breast cancer is the leading cancer site for women, both nationally and in each 

of the four border states. In 2004, an estimated 216,000 new cases of invasive 

breast cancer were diagnosed in the United States (Jemal, 2004b); in the four 

border states a combined total of 37,000 new cases of invasive breast cancer was 

reported (USCSWG, 2007). Breast cancer also was the leading cancer site for 

Hispanic women in the United States and the border states. A combined total 

of nearly 5,900 new cases of invasive breast cancer were diagnosed in Hispanic 

women in the border states in 2004.

Breast cancer incidence rates in Table 3 are based on combined data for 2002-

2004 to improve the precision of the rates. Nationally, the female breast cancer 

rate was more than 25 percent lower for Hispanic women than for all ethnicities 

combined (88.4 and 121.7 per 100,000, respectively). Similarly, Hispanic breast 

cancer rates were 25 percent or more below the all-ethnicity breast cancer rate in 

each of the border states. Female breast cancer rates for all ethnicities combined 

were significantly lower than the national rate for the states of Arizona, New 

Mexico, and Texas; California’s rate was statistically similar to the national rate. 

Among Hispanic women, only Texas had a statistically lower incidence of breast 

cancer than the national Hispanic rate (82.8 versus 88.4).

Although county-level data on cancer incidence are available through the NPCR 

website, it is not possible to provide county-level incidence rates for several 

reasons. First, it was not possible to obtain rates for consistent years for all of 

Table 2: Delay-adjusted trends in cancer incidence rates for the top 5 cancers, 

by sex, for all ethnicities

Annual percent Annual percent

Site Interval change Site Interval change

All sites 1995-2004 -0.2 All sites 1999-2004 -0.5

Prostate 1995-2004 0.4 Breast 2001-2004 -3.5**

Lung and bronchus 1991-2004 -1.8** Lung and bronchus 1998-2004 -0.1

Colon and rectum 1998-2004 -2.6** Colon and rectum 1998-2004 -2.2**

Urinary bladder 1999-2004 -0.9 Corpus and uterus 1998-2004 -0.8

NHL* 1991-2004 0.3 NHL* 1988-2004 1.4**

Males Females
 Chapter 6 - Breast and Cervical Cancer

205 

the border counties. In addition, not all of the border states provide countylevel incidence information for Hispanics. Finally, only age-adjusted rates are 

provided for counties, so it was not possible to combine data across counties 

to measure incidence for the combined border counties of each state, or for all 

border counties combined.

Female breast cancer incidence rates have fallen rapidly in recent years, declining 

by 3.5 percent per year from 2001-2004 (Espy, 2007). A number of factors 

are known to influence incidence trends in age-adjusted breast cancer rates, 

including changes in obesity levels, the rate of mammography screening, 

hormone therapy, and other factors. The recent decline appears to be the result 

of declines in the use of hormone replacement therapy in postmenopausal 

women as well as a leveling-off in the rate of mammography screening (Ravdin, 

2007; Jemal, 2007).

The lower breast cancer incidence rate for Hispanics also may be attributed to 

a number of factors. Hispanic ethnicity is underreported in cancer registries 

and likely remains underestimated even after the application of the adjustment 

algorithm described in the methods section above. Breast cancer screening rates 

for Hispanic women are lower than for non-Hispanic whites, although this 

difference is more influenced by factors associated with access to care than by 

language barriers or ethnicity (Selvin, 2003; Thompson, 2002). Risk factors for 

breast cancer include reproductive factors (higher age at first birth, low number 

of births, short length of breastfeeding, and other factors affecting hormone 

levels), overweight/obesity in postmenopausal women, diet, exercise, gene 

Table 3: Age-adjusted invasive incidence rates for breast and cervical cancer, 

USA and border states, 2002-2004

Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2004 

Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention and National Cancer Institute; 2007.

* 95% confidence interval

Rates are per 100,000 population, age-adjusted to the US 2000 population. 

USA 121.7 121.4, 122.1 88.4 87.4, 89.4 8.3 8.2, 8.4 13.0 12.6, 13.3

Arizona 109.9 107.7, 112.1 82.1 76.9, 87.5 7.2 6.6, 7.8 10.2 8.6, 12.1

California 122.7 121.7, 123.6 87.0 85.2, 88.8 8.4 8.1, 8.6 13.4 12.7, 14.0

New 

Mexico

108.5 104.8, 112.3 85.2 79.6, 91.0 8.3 7.3, 9.4 9.8 8.0, 11.9

Texas 115.2 114.0, 116.4 82.8 80.6, 85.0 10.0 9.6, 10.3 14.9 14.0, 15.7

Breast Cervix

All Ethnicities Hispanic All Ethnicities Hispanic

Rate C.I.* Rate C.I.* Rate C.I.* Rate C.I.*
Border Lives: Health Status in the United States-Mexico Border Region

206

mutations, alcohol consumption, and others (Howe, 2006; Peto, 2001). Hispanic 

women differ from non-Hispanic white women in terms of many of these risk 

factors. For example, Hispanic women have higher rates of teen pregnancy and 

higher number of births than non-Hispanic whites, as described in Chapter 4, 

“Maternal, Infant, and Child Health.” Despite a lower incidence rate for breast 

cancer, however, Hispanic women present with more advanced disease when 

diagnosed, even in settings with equal screening (Watlington, 2007).

Incidence of cervical cancer

Cervical cancer was the 13th leading cancer for U.S. women in 2004, with an 

estimated 10,500 cases diagnosed nationally (Jemal, 2004a) and 2,700 new cases 

diagnosed in the border states (USCSWC, 2007). Among Hispanic women, 

cervical cancer was the 7th leading cancer nationally, and the 6th or 7th leading 

cancer in the border states. A total of 1,023 new cases of cervical cancer were 

diagnosed in the four border states in 2004.

The national incidence rate for invasive cervical cancer in 2002-2004 was more 

than 50 percent higher in Hispanics than for all ethnicities combined (13 

percent and 8.3 percent, respectively), as shown in Table 3. The all-ethnicities 

rate in Arizona was significantly lower than the national rate (7.2 as compared 

to 8.3), while the Texas rate was significantly higher (10.0 versus 8.3). The 

incidence of cervical cancer for Hispanic women in Arizona and New Mexico 

(10.2 and 9.8, respectively) was significantly lower than the national Hispanic 

rate (13.0). However the cervical cancer incidence rate was 14.9 in Texas, 

significantly higher than the national rate. Although the exact incidence of 

cervical cancer for the border region is not available, data suggest that the rate is 

higher than the national rate (Giuliano, 2001).

Research conducted in the 1980s and 1990s provided evidence for an etiological 

role of infection with sexually transmitted human papillomavirus (HPV) as 

the primary cause of cervical cancer (Schiffman, 1993). Other factors that may 

mediate the risk of cervical cancer are smoking, parity, use of oral contraceptives, 

other infections, and host susceptibility (Franco, 2003).

The decline in the national incidence of cervical cancer began earlier and the rate 

has fallen even more rapidly than breast cancer. The national incidence rate for 

cervical cancer began falling in 1975 and from 1996 to 2004 fell at an annual 

rate of 3.7 percent, using delay-adjusted incidence data. Among Hispanics, 

the age-adjusted incidence rate has declined at an annual rate of 3.6 percent 

from 1995 to 2003, based on unadjusted data (Howe, 2006). Screening and 

treatment of precancerous lesions has had a clear impact on cervical cancer 

incidence (Chan, 2003), although Papanicolaou (Pap) smear screening remains 

less common among Hispanics than in non-Hispanic whites, 74.7 percent versus 
 Chapter 6 - Breast and Cervical Cancer

207 

80.2 percent (Howe, 2006). The discovery of the role of human papillomaviruses 

(HPVs) in cervical cancer, followed by the development of HPV vaccines, may 

play a major role in further reduction of cervical cancer (Peto, 2001).

Cancer mortality

One in every four deaths in the United States is from cancer. Cancer is the 

second leading cause of death in both the United States as a whole, as well as in 

the 44 U.S. counties that lie north of the U.S.-Mexico border. In 2004, more 

than 553,000 deaths due to malignant neoplasms (cancer) took place in the 

United States (Miniño, 2007). In the same year there were slightly more than 

100,000 cancer deaths in the border states and 10,260 deaths from cancer in the 

border region.

Figures 2a and 2b summarize 2004 age-adjusted cancer death rates by sex for 

the United States, border states, and the combined 44 border counties. For both 

men and women, U.S. cancer death rates per 100,000 were one-third lower 

for Hispanics than for non-Hispanic whites, 151 versus 229 for men and 101 

compared to 161 for women. Hispanic cancer death rates also were significantly 

lower than the non-Hispanic white rate for men in the states of California and 

Texas, and for women in Arizona, California, and Texas. A comparison of cancer 

death rates across the four border states shows that Texas had the highest rates 

for men and women (all ethnicities combined), 231 and 152, and New Mexico 

had the lowest cancer death rates in the four states, 189 for men and 135 for 

women. Among Hispanics, however, New Mexico had the highest rates (187 for 

men, 123 for women) while California had the lowest death rates for men and 

women (146 and 102, respectively).

Figure 2a: Age-adjusted cancer death rates* by ethnicity, males; USA 

border states, and 44 border counties, 2004
Border Lives: Health Status in the United States-Mexico Border Region

208

For the border counties, cancer death rates for all ethnicities combined were 

one-third lower than the national death rate for men (194 versus 227) and 15 

percent lower than the national rate for women (134 versus 157). The border 

county cancer death rates for Hispanics were statistically similar to the national 

Hispanic rates, for both men and women. Death rates for all ethnicities were 

similar to the rates for non-Hispanic whites, nationally and in the border states. 

In the border counties, the non-Hispanic white rate was lower than the national 

rate for men and statistically similar for women.

As with cancer incidence data, there is concern that cancer deaths among 

Hispanics are undercounted because of inaccurate reporting of Hispanic origin 

on the death certificate. The most recent review of this issue, using 1989-99 

survey data matched to death certificates, found that 7 percent of deaths in 

Hispanics were erroneously identified as non-Hispanic (Rosenberg, 1999). The 

same report however indicated that the Hispanic death rate was underestimated 

by only 2 percent, because of undercoverage of Hispanics in the decennial 

census and population estimates.

Figure 3 presents 2002-2004 cancer death rates for the combined border 

counties of each state. Arizona and California had the highest cancer death 

rates for men (211 and 210, respectively), while New Mexico and Texas had 

significantly lower male death rates (191 and 171 respectively). The same pattern 

held for both sexes combined. For women, the Texas border counties had the 

Figure 2b: Age-adjusted cancer death rates* by ethnicity, females, USA, border 

states, and 44 border counties, 2004

Source: National mortality files, NCHS/CDC

* Age-adjusted to the U.S. 2000 standard population
 Chapter 6 - Breast and Cervical Cancer

209 

lowest rate (116) while the border areas of the other three states had significantly 

higher female cancer death rates. The highest female death rate due to cancer 

was in the California border counties (152).

The three leading sites for cancer deaths are the same nationally as for the 

44 border counties. For men, the three leading sites are lung and bronchus, 

prostate, and colon and rectum. For women, the most important sites are lung 

and bronchus, breast, and colon and rectum. For both the United States and 

the 44 border counties, death rates for all three sites were substantially higher 

for non-Hispanic whites than for Hispanics in 2002-04, as shown in Table 4. 

For lung and bronchus cancer, non-Hispanic white rates were two times higher 

for men and three times higher for women. In the border counties, the nonHispanic white rates for lung and bronchus cancer were 1.7 times higher for 

men and 3.1 times higher for women. Death rates for the other cancer sites were 

also higher for non-Hispanic whites, although the differentials were smaller: The 

rate ratio for prostate cancer was 1.2 nationally and 1.1 for the border region 

(just shy of statistical significance). Rate ratios for breast cancer were similar: 1.6 

nationally and 1.5 for the border counties. Colon and rectum rate ratios were in 

the 1.2 to 1.6 range. For all ethnicities, death rates for all three leading sites were 

higher for the United States than for the border, but this was primarily because 

of the higher proportion of Hispanics in the border counties. Border Hispanics 

did have higher death rates than non-Hispanic whites for uterine, cervical, liver 

and stomach cancer (data not shown).

Figure 3: Age-adjusted cancer death rates*, all sites, border counties 2002-2004

Source: National mortality files, NCHS/CDC

* Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population.
Border Lives: Health Status in the United States-Mexico Border Region

210

Trends in cancer death rates

Age-adjusted cancer death rates have been declining for all sites combined in 

recent years and rates also have declined for many individual sites (Espy, 2007). 

At the national level, death rates declined significantly between 1995 and 

2004 for most of the ten leading sites, with the exception of liver (increasing), 

pancreatic (stable), and esophageal (increasing) cancer for men, and lung and 

bronchus (increasing), pancreatic (stable), ovarian (stable), and uterine (stable) 

cancer for women. For Hispanics, significant declines were recorded for most of 

the ten leading sites, except for liver (increasing), pancreas (stable), and kidney 

and renal pelvis (stable) for men. For Hispanic women, there were no significant 

increases in death rates for the top 10 cancer sites, although trends were stable 

for cancer of the colon and rectum, pancreas, ovary, and liver cancers. 

Table 4: Age-adjusted cancer death rates, by site, sex and ethnicity, 

USA and 44 border counties, 2002-2004

Source: National mortality files, NCHS/CDC.

* Rate ratio is statistically significant (p<.05).

Rates per 100,000 population, age-adjusted to the US-2000 standard population.

Male NHW/Hispanic

Rate CI Rate CI Rate CI rate ratios

Lung and bronchus 71.6 71.4, 71.9 34.6 33.8, 35.4 73.5 73.2, 73.8 2.1*

Prostate 26.6 26.4, 26.8 20.2 19.5, 20.9 24.7 24.5, 24.9 1.2*

Colon and rectum 22.7 22.5, 22.9 16.4 15.8, 17.0 22.5 22.3, 22.7 1.4*

Female NHW/Hispanic

Rate CI Rate CI Rate CI rate ratios

Lung and bronchus 41.2 41.0, 41.4 14.6 14.1, 15.0 44.4 44.2, 44.6 3.0*

Breast 25.1 25.0, 25.2 15.7 15.3, 16.2 25.1 24.9, 25.3 1.6*

Colon and rectum 16.1 16.0, 16.2 10.7 10.3, 11.1 15.9 15.7, 16.0 1.5*

Male NHW/Hispanic

Rate CI Rate CI Rate CI rate ratios

Lung and bronchus 52.0 50.4, 53.6 36.3 33.9, 38.7 60.2 58.1, 62.3 1.7*

Prostate 24.6 23.5, 25.7 22.2 19.7, 24.8 25.5 24.1, 26.8 1.1

Colon and rectum 18.4 17.5, 19.3 16.0 14.4, 17.6 19.5 18.3, 20.7 1.2*

Female NHW/Hispanic

Rate CI Rate CI Rate CI rate ratios

Lung and bronchus 30.3 29.3, 31.4 13.2 12.0, 14.4 41.0 39.4, 42.6 3.1*

Breast 23.0 22.1, 23.9 17.5 15.9, 19.0 26.4 25.1, 27.8 1.5*

Colon and rectum 13.1 12.4, 13.8 9.8 8.7, 10.8 14.6 13.6, 15.5 1.5*

United States

44 border counties

All ethnicities Hispanic Non-Hispanic White

All ethnicities Hispanic Non-Hispanic White

All ethnicities Hispanic Non-Hispanic White

All ethnicities Hispanic Non-Hispanic White
 Chapter 6 - Breast and Cervical Cancer

211 

These reductions are the result of changes in risk factor levels, improvements 

in early detection and treatment, and reductions in inequalities in cancer care, 

among others (Howe, 2006). At the national level, much of the decline in lung 

cancer deaths results from the decline in tobacco use in recent decades. Timely 

detection and treatment largely account for the reductions in death rates due to 

colorectal, female breast, and prostate cancer.

Table 5 presents the annual percent change in cancer death rates for all sites, for 

the United States and the 44 border counties between 1999 and 2004. For the 

United States, significant downward trends in cancer death rates were reported 

for both sexes and all ethnicities combined. In the border counties, declines 

were reported for all groups. However some of the downward trends were not 

statistically significant because of small numbers.

Breast cancer mortality

Breast cancer is second only to lung cancer as the leading cause of cancer-related 

deaths among women in the United States, while in the border region breast 

cancer is the leading cause of cancer deaths. Breast cancer death rates in the 

United States have fallen substantially in the past decade, declining at an annual 

rate of 2.3 percent from 1995 to 2004, despite a small increase in the incidence 

of breast cancer (Espy, 2007). In 2004, 41,000 U.S. women died from breast 

cancer nationally, while there were 7,600 female breast cancer deaths in the 

border states and nearly 800 in the combined border counties.

1999 2004 APC 1999 2004 APC

Both sexes 200.8 185.8 -1.5* Both sexes 173.7 159.2 -1.7*

Male 251.9 227.7 -2.0* Male 213.1 194.1 -1.9*

Female 167.6 157.4 -1.2* Female 144.8 133.7 -1.6*

Both sexes 134.8 121.9 -2.0* Both sexes 142.8 127.1 -2.3*

Male 170.7 151.2 -2.4* Male 181.2 162.3 -2.2

Female 110.9 101.4 -1.8* Female 115.8 102.9 -2.3*

Both sexes 201.3 188.6 -1.3* Both sexes 188.4 178.4 -1.1*

Male 250.4 229.4 -1.7* Male 227.1 212.2 -1.3

Female 169.4 160.9 -1.0* Female 159.4 152.8 -0.8

Hispanic

NHW

Hispanic

NHW

44 border counties

All ethnicities

USA

All ethnicities

Table 5: Annual percent change in age-adjusted cancer death rates, all sites, by 

sex and ethnicity, USA and 44 border counties, 1999 and 2004

Source: National mortality files, NCHS/CDC

* Trend is statistically significant (p<.05) 

Rates are per 100,000, age-adjusted to the U.S. 2000 standard population.
Border Lives: Health Status in the United States-Mexico Border Region

212

Table 6 shows female breast cancer death rates in 2002-2004 for the United 

States, the 44 border counties, and the combined border counties of each state. 

Both nationally and in the combined border counties of each state, breast cancer 

death rates were significantly lower for Hispanic women as compared to nonHispanic white women. Nationally, the non-Hispanic white death rate was 

50 percent higher than the Hispanic rate, while in the 44 border counties the 

non-Hispanic white death rate was 60 percent above the Hispanic rate. For all 

ethnicities combined, the border counties of Arizona and Texas had significantly 

lower death rates than the United States (21.8 and 19.3 versus 25.1). However, 

when compared separately the death rates for non-Hispanic white and Hispanic 

women in the border regions of all four states were higher than the U.S. rates 

(with the sole exception of Arizona non-Hispanic white women), although none 

of these differences reached statistical significance.

Cervical Cancer Mortality

Cervical cancer was the fourteenth leading cause of cancer-related deaths in the 

United States in 2004, but was the tenth leading cause among U.S. Hispanics. 

More than 3,800 women died of cervical cancer in 2004 in the United States. 

The U.S. cervical cancer death rate has declined substantially in recent years, 

falling at an annual rate of 3.5 percent between 1995 and 2004.

Table 7 provides cervical cancer death rates for the United States and the border 

region in 2002-2004. The cervical cancer death rate was significantly higher 

for Hispanic women than for non-Hispanic white women, at the national level 

and in the border region. The excess varied from 50 percent higher nationally 

to nearly three times as high in the Arizona border counties. For all ethnicities 

combined, the death rate in the 44 border counties was significantly higher than 

the national rate (2.9 and 2.5, respectively). Within the border region, the Texas 

border counties had the highest death rate (4.1) for all ethnicities combined. 

NHW/Hispanic

Rate C.I.* Rate C.I.* Rate C.I.* Rate ratios

USA 25.1 25.0, 25.2 25.1 24.9, 25.3 15.7 15.3, 16.2 1.6

Border counties 23.0 22.1, 23.9 26.4 24.2, 28.7 17.5 15.9, 19.0 1.5

Arizona border 21.8 19.8, 23.8 22.9 19.8, 26.0 17.1 12.8, 21.4 1.3

California border 25.7 24.2, 27.1 27.8 25.0, 30.6 18.2 14.9, 21.4 1.5

New Mexico border 25.8 21.4, 30.2 31.3 23.1, 39.5 16.5 10.3, 22.6 1.9

Texas border 19.3 17.8, 20.9 27.4 22.6, 32.2 17.2 15.2, 19.2 1.6

All Ethnicities Non-Hispanic W hite Hispanic

Table 6: Age-adjusted death rates for female breast cancer, USA and border 

counties, 2002-2004

Source: National mortality files, NCHS/CDC.

* 95% confidence interval

Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population.
 Chapter 6 - Breast and Cervical Cancer

213 

Comparing rates separately for non-Hispanic white and Hispanic women shows 

that death rates in the Texas border counties were much higher than rates in the 

border areas of the other three states and significantly higher than national rates.

Risk Factor Prevalence and Screening

Advances in the biological sciences and epidemiology have led to the 

identification of many important causes of cancer. These findings have led 

to important gains in cancer prevention, achieved in part by reducing the 

prevalence of risk factors. Screening tests for cancer or precancerous lesions 

have also increased with the development of new and improved screening 

methodologies. The identification of cancers in their earliest stages, combined 

with more effective treatments, has reduced age-adjusted cancer death rates for 

many types of cancer.

One factor that is clear from data on cancer incidence and deaths is the 

increasing risk of cancer with age, particularly beyond age 35 years. Figure 4

displays the rising level of male and female cancer death rates with age in the 

border counties in 2004. This age pattern has important implications given the 

rapid aging of the border population (see Chapter 1, “The U.S. Population at 

the Border”). Unless advances in cancer prevention and treatment continue to 

drive down incidence and death rates, the number of cancer cases and deaths will 

increase rapidly as the population ages. A growing number of cancer cases will 

further burden health care providers and health facilities in the border region.

Scientific research on the causes and risk factors for cancer has yielded increasing 

returns in recent years. Much of this information has been summarized on the 

website of the National Cancer Institute (2008). The carcinogenic effect of 

tobacco has been well established, particularly for lung, laryngeal, pancreatic, 

Rate C.I.* Rate C.I.* Rate C.I.*

USA 2.5 2.4, 2.5 2.1 2.1, 2.2 3.1 2.9, 3.3

Border counties 2.9 2.6, 3.3 1.5 1.1, 2.0 3.9 3.2, 4.5

Arizona border 1.7 1.1, 2.2 1.0 0.7, 1.2 2.8 2.1, 3.5

California border 1.9 1.5, 2.3 1.5 0.9, 2.1 2.4 1.3, 3.5

New Mexico border 3.4 2.3, 4.5 1.7 1.0, 2.4 4.6 1.9, 7.3

Texas border 4.1 3.4, 4.8 3.1 2.5, 3.7 4.5 3.6, 5.5

All Ethnicities Non-Hispanic White Hispanic

Table 7: Age-adjusted death rates for cervical cancer, USA and border counties, 

2002-2004

Source: National mortality files, NCHS/CDC

* 95% confidence interval

Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population.
Border Lives: Health Status in the United States-Mexico Border Region

214

bladder, kidney, mouth, and esophageal cancers. Tobacco also has been 

identified as a cofactor in cervical, stomach and liver cancers. Dietary fats have 

been linked to colon cancer and possibly to breast cancer in postmenopausal 

women. Overweight contributes to cancer risk, including postmenopausal 

breast cancer, endometrial cancer, and others. Genetic factors play a role in 

many cancers, including BRCA1 and BRCA2 genes for hereditary breast cancer. 

Human papillomavirus (HPV) has been detected in virtually all cervical cancers 

worldwide, and along with various cofactors including smoking and others, leads 

to the development of cervical cancer. Reproductive factors that affect female 

hormone levels, along with hormone therapies, have been linked to a number of 

cancers including breast, uterine, and ovarian cancer. Viruses and retroviruses play 

an important role in the development of several cancers. As noted earlier, H pylori 

is a major factor in the development of stomach cancer, along with a diet that is 

high in preserved foods that are pickled, smoked or heavily salted. Hepatitis B and 

C viruses have been linked to the development of liver cancers. Heavy alcohol use 

is a factor in the development of liver, breast and laryngeal cancers.

Table 8 provides data on risk factor prevalence and screening rates for the 

United States, the four border states, and the border counties. Data are 

presented by ethnicity where available. Information for the border counties is 

only available for the 32 Texas counties on or near the Texas-Mexico border. 

For most risk factors, state prevalence rates were similar to U.S. rates, although 

Hispanic rates were generally higher than the all-ethnicity rates. Risk factor 

0

500

1000

1500

2000

2500

0 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age

Rate per 100,000

Male Female

Figure 4: Age-specific death rates due to cancer, border counties, 2004

Source: National mortality files, NCHS/CDC
 Chapter 6 - Breast and Cervical Cancer

215 

prevalences in the Texas border region were even less favorable, with the 

exception of the smoking rate. California had the lowest percentage of current 

smokers (15.2), lower than the United States (20.4) and the other three border 

states. In all areas, smoking rates for both sexes combined were similar

for Hispanics and non-Hispanic whites, but sex-specific rates differed 

substantially. Smoking rates for Hispanic men were similar to or higher than 

smoking levels for non-Hispanic white men, while smoking rates for Hispanic 

women were half or less the rate for non-Hispanic white women (data not 

shown). The high levels of obesity and physical inactivity were troubling for all 

areas and for Hispanics in particular. Health insurance coverage was significantly 

lower in all four border states than nationally, with the lowest rate in Texas 

(28.5 percent without coverage) almost twice the national rate of 14.5 percent. 

Among Hispanics, 48.5 percent lacked health insurance in Arizona, and 55.8 

Table 8: Cancer risk factors, access to care, and use of cancer screening, USA, 

border states, and Texas border counties, 2005

Source: BRFSS/CDC

a

 Not available

b

 2004

Ethnicity USA Arizona California New Mexico Texas TX border

Risk factors

All 20.4 20.4 15.2 21.6 20.1 18.1

Hispanic 17.5 21.2 15.0 23.6 16.2 18.6

All 27.9 21.4 22.6 21.8 27.1 30.9

Hispanic 26.7 23.0 27.1 26.5 31.9 34.9

All 25.5 22.6 26.0 22.9 27.4 29.1

Hispanic naa na 26.7 na 35.6 31.5

All 14.3 14.5 14.0 10.6 14.3 15.9

Hispanic 16.9 16.9 16.7 13.9 17.4 16.6

All 5.2 6.3 6.2 4.1 5.3 5.5

Hispanic 5.2 5.0 6.4 4.0 6.0 6.3

All 77.4 77.1 73.1 77.6 78.6 78.7

Hispanic 77.9 79.3 73.5 82.5 79.5 80.0

Access to health care

All 14.5 20.9 17.2 21.9 28.5 47.5

Hispanic 36.1 48.5 31.9 32.8 55.8 61.3

Cancer screening

All 74.9 75.5 76.5 69.1 67.8 62.2

Hispanic na na na na 60.4 58.4

All 53.5 52.1 53.9 50.7 48.4 40.7

Hispanic na na na na 40.6 30.1

All 26.5 31.2 23.3 25.9 23.4 20.3

Hispanic na na na na 14.9 10.3

All 86.0 85.2 84.8 84.7 82.2 78.6

Hispanic na na na na 79.2 76.8

All 51.8 54.3 51.6 49.1 49.4 40.3

Hispanic na na na na 28.7 29.2

Percent with colorectal 

cancer screening, age 50+b

Percent with fecal occult 

blood test in past 2 yearsb

Percent with pap smear in 

past 3 years, age 18+b

Percent with PSA test in last 

year, age 50+b

Percent current smokers, age 

18+ 

Percent obese, age 18+

Percent with no leisure-time 

physical activity, age 18+

Percent binge drinking (5+ 

drinks), age 18+

Percent heavy drinking (2+/ 

day men, 1+/day women)

Percent with less than 5 fruits 

and vegetables per day

Percent with no health 

insurance coverage, age 18+

Percent with mammography 

in past 2 years, age 40+b
Border Lives: Health Status in the United States-Mexico Border Region

216

percent in Texas. The poorest level of health insurance coverage by far was for 

Hispanics in the border region of Texas (61.3 percent without health insurance). 

Cancer screening rates in the border states were similar to the national levels, 

although the rates for Hispanics in Texas and in the Texas border counties were 

lower. Separate data from the California Health Interview Survey also found 

significantly lower cancer screening rates for Hispanics than for non-Hispanic 

whites (data not shown) (California Department of Public Health, 2008).

Differences in screening rates between Hispanics and non-Hispanic whites 

may account for some of the differences in reported cancer incidence rates. As 

noted earlier, changes in screening rates can affect trends in cancer incidence. 

An increase in the use of cancer screening in a population can lead to a rise in 

cancer incidence because of earlier detection of tumors (White, 1990; Garfinkle, 

1994). A large part of the increase in breast cancer incidence in the 1980s 

has been attributed to the increased use of mammography for breast cancer 

screening (Jemal, 2007). Lower cancer screening rates in Hispanics, as compared 

to other populations, may account for some of the lower cancer incidence rates 

reported for Hispanics.

Summary and Recommendations

In both the United States and the border region, progress has been made in the 

fight against cancer. Gains in cancer prevention and treatment have reduced 

cancer incidence and mortality. Yet the burden of cancer remains. Cancer is still 

the second leading cause of death in the nation and on the border.

For most of the leading cancers, incidence rates and mortality are substantially 

lower for Hispanics than for non-Hispanic whites. Some of this difference 

can be linked to lower levels of risk factors, such as lower smoking rates in 

Hispanics, while some of the difference may be due to underreporting of 

Hispanic cancers. However, much of this difference remains to be explained, 

particularly given the low socioeconomic status and poor access to health care of 

the nation’s Hispanic population. This apparent contradiction has been termed 

the “Hispanic paradox” (Scribner, 1996)1

.

Cancer mortality in the border counties is lower than the national level, owing 

to low cancer death rates in border Hispanics and below-average cancer death 

rates for border non-Hispanic whites. Cancer mortality remains significantly 

higher for non-Hispanic whites than for Hispanics in the four border states 

and border counties. Overall, the highest cancer death rate was in the state of 

Texas and the lowest in New Mexico, but rankings differed for comparisons by 

1 See also Chapter 4: “Maternal, Infant, and Child Health” and Chapter 8: “Heart Disease and 

Stroke” for further discussion of the Hispanic paradox.
 Chapter 6 - Breast and Cervical Cancer

217 

ethnicity, gender and site. Within the 44-county border region, breast cancer 

mortality rates for the counties of Arizona (21.8) and Texas (19.3) were below 

the national average of 25.1 in 2002-04, with non-Hispanic whites having 

higher rates than Hispanics. Texas border counties (4.1) exceeded the national 

average death rate of 2.5) for cervical cancer, with rates above the national level 

for both Hispanic (4.5) and non-Hispanic white (3.1) women. The cervical 

cancer death rate for Hispanics was more than twice the non-Hispanic white 

rate (3.9 versus 1.5) in the combined border counties. The differential was nearly 

three to one in the Arizona border counties (1.0 versus 2.8).

Ethnic and socioeconomic disparities in access to care preclude many U.S. 

residents, especially those living in the border region, from obtaining preventive 

and adequate healthcare. In all four border states, health insurance coverage 

is significantly lower for the Hispanic population. Despite the availability of 

screening tests, screening rates are lower for Hispanics than for non-Hispanic 

whites in the two states with available data: Texas and California.

Progress toward the Healthy Border 2010 objectives of reducing breast and 

cervical cancer mortality in the border region should focus on improving 

early cancer detection through mammography, Pap, and colorectal cancer 

screening tests, creating public health education campaigns targeting the 

border population, and a research agenda that includes participation of ethnic 

minority groups. Given the higher levels of stomach, liver, and cervical cancer 

in Hispanics, more border resources should be devoted to immunization efforts 

against HPV and hepatitis-B, as well as treatment for H pylori infections. The 

following recommendations focus on areas of further research, public health 

interventions, and policy development.

•	 Further research. Further research is needed regarding incidence, causes, and 

treatment of cancers. Communication, collaboration, and training among 

cancer researchers need to be increased. An adequate infrastructure must 

be developed to increase funding for cancer research. Cancer researchers 

from under-represented racial and ethnic groups must be actively recruited, 

trained, and retained. Improvements are needed in the accessibility and 

analysis of cancer research data. Participation of minority and underserved 

populations in clinical trials must be included and encouraged.

•	 Public health interventions. Public health interventions should focus on 

building partnerships with public and private sectors at the state and 

community levels to develop prevention and early detection programs. State 

and community coalitions need to be built to deliver preventive health 

services to medically underserved women. Preventive programs should focus 

primarily on public health education and interventions to reduce risk factors 

like tobacco smoking, obesity, alcohol use, and to encourage increased 

physical activity and better nutrition.
Border Lives: Health Status in the United States-Mexico Border Region

218

•	 Policy. Policy makers, stakeholders, public health agencies, and healthcare 

providers should work to close the gap in health disparities, reduce illness, 

and improve early detection rates targeting the U.S.-Mexico border 

population — specifically minority and underinsured populations. Healthcare coverage should be made universal and comprehensive, continuous, 

and affordable to individuals and their families. Access to high-quality care 

should be ensured. Moreover, policies, interventions, and health education 

initiatives should be considered and implemented in a transnational 

context given the proximity and the cross-border nature of the U.S.-Mexico 

population and region.

References

American Cancer Society. (2008). Cancer facts and figures for Hispanics/

Latinos, 2006-2008. American Cancer Society, Atlanta, GA.

American Cancer Society. (2008). Cancer facts and figures 2008. Atlanta; 

American Cancer Society.

Brown, L.M. (2000). Helicobacter pylori: epidemiology and routes of 

transmission. Epidemiology Reviews, 22, 283-297.

California Department of Public Health. California health interview survey. 

Retrieved July 7, 2008, from http://ww2.cdph.ca.gov/data/surveys/

Pages/CHIS.aspx

Chan, P.G., Sung, H.Y., Swawya, G.F. (2003). Changes in cervical cancer 

incidence after three decades of screening U.S. women less than 30 

years old. Obstetrics and Gynecology, 102, 765-773.

Donato, F., Boffetta, P., Puoti, M. (1998). A meta-analysis of epidemiological 

studies on the combined effect of hepatitis B and C virus infections in 

causing hepatocellular carcinoma. International Journal of Cancer, 75, 

347-354.

Espy, D.K., Wu, X.C., Swan, J., Wiggins, C., Jim, M.A., et al. (2007). Annual 

report to the nation on the status of cancer, 1975-2004, featuring 

cancer in American Indians and Alaska Natives. Cancer, 110, 2119-

2130.

Franco, E.L., Schlecht, N.F., Saslow, D. (2003). The epidemiology of cervical 

cancer. Cancer Journal, 9, 348-359.
 Chapter 6 - Breast and Cervical Cancer

219 

Frisell, J., Eklund, G., Hellstron, L., Lidbrink, E., Rutqvist, L.-E., et al. (1991). 

Randomized study of mammography screening - preliminary report on 

mortality in the Stockholm trial. Breast Cancer Research and Treatment, 

18, 49-56.

Garfinkle L., Boring, C.C., Heath, C.W. (1994). Changing trends: An overview 

of breast cancer incidence and mortality. Cancer, 74(Suppl 1), 222-227.

Giuliano, A.R., Papenfuss, M., Abrahamsen. M., et al. (2001). Human 

papillomavirus infection at the United States-Mexico border: 

implications for cervical cancer prevention and control. Cancer 

Epidemiology, Biomarkers & Prevention; 10, 1129-1136.

Gorin, S.S., Heck, J.E. (2005). Cancer screening among Latino subgroups in 

the United States. Preventive Medicine, 40, 515-526.

Howe, H.L., Wu, X., Ries, L.A., Cokkinides, V., Ahmed, F., et al. (2006). 

Annual report to the Nation on the status of cancer, 1975-2003, 

featuring cancer among U.S. Hispanic/Latino populations. Cancer, 

107(8), 1711-1740.

Jemal, A., Clegg, L.X., Ward, E., Ries, L.A., Wu, X., et al. (2004a). Annual 

report to the nation on the status of cancer, 1975-2001, with a special 

feature regarding survival. Cancer, 101, 3-27.

Jemal, A., Tiwari, R.C., Murray, T., Ghafoor, A., Samuels, A., et al. (2004b). 

Cancer Statistics, 2004. CA: A Cancer Journal for Clinicians, 54(1), 

8-29.

Kim, H.J., Fay, M.P., Feuer, E.J., Midthune, D.N. (2000). Permutation tests 

for joinpoint regression with application to cancer rates. Statistics in 

Medicine, 19, 335-351.

Jemal, A., Ward, E., Thun, M.J. (2007). Recent trends in breast cancer 

incidence rates by age and tumor characteristics among U.S. women. 

Breast Cancer Research, 9, R28.

Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., et al. (2008). Cancer statistics, 

2008. CA A Cancer Journal for Clinicians, 58, 71-96.

Miniño, A.M., Heron, M.P., Murphy, S.L., Kochanek, K.D. (2007). Deaths: 

Final data for 2004. National vital statistics reports, 55(19). National 

Center for Health Statistics. 
Border Lives: Health Status in the United States-Mexico Border Region

220

McQuillan, G.M., Kruszon-Moran, D., Kottiri, B., Curtin, L.R., Lucas, 

J.W., Kington, R.S. (2004). Racial and ethnic differences in the 

seroprevalence of 6 infectious diseases in the United States: Data from 

NHANES III, 1988-1994. American Journal of Public Health, 94, 1952-

1958.

National Cancer Institute. (2008). Cancer Risk Factors. Retrieved July 9, 2008, 

from http://rex.nci,nih.gov/NCI_Interface/raterisk/risks73.html

Peto, J. (2001). Cancer epidemiology in the last century and the next decade. 

Nature, 411, 390-395.

Ramirez, A.G., Gallion, K.J., Suarez, L., Giachello, A.L, Marti, J.R., et al. 

(2005). A national agenda for Latino cancer prevention and control. 

Cancer, 103, 2209-2215.

Ravdin, P.M., Cronin, K.A., Howlader, N., Berg, C.D., Chlebowski, R.D., et al. 

(2007). The decrease in breast-cancer incidence in 2003 in the United 

States. New England Journal of Medicine, 356, 1670-1674.

Ries, L.A., Melbert, D., Krapcho, M., Stinchcomb, D.G., Howlader, N., et al. 

(eds). (2008). SEER Cancer Statistics Review, 1975-2005, National 

Cancer Institute. Bethesda, MD. Retrieved June 27, 2008 from http://

seer.cancer.gov/csr/1975_2005/ Based on November 2007 SEER data 

submission, posted to the SEER web site, 2008.

Rosenberg, H., Maurer, J., Sorlie, P., Johnson, N. (1999). Quality of death rates 

by race and Hispanic origin: A summary of current research. National 

Center for Health Statistics. Vital and Health Statistics, 2, (128).

Schiffman, M.H., Bauer, H.M., Hoover, R.N., et al. (1993). Epidemiologic 

evidence showing that human papillomavirus infection causes most 

cervical intraepithelial neoplasia. Journal of the National Cancer Institute

8, :958-964.

Scribner, R. (1996). Paradox as paradigm – The health outcomes of MexicanAmericans. American Journal of Public Health, 86, 303-305.

Selvin, E., Brett, K.M. (2003). Breast and cervical cancer screening: 

Sociodemographic predictors among White, Black, and Hispanic 

women. American Journal of Public Health, 93, 618-623.
 Chapter 6 - Breast and Cervical Cancer

221 

Stewart, S.L., King, J.B., Thompson, T.D., et al. (2004). Cancer mortality 

surveillance–United States, 1990-2000. Morbidity & Mortality Weekly 

Report. Surveillance Summaries; 53, 1-108.

Thompson, B., Coronado, G.D., Solomon, C.C., McClerran, D.F., Neuhouser, 

M.L., Feng, Z. (2002). Cancer Causes and Control, 13, 719-728.

U.S. Cancer Statistics Working Group. (2007). United States Cancer Statistics: 

1999–2004 Incidence and Mortality Web-based Report. Atlanta: U.S. 

Department of Health and Human Services, Centers for Disease Control 

and Prevention and National Cancer Institute. Retrieved June 24, 2008, 

from www.cdc.gov/uscs.

Walboomers, J.M., Jacobs, M.V., Manos, M.M., Bosch, F.X., Kummer, J.A., 

et al. (1999). Human papillomavirus is a necessary cause of invasive 

cervical cancer worldwide. Journal of Pathology, 189, 12-19.

Watlington, A.T., Byers, B., Mouchawar, J., Sauaia, A., Ellis, J. (2007). Does 

having insurance affect differences in clinical presentation between 

Hispanic and non-Hispanic white women with breast cancer? Cancer, 

109, 2093-2099.

White, E., Lee, C.Y., Kristal, A.R. (1990). Evaluation of the increase in breast 

cancer incidence in relation to mammography use. Journal of the 

National Cancer Institute, 82, 1546-1552.

Zembrana, R.E., Breen, N., Fox, S.A., Gutierrez-Mohamed, M.L. (1999). 

Use of cancer screening practices by Hispanic women: Analyses by 

subgroup. Preventive Medicine, 29(6), 466-477.

223 

Diabetes is a major public health problem and an important cause of 

morbidity in both the United States and the U.S.-Mexico border 

region. In 2005, approximately 20.8 million persons were afflicted 

with diabetes, about 7.0 percent of the total U.S. population. In 2004, diabetes 

was the sixth leading cause of death in the United States (Heron, 2007, Miniño, 

Heron, Murphy, & Kochankek, 2007). For Hispanics, diabetes was the fifth, 

and for non-Hispanic whites the seventh, leading cause of death in the United 

States (Heron, 2007).

The prevalence of diabetes increases with age, and the disease disproportionately 

affects certain racial and ethnic minority populations. Diabetes affects Hispanics 

1.5 times more than non-Hispanic whites. The growth of the U.S. population, 

which includes increases in elderly, racial, and ethnically diverse populations, 

predicts a substantial rise in the number of persons with diabetes.

Diabetes contributes significantly to the cost of health care in the United States. 

The direct and indirect costs associated with diabetes in 2002 reached $132 

billion per year (Hogan, Dall, & Nikolov, 2003).

Diabetes is a major focus area of the Healthy Border 2010 program. Two 

Healthy Border objectives address diabetes: (a) reduce diabetes mortality by 10 

percent and (b) maintain diabetes hospitalization rates at their 2000 level (U.S.-

Mexico Border Health Commission, 2003). This chapter provides an overview 

of the current mortality and hospitalization rates along the U.S. side of the U.S.-

Mexico border area1

. Mortality and hospitalization discharge rates are presented 

by area, race, and age.

1 The United States-Mexico border region is defined as the area of land being 100 kilometers (62.5 

miles) north and south of the international boundary (La Paz Agreement). It stretches approximately 2000 

miles from the southern tip of Texas to California.

CHAPTER 7

DIABETES
Border Lives: Health Status in the United States-Mexico Border Region

224

Understanding Diabetes

Diabetes mellitus results from a defect in insulin production, action — or 

both — associated with high levels of blood glucose. There are three major 

types of diabetes mellitus: type 1, type 2, and gestational diabetes. Type 1 

diabetes develops when the body’s immune system destroys the pancreatic beta 

cells that make insulin. Previously called insulin-dependent diabetes mellitus, 

or juvenile-onset diabetes, type 1 diabetes usually affects children and young 

adults and accounts for 5 to 10 percent of all diagnosed cases of diabetes in the 

United States. Type 2 diabetes, previously called non-insulin-dependent diabetes 

mellitus or adult-onset diabetes, usually begins as insulin resistance in which 

cells do not use insulin properly. The majority of all diagnosed diabetes cases 

(90 to 95 percent) are classified as type 2 diabetes. Gestational diabetes is a form 

of glucose intolerance diagnosed in some women during pregnancy. During 

pregnancy, gestational diabetes requires treatment to normalize maternal blood 

glucose levels to avoid complications in the infant. This phenomenon occurs 

in approximately four percent of pregnancies in women in the United States 

and usually disappears after the woman gives birth. However, 5 to 10 percent 

of women with gestational diabetes will subsequently develop type 2 diabetes 

(Report of the Expert Committee, 1997).

Diabetes Risk Factors: Age, Weight, and Genetics

Many of the risk factors for diabetes are the same as those for chronic conditions 

such as cardiovascular disease. In addition, diabetes has been found to be 

an independent risk factor for coronary heart disease because of its intricate 

relationship with lipoproteins and atherosclerosis. The vast majority of 

individuals with diabetes die from some type of cardiovascular disease, due to 

the fact that diabetes affects cholesterol levels (National Heart, Lung, and Blood 

Institute [NHLBI], 1996). One study found that diabetes doubled the risk of 

coronary heart disease and that this risk doubled when hypertension was present 

(NHLBI, 1994a). The following paragraphs briefly describe the effects of three 

main risk factors associated with diabetes: age, weight, and genetics.

Age

The likelihood of developing diabetes increases with age. In a study using data 

from the Behavioral Risk Factor Surveillance System (BRFSS), Mokdad et al. 

(2001) found that the national diabetes prevalence for subjects aged 18 to 29 

years was 2.1 percent, whereas for those aged 70 years or older the prevalence 

was 15.5 percent. For all ages combined, women were reported to have higher 

diabetes prevalence than men, with 8.9 and 6.8 percent, respectively. Diagnoses 

of type 2 diabetes are increasing in children and adolescents, principally among 
 Chapter 7 - Diabetes

225 

high-risk ethnic minority groups, which include American Indians, blacks, 

Hispanics, and Pacific Islanders (American Diabetes Association [ADA], 2000; 

Hogan, et al, 2003; National Diabetes Information Clearinghouse [NDIC], 

2005). In 2003, about 206,000 people under the age of 20 years had diabetes, 

representing 0.25 percent of all people in this age group (Centers for Disease 

Control [CDC], 2004a; HHS, 2000). The prevalence of diabetes in American 

Indian children was estimated to be 4.5 per 1000 (Fagot-Campagna, Burrows, 

& Williamson, 1999). To date, the cause of the increase in diabetes in children 

and adolescents has not been firmly elucidated. However, this increase follows 

closely the obesity epidemic currently present across the United States.

Weight

Overweight2

 and obesity3 have been found to be independent risk factors for 

diabetes. A strong association has been found between obesity and risk for 

development of diabetes (Hu et al., 2001), especially for fat that is stored in the 

upper body (Hu et al., 2001; Wei et al., 1997).

The prevalence of both obesity and diabetes in the United States increased 

substantially from 1990 to 2000 (Mokdad et al., 2001). A study using BRFSS 

(Mokdad et al., 2001) found that the prevalence of obesity was 19.8 percent in 

2000 and 20.9 percent in 2001. Furthermore, adults with a BMI ≥ 40 were at 

higher risk (odds ratio of 7.37, 95 percent confidence interval: 6.39 to 8.50) 

for developing diabetes than adults with normal weight. Men had a higher 

prevalence of obesity than women (21.0 and 20.8 percent respectively). Blacks 

had the highest obesity prevalence at 31.1 percent, compared with Hispanics 

(23.7 percent) and non-Hispanic whites (19.6 percent). Obesity increased with 

age, with the highest prevalence found in subjects in the 50 to 59 year age range. 

Obesity prevalence decreased with education: Those with less-than-high-school 

education had a prevalence of 27.4 percent and those with more-than-college 

education had a prevalence of 15.7 percent. Among the U.S. border states, 

Texas had the highest prevalence of obesity at 23.8 percent, and Arizona had 

the lowest at 17.9 percent. California had a prevalence of 20.9 percent and New 

Mexico 18.8 percent.

Research has shown that changes in lifestyle can prevent or delay excessive 

weight gain and consequently the onset of type 2 diabetes (Will, Williamson, 

Ford, Calle, & Thun, 2002). Therefore, physical exercise and weight loss are 

essential elements to the diabetes control regimen.

2 Body mass index (BMI) 25-29.9.

3 Body mass index (BMI) > 30.
Border Lives: Health Status in the United States-Mexico Border Region

226

Genetics

Diabetes is influenced by heredity as well as by modifiable risk factors such as 

weight gain and dietary habits (NHLBI, 1996). Diabetes onset is caused by 

different factors, yet two factors are primarily important: a predisposition to the 

disease and an environmental trigger. 

One such example of a genetic predisposition is found among the Pima 

Indians. The Pima Indians are a unique group of people that have been studied 

extensively in regards to their recent increase in diabetes morbidity. The Pima 

Indians in Arizona have one of the highest prevalence rates of type 2 diabetes in 

the world. In 2003 (CDC, 2004a, 2005b), about 27 percent of Pima Indians 

were reported to have diabetes. It is estimated that more than half of adults over 

the age of 35 years are afflicted with diabetes (Pratley, 1998). The increased 

prevalence of diabetes among this ethnic group is a recent phenomenon, which 

has been largely attributed to the “thrifty gene” theory. This theory suggests that 

a change from an agricultural to a modern American lifestyle, characterized by 

physical inactivity and western diet, has contributed to increased rates of obesity

and diabetes (Pratley, 1998).

Type 2 diabetes, long considered a disease of older age, was first reported in 

adolescents among Pima Indians in 1979 (ADA, 2000). By 1996, the estimated 

diabetes prevalence in Pima Indians ages 15 to 19 years was 50.9 per 1000, 

and 22.3 per 1000 for those ages 10 to 14 years (Fagto-Campagna et al., 1999, 

Thackeray, Merrill, & Neiger, 2004).

Overall, diabetes prevalence rates are higher for American Indians compared 

to non-Hispanic whites. The prevalence of diagnosed diabetes is generally 

two to four times higher in American Indians compared to non-Hispanic 

whites (Thackeray, et al., 2004). It is worth noting that the Mexican-American 

population, the largest Hispanic group on the border, shares in the American 

Indian gene pool, along with a mixture of European and African roots, 

rendering this population susceptible to the effect of the “thrifty gene” as well 

(Idrogo & Mazze, 2004). It is possible that the relation to American Indians 

may in part explain our findings of higher prevalence of diabetes in the Hispanic 

population.

Studies comparing the prevalence of diabetes among individuals with similar 

genetic predisposition and different lifestyles indicate that modifications in 

behavioral risk factors such as diet and exercise may be capable of overriding a 

genetic predisposition to diabetes (U.S. Public Health Service, 1993). However, 

these results were not conclusive and further research is needed. Nonetheless, 

studies have found that individuals with diabetes who actively modify other 

health risks via weight control, physical activities, and by maintaining a 
 Chapter 7 - Diabetes

227 

consistent dietary intake low in sodium and sugar reduce their chances of 

diabetes complications (Zonseing, 1993).

Complications of Diabetes

Studies have shown that people with diabetes are at higher risk than are those 

without diabetes for complications due to heart disease, blindness, kidney 

failure, amputation of the extremities, stroke, dental disease, and other chronic 

conditions (Gu, Cowie, & Harris, 1999; Ingram, Gallegos, & Elenes, 2005; 

Kuulasmaa et al., 2000; Nathan, 1993; & Okoro et al., 2004). Mortality from 

heart disease among industrialized countries has been declining over the last 

decades (Kuulasmaa et al., 2000). However, this rate is still higher for people 

with diabetes than for those without diabetes (Gu et al., 1999), making heart 

disease the most frequent comorbidity cause of mortality among people 

with diabetes (Gu et al., 1999, Stamler, Vaccaro, Neaton, & Wentworth, 

1993). Further risk factors contributing to this association include high total 

cholesterol, high blood pressure levels, smoking, and obesity. Although the 

prevalence of these conditions has been declining in the general population (Gu, 

et al., 1999) — with the exception of obesity (Burke, et al., 2003) — significant 

increases have been reported for diabetics in mean blood pressure and mean 

cholesterol levels (Okoro et al., 2004). One of two people with diabetes still has 

high cholesterol, one of three has high blood pressure, and one in six is a smoker 

(Imperatore et al., 2004). Yet these complications can be easily prevented or 

delayed with appropriate health-and preventive-care practices.

Methods

Analyses for this study used two main sources of information to delineate 

mortality and hospitalization discharge rates due to diabetes along the border. 

Rates were age adjusted4

 to provide a standardized comparison among the 

regions. The age-adjusted rates as well as their respective standard error (reported 

in parentheses) are provided in the text. Information on the applicability of 

the age-adjustment procedure utilized in this study is discussed in more detail 

elsewhere (Klein & Schoenborn, 2001). Z tests for two independent groups 

were used to compare statistical difference between the groups5.

Mortality data from the NCHS for the years 1998 to 2004 by ethnicity 

(Hispanic and non-Hispanic white) for the border area were used to identify 

4 Age adjustment to the 2000 U.S. standard population is the application of observed age-specific 

rates to a standard age distribution to eliminate differences in crude rates in population of interest that result 

from differences in the population’s age distributions.

5 The z-test is a statistical test used in inference which determines if the difference between two 

means is large enough to be statistically significant, that is, if it is unlikely to have occurred by chance.
Border Lives: Health Status in the United States-Mexico Border Region

228

diabetes as the underlying cause of death. Comparisons of mortality rates were 

made between the four border states – Arizona, California, New Mexico, and 

Texas – and between border counties in these states. Hospitalization discharge 

data were obtained from the available public use hospital discharge data file 

system of each border state. Diabetes hospitalization discharge rates were 

presented for the total border population as well as by Hispanic and nonHispanics.

Results

Prevalence of diabetes

Diabetes prevalence has increased in the United States in recent years. Data from 

the BRFSS6

 for 2000 show that the self-reported age-adjusted national diabetes 

prevalence was 4.5 percent. In a six-year period, the age-adjusted diabetes 

prevalence rose to 5.3 percent. Another more complete study shows that the 

standardized diabetes prevalence is even higher than the one reported by BRFSS. 

Results of the National Health & Nutrition Examination Survey (NHANES) 

show that the age-adjusted diabetes prevalence for 1999-2002 is 6.5 percent for 

the overall population. In addition, both non-Hispanic blacks (3.6 percent) and 

Mexican Americans (3.0 percent) report higher prevalence than non-Hispanic 

whites (2.7 percent). A clear trend in both studies shows that minority females 

have a greater proclivity to be identified as diabetic than males (Cowie et al., 

2006).

This increase in diabetes also has taken place in the states that comprise the 

U.S.-Mexico border region. In 2000-2005, the age-adjusted prevalence for 

each border state was found to be higher than the national incidence for 

each respective year (Figure 1). In 2005, New Mexico and Arizona reported 

the lowest diabetes prevalence among the border states with 6.7 percent and 

6.9 percent respectively. On the other hand, Texas and California reported 

higher prevalence rates than the national rate with 8.2 percent and 7.4 percent 

respectively. Texas reported higher diabetes prevalence among the border states 

from 2000 to 2005. In 2005, half of the 32 counties that comprise the Texas 

border region had estimated age-adjusted diabetes prevalence rates of 8.2 percent 

or higher. Among the Texas border counties, Kenedy and Kinney Counties 

reported the highest age-adjusted diabetes prevalence among all border counties7

with 11.3 percent and 10.1 percent respectively. In 2005, a BRFSS survey done 

by the Texas Health department showed that for the cluster of Texas border 

counties, the unadjusted self-reported diabetes prevalence was 8.5 percent8

.

Although diabetes prevalence data for the counties along the U.S.-Mexico 

6 http://apps.nccd.cdc.gov/BRFSS/

7 http://apps.nccd.cdc.gov/DDTSTRS/statePage.aspx?state=Texas

8 http://www.dshs.state.tx.us/chs/brfss/query/brfss_form.shtm
 Chapter 7 - Diabetes

229 

border are limited, data from the Diabetes Prevention and Control Project, a 

study coordinated by the Pan American Health Organization (PAHO) along the 

U.S.-Mexico Border, and the state and local health departments of each border

state, provides additional information. This survey was conducted from 2001 

to 2002. Taking the border area as one epidemiological unit, it showed that the 

self-reported prevalence of diabetes in the U.S. portion of the border area was 

16.1 percent and that 13.6 percent of the U.S. border population had been 

diagnosed with prediabetes9. An interesting finding from this study was that 2.6 

percent of the border population was unaware of having diabetes at the time of 

the survey. This finding is comparable to that by NHANES, which showed that, 

from 1999 to 2002, approximately 2.8 percent of the United States population 

with diabetes was unaware that they suffered from this condition. Moreover, 

this trend was more pronounced among non-Hispanic blacks (3.6 percent) and 

Mexican Americans (3.0 percent) than non-Hispanic whites (2.7 percent).

Self-reported diabetes prevalence and self-glucose monitoring

Self-glucose monitoring rates among diabetics also have increased. In 2000, 

approximately 48.4 percent of the United States population with diagnosed 

diabetes reported daily self-monitoring blood glucose practices (BRFSS). In 

2005, the prevalence of self-monitoring blood glucose increased to nearly two of 

every three or 61.0 percent of Americans with diabetes. BRFSS data from 2005 

showed that the U.S.-Mexico border states had higher age-adjusted prevalence 

for self-monitoring of blood glucose than the national estimate. The percent of 

adults with diabetes who self-monitored their glucose levels on a daily basis was 

9 Pre-diabetes is a condition that occurs when a person’s blood glucose levels are higher than normal 

but not high enough for a diagnosis of type 2 diabetes (< 125 mg/dl > 100 mg/dl).

Figure 1: Adult population (18 years and older) self-reported diabetes 

prevalence, BRFSS 2000-2005
Border Lives: Health Status in the United States-Mexico Border Region

230

67 percent for the state of New Mexico and 65 percent for Arizona, both rates 

higher than the national percentage. However, only 52 percent of individuals 

with diabetes in California, a state with a high diabetes prevalence, reported that 

they self-monitored their blood glucose.

Healthcare visits for diabetes

Another outcome reported from BRFSS data was a modest increase in the 

percent of individuals who visited a doctor in the last year due to their diabetes. 

In 2000, approximately 86.0 percent of Americans with diabetes had seen a 

health-care professional due to their disease. In 2005, the national percentage 

increased to 87.7 percent. At the border, this trend was replicated for the states 

with high diabetes prevalence such as New Mexico, which reported the highest 

percentage of doctor visits for all border states at 91.0 percent. However, from 

2000 to 2004, Texas and California reported lower percentages for visits to 

health-care providers for diabetes than the national average (Figure 2).

Hemoglobin A1c test

Hemoglobin A1c10testing is recommended to monitor blood sugar control and 

ultimately to judge whether a treatment plan provided by a health professional 

is adequately working (ADA, 2007)11. From 2000 to 2005, about two of 

10 The hemoglobin A1c test (also known as glycosylated hemoglobin or HbA1c) provides information 

of the average blood glucose control for the past 2 to 3 months. The results allow for an evaluation of how well 

a particular diabetes treatment plan is working.

11 http://www.diabetes.org/type-1-diabetes/a1c-test.jsp

Figure 2: Adult diabetic population who have seen a health professional in the 

past year. BRFSS 2000-2005
 Chapter 7 - Diabetes

231 

every three Americans with diabetes had at least two or more hemoglobin A1c 

tests performed in the previous year (Figure 3). In 2005 the prevalence of 

hemoglobin A1c testing along the border was higher for those states with higher

diabetes prevalence such as Texas and New Mexico (67.0 percent and 69.0 

percent, respectively). Since 2002, the prevalence of hemoglobin A1c testing for 

the state of California has been in decline. This finding creates some concern 

because of the high prevalence of diabetes in California.

Foot examination

Foot examination has been a traditional and inexpensive method to physically 

examine the effects of diabetes. Comprehensive foot examination can help detect 

potential nerve damage in the feet or poor blood flow in the diabetic individual 

(ADA, 2008). Based on BRFSS data, in 2000, more than three of five (61.3 

percent) Americans with diabetes had foot examinations in the last year. In 2005, 

the percentage increased to two of every three Americans (66.0 percent). Since this 

technique is inexpensive it has been used widely, in particular in the border states 

with high diabetes prevalence. In 2005, Texas (67.0 percent) and New Mexico 

(69.0 percent) reported a higher percentage of foot examinations in the past year 

than the national level. However, the states of California (62.0 percent), and 

Arizona (67.0 percent) reported either a small increase or a decline for the same 

time period. The percentage of foot examinations for diabetics in California was 

four points less than the national average and five points less than that reported by 

Texas, with a similar prevalence of individuals with self-reported diabetes.

Recent data showed that the number of persons with diabetes in the United 

States increased by approximately 50 percent, from 10.1 million in 1997 to 

Figure 3: Adult diabetic population who had 2 or more hemoglobin A1c testing 

in the last year. BRFSS 2000-2005
Border Lives: Health Status in the United States-Mexico Border Region

232

15.2 million in 2004, while the population growth for that same period was 

only 8 percent (CDC, 1997; CDC, 2005a). The number of ambulatory care 

visits to physician’s offices and hospitals related to diabetes for that same period 

increased by 41 percent. Population growth, including an increase in elderly and 

minority populations, predicts a substantial increase in the number of persons 

with diabetes. Based on data from the 2000 Census Bureau, the number of 

self-reported people with diabetes predicted for the year 2010 is approximately 

14.5 million, and about 17.4 million for the year 2020 (U.S. Census Bureau; 

Hu et al., 2001). It is predicted that without effective interventions, diabetes 

prevalence will continue to rise.

Diabetes and Ethnicity

The Hispanic population in the United States is composed of Mexican, Puerto 

Rican, Cuban and other Latin American populations (Hanis, Hewett-Emmet, 

Bertin, & Schull, 1991; Idrogo, & Mazze, 2004). In 2000, 35.3 million 

persons in the United States identified themselves as Hispanic, constituting 

12.5 percent of the U.S. population (Grieco & Cassidy, 2001). Hispanics are 

disproportionately affected by diabetes in the United States (CDC, 1999). 

Although they comprise the largest minority population in the United States, 

they are somewhat underserved by the health-care system (Lieu, Newacheck, 

& McManus, 1993). A recent study using data from the BRFSS survey for 

the six geographic areas with the greatest proportions of Hispanics (including 

California, Florida, Illinois, New York, Texas, and Puerto Rico), estimated that, 

overall, the 1998-2002 self-reported age-adjusted diabetes prevalence among 

Hispanics was 9.8 percent.

This prevalence was approximately twice the 5.0 percent prevalence among nonHispanic whites (CDC, 2004b). Furthermore, it is projected that the number of 

Hispanics diagnosed with diabetes will double between the years 2002 and 2020, 

whereas the number of non-Hispanic blacks and non-Hispanic whites diagnosed 

with diabetes will increase by 50 percent and 27 percent, respectively (Hogan, et 

al., 2003). Diabetes prevalence among non-Hispanic blacks ages 20 years or older 

is reported to be 11.4 percent (CDC, 2004a; 2005, HHS, 2000).

Mortality

The 2004 age-adjusted diabetes12 mortality rate per 100,000 population for the 

combined four border states was 24.7 (0.21). Among the border states, New 

Mexico reported the highest rate with 31.4 (1.31) deaths per 100,000; followed 

by Texas 29.9, (0.41), California 22.2 (0.26), and Arizona 20.8 (0.60) (Figure 

12 Defined by ICD-10: E10-E14 DIABETES MELLITUS
 Chapter 7 - Diabetes

233 

4). Differences in age-adjusted diabetes deaths between the states of New 

Mexico and California (Z=6.89, p=0.001), as well as New Mexico and 

Arizona (Z= 1.44, p=0.001) were found to be significantly different. However, 

no differences were found in mortality rates between the states of New Mexico 

and Texas (Z=1.09, p=0.27). Among the four border states, the states of 

New Mexico and Texas had the highest diabetes mortality rates per 100,000 

population (31.4 and 29.9 respectively), surpassing the age-adjusted national 

average of 24.5 per 100,000 population described by Miniño (2007).

Figure 4: Age-adjusted mortality rates for diabetes by states, 2004

Figure 5: Age-adjusted mortality rates for diabetes by border counties, 2004 Number of deaths per 100,000 population age-adjusted to the 2000 U.S. standard population

Source: 2004 mortality data, NCHS. P-values were <0.05 for difference between Arizona, New Mexico, Texas, 

and USA, and between California, New Mexico, and USA. Difference were not significant between Arizona and 

California and between New Mexico and Texas.

Source: 2004 mortality data, NCHS. P-values were <0.05 for difference between Arizona, New Mexico, Texas, and 

USA, and between California, New Mexico, Texas, and USA. Difference were not significant between New Mexico 

na and Texas.

Number of deaths per 100,000 population age-adjusted to the 2000

 U.S. standard population
Border Lives: Health Status in the United States-Mexico Border Region

234

For the whole cluster of border counties, the 2004 age-adjusted diabetes 

mortality rate was 25.2 (0.63) per 100,000 population (see Figure 5). Among 

border counties, New Mexico also showed the highest age-adjusted mortality 

with an age-adjusted rate of 39.0 (3.47) per 100,000 population, followed by 

Texas 33.5 (1.35), Arizona 21.4 (1.25), and California 20.3 (0.85). Mortality 

rates were statistically different between New Mexico border counties and 

California border counties (Z=5.23, p=0.001), and between New Mexico and 

Arizona border counties (Z= 4.76, p=0.001). No difference was found between 

age-adjusted mortality rates between New Mexico and Texas border counties 

(Z=1.47, p=0.14).

For the combined years of 2000 to 2004, National Center for Health Statistics 

(NCHS) data showed that the specific border county with the highest diabetes 

mortality rate was the Texas border county of Maverick with a death rate of 55.3 

per 100,000 population, while the lowest mortality rate was for the Arizona 

border county of Yuma with a rate of 16.5 (Table 1).

Table 1: Age adjusted mortality rates for diabetes by selected border counties 

for the years 2002-2004

Source: 2002-2004 mortality data, NCHS

Arizona border 21.0 0.72

 Cochise 21.7 2.34

 Pima 20.7 0.84 

 Santa Cruz 18.5 4.16

 Yuma 23.5 2.07

California border 19.4 0.48

 Imperial 28.5 2.83

 San Diego 19.0 0.49

New Mexico border 37.9 1.98 

 Dona Ana 50.0 3.29

 Otero 28.2 3.87

Texas border 38.1 0.84

 Cameron 40.1 2.09

 El Paso 45.3 1.66

 Hidalgo 34.5 1.57

 Maverick 35.4 5.55

 Starr 19.1 3.92

 Val Verde 27.2 4.56

 Webb 43.2 3.30

Border

Morality

Rate

26.0

Standard

Error

0.37
 Chapter 7 - Diabetes

235 

Diabetes Mortality and Age

Age-specific diabetes mortality rates for 2004 showed that the mortality rate per 

100,000 population increased by age and was consistently higher for the border 

states of Texas and New Mexico (Figure 6). This trend was replicated in the 

border counties (Figure 7).

Figure 6: Mortality rates for diabetes by state and age group, 2004

Figure 7: Mortality rates for diabetes by border counties and age group, 2004
Border Lives: Health Status in the United States-Mexico Border Region

236

Diabetes Mortality and Ethnicity

The 2004 age-adjusted diabetes mortality rates for Hispanics were almost double 

the rates for non-Hispanic whites. Rates were higher for the states of Texas and 

New Mexico: 46.0 (1.17), and 43.3 (2.76) for Hispanics, and 23.0 (0.43) and 

21.9 (1.42) for non-Hispanic whites, respectively (Figure 8). This trend was also 

found in Arizona, with a diabetes mortality rate of 38.2 (2.67) for Hispanics and 

17.3 (0.61) for non-Hispanic whites, and in California with an age-adjusted

rate of 34.9 (0.85) for Hispanics and 18.0 (0.30) for non-Hispanic whites.

The age-adjusted diabetes mortality rate for the combined border counties was 

nearly two times higher for Hispanics [38.4 (1.61)] than for non-Hispanic 

whites [17.8 (0.93)] and this difference was significantly different (z=11.01, 

p=0.001; Figure 9).

New Mexico border counties had the highest age-adjusted diabetes mortality 

rates for Hispanics of 49.5 (7.61) per 100,000 population, and 33.5 (5.05) for 

non-Hispanic whites (p = 0.079) (Figure 5). Diabetes mortality rates for the Texas 

border counties were 39.2 (2.12) for Hispanics and 20.5 (2.70) for non-Hispanic 

whites (Z=5.45, p=0.001). Arizona border counties had a mortality rate of 36.6 

(4.73) for Hispanics and 16.8 (1.70) for non-Hispanic whites (Z =3.94, p=0.001). 

California border counties reported the lowest diabetes age-adjusted mortality rate 

for Hispanics in the border region with 33.8 (3.49), and 16.4 (1.20) deaths per 

100,000 for non-Hispanic whites (Z =4.72, p=0.001). Mortality rate differences 

between Hispanic and non-Hispanic whites between border counties were 

statistically significant. The appendix to Chapter 7 provides additional information 

on diabetes mortality trends for the years 1998, 2000, 2002, and 2004.

Figure 8: Age-adjusted mortality rates for diabetes by race and state, 2004
 Chapter 7 - Diabetes

237 

Diabetes Hospitalization along the Border

People with diabetes are more likely to be hospitalized and incur nearly twice 

the total inpatient costs per capita of people without diabetes (Jiang, Stryer, 

Friedman, & Andrews, 2003). Hospitalization rates due to diabetes vary by age, 

race/ethnicity and other factors. In a study by Albertorio-Diaz, Notzon, and 

Rodriguez-Lainz (2007), 2000 age-adjusted diabetes hospital discharge rates 

were compared for the states of California, Arizona, and Texas (authors were 

unable to obtain data from the state of New Mexico). Records were obtained 

from the corresponding health departments and represented data from licensed 

inpatient hospitals. Diabetes hospitalization discharge was identified using 

the definition provided by the Healthy Border 2010 report, (U.S.-Mexico 

Border Health Commission, 2003). Diabetes hospitalization was defined as 

subjects who had been admitted as inpatients to these facilities with a first-listed 

diagnosis of diabetes (ICD-9 CM code 250) and who had been subsequently 

discharged. Discharges were classified in two groups (border counties and nonborder counties) based on the patient’s county of residence.

The authors identified a total of 86,198 hospital discharge records from these 

three states that satisfied the diabetes criteria (1.2 percent of the total number 

of discharges). Hospital discharge data showed that the age-adjusted rate per 

10,000 population was 17.0 (0.10) for the state of Texas, while California and 

Arizona had a hospital discharge rate of 14.2 (0.07) and 13.4 (0.16) respectively.

The age-adjusted diabetes hospital discharge rate for the Texas border counties 

was 26.1 (0.39) while the rates for Arizona and California border counties were 

Figure 9: Age-adjusted mortality rates for diabetes by race and border county, 

2004
Border Lives: Health Status in the United States-Mexico Border Region

238

14.9 (0.35) and 11.5 (0.20) respectively. These rates were significantly different 

between the states of Texas and Arizona (z=21.37, p=0.001) and between Texas 

and California (z= 33.31, p=0.001).

The state of Texas had the highest age-adjusted diabetes discharge rate for males 

at 17.1 (0.14), and females at 16.9 (0.13) per 10,000 population, followed by 

the state of California with 15.9 (0.11) for males and 12.8 (0.09) for females. 

Arizona had a discharge rate of 14.7 (0.25) for males and 12.2 (0.22) and 

females.

The age-adjusted discharge rate for males in the border counties of Texas was 

28.0 (0.60) while the discharge for females was 24.6 (0.51) per 10,000. The 

discharge rates for the border counties of Arizona were 15.7 (0.53) for males and 

14.1 (0.48) for females, and 13.5 (0.33) and 9.7 (0.26) for males and females 

for the border counties of California.

Diabetes discharge by ethnicity

Similar differences were seen by state and border counties for Hispanics and 

non-Hispanics, with the former having higher age-adjusted diabetes discharge 

rates than non-Hispanics. At the state level, Texas reported the highest ageadjusted discharge rate for Hispanics of 26.8 (0.28) per 10,000 population. The 

state of Arizona had the next highest level at 23.8 (0.64), followed by California 

at 23.0 (0.22). The age-adjusted diabetes discharge rates for non-Hispanics were 

15.5 (0.11), 13.7 (0.19), and 15.0 (0.09) for Texas, Arizona, and California, 

respectively. Within the border counties, Texas again reported the highest 

age-adjusted diabetes discharge rate for Hispanics of 32.1 (0.51) per 10,000, 

followed by Arizona 21.6 (0.96), and California 21.5 (0.72). The age-adjusted 

rates for non-Hispanics who lived in the border counties were 13.6 (0.61), 15.1 

(0.44), and 11.1 (0.24) for Texas, Arizona, and California, respectively.

The authors cited possible limitations to their study, such as subjects’ access 

to hospital care and repeated hospitalizations of some individuals, as well as 

limitations related to the type and the form of the data collected through the 

different hospital systems.

Discussion

Mortality

Results showed that, in 2004, New Mexico and Texas had the highest diabetes 

mortality rates among the border states, surpassing the national average. New 

Mexico and Texas had the highest diabetes mortality rates, as shown when data 
 Chapter 7 - Diabetes

239 

were analyzed by age and race, with Hispanics having higher rates than nonHispanic whites. These differences may suggest variations in the presence of 

factors that contribute to the morbidity and mortality from diabetes including 

diet, level of physical activity, access to health care, and other genetic or 

environmental risk factors.

Results from our study show that diabetes mortality rates were higher for the 

states of Texas and New Mexico, as well as for the border counties of these states. 

Mortality rates in this area were also higher for Hispanics than for non-Hispanic 

whites. In addition, hospital discharge rates were higher for males than for 

females in all border states.

Hospitalization

Texas reported the highest diabetes hospital discharge rate at either the state 

or border county level. Consistent with previous literature, males had higher 

hospital discharge rates than females.

Hispanics had a higher diabetes hospitalization discharge rate than nonHispanics along the border. This finding was consistent in the three clusters 

of border counties under review. Again, Texas border counties showed an 

alarmingly high rate of diabetes discharges.

Recommendations to Address Diabetes along the Border

The prevalence of diabetes in the United States is increasing. With a current 

prevalence of 6.3 percent, which is projected to double by the year 2020, 

diabetes is a serious public health problem. In addition, diabetes is associated 

with many health complications which exacerbate the scope of the problem. The 

increase in lifespan and growth of minority populations contribute to higher 

diabetes rates at the border.

Based on our analysis, we have divided our recommendations into three main 

strategies: (a) research, (b) public health intervention, and (3) policy making. 

Augmenting current efforts in all three of these areas is necessary to alleviate 

diabetes morbidity and mortality and to lessen the diabetes burden in the U.S.-

Mexico border area.

Research

While advances have been achieved in diabetes research, it is still necessary to 

increase and supplement several lines of diabetes research, specifically in the 

areas of diabetes prevention, early diagnosis, appropriate diabetes treatment and 
Border Lives: Health Status in the United States-Mexico Border Region

240

management, progress of epidemiology, and surveillance systems. Emphasis 

should also be placed on enhancing transitional research that can contribute to 

the areas of diabetes prevention and early intervention programs in the United 

States as well as those across the border with Mexico. Research should also target 

the areas of comorbidity with other conditions such as tuberculosis and diabetes. 

Moreover, the association between diabetes and depression is an important area 

of research in need of further exploration.

Public health interventions

One of the essential functions of public health is to create and strengthen 

collaborations between the different sectors of the community and public health 

organizations. These collaborations should focus on programs that expand 

community-based health promotion, education, nutrition, and physical activity. 

Measures aimed at prevention and management of diabetes must include people 

of all ages and from a variety of backgrounds including racial, ethnic, and 

religious groups, while giving consideration to their unique needs. Institutions 

such as schools, workplaces, and churches should be integrated into these health 

programs. These programs should have measurable outcomes to evaluate their 

progress and sustainability and, whenever possible, follow already published 

guidelines like those published by the Centers for Disease Control and 

Prevention and the National Institutes of Health National Diabetes Education 

Program.

Policy

It is important to establish awareness among policy makers, public health 

professionals, and other stakeholders who have an integral role in policy 

development of the importance of diabetes as a public health problem. Policies 

should be developed that focus on strengthening advocacy on behalf of people 

afflicted with diabetes. Such policies should include (a) campaigns to increase 

awareness among the public of the seriousness of diabetes; (b) an increase in 

prevention initiatives that support policies and programs aimed at screening, 

health and nutrition education, promotion of physical activity, and selfmanagement, and (c) health insurance programs that are aimed at preventive 

care and assure access to health-care providers, thus allowing enrollees to receive 

quality treatment and management. These policy recommendations should be 

implemented in a binational context in order to assure regional impact, as well 

as to influence the population who live along the U.S.-Mexico border.
 Chapter 7 - Diabetes

241 

References

Albertorio-Diaz J., Notzon F., Rodríguez-Lainz A. (2007, April). Diabetes 

hospitalization at the U.S.-Mexico border. (2007). Preventing Chronic 

Disease 4 (2), A28. Retrieved September 27, 2007, from http://www.

cdc.gov/pcd/issues/2007/apr/06_0073.htm

American Diabetes Association (nd). Gestational diabetes. Retrieved August 21, 

2007, from http://www.diabetes.org/gestational-diabetes.jsp

American Diabetes Association. (2000). Type 2 diabetes in children and 

adolescents. Diabetes Care, 23, 381-389.

Burke, J.P., Williams, K., Narayan, K.M., Leibson, C., Haffner, S.M., Stern, 

M.P. (2003). A population perspective on diabetes prevention: whom 

should we target for preventing weight gain? Diabetes Care 26), 1999-

2004.

Centers for Disease Control and Prevention. (1997). Trends in the prevalence 

and incidence of self-reported diabetes mellitus–United States, 1980-

1994. Journal of the American Medical Association, 278, 1564-1565.

Centers for Disease Control and Prevention. (1999). Self-reported prevalence 

of diabetes among Hispanics–United States, 1994-1997. Morbidity and 

Mortality Weekly Report, 48(1), 8-12.

Centers for Disease Control and Prevention. (2004a). General information and 

national estimates on diabetes in the United States, 2005. [Fact sheet]. 

Rev ed. Atlanta, GA: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention. Retrieved September 27, 

2007, from http://www.cdc.gov/diabetes/pubs/pdf/ndfs2005.pdf.

Centers for Disease Control. (2004b). Prevalence of diabetes among Hispanicsselected areas, 1998-2002. Morbidity and Mortality Weekly Report, 53, 

941-944. Retrieved October 3, 2007, from http://www.cdc.gov/mmwr/

preview/mmwrhtml/mm5340a3.htm

Centers for Disease Control and Prevention, Diabetes Data and Trends. (2005a). 

Crude and age-adjusted prevalence of diagnosed diabetes per 100,000 

population, United States, 1980-2005. Retrieved September 27, 2007, 

from www.cdc.gov/diabetes/statistics/prev/national/figage.htm
Border Lives: Health Status in the United States-Mexico Border Region

242

Centers for Disease Control and Prevention. National Center for Chronic 

Disease Prevention and Health Promotion. (2005b). Number of 

Americans with diabetes continues to increase. [Fact sheet]. Retrieved 

August 8, 2007, from http://www.cdc.gov/od/oc/media/pressrel/

fs051026.htm.

Cowie, C.C., Rust, K.F., Byrd-Holt, D.D., Eberhardt, M.S., Flegal, K.M., 

Engelgau, M.M., et al. (2006). Prevalence of diabetes and impaired 

fasting glucose in adults in the U.S. population: National Health And 

Nutrition Examination Survey 1999-2002. Diabetes Care, 29, 1263-

1268.

Diabetes Data and Trends. Centers for Disease Control and Prevention National 

Center for Chronic Disease Prevention and Health Promotion Division 

of Diabetes Translation. Texas Health Department. Retrieved June 

27, 2008, from http://apps.nccd.cdc.gov/DDTSTRS/statePage.

aspx?state=Texas

Fagot-Campagna, A., Burrows, N.R., & Williamson, D.F. (1999). The public 

health epidemiology of type 2 diabetes in children and adolescents: a 

case study of American Indian adolescents in the Southwestern United 

States. Clinica Chimica Acta, 286(1-2), 81-95.

Grieco, E.M., & Cassidy, R.C. (2001, March). Overview of race and Hispanic 

origin: census 2000 brief. United States census 2000. Washington, 

DC: U.S. Department of Commerce, U.S. Census Bureau. Retrieved 

September 27, 2007, from http://www.census.gov/prod/2001pubs/

c2kbr01-1.pdf

Gu, K., Cowie, C. C., & Harris, M. I. (1999). Diabetes and decline in heart 

disease mortality in U.S. adults. Journal of the American Medical 

Association, 281, 1291-1297.

Hanis, C. L., Hewett-Emmett, D., Bertin, T. K., & Schull, W.J. (1991). Origins 

of U.S. Hispanics. Implications for diabetes. Diabetes Care, 14, 618-

627.

Heron M.P. (2007). Deaths: Leading causes for 2004. National vital statistics: 

Introduction reports; 156 (5).Hyattsville, MD: National Center for 

Health Data and Methods Statistics.

Hogan, P., Dall, T., & Nikolov, P. (2003). Economic costs of diabetes in the 

U.S. in 2002. Diabetes Care, 26, 917-932.
 Chapter 7 - Diabetes

243 

Hu, F. B., Leitzmann, M. F., Stampfer, M. J., Colditz, G. A., Willett, W. C., 

& Rimm, E. B. (2001). Physical activity and television watching in 

relation to risk for type 2 diabetes mellitus in men. Archives of Internal 

Medicine, 161, 1542-1548.

Idrogo, M., & Mazze, R. (2004). Diabetes in the Hispanic population. High 

risk warrants targeted screening and treatment. Postgraduate Medicine, 

116, 26-32, 35-26.

Imperatore, G., Cadwell, B.L., Geiss, L., Saadinne, J.B., Williams, D.E., Ford, 

E.S., et al. (2004). Thirty-year trends in cardiovascular risk factor 

levels among U.S. adults with diabetes: National Health and Nutrition 

Examination Surveys, 1971-2000. American Journal of Epidemiology, 

160, 531-539.

Ingram M., Gallegos G., Elenes J.. (2005, November 3). Diabetes is a 

community issue: the critical elements of a successful outreach and 

education model on the U.S.-Mexico border. Preventing Chronic 

Disease, 2(1), A15. Retrieved June 28, 2008, from http://www.

pubmedcentral. nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=1

5670468

Jiang, H.J., Stryer, D., Friedman, B., & Andrews, R. (2003). Multiple 

hospitalizations for patients with diabetes. Diabetes Care, 26, 1421-

1426.

Klein R.J., Schoeborn CA. (2001). Age adjustment using the 2000 projected 

U.S. population. Healthy People Statistical Notes, 20, Hyattsville, MD: 

National Center for Health Statistics.

Kuulasmaa, K., Tunstall-Pedoe, H., Dobson, A., Fortmann, S., Sans, S., 

Tolonen, H., et al. (2000). Estimation of contribution of changes in 

classic risk factors to trends in coronary-event rates across the WHO 

MONICA Project populations. Lancet, 355, 675-687.

Lieu, T.A., Newacheck, P.W., & McManus, M.A. (1993). Race, ethnicity, and 

access to ambulatory care among U.S. adolescents. American Journal of 

Public Health, 83, 960-965.

Miniño AM, Heron MP, Murphy SL, Kochankek, KD. (2007). Deaths: Final 

Data for 2004. National Vital Statistics Reports, 55(19). Hyattsville, 

MD: National Center for Health Statistics.
Border Lives: Health Status in the United States-Mexico Border Region

244

Mokdad, A.H., Bowman, B.A., Ford, E.S., Vinicor, F., Marks, J.S., & Koplan, 

J.P. (2001). The continuing epidemics of obesity and diabetes in the 

United States. Journal of the American Medical Association, 286, 1195-

1200.

Mokdad, A.H., Ford, E.S., Bowman, B.A., Dietz, W.H., Vinicor, F., Bales, V.S., 

et al. (2003). Prevalence of obesity, diabetes, and obesity-related health 

risk factors, 2001. Journal of the American Medical Association, 289, 76-

79.

Nathan, D.M. (1993). Long-term complications of diabetes mellitus. New 

England Journal of Medicine, 328, 1676-1685.

National Center for Chronic Disease Prevention and Health Promotion.

2000 Behavioral Risk Factor Surveillance System. Retrieved June 27, 

2008, from http://apps.nccd.cdc.gov/BRFSS/

National Heart, Lung, and Blood Institute. National High Blood Pressure 

Education Program: Working Group report on Hypertension in 

Diabetes. (1994a). Bethesda, MD: National Institute of Health, NIH. 

Pub No. 94-3530.

National Heart, Lung, and Blood Institute. Obesity Education Initiative: 

Strategy Development Workshop for Public Education on Weight and 

Obesity Summary Report (1994b). Bethesda, MD: National Institute 

of Health, NIH. Pub No. 94-3314

National Heart, Lung, and Blood Institute. Latino Community Cardiovascular 

Disease Prevention and Outreach Initiative: Background Report (1996). 

Bethesda, MD: National Institute of Health, NIH. Pub No. 96-3230

National Institute of Diabetes and Digestive and Kidney Diseases, National 

Diabetes Information Clearinghouse. (2005). National Diabetes 

Statistics Fact Sheet. Retrieved March 4, 2005, from http://diabetes.

niddk.nih.gov/dm/pubs/statistics/index.htm.

Okoro, C.A., Mokdad, A.H., Ford, E.S., Bowman, B.A., Vinicor, F., & Giles, 

W.H. (2004). Are persons with diabetes practicing healthier behaviors 

in the year 2001? Results from the Behavioral Risk Factor Surveillance 

System. Preventive Medicine, 38(2), 203-208.
 Chapter 7 - Diabetes

245 

Pan American Health Organization. (2003). The U.S.-Mexico Border Diabetes 

Prevention and Control Project, first report of results. Retrieved 

October 3, 2007, from http://www.fep.paho.org/english/publicaciones/

Diabetes/Diabetes%20first%20report%20of%20Results.pdf

Pratley, R.E. (1998). Gene-environment interactions in the pathogenesis of type 

2 diabetes mellitus: lessons learned from the Pima Indians. Proceedings 

of the Nutritional Society, 57(2), 175-181.

Report of the expert committee on the diagnosis and classification of diabetes 

mellitus. (1997). Diabetes Care, 20, 1183-1197.

Stamler, J., Vaccaro, O., Neaton, J.D., & Wentworth, D. (1993). Diabetes, 

other risk factors, and 12-yr cardiovascular mortality for men screened 

in the Multiple Risk Factor Intervention Trial. Diabetes Care, 16, 434-

444.

State of Texas Health Services. Behavioral Risk Factor Surveillance System. 

Retrieved June 27, 2008, from http://www.dshs.state.tx.us/chs/brfss/

query/brfss_form.shtm

Thackeray, R., Merrill, R.M., & Neiger, B.L. (2004). Disparities in diabetes 

management practice between racial and ethnic groups in the United 

States. Diabetes Educator, 30, 665-675.

Troiano, R. P., & Flegal, K. M. (1998). Overweight children and adolescents: 

description, epidemiology, and demographics. Pediatrics, 101(3 Pt 2), 

497-504.

U.S. Census Bureau. Population projections. Retrieved June 28, 2008 from 

http://www.census.gov/population/www/projections/popproj.html. 

Accessed March 22, 2005.

U.S. Department of Health and Human Services. (2000). Healthy people 2010: 

Understanding and improving health, 2nd ed. Washington, DC: U.S. 

Government Printing Office.

U.S.-Mexico Border Health Commission. (2003). Healthy border 2010: An 

agenda for improving health on the United States-Mexico Border. 

Retrieved August 2, 2007, from http://www.borderhealth.org/files/

res_63.pdf
Border Lives: Health Status in the United States-Mexico Border Region

246

U.S. Public Health Service. Minority Programs of the National Heart, Lung, 

and Blood Institute, Fiscal Year 1992, (1993). Bethesda, MD: National 

Institutes of Health, NIH Pub. No. 93-3037.

Wei, M., Gaskill, S. P., Haffner, S. M., & Stern, M. P. (1997). Waist 

circumference as the best predictor of noninsulin dependent diabetes 

mellitus (NIDDM) compared to body mass index, waist/hip ratio and 

other anthropometric measurements in Mexican Americans–a 7-year 

prospective study. Obesity Research, 5(1), 16-23.

Will, J. C., Williamson, D. F., Ford, E. S., Calle, E. E., & Thun, M. J. (2002). 

Intentional weight loss and 13-year diabetes incidence in overweight 

adults. American Journal of Public Health, 92, 1245-1248.

Zonszein, J. (1993). Latinos and diabetes Diabetes Spectrum 6(2):88-91, 136-

137.
247 

Heart disease and stroke are the leading causes of illness and death in 

both the United States and the U.S.-Mexico border region. Heart 

attack and stroke are the principal outcomes of cardiovascular disease, 

defined by the National Heart, Lung, and Blood Institute (NHLBI) as diseases 

and injuries of the heart, blood vessels of the heart, and the system of blood 

vessels throughout the body, including the brain (2007). This chapter offers a 

review of the available information on heart disease and stroke in the border 

region, including morbidity and mortality levels and trends, as well as the 

prevalence of risk factors.

Understanding Heart Disease and Stroke

Cardiovascular diseases result from a variety of factors: Ischemia refers to the 

lack of oxygen in tissues due to obstruction of blood flow — in this case to the 

heart or brain. Ischemia can result from atherosclerosis, a term referring to the 

thickening and hardening of the arteries (National Heart, Lung, and Blood 

Institute [NHLBI], 2006). Atherosclerosis involves the buildup of fatty plaque 

and other substances in arterial walls. Continued growth of plaque will reduce 

blood flow through the artery; blood clots can also develop at the site of plaque. 

Narrowing of the coronary arteries that feed the heart, known as coronary artery 

disease, can cause insufficient blood flow to the heart, leading to angina or chest 

pain. Blood clots in the coronary arteries that cut off most or all blood flow to a 

section of the heart will cause permanent damage to the heart muscle – that is, 

a heart attack or myocardial infarction. This in turn can lead to congestive heart 

failure, heart arrhythmias, or sudden cardiac death. Blood clots in the arteries 

supplying the brain can block blood supply to a section of the brain, leading to 

an ischemic stroke (NHLBI, 2006).

CHAPTER 8

HEART DISEASE AND STROKE
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Hypertension, or high blood pressure, is a major factor in the development of 

heart disease and stroke (NINDS, 2004). Hypertension can cause injuries to 

the arterial walls, beginning the process of atherosclerosis. Hypertension results 

from muscular constriction of small arteries, in most cases of unknown cause. 

This increased workload can cause the heart to enlarge and weaken, increasing 

the risk of congestive heart failure and heart attack. In the brain, hypertension 

can lead to arterial hemorrhage, producing a hemorrhagic stroke or arterial 

blockage producing an ischemic stroke. Cerebrovascular disease includes both 

hemorrhagic stroke and ischemic stroke.

Heart Disease, Stroke, and Healthy Border 2010 

Healthy Border 2010 is designed to address some of the leading health problems 

on the U.S.-Mexico border, and in particular to eliminate health disparities 

(U.S.-Mexico Border Health Commission, 2003). None of the Healthy Border 

2010 program’s 20 objectives directly focus on cardiovascular disease because 

observed heart disease and stroke death rates for the border are lower than U.S. 

national rates. However, heart disease and stroke remain two of the leading 

causes of death for border residents.

The Healthy Border 2010 objectives, as well as those of the Healthy Gente 2010 

program (Arizona Office of Border Health, 2004), include several of the most 

important risk factors for cardiovascular disease. These include reducing deaths 

and hospitalizations due to diabetes; reducing obesity, that is, the proportion 

of the population with a body mass index of 30 or more; and reducing tobacco 

consumption among adults and teenagers. Improvements in these areas will 

certainly reduce deaths and disabilities due to cardiovascular disease. However, 

development of additional Healthy Border objectives directly focused on 

cardiovascular disease could reduce its impact even further and be an important 

step toward elimination of health disparities related to heart disease and stroke 

in the border population.

Levels and Trends in Heart Disease and Stroke

Heart disease and stroke are the first and third leading causes of death, 

respectively, in the United States (NHLBI, 2007). These diseases also rank as 

the first and third leading causes of death for the four U.S. border states and the 

44-county border region. Heart disease and stroke are also important causes of 

disability. Heart disease was the third leading chronic condition causing activity 

limitation in 2000, affecting 4.4 million persons in the United States. Stroke 

was the cause of disability in an additional 1.6 million people. Combined, heart 

disease and stroke caused more disability than any other chronic conditions.
 Chapter 8 - Heart Disease and Stroke

249 

 

 United States 

 

Total 652,486 27.2 217.0 (216.4, 217.5) 150,074 6.3 50.0 (49.7, 50.2)

Male 321,973 27.2 267.9 (267.0, 268.8) 58,800 5.0 50.4 (50.0, 50.8)

Female 330,513 27.2 177.3 (176.7, 177.9) 91,274 7.5 48.9 (48.6, 49.2)

 

Border Counties 

 

Total 11,926 26.2 185.8 (182.5, 189.2) 2,848 6.3 44.4 (42.8, 46.1)

Male 6,363 26.9 234.6 (228.8, 240.4) 1,165 4.9 43.7 (41.2, 46.3)

Female 5,563 25.6 146.7 (142.8, 150.5) 1,683 7.7 44.3 (42.2, 46.5)

 

AZ border 2,572 24.5 184.6 (177.4, 191.7) 620 5.9 44.2 (40.8, 47.7)

CA border 5,506 26.4 190.5 (185.5, 195.6) 1,499 7.2 51.8 (49.1, 54.4)

NM border 589 25.5 180.5 (165.8, 195.2) 125 5.4 38.9 (32.0, 45.7)

TX border 3,259 27.7 180.0 (173.8, 186.2) 604 5.1 33.4 (30.8, 36.1)

These two diseases are also major contributors to rising health-care costs. Their 

impact on health-care expenditures arises not only from extended hospital stays, 

but also from expensive medical procedures and the use of costly medications 

requiring lengthy regimens. The estimated economic cost of cardiovascular 

disease for 2007 was about $432 billion, of which $283 billion was for direct 

health expenditures (NHLBI, 2007).

In 2004, heart disease accounted for more than 650,000 deaths in the United 

States, about 27 percent of all deaths. Table 1 shows deaths and death rates due 

to cardiovascular disease and stroke for the United States and the border region. 

Heart disease was the cause of about 11,900 deaths on the border in 2004, or 

about 26 percent of all deaths. Although the proportion of deaths due to heart 

disease was about the same for the United States and the border region, the ageadjusted death rate for heart disease was 14 percent lower for border residents. 

The age-adjusted stroke death rate was 11 percent lower on the border. Heart 

disease death rates were much lower for women than men in both the United 

States (34 percent lower) and the border region (37 percent lower). The stroke 

death rate was 3 percent lower for women than men at the national level, but 

the female-male difference was not statistically significant for border residents. 

The border counties of Texas had the lowest heart disease rates and California 

border counties had the highest, but the difference was not statistically 

significant. The stroke death rate was lowest in the Texas border region and 

highest for California border residents.

Table 1: Cardiovascular disease deaths and death rates, United States and U.S.-

Mexico border counties, 2004

Source: National mortality files, NCHS/CDC

*Rates per 100,000 population,age-adjusted to U.S.2000 standard population

**95 Percent confidence interval

Heart Disease Deaths and Death Rates Stroke Deaths and Death Rates

Number Percent CI**

Ageadjusted 

rate* Number Percent CI**

Ageadjusted 

rate*
Border Lives: Health Status in the United States-Mexico Border Region

250

Lower heart disease death rates for Hispanics, including Mexican-Americans, as 

compared to non-Hispanic whites, have been observed in many studies (Becker, 

1988; Cooper, 2000; Liao, 1997; Sorlie, 1993). Some of these studies were 

based on aggregate data, using death certificate data combined with population 

data from the U.S. Census (Becker, 1988; Cooper, 2000). Others used the 

National Death Index to track individuals participating in national surveys or in 

cohort studies (Liao, 1997; Sorlie, 1993). Both types of studies reached the same 

conclusion: death rates due to heart disease were notably lower for Hispanics 

than for non-Hispanic whites.

This large mortality advantage for Hispanics, combined with high levels of some 

risk factors such as diabetes and obesity and low socioeconomic status, has been 

termed the “Hispanic paradox.”

However, a number of studies have provided evidence against the Hispanic 

paradox (Hunt 2002, 2003; Palloni, 2004; Patel, 2004; Poe, 1993; Stern, 

1999; Swenson, 2002). Several of these reports were based on data from the 

San Antonio Heart Study, a cohort study that determined the vital status of 

participants through links to the National Death Index and via active follow-up. 

The studies showed that Mexican-American participants were at equal or greater 

risk of death due to cardiovascular disease or to all causes, as compared to nonHispanic whites, after correcting for the undercount of Hispanic deaths using 

the National Death Index, and adjusting for age, sex, and possible confounders 

(Hunt 2002, 2003; Patel, 2004; Stern, 1999).

The authors argue that studies based on aggregate data understate Hispanic 

mortality because of discrepancies in ethnic classification and incomplete death 

registration. Errors in identification of ethnicity arise because the aggregate data 

are based on both death registration and Census figures, and only in the Census 

is ethnic identity obtained directly from the respondent. They also suggest that 

death registration for Hispanics may be incomplete due to return migration to the 

country of origin of immigrants in poor health. Cohort studies using the National 

Death Index alone may underestimate Hispanic mortality because of challenges 

in matching Hispanic participants to the National Death Index. These problems 

include missing or inaccurate social security numbers for undocumented 

Hispanics or those involved in agriculture or domestic service, as well as Hispanic 

naming conventions that affect how names are reported to survey interviewers 

and on death certificates (Patel, 2004). Of the remaining studies, one used 

mathematical modeling to test various hypotheses regarding the Hispanic paradox 

and concluded that return migration of foreign-born immigrants likely accounts 

for the lower mortality rate of this group (Palloni, 2004).

Another cohort study of Hispanics and non-Hispanic whites, the San Luis 

Valley Diabetes Study, provided mixed findings regarding the Hispanic 
 Chapter 8 - Heart Disease and Stroke

251 

advantage in mortality due to cardiovascular disease or to all causes (Swenson, 

2002). Among study participants who did not have diabetes, the mortality rates 

for all causes combined, cardiovascular disease and coronary heart disease were 

not significantly different for Hispanics and non-Hispanic whites. Among study 

participants who had diabetes, the Hispanic mortality rate for all causes was 

not significantly different from the non-Hispanic white rate. For males with 

diabetes, however, the cardiovascular disease mortality rate for Hispanics was 

significantly lower than for non-Hispanic whites.

Figure 1 provides age-adjusted death rates due to heart disease and stroke by 

ethnicity for the United States and the border region in 2004. At both the 

national level and on the border, heart disease and stroke death rates were 

significantly lower for Hispanics. For the United States, the Hispanic rate for 

heart disease was 21 percent lower than for non-Hispanic whites, while in the 

border region the Hispanic rate was 15 percent lower than the non-Hispanic 

white rate. The heart disease death rate for border Hispanics was higher than 

the national Hispanic rate (166.8 versus 158.4), although the difference was just 

shy of statistical significance. For non-Hispanic whites, the national and border 

heart disease death rates were not significantly different. It is worth noting, 

however, that mortality data combine information from death certificates and 

the Census, and so death rates for specific ethnic groups are subject to the same 

ethnicity classification errors mentioned above regarding aggregate data.

Figure 1: Age-adjusted death rates* due to heart disease and stroke by 

ethnicity, United States and border region, 2004

Source: National mortality files, NCHS/CDC

 *Rates adjusted to U.S. 2000 standard population.
Border Lives: Health Status in the United States-Mexico Border Region

252

Trends in Heart Disease and Stroke

Heart disease and stroke death rates have been decreasing in the United States 

for several decades. Between 1972 and 2004, the coronary heart disease death 

rate fell by 66 percent (NHLBI, 2007). Between 1990 and 2004, the national 

heart disease death rate dropped by 32 percent, and the stroke death rate fell 

by 23 percent. Heart disease death rates fell for all racial groups and genders, 

although the declines were greater in some groups than others.

As illustrated by Figure 2, death rates due to heart disease and stroke fell sharply 

between 1990 and 2004 for the border population. For both men and women 

the heart disease death rate fell by nearly one-third, approximating the decline 

in national death rates. Stroke death rates in the border region fell at nearly 

the same pace, dropping by 27 percent for men and 29 percent for women. 

Nationally, the stroke death rate fell by about the same amount for men, but for 

women the decline was somewhat smaller (21 percent). Trends in heart disease 

and stroke death rates were approximately the same for border Hispanics and 

non-Hispanic whites.

Age Patterns in Heart Disease and Stroke

Cardiovascular disease and death rates rise sharply with age and are particularly 

high among those aged 65 and older. Heart disease death rates begin rising at an 

Figure 2: Trends in age-adjusted* death rates due to heart disease and stroke, 

U.S.-Mexico border, 1990-2004

Source: National mortality files, NCHS/CDC 

*Rates adjusted to U.S. 2000 standard population
 Chapter 8 - Heart Disease and Stroke

253 

earlier age among men than women, but the rates for both sexes reach significant 

levels by age 65 and rise substantially in the years beyond (NHLBI, 2007). Figure 

3 shows age-specific death rates by sex for U.S. counties on the U.S.-Mexico 

border; similar patterns exist for the United States. Stroke death rates also increase 

rapidly among persons aged 65 and older. The age pattern of these diseases has 

important implications, as the population of both the United States and the 

border are rapidly aging. In 2000, about 12.4 percent of the U.S. population was 

aged 65 years or more, and this proportion is expected to reach 19.7 percent by 

2030 (U.S. Census Bureau, 2005). Population projections by age are not available 

for the border counties, but in the four border states the percent of the population 

aged 65 or more will grow from 10.6 percent in 2000 to 17.7 percent in 2030. 

Heart disease and stroke deaths on the border account for 30 percent of all deaths 

among persons aged 65 to 74 years, and 44 percent of deaths among those aged 

85 years or more. Thus, the rapidly growing elderly population means that, even 

with continuing declines in cardiovascular death rates among people of all ages, 

the number of heart disease and stroke deaths may increase substantially in the 

future. This will present a particular challenge for already overburdened health 

care providers and health facilities in the border region.

Heart Disease and Stroke Morbidity

In 2004, nearly 16 million people nationwide were estimated to have coronary 

heart disease, the most important component of heart disease, and nearly 6 

Figure 3: Age-specific death rates due to heart disease, U.S.-Mexico border 

counties, 2004

Source: National mortality files, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

254

million to have cerebrovascular disease (NHLBI, 2007). Some information is 

available on heart disease and stroke morbidity for the border region as well. 

Data for the 44 border counties plus Maricopa County, Arizona, were produced 

by combining data from the 2000-2003 years of the National Health Interview 

Survey (NHIS), which produced a total of 5,139 interviews with adults aged 

18 or more years (Albertorio, 2008). The NHIS collects information from 

respondents about a variety of cardiovascular diseases or conditions, including 

angina, coronary heart disease, heart attack, and stroke. The combined data 

showed rates for each of these diseases were low for border residents, ranging 

from one to three percent. Differences between Hispanic and non-Hispanic 

rates for the border population were small and not statistically significant; the 

same was true for differences between the border rates and national rates.

Statewide data are available on hospitalizations for three of the four border 

states: Arizona, California, and Texas (Arizona Department of Health Services, 

2000; California Office of Statewide Health Planning and Development, 2004; 

Texas Health Care Information Council, 2001). Combining these data sources 

provided some information on hospital-based care for heart disease and stroke 

in the border region. Based on age-adjusted rates per 10,000 population, the 

discharge rate for heart disease for the border counties was significantly lower 

than for the non-border regions of those states, 114.9 versus 128.4. Comparison 

of these figures to results from the National Hospital Discharge Survey (HDS) 

shows that the border and non-border rates from the three border states were 

lower than the national rate of 157.7 for heart disease, but higher than the 

discharge rate of 96.8 for the Western region of the United States (Kozak, 

2002). The Western region as defined by the HDS includes both California 

and Arizona. The hospital discharge rate for acute myocardial infarction (AMI) 

was similar in the border and non-border regions of Arizona, California, and 

Texas (19.9 versus 22.1). The border and non-border AMI discharge rates were 

significantly lower than the national rate of 28.1, but were similar to the rate for 

the Western region, 19.4.

The discharge rate for cerebrovascular disease, including hemorrhagic and 

ischemic stroke, was significantly lower for border residents of the three states 

than for non-border residents (28.0 versus 34.0). The rate for border residents 

was also lower than the national rate of 35.0, but it was higher than the rate in 

the Western region, where it was 23.9.

While lower discharge rates for cardiovascular diseases might be attributed to 

poorer access to care on the border, the border discharge rate remained lower 

than the non-border rate even for acute myocardial infarctions, a diagnosis that 

usually requires hospitalization. The lower discharge rate could be due to lower 

rates of heart disease, which would conform with the lower death rates due to 

heart disease for border residents. However, lower discharge rates also could be 
 Chapter 8 - Heart Disease and Stroke

255 

explained by a greater likelihood of border residents to die from heart disease 

or stroke without being hospitalized, or a greater likelihood to die during or 

following hospitalization, thus eliminating rehospitalization for future treatment 

of the same condition (Goff, 1994; Hunt, 2003; Pandey, 2001).

The hospital discharge databases also provide information on the use of 

cardiovascular procedures during hospitalization. Coronary artery bypass grafts 

are widely used in the United States to open the severely occluded (blocked) 

coronary arteries. The national bypass rate was 18.7 bypass grafts per 10,000 

persons in 2000 (Kozak, 2002). Hospital discharge data for Arizona, California 

and Texas showed the bypass rate for their border counties was lower than 

the national rate, at 10.1 grafts per 10,000 border residents. The non-border 

counties of the three states reported higher bypass rates, at 11.7 per 10,000. 

Atherosclerosis can also be addressed by angioplasty (insertion and inflation 

of a balloon within the artery) and the use of stents to keep the artery open. 

Angioplasties were performed in the border counties at the rate of 18.5 per 

10,000, compared to a rate of 19.9 in the non-border counties of the three states 

and 36.9 for the entire U.S. population.

Cardiovascular Disease Risk Factors

The primary risk factors for heart disease and stroke are hypertension (high blood 

pressure), cigarette smoking, high blood cholesterol, overweight and obesity, 

physical inactivity, and diabetes (U.S. Department of Health and Human Services 

[HHS], 2000). This section provides an overview of the prevalence levels of 

each cardiovascular disease risk factor at the border and nationally, the need for 

screening, and various means of addressing those risk factors.

Primary prevention of cardiovascular diseases, in particular through lifestyle 

interventions, is recommended by organizations such as the American 

Heart Association (2007). Primary prevention is also the cornerstone of the 

Healthy People 2010 objectives regarding heart disease and stroke (HHS, 

2000). Medications and/or surgery can be used to address risk factors such 

as hypertension or high blood cholesterol, as well as for the treatment of 

cardiovascular disease. Referral of individuals for medical care, however, depends 

on screening to identify risk factors or the early stages of cardiovascular disease. 

This is one of the great challenges for the border as low rates of health insurance 

coverage and the limited availability of health facilities and personnel limit both 

screening and provision of medical treatments.

Hypertension

High blood pressure, or hypertension, is a major risk factor for both heart 

disease and stroke (NINDS, 2004). Hypertension is defined as blood pressure of 
Border Lives: Health Status in the United States-Mexico Border Region

256

greater than 140 mm Hg systolic (the pressure when the heart pumps) and 90 

mm Hg diastolic (the pressure when the heart relaxes), usually noted as 140/90 

mm Hg. People who are taking antihypertensive medication are also considered 

hypertensive, even if their blood pressure falls below these numbers.

Studies identifying the importance of blood pressure for cardiovascular health 

have led to large and sustained public health campaigns, beginning in the 1990s, 

to educate the public about the risks of high blood pressure (Roccella, 1998). 

About 90 percent of adults now have their blood pressure checked at least once 

every two years. The proportion of people with hypertension who were able 

to control their blood pressure via medication and lifestyle changes rose from 

16 percent in 1971-72 to about 65 percent in 1988-1994 (HHS, 2000). The 

overall prevalence of hypertension fell nationally from 32 percent in 1976-1980 

to 22 percent in 1988-1994, but rose to 28 percent in 1999-2000 and remained 

at that level through 2006 (Ostchega, 2008).

The prevalence of hypertension in Mexican-Americans is surprisingly 

low, despite high levels of risk factors such as diabetes, obesity and low 

socioeconomic status. Analysis of national data from the National Health and 

Nutrition Examination Survey (NHANES) showed the age-adjusted prevalence 

of hypertension in Mexican-Americans was 21.3 percent in 1988-91, similar 

to the level in non-Hispanic whites (19.2 percent) and much lower than 

among blacks (30.2 percent); (Centers for Disease Control and Prevention 

[CDC], 1995). A number of other studies have documented low rates of 

high blood pressure in Mexican-Americans, despite high rates of risk factors 

for hypertension (Haffner, 1993; Sorel, 1991; Stern 1981; Winkleby, 1998). 

The good performance of Mexican-Americans on this health measure has 

contributed to the debate about the Hispanic paradox.

However, further work in this area has shown that relatively low levels of 

hypertension prevalence do not necessarily translate into high levels of 

hypertension control. Several studies have reported that, compared to nonHispanic whites and non-Hispanic blacks with hypertension, MexicanAmericans with high blood pressure are less aware of their condition, a smaller 

percentage are under treatment, and a lower proportion have their blood 

pressure under control (CDC, 1995, 2005; Haffner, 1993). Figure 4 depicts 

levels of hypertension prevalence, awareness, treatment and control among 

different ethnic groups in the United States. Hypertension-related mortality 

in Mexican-Americans rose by 31 percent from 1995-2002, a greater level of 

increase than among non-Hispanic whites (27 percent; CDC, 2005).

Limited information is available concerning hypertension among residents 

of the U.S.-Mexico border region. However, combining data from the 2000-

2003 NHIS provides one estimate. The NHIS data indicate that, among the 

border population aged 18 years or more, 20.6 percent (age-adjusted) had been 
 Chapter 8 - Heart Disease and Stroke

257 

diagnosed with high blood pressure. Of Hispanics in the border region, 22 

percent had been diagnosed with high blood pressure, compared to 20 percent 

of non-Hispanics, a difference that was not statistically significant (Albertorio, 

2008). This estimate is similar to that of the 2004 Texas BRFSS, which surveyed 

respondents in three border counties of that state. In the Texas study, 21 percent 

of adults aged 18 years or more reported doctor-diagnosed hypertension.

Smoking

Cigarette smoking is the most powerful modifiable risk factor for both heart 

disease and stroke. Cigarette smoke has been shown to cause coronary heart 

disease in both smokers and in non-smokers exposed to second-hand smoke 

(HHS, 1989, 2006). Other conditions caused by cigarette smoking include 

arteriosclerotic peripheral vascular disease, and stroke, probably as a result of 

increased atherosclerosis, increased thrombosis or blood clots, production of 

heart arrhythmias, and reduced oxygen delivery (HHS, 1990). Smoking is 

directly responsible for a larger proportion of stroke in younger adults than in 

older adults, and heavy smokers are at greater risk than light smokers. Smoking 

increases the risk of stroke by increasing atherosclerosis and by raising the level 

of blood-clotting factors such as fibrinogen (NINDS, 2004). Compared to 

lifetime non-smokers, smokers have twice the risk of dying from coronary heart 

disease and twice the risk of dying from stroke.

Figure 4: Levels of hypertension prevalence, awareness, treatment, and control, 

United States 1999-2002

Source: CDC. Racial/ethnic disparities in prevalence, treatment, and control of hypertension – 

United States, 1999-2002. MMWR 2005; 54:7-9.
Border Lives: Health Status in the United States-Mexico Border Region

258

Smoking cessation produces immediate health gains, and these gains gradually 

increase with long-term abstinence. The excess risk of death from coronary 

artery disease is reduced by about half after one year of smoking abstinence. 

After 15 years of abstaining from smoking, a former smoker’s risk of coronary 

heart disease and death from all causes is similar to lifetime non-smokers. Stroke 

risk decreases dramatically after two to four years of abstinence from smoking, 

and after 15 years the risk level is similar to those who have never smoked.

The national prevalence of cigarette smoking among adults aged 18 years or 

more declined during the 1990s and early 2000s from 27 percent in 1992, to 

23 percent in 2000, and 21 percent in 2004 (NCHS). Annual reductions in 

smoking prevalence have been somewhat larger in more recent years. Rates of 

cigarette smoking have also declined for various race/ethnicity groups, including 

Hispanics and Mexican-Americans. Figure 5 displays current differences in ageadjusted smoking rates and smoking status by race and ethnicity in 2004. Not 

only were cigarette smoking rates lower for Hispanics and Mexican-Americans, 

but the proportion of every-day smokers was much smaller, indicating a lower 

level of tobacco consumption among Hispanic and Mexican-American smokers 

(Lethbridge, 2004).

Smokers and other tobacco users usually begin using tobacco products during 

adolescence, developing an addiction that is difficult to break in adult life. In 

the 2005 Youth Risk Behavior Survey a large proportion of high school students 

Figure 5: Cigarette smoking rates* among persons 18 years of age and over, by 

smoking status and race/ethnicity, United States 2004

Source: Lethbridge-Ceiku, M., Rose, D., & Vickerie, J. Summary health statistics for U.S. adults: 

National Health Interview Survey, 2004. *Age-adjusted to the U.S. 2000 standard population
 Chapter 8 - Heart Disease and Stroke

259 

reported current smoking (defined as having smoked at least one day in the 30 

days preceding the survey) and current frequent smoking (defined as having 

smoked on 20 of 30 days before survey; CDC, 2006). The rates of current 

and current frequent smoking among high school students increased during 

the 1990s but declined in the early 2000s. In 2005, 23 percent of high school 

students were current smokers, and 9.4 percent were current frequent smokers.

The combined 2000-2003 NHIS provides some smoking information for the 

U.S.-Mexico border population (Albertorio, 2008). Figure 6 presents ageadjusted rates of cigarette smoking by smoking status for the United States and 

border residents. For the years 2000-2003, the proportion of border residents 

who were current smokers was smaller than the national rate, 17.4 percent versus 

22.4 percent. In the border region, the current smoking rate among Hispanics 

was lower than among non-Hispanics (15.5 percent versus 19.1 percent), 

although this difference is not statistically significant. The rate of every-day 

smoking was also much smaller for border Hispanics than for non-Hispanics.

While smoking rates are relatively low on the border, they are still higher than 

in the race/ethnicity group with the lowest smoking rate in the United States, 

Asian-Americans (11.2 percent). Current smoking rates expose a significant 

number of border residents to excess risk of heart disease and stroke. Continued 

efforts are needed to reduce the border smoking rate.

Figure 6: Cigarette smoking rates* among persons 18 years of age and over, by 

smoking status and race/ethnicity, United States and U.S.-Mexico border, 2000-

2003 

Source: 2000-2003 National Health Interview Surveys, National Center for Health Statistics 

*Age-adjusted to the U.S. 2000 standard population.
Border Lives: Health Status in the United States-Mexico Border Region

260

High blood cholesterol

Blood cholesterol level is directly related to the risk of coronary heart disease 

and also contributes to stroke risk (Cleeman, 1998; NINDS, 2004). The 

Framingham Heart Study documented the increasing risk of coronary heart 

disease with increases in cholesterol level (Kannel, 1979). Results from the 

Multiple Risk Factor Intervention Trial (MRFIT) suggest that coronary heart 

disease risk at 240 mg/dL is double that at 200 mg/dL and a cholesterol level of 

240-300 mg/dL raises coronary heart disease risk to more than four times that at 

200 mg/dL (NCEP, 1990).

These and other trials also demonstrated that total cholesterol is only part of the 

risk picture. Cardiovascular disease risk is also affected by the balance between 

the two types of cholesterol – high-density lipoproteins (HDL) and low-density 

lipoproteins (LDL) – and a third type of fat carried in the bloodstream, called 

triglycerides. HDL cholesterol is “good” cholesterol that helps prevent plaque 

from building up in arteries. An HDL level of 40 mg/dL or less is considered 

a major risk factor for heart disease. HDL levels of 60 mg/dL and above are 

desirable because they help to lower the risk of heart disease. LDL cholesterol is 

“bad” cholesterol that promotes plaque build-up on arterial walls. LDL levels of 

160 mg/dL and above are considered high. Triglycerides are another lipoprotein 

found in the bloodstream. Triglycerides can also contribute to atherosclerosis, 

and levels of 200 mg/dL and above are considered high (NHLBI, 2005).

These results, combined with findings on the effectiveness of dietary 

intervention and drug treatment in controlling blood cholesterol levels, led to 

the establishment of the National Cholesterol Education Program (NCEP) in 

1985 (Cleeman, 1998). The NCEP was implemented to increase professional 

and public cholesterol awareness, educate the public on the need for regular 

measurement of cholesterol, promote changes in diet to reduce fat intake, and 

encourage physical fitness and weight control. Guidelines developed by the 

NCEP recommend a total blood cholesterol level of 200 mg/dL or lower as the 

desirable level, with levels between 200-239 mg/dL considered borderline high 

and those above 240 mg/dL as high blood cholesterol. The NCEP and similar 

programs recommended that adults aged 20 years or more have their total and 

LDL cholesterol measured at least once every five years, that treatment with diet 

and/or drugs be initiated at lower cholesterol levels than previously used, and 

that men and women receive similar treatment.

As a result of these programs, major changes have been noted in physician and 

public awareness of the dangers of high cholesterol. Much remains to be done, 

however, to extend recommended treatment to all those who would benefit, 

particularly those with coronary heart disease. Based on the NCEP guidelines 

and blood cholesterol levels from the 1988-1991 NHANES survey, nearly 30 
 Chapter 8 - Heart Disease and Stroke

261 

percent of U.S. adults require medically supervised cholesterol reduction. This 

percentage includes the 10 million-plus coronary heart disease patients in the 

United States (Sempos, 1993). In the late 1990s, only one-third to one-half 

of coronary heart disease patients were receiving dietary or pharmacological 

treatment for high cholesterol, while an estimated 85 percent of patients would 

have benefited from such treatment (Cleeman, 1998).

Between 1988 and 2002 the use of diet and medical interventions grew, in 

particular the use of drugs to lower cholesterol levels. From 1988-1994 to 

1999-2002, the use of statins to reduce cholesterol in U.S. adults increased 

significantly, from 3.4 percent to 9.3 percent; among Mexican-Americans the 

use of statins rose from 2.4 to 6.0 percent (Carroll, 2005). The result has been 

continued declines in total and LDL cholesterol in U.S. men and women, 

particularly in men 60-74 years of age and women 50-74 years. Nevertheless, 

decreases in cholesterol levels were smaller than in previous decades, possibly 

because of the increased prevalence of obesity. Among Mexican-Americans, the 

only significant declines from 1988-94 to 1999-2002 occurred in total and LDL 

cholesterol for women (Carroll, 2005).

Age-adjusted cholesterol measures for the Hispanic population are similar to 

those for non-Hispanic whites, with the exception of triglycerides (Table 2). 

Average total cholesterol for Hispanics is slightly lower than in non-Hispanic 

whites, 202 mg/dL versus 204 mg/dL, but the difference is not statistically 

significant; the same is true for LDL cholesterol. The major difference is in the 

significantly higher level of triglycerides – 139 mg/dL for Hispanics, compared 

to 125 mg/dL for non-Hispanic whites and 94 mg/dL for non-Hispanic blacks. 

High levels of triglycerides appear to increase the risk of coronary heart disease, 

but more research is required before the connection is definitively established. 

Various reports published by the San Antonio Heart Study group have found 

roughly similar results for Mexican-Americans and non-Hispanic whites in an 

area near the U.S.-Mexico border (Hunt, 2003; Stern, 1999). No information is 

available on blood cholesterol levels for the population of the border region.

Table 2: Age-adjusted blood cholesterol levels by race and ethnicity, United 

States adults aged 20 years or more, 1999-2002 

Source: Carroll, M.D., Lacher, D.A, Sorlie, P.D., Cleeman, J.I., Gordon, D.J., Wolz, M., et al. 

(2005). Trends in serum lipids and lipoproteins of adults, 1960-2002. Journal of the American 

Medical Association, 294, 1773-1781.

 

 Total cholesterol 204 199 202

 HDL 51.2 54.5 48.9

 LDL 124 121 121

 Triglycerides 125 94 139

Non-Hispanic whites Non-Hispanic blacks Hispanic
Border Lives: Health Status in the United States-Mexico Border Region

262

Overweight, obesity, and physical inactivity

The increasing level of overweight and obesity is a growing public health 

problem for border residents and for all U.S. residents. Overweight or obese 

individuals are at increased risk of illness from high blood pressure, high blood 

cholesterol and other lipid disorders, type 2 diabetes, heart disease, stroke, 

gallbladder disease, sleep apnea, and certain cancers (HHS, 2000). The total 

cost of obesity-related illness in the United States is about $100 billion per year 

(Wolf, 1998). Men in the highest obesity category have more than double the 

risk of hypertension or high blood cholesterol, or both, compared to males of 

normal weight. Women in the highest obesity group are four times as likely 

to develop either or both of these risk factors compared to women of normal 

weight (HHS, 2000).

Prevention or reversal of overweight remains a challenge for individuals, the 

medical community, and public health practitioners. Overweight and obesity 

have been increasing since the 1970s in the United States, based on actual 

measurement of heights and weights collected through various rounds of the 

NHANES survey (Flegal, 1998). Increasing overweight is occurring in adults, 

adolescents, and children of all ethnicities. Mexican-Americans are among 

the most vulnerable, as NHANES surveys since the 1980s show high levels of 

obesity in Mexican-Americans in all three groups. NHANES collects data on 

Mexican-Americans, not on all Hispanics in the United States.

Public health campaigns and physician advice to develop a healthy diet, 

reduce caloric intake and increase physical activity have had little impact on 

the increasing levels of overweight and obesity. Few drugs exist that can help 

to reduce weight, and most have side effects that discourage use. Surgical 

treatments exist such as stomach stapling or banding, but the relatively high 

level of complications for these procedures limit their use primarily to the 

morbidly obese.

Table 3 provides national data on obesity trends for non-Hispanic whites, 

non-Hispanic Blacks, and Mexican-Americans from the 1980s to 2004. The 

results show increasing levels of obesity for all groups, but also the higher 

prevalence of obesity among Mexican-American women as compared to white 

non-Hispanic women. Obesity data based on actual measurement of heights 

and weights do not exist for the border region, but self-reported data are 

available from the 2000-2003 NHIS (Albertorio, 2008). The NHIS reported 

an age-adjusted obesity prevalence for the border of 21.9. There was a large and 

statistically significant difference in the level of obesity between Hispanics and 

non-Hispanics, 28.7 percent versus 17.6 percent. In addition, the 2004 Texas 

Behavioral Risk Factor Surveillance System (BRFSS) included a supplementary 

sample for Cameron, Webb, and Starr Counties, all of which border Mexico 
 Chapter 8 - Heart Disease and Stroke

263 

(unpublished data). The survey was conducted by telephone, which has been 

shown to underestimate obesity. However, the survey still reported an alarmingly 

high overall prevalence of obesity of 32 percent, plus an additional 37 percent 

who were overweight. Comparable obesity rates from other BRFSS surveys were 

26 percent for Texas and 23 percent nationally.

Public health and physician recommendations regarding increased physical 

activity also appear to have fallen on deaf ears. The proportion of Americans 

who engaged in no leisure-time activity rose from 24 percent in 1985 to 40 

percent in 1997 (HHS, 2000). Hispanics were the race or ethnic group with 

the highest level of inactivity, at 54 percent. Data from the Youth Risk Behavior 

Surveillance System indicate that major declines in vigorous physical activity 

among adolescents take place during the high school years, setting the pattern 

for inactivity in the adult years (HHS, 2000).

Physical activity is important both to prevent overweight and obesity and for its 

independent effects on high blood pressure and other risk factors. Several studies 

of Mexican-Americans document higher levels of no leisure-time physical 

activity than among whites for both men and women (Wei, 1996; Winkleby, 

1998). A national study reported that twice as many Mexican-American as white 

women engaged in no leisure-time physical activity, 44 percent versus 21 percent

 (Winkleby, 1998). This study also demonstrated that the level of physical 

inactivity among Mexican-American women remained higher than among white 

women regardless of the level of education. The 2000-2003 NHIS data showed 

that 43.2 percent (age-adjusted) of the entire border population had no leisuretime physical activity (Albertorio, 2008). More than half (54 percent) of all 

Hispanics and 36 percent of non-Hispanics reported no leisure-time activity.

Table 3: Age-adjusted prevalence of obesity by race and ethnicity for men and 

women aged 20-74 years, United States

Sources: Flegal, K.M., Carroll, M.D., Kuczmarski, R.J., & Johnson, C.L. (1998). Overweight and 

obesity in the United States: Prevalence and trends, 1960-1994. International Journal of Obesity, 

22, 39-47. Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.S., Tabak, C.J., Flegal, K.M. 

Prevalence of overweight and obesity in the United States, 1999-2004. (2006). Journal of the 

American Medical Association. 295. 1549-1555. * Non-Hispanic White and non-Hispanic Black 

data are from NHANES II, 1976-80; Hispanic data are from Hispanic NHANES, 1982-84. ** Data 

for 2003-04 are for men and women aged 20 years or more.

1976-80 or

1982-94* 12.0 14.8 15.0 30.0 15.4 25.4

1988-94 20.0 22.4 21.3 37.4 23.1 34.2

2003-04** 31.1 30.2 34.0 53.9 31.6 42.3

Male Female Male Female Male Female

Non-Hispanic Whites Non-Hispanic Blacks Mexican-Americans*
Border Lives: Health Status in the United States-Mexico Border Region

264

Diabetes

Diabetes has been closely associated with both risk factors for cardiovascular 

disease and cardiovascular disease itself. Common complications of diabetes 

include overweight, hypertension, and coronary heart disease. People with 

diabetes are also more likely to have a poor lipid profile, including high total 

cholesterol levels, low levels of HDL, and high levels of LDL and triglycerides. 

According to the National Diabetes Data Group (National Institutes of Health, 

1995), the most common cause of death in adults with diabetes is coronary heart 

disease. In people with diabetes, heart disease appears earlier in life and is more 

often fatal than in people without diabetes. Women with diabetes are affected 

by heart disease almost as often as men. Adults with diabetes have heart disease 

death rates two to four times higher than adults without diabetes; the risk for 

stroke is two to four times higher and the risk of death from stroke is 2.8 times 

higher among people with diabetes (American Diabetes Association, 2006).

Two cohort studies of Hispanics and non-Hispanic whites have looked at the 

association between diabetes and heart disease: the San Luis Valley Study and 

the San Antonio Heart Study (Stern, 1999; Swenson, 2002). Curiously, these 

two well-executed longitudinal studies came to opposite conclusions regarding 

the risk of heart disease among Hispanics with diabetes. The San Antonio Heart 

Study determined that the risk of cardiovascular disease was twice as great for 

Mexican-American diabetics as for non-Hispanic white diabetics. The San Luis 

Valley Diabetes Study found that male Hispanics with diabetes had a statistically 

significant decreased risk of cardiovascular disease. The San Antonio study 

had a much larger sample size and was able to obtain statistically significant 

differences for most study comparisons, but on the other hand relied on death 

certificate data to determine cause of death. The San Luis Valley study had a 

smaller sample size and so was able to show statistical significance for fewer 

of its findings, but used medical records of decedents to assign cause of death, 

a potentially more accurate source of information on the cause of death. The 

opposing conclusions of these two studies may be due to the different outcome 

measures used: The San Antonio study used any mention of cardiovascular 

disease, whether the underlying cause of death or not, as the outcome of 

interest; in the San Luis Valley study the outcome of interest was cardiovascular 

disease as the underlying cause of death.

Proper management of diabetes can help to reduce the risk of cardiovascular 

disease. By maintaining blood glucose (sugar) levels as close to normal as 

possible, people with diabetes may be able to lessen their risk of cardiovascular 

disease. The Diabetes Control and Complications Trial (1993) found that 

improved control of blood glucose levels in young adults with insulin-dependent 

diabetes mellitus may have reduced their excess risk of heart disease. Controlling

blood pressure can reduce the incidence of cardiovascular disease by one-third or 
 Chapter 8 - Heart Disease and Stroke

265 

more, and improving control of cholesterol or blood lipoproteins (HDL, LDL, 

triglycerides) can reduce cardiovascular complications by 20 percent or more 

(American Diabetes Association, 2006).

Detailed information on diabetes mortality, morbidity, and risk factors in the 

border region is provided in Chapter 7, “Diabetes.”

Conclusion

Heart disease and stroke have a major impact on health in the border region, 

causing disease, disability, and death. Mortality data suggest that Hispanics have 

much lower death rates due to heart disease and stroke than do non-Hispanic 

whites. This observed difference, in combination with higher levels of certain 

risk factors for Hispanics, gave rise to the theory of the “Hispanic paradox.” 

However, careful examination of longitudinal cohort studies raises questions 

about the Hispanic advantage in heart disease and stroke.

Over the last several decades, heart disease and stroke death rates have fallen, 

both in the United States and in the border area. However, heart disease and 

stroke remain the first and third leading causes of death for border residents. 

Cardiovascular disease death rates also rise sharply with age and are particularly 

high after age 65. As the elderly population in the border region grows, both 

because current residents are aging in place and because retirees are relocating 

to the area, the impact of heart disease and stroke on the region can be expected 

to increase. Hospital discharge rates for diagnoses associated with cardiovascular 

disease are generally lower on the border than in the rest of the United States.

A large percentage of the border population displays risk factors for 

cardiovascular disease, including high levels of obesity and physical inactivity, 

a high rate of diagnosed diabetes, and problems with blood pressure awareness 

and control. Compared to the U.S. population, border residents have advantages 

in terms of some risk factors, including lower rates of hypertension and of 

cigarette smoking.

This review of heart disease and stroke in the U.S.-Mexico border region 

suggests that public health efforts should continue to emphasize the Healthy 

Border and Healthy Gente 2010 program objectives targeting diabetes, obesity, 

and smoking, all of which contribute to cardiovascular disease. An additional 

recommendation, based on the findings of this review, is that hypertension 

screening and control be added to the list of Healthy Border 2010 objectives. 

Public and private health services should continue to promote health education 

regarding risk factors for cardiovascular disease and their control. Because of the 

lifestyle factors implicit in the development of many of these risk factors, schools 

should be enlisted to ensure that the health education and health promotion 

messages reach border youth as well as adults.
Border Lives: Health Status in the United States-Mexico Border Region

266

References

American Diabetes Association. (2006). Complications of diabetes in the United 

States. Retrieved April 15, 2006 from http://diabetes.org/diabetesstatistics/complications.jsp

American Heart Association. (2007). Primary prevention in the adult. Retrieved 

October 4, 2007, from http://www.americanheart.org/presenter.

jhtml?identifier=4704.

Albertorio, J.R. (2008). Chapter 3: Access to and use of health care. In , F.C. 

Notzon (Ed.),. Border lives (pp aa-BB). El Paso, TX: U.S.-Mexico 

Border Health Commission

Arizona Department of Health Services. (2000). Arizona inpatient discharge 

data. Hospital inpatient and emergency room statistics by first-listed 

diagnosis. Retrieved October 4, 2007 from http://www.azdhs.gov/plan/

hip/by/diagnosis/index.htm

Arizona Office of Border Health. (2004). Healthy Gente 2010. Arizona 

Department of Health Services. Retrieved August 17, 2007, from 

http://www.azdhs.gov/phs/borderhealth/healthy_gente.htm

Becker T.M., Wiggins C., Key C.R., Samet J.M. (1988). Ischemic heart disease 

mortality in Hispanics, American Indians, and non-Hispanic Whites in 

New Mexico, 1958-1982. Circulation, 78, 302-309.

California Office of Statewide Health Planning and Development. (2004). 

California Patient Discharge Database, 2000. Retrieved June 20 2004, 

from http://www.oshpd.state.ca.us/HID/HID/patient/discharges/index.

html

Carroll, M.D., Lacher, D.A, Sorlie, P.D., Cleeman, J.I., Gordon, D.J., Wolz, 

M., et al. (2005). Trends in serum lipids and lipoproteins of adults, 

1960-2002. Journal of the American Medical Association, 294, 1773-

1781.

Centers for Disease Control and Prevention. (1995). Hypertension among 

Mexican-Americans – United States, 1982-1984 and 1988-1991. 

Morbidity and Mortality Weekly Reports, 44, 635-639.

Centers for Disease Control and Prevention. (2005). Racial/ethnic disparities 

in prevalence, treatment, and control of hypertension – United States, 

1999-2002. Morbidity and Mortality Weekly Reports, 54, 7-9.
 Chapter 8 - Heart Disease and Stroke

267 

Centers for Disease Control and Prevention. (2006). Cigarette use among high 

school students – United States, 1991- 2005. Morbidity and Mortality 

Weekly Reports, 55, 724-726.

Centers for Disease Control and Prevention. (2006a). Hypertension-related 

mortality among Hispanic subpopulations – United States, 1995- 2002. 

Morbidity and Mortality Weekly Reports, 55, 177-180.

Cleeman J.I., Lenfant C. (1998). The National Cholesterol Education Program: 

Progress and prospects. Journal of the American Medical Association, 280, 

2099-2104.

Cooper R, C. J., Desvigne-Nickens P., Fortmann S.P., Friedman L., Havlik R., 

et al. (2000). Trends and disparities in coronary heart disease, stroke, 

and other cardiovascular diseases in the United States: Findings of the 

National Conference on Cardiovascular Disease Prevention. Circulation, 

102, 3137-3147.

Diabetes Control and Complications Trial Research Group. (1993). The effect 

of intensive treatment of diabetes on the development and progression 

of long-term complications in insulin-dependent diabetes mellitus. New 

England Journal of Medicine, 329, 977-986.

Flegal K.M., Carroll M.D., Kuczmarski R.J., & Johnson, C.L. (1998). 

Overweight and obesity in the United States: Prevalence and trends, 

1960-1994. International Journal of Obesity, 22, 39-47.

Goff D.G., Ramsey D. J., Labarthe D.R., Nichaman M.Z. (1994). Greater 

case-fatality after myocardial infarction among Mexican-Americans and 

women than among non-Hispanic whites and men: The Corpus Christi 

Heart Project. American Journal of Epidemiology, 139, 474-483.

Haffner S.M., Morales P.A., Hazuda H.P., Stern M.P. (1993). Level of control 

of hypertension in Mexican-Americans and non-Hispanic whites. 

Hypertension, 21, 83-88.

Hunt K.J., Resendez R.G., Williams K., Haffner S.M., Stern M.P., Hazuda 

H.P. (2003). All-cause and cardiovascular mortality among MexicanAmerican and non-Hispanic White older participants in the San 

Antonio Heart Study – Evidence against the “Hispanic paradox.” 

American Journal of Epidemiology 158, 1048-1057.
Border Lives: Health Status in the United States-Mexico Border Region

268

Hunt K.J., Williams K., Resendez R.G., Hazuda H.P., Haffner S.M., Stern 

M.P. (2002). All-cause and cardiovascular mortality among diabetic 

participants in the San Antonio Heart Study: Evidence against the 

“Hispanic paradox.” Diabetes Care, 26, 1557-1563.

Kannel W.B., Castel W. P., Gordon T. (1979). Cholesterol in the prediction of 

atherosclerotic disease. Annals of Internal Medicine, 90, 85-91.

Kozak L.J., Hall M.J., Owings M.F. (2002). National Hospital Discharge 

Survey: 2000 annual summary with detailed diagnosis and procedure 

data. Vital Health Statistics, 13(353), 1-194. (HHS publication no. 

(PHS) 2003-1724). Bethesda, MD: National Center for Health 

Statistics.

Lethbridge-Cejku M., Rose D., Vickerie J. (2006). Summary health statistics for 

U.S. adults: National Health Interview Survey, 2004. Vital and Health 

Statistics, 10(228). Bethesda, MD: National Center for Health Statistics.

Liao Y, C. R., Cao G, Kaufman JS, Long AE, McGee DL. (1997). Mortality 

from coronary heart disease and cardiovascular disease among adult 

U.S. Hispanics: Findings from the National Health Interview Survey 

(1986 to 1994). Journal of the American College of Cardiology, 30, 1200-

1205.

National Center for Health Statistics. (2000). Summary health statistics for 

U.S. adults: National Health Interview Survey (various years). Vital and 

Health Statistics. Series 10

National Cholesterol Education Program. (1990). Report of the Expert Panel on 

Population Strategies for Blood Cholesterol Reduction (NIH Publication 

90-3046). Bethesda, MD: National Institutes of Health, National 

Heart, Lung, and Blood Institute.

National Heart, Lung and Blood Institute (2005). High Blood Cholesterol: 

What You Need to Know. Retrieved October 5, 2007, from http://

www.nhlbi.nih.gov/health/public/heart/chol/wyntk.htm.

National Heart, Lung and Blood Institute.(2006). What is Atherosclerosis? 

Retrieved March 15, 2006, from www.nhlbi.nih.gov/health/dci/

Diseases/Atherosclerosis/Atherosclerosis_WhatIs.html.
 Chapter 8 - Heart Disease and Stroke

269 

National Heart, Lung and Blood Institute (2007). Morbidity and Mortality: 

2007 Chart Book on Cardiovascular, Lung and Blood Diseases. Bethesda 

MD: Author. Retrieved 10/1/07, from http://www.nhlbi.nih.gov/

resources/docs/cht-book.htm

National Institutes of Health, National Institute of Diabetes and Digestive and 

Kidney Diseases, National Diabetes Data Group. (1995). Heart Disease 

and Stroke. Diabetes in America, (2nd ed.). (NIH Publication No. 95-

1468). Bethesda, MD: Author.

National Institute of Neurological Diseases and Stroke (2004). Stroke: Hope 

Through Research. Retrieved April 15, 2006, from www.ninds.nih.gov/

disorder/stroke/detail_stroke_pr.htm.

Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.S., Tabak, C.J., Flegal, 

K.M. (2006). Prevalence of overweight and obesity in the United States, 

1999-2004. Journal of the American Medical Association, 295, 1549-

1555.

Palloni A., Arias E.(2004). Paradox lost: Explaining the Hispanic adult mortality 

advantage. Demography, 41, 385-415.

Pandey D.K., Labarthe D.R., Goff D.C., Chan W., Nichaman M.Z.. (2001). 

Community-wide coronary heart disease mortality in MexicanAmericans equals or exceeds that in non-Hispanic whites: The Corpus 

Christi Heart Project. American Journal of Medicine 110, 81-87.

Patel K.V., Eschbach K., Ray L.A., Markides K.S. (2004). Evaluation of 

mortality data for older Mexican-Americans: Implications for the 

Hispanic paradox. American Journal of Epidemiology, 159, 707-715.

Poe G.S., Powell-Griner E., McLaughlin J.K., Placek P.J. Thompson G.B., 

Robinson K. (1993). Comparability of the death certificate and the 1986 

National Mortality Followback Survey. Retrieved April 15, 2006. from 

http://www.cdc.gov/nchs/data/series/sr_02/sr02_118.pdf.

Ostchega Y., Yoon S.S., Hughes J., Louis T. (2008). Hypertension awareness, 

treatment and control – continued disparities in adults: United States, 

2005-2006. NCHS data brief no. 3. Hyattsville, MD: National Center 

for Health Statistics. Retrieved April 15, 2006, from http://www.cdc.

gov/nchs/data/databriefs/db03.pdf
Border Lives: Health Status in the United States-Mexico Border Region

270

Roccella E.J., Horan M.J. (1988). The National High Blood Pressure Education 

Program: Measuring progress and assessing its impact. Health 

Psychology, 7, (Suppl.), 297-303.

Sempos C.T., Cleeman J.I., Carroll M.D., Johnson C.L., Bachorik P.S., Gordon 

D.J., et al. (1993). Prevalence of high blood cholesterol among U.S. 

adults: An update based on guidelines from the second report of the 

National Cholesterol Education Program Adult Treatment Panel. 

Journal of the American Medical Association, 269, 3009-3014.

Sorel J.E., Ragland D.R., Syme S.L. (1991). Blood pressure in MexicanAmericans, Whites and Blacks: The Second National Health and 

Nutrition Examination Survey and the Hispanic Health and Nutrition 

Examination Survey. American Journal of Epidemiology, 134, 370-378.

Sorlie P.D., Backlund E., Johnson N.J., Rogot E. (1993). Mortality by Hispanic 

status in the United States. Journal of the American Medical Association, 

270, 2464-2468.

Stern, M.P., Gaskill S.P., Allen C.R., et al. (1981). Cardiovascular risk factors in 

Mexican-Americans in Laredo, Texas. American Journal of Epidemiology, 

113, 546-555.

Stern, M.P., Wei, M. (1999). Do Mexican-Americans really have low rates of 

cardiovascular disease? Preventive Medicine, 29(6 Pt 2), S90-95.

Swenson, C.J., Trepka, M., Rewers, M.J., Scarbro, S., Hiatt, W.R., Hamman, 

R.F. (2002). Cardiovascular disease mortality in Hispanics and nonHispanic Whites. American Journal of Epidemiology, 156, 919-928.

Texas Health Care Information Council (2001). Texas hospital inpatient 

discharge public use data file 2000. [Data file]. Austin, TX.

U.S. Census Bureau. (2005). Interim projections consistent with Census 2000. 

Retrieved April 15, 2006, from www.census.gov/population/www/

projections/popproj.html.

U.S. Department of Health and Human Services, Office of the Surgeon 

General, Office on Smoking and Health. (1989). Reducing the Health 

Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon 

General. (HHS Pub. No. (CDC) 89-8411). Bethesda, MD: Author.
 Chapter 8 - Heart Disease and Stroke

271 

U.S. Department of Health and Human Services. (1990). The health benefits of 

smoking cessation: A report of the surgeon general. (HHS Pub. No. (CDC) 

90-8416). Bethesda, MD: Author.

U.S. Department of Health and Human Services. (2000). Heart disease and 

stroke. In Healthy People 2010. (chap 12). Bethesda: MD: Author.

U.S. Department of Health and Human Services. (2006). The health 

consequences of involuntary exposure to tobacco smoke: A report of the 

Surgeon General – executive summary. Bethesda, MD: Author.

U.S.-Mexico Border Health Commission. (2003). Healthy Border 2010: An 

agenda for improving health on the United States-Mexico Border. El Paso, 

TX. 

Wei, M, V. R., Mitchell, B.D., et al. (1996). Migration status, socioeconomic 

status and mortality rates in Mexican Americans and Non Hispanic 

Whites: The San Antonio Heart Study. Annals of Epidemiology 6, 307-

313.

Winkelby, M.A., Kraemer, H.C., Ahn, D.K., Varaday, A.N. (1998). Ethnic and 

socioeconomic differences in cardiovascular disease risk factors: Findings 

for women from the Third National Health and Nutrition Examination 

Survey, 1988-1994. Journal of the American Medical Association, 280, 

356-362.

Wolf, A.M., Colditz, G.A. (1998). Current estimates of the economic cost of 

obesity in the United States. Obesity Research, 6, 97-106.

273 

I

njury is a major cause of death in the United States as well as in the U.S.-

Mexico border region. About two-thirds of all injury deaths are due to 

accidents or unintentional injuries. The remaining third are the result of 

intentional injuries, including suicides and homicides, and deaths with intent 

undetermined. Unintentional injuries alone were the fifth leading cause of death 

nationally and the fourth leading cause of death for the border in 2004.

This chapter reviews the various causes of unintentional and intentional injury 

deaths in the border region, with comparisons to the United States and other 

areas where appropriate. Information on injury deaths used in this chapter 

is from the National Vital Statistics Data System of the National Center for 

Health Statistics. Data for the border region are based on deaths occurring in the 

United States to residents of the 44 border counties. The analysis also considers 

injury death rates for various components of the border population, including 

men and women as well as Hispanics and non-Hispanic whites. Particular 

attention is paid to the younger ages, as many injury deaths are concentrated 

below age 45, and for some causes below age 25 years. Deaths among the 

young have the greatest impact on life expectancy and are viewed by many as 

representing the greatest loss to society.

To develop effective injury prevention programs, policy makers and public 

health leaders need information about who is dying from injuries, where they 

are dying, and how they are dying. To that end, this chapter focuses on the 

causes of injury deaths in the border region.

Understanding Injury

Injury results from the transfer of one or more types of physical energy 

(mechanical, thermal, etc.) in amounts or at rates that exceed human tolerance 

CHAPTER 9

INJURIES
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274

(Baker, 1992). Injury may also result from the lack of an essential substance, 

such as oxygen deprivation. Injury deaths may be intentional, such as homicide 

or suicide, unintentional, or of undetermined intent. Unintentional injuries 

may result from a variety of mechanisms, including motor vehicle crashes, 

fires, poisoning and falls. Although unintentional injuries are often referred to 

as accidents, in most cases the results are not accidental in the sense of being 

random, unpreventable events. Considerable evidence exists that most injuries 

can be predicted and therefore are preventable (Pless, 2005).

Economic costs of injury include not only the direct costs of medical care 

and rehabilitation, but also the loss of income to the individual and loss of 

productivity to society. Unintentional injuries alone cost the nation an estimated 

$565 billion in 2004, equivalent to $2,000 per capita or about $5,100 per 

household (National Safety Council [NSC], 2007). These costs far outweigh the 

costs of prevention. For example, it is estimated that each child auto safety seat 

saves an amount equal to its cost in direct medical costs and 15 times as much 

in indirect costs. Likewise, every bicycle helmet is estimated to save eight times 

its cost in direct medical and other costs (NSC, 1995).

Injuries and Healthy Border 2010 

In recognition of the importance of injuries to the overall health of border 

residents, Healthy Border includes three injury objectives among the program 

total of 21 objectives on the U.S. side. The injury objectives and their 2010 

targets focus on childhood injuries, injuries due to motor vehicle crashes, 

and suicides. Specifically, the objectives are: (a) reduce the death rate due to 

unintentional injuries by 30 percent for children zero to four years of age; 

(b) reduce the death rate due to motor vehicle crashes by 25 percent; and (c) 

reduce the death rate due to suicide by 15 percent (U.S.-Mexico Border Health 

Commission, 2003).

Injury Deaths by Intent

Injuries accounted for more than 3,400 deaths on the U.S.-Mexico border in 

2004, or about 7.5 percent of all border deaths. Table 1 shows injury deaths by 

intent in the border region. Nationally, injuries were somewhat less likely to be 

a cause of death, accounting for seven percent of all deaths. Both in the border 

region and nationally, about two-thirds of injury-related deaths in 2004 were 

due to unintentional injuries, while one-third were due to intentional causes. In 

2004 more than 2,300 border residents died from unintentional injuries.
 Chapter 9 - Injuries

275 

Unintentional injury deaths represented about five percent of all deaths in 

the border region and were the fourth leading cause of death. When ranked 

according to a measure known as the years of potential life lost (YPLL), 

unintentional injuries were the second leading cause of death. The YPLL measure 

assumes a potential life span of 75 years and adds up the years of life lost by 

those dying before age 75. In addition, unintentional injuries were the leading 

cause of death for residents less than 45 years of age, accounting for more than 

one-quarter of all deaths for this age group. The same age pattern held for both 

Hispanics and non-Hispanic whites in the border region. Together, unintentional 

and intentional injury deaths accounted for 40 percent of deaths among border 

residents less than 45 years of age, far higher than the proportion due to cancer 

(12 percent), the most common natural cause of death in this age group.

Within the border region, injuries accounted for a larger proportion of deaths in 

Arizona and New Mexico border counties compared to the border counties of 

California and Texas. In Arizona and New Mexico border counties, death rates 

per 100,000 population were almost exactly double the Texas border counties’ 

death rate for all types of injuries, 73.2 and 72.5 versus 36.8. This disparity 

was roughly the same for both unintentional and intentional injury deaths. 

Disparities were slightly smaller but still substantial for the four border states.

Both nationally and at the border, injury death rates in 2004 were much lower 

for women than for men, and for Hispanics as compared to Non-Hispanic 

whites, as shown in Table 2. The unintentional injury death rate for men was 

Table 1: Injury deaths by intent, U.S.-Mexico border counties, 2004

Source: National mortality data, NCHS/CDC

Note: Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population

 All Injuries Unintentional Intentional Injuries

 

Area Number Rate deaths Number Rate Number Rate

 

United States 167184 56.4 7.0 112012 37.7 50196 17.0

Border states 35230 54.8 7.9 22926 36.1 11635 17.5

Arizona 4388 77.2 10.0 2853 50.1 1411 22.5

California 16786 47.6 7.2 10530 30.1 5929 16.3

New Mexico 1790 95.4 12.8 1254 67.1 535 28.0

Texas 12266 57.6 8.0 8289 39.6 3760 16.8

Border counties 3423 50.3 7.5 2306 33.8 1059 15.7

Arizona border 933 73.2 8.9 618 47.8 291 23.4

California border 1474 47.8 7.1 972 31.5 479 15.6

New Mexico border 227 72.5 9.8 150 47.5 77 25.0

Texas border 789 36.8 6.7 566 26.2 212 10.1

Percent

of all

Injuries
Border Lives: Health Status in the United States-Mexico Border Region

276

more than twice that for women (46.9 vs. 21.2), while for intentional injury 

deaths the male rate was nearly four times the rate for women (25.2 vs. 6.8). In 

the border region, large differentials also existed by ethnicity, with substantially 

higher death rates among non-Hispanic whites than for Hispanics, for both 

unintentional injuries (40.7 vs. 26.9) and intentional injuries (19.4 vs. 10.2).

When these sex and ethnicity groups were combined, even larger differentials 

were seen, as depicted in Figure 1. For example, the intentional injury death rate 

for border Hispanic men was more than twice the level for Hispanic women, and 

the same male-female differential was true for non-Hispanic whites. Throughout 

the border region, injury death rates were substantially higher for non-Hispanic 

whites than for Hispanics for both types of injury deaths and for both sexes.

Table 2: Unintentional and intentional injury death rates by sex and ethnicity, 

U.S.-Mexico border counties, 2004

Source: National mortality data, NCHS/CDC

Note: Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population 

*C.I. = 95% confidence interval 

Figure 1: Unintentional and intentional injury death rates by sex and ethnicity, 

U.S.-Mexico border counties, 2004

Source: National mortality data, NCHS/CDC

Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population.

 Unintentional Intentional 

 

 Rate 95% C.I. Rate 95% C.I.

 

Male 46.9 (44.6, 49.3) 26.1 (24.3, 27.8)

Female 21.2 (19.7, 22.8) 7.7 (6.7, 8.6)

Hispanic 26.9 (24.7, 29.2) 10.8 (8.3, 13.4)

White non-Hispanic 40.7 (36.9, 44.5) 20.6 (16.7, 24.4)
 Chapter 9 - Injuries

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Unintentional Injury Deaths by Cause

Unintentional injury deaths result from a variety of causes, including motor 

vehicle crashes, firearms, drowning, falls, poisoning, and other mechanisms. 

Understanding the causes of injuries is an essential step toward devising effective 

injury prevention programs. Prevention of unintentional injuries requires 

addressing a group of complex problems involving different sectors of society, 

including health, education, transportation, law, engineering and others. 

Because many of these activities are aimed at modifying human behavior, they 

must be culturally and linguistically appropriate.

Table 3 provides data on the leading causes of injury death for all ages combined 

and for those below age 45. Little difference was observed between the United 

States and the border region in the ranking of causes of unintentional injury 

death by age. In both areas, motor vehicle crashes were the most common cause 

of unintentional injury death, accounting for nearly half of these deaths, followed 

by unintentional poisonings and falls. In the following sections, each leading 

cause of unintentional injury death shown in Table 3 is considered in turn.

In most mortality reports, unintentional injury deaths are grouped into one 

category and ranked in comparison to other causes of death. As a result, the 

category of unintentional injury deaths due to all causes is usually ranked as 

the fourth leading cause of death, as was mentioned above. One of the goals 

of this analysis was to show the importance of each of the various causes of 

unintentional injury death. Thus, each major cause of injury death is ranked 

separately, in comparison to all other causes of death.

Table 3: Leading causes of unintentional injury deaths, United States and U.S. 

Mexico border counties, 2004

 United States Border

 

Cause All ages 0-44 years All ages 0-44 years

Total number 112,012 50,311 2,306 1,060

 

 Percent distribution 

Motor vehicle

crash 40.1 53.9 42.1 56.5

Poisoning 18.7 24.7 22.7 26.4

Falls 16.8 2.6 15.0 1.1

Drowning 3.0 4.3 4.0 4.3

Source: National mortality data, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

278

Motor Vehicle Crashes

The causes of motor vehicle crashes are well known, and national road safety 

campaigns have succeeded in substantially reducing motor vehicle crash deaths 

in recent decades. Nonetheless, motor vehicle crashes remain the largest single 

cause of unintentional injury deaths, accounting for 40 percent of these deaths 

nationwide in 2004. Motor vehicle crashes are also a major source of injury 

and an important cause of property damage. Economically, motor vehicle crash 

deaths, injuries, and property damage impose a major burden on the nation.

Motor vehicle crashes are the result of a number of factors, some of which arise 

from inadequate government infrastructure and insufficient enforcement of 

driving regulations. Increased traffic volume, the result of a growing number of 

vehicles and passenger miles driven annually, poses one of the biggest challenges 

to reducing motor vehicle crash deaths. Local, state, and national governments 

have difficulty providing sufficient and safe roadways to accommodate growing 

vehicular traffic. Driver behavior also causes many crashes. High-risk behaviors 

include lack of compliance with driving regulations, use of alcohol or illegal 

drugs that impair drivers’ performance, and failure to use passenger restraints. 

Government enforcement of driving regulations is an effective way to address 

these behaviors, but funding for enforcement efforts is often limited.

In 2004, injury resulting from motor vehicle crashes was the eighth leading 

cause of death, both nationally and for the border region. Table 4 shows motor 

vehicle crash deaths, death rates, and ranking in the border region. The death

Table 4: Motor vehicle crash deaths, death rates, and ranking, 2004

Source: National mortality data, NCHS/CDC

Notes: Rates are per 100,000 population, age-adjusted to the US 2000 standard population;

CI* = 95% confidence interval

USA 44,933 15.2 (15.0, 15.3) 8 1 21.4 (21.2, 21.7) 9.3 (9.1, 9.4)

Arizona 1,156 20.1 (19.0, 21.3) 8 1 27.1 (25.2, 29.0) 13.3 (11.5, 15.2)

California 4,319 12.1 (11.8, 12.5) 8 1 16.9 (16.3, 17.5) 7.5 (6.9, 8.0)

New Mexico 533 27.9 (25.5, 30.3) 6 1 38.6 (34.5, 42.6) 17.6 (14.3, 20.8)

Texas 3,816 17.2 (16.7, 17.8) 6 1 24.5 (23.5, 25.4) 10.4 (9.7, 11.2)

Border counties 971 14.0 (13.1, 14.9) 8 1 19.7 (18.2, 21.2) 8.5 (7.5, 9.4)

Arizona border 230 18.0 (15.7, 20.4) 8 1 22.5 (18.7, 26.3) 13.8 (10.9, 16.6)

California border 371 12.0 (10.8, 13.2) 8 1 17.6 (15.5, 19.7) 6.3 (5.1, 7.6)

New Mexico border 64 19.8 (14.8, 24.7) 6 1 26.5 (18.3, 34.8) 13.3 (7.7, 18.8)

Texas border 306 13.5 (11.9, 15.0) 6 1 19.9 (17.2, 22.6) 7.5 (5.9, 9.0)

 

Border counties:

- Hispanics 469 13.8 (12.5, 15.1) 5 1 19.9 (17.6, 22.1) 8.1 (6.7, 9.5)

- non-Hispanic white 412 14.3 (12.9, 15.7) 9 1 19.6 (17.3, 21.9) 8.9 (7.3, 10.5)

Average

Annual

Number Rate CI* Rate CI* Rate CI*

Both Sexes Males Females

All

Causes

Ranking 

Unintentional

Injury
 Chapter 9 - Injuries

279 

rate from motor vehicle crashes exceeded the national rate of 15.2 per 100,000 

population in three of the four border states and in the border regions of two 

of those states. The highest death rates were reported in the state and border 

area of New Mexico. The New Mexico motor vehicle crash death rate was 

27.9, about 80 percent higher than the national rate; the New Mexico border 

rate was 19.8, or 30 percent above the national figure, although this difference 

was not statistically significant. In Arizona, the statewide death rate was 20.1 

and the rate for Arizona border counties was 18.0, both substantially above 

the national rate. The death rate for the entire border area (14.0) was eight 

percent lower than the national rate, largely due to the low death rates in the 

border regions of California (12.0) and Texas (13.5). The death rate for border 

Hispanics was slightly lower than the border non-Hispanic white rate (13.8 

versus 14.3), but the difference was not statistically significant. However, among 

border Hispanics, motor vehicle crashes were the fifth leading cause of death, 

while among non-Hispanic whites they were the ninth leading cause of death. 

The death rate for men was consistently higher than for women, nationally and 

across the border region.

Although the motor vehicle crash death rate declined substantially from 1990 

to 2000 for both the United States and for border counties, it did not change 

significantly between 2000 and 2004. Figure 2 shows these trends. Across the 

four border states, the motor vehicle crash death rate rose from 2000 to 2004 in 

Figure 2: Motor vehicle crash death rates, United States, border states, and 

border counties, 1994, 2000, and 2004

Source: National mortality data, NCHS/CDC

Rates are per 100,000 population, age-adjusted to the U.S. standard 2000 population. 
Border Lives: Health Status in the United States-Mexico Border Region

280

California and New Mexico but declined in Texas. The increase in Arizona from 

2000 to 2004 was not statistically significant.

Motor vehicle crash death rates were also available for individual border 

counties. Because the number of these deaths was quite small for many border 

counties, the counties were grouped into clusters and five years of data were 

combined to produce more stable and statistically reliable rates. Figure 3 

provides a border map depicting death rates in 2000-2004 for 13 clusters of 

counties along the U.S.-Mexico border. The lowest rates, ranging from 10.5 

to 14.8 deaths per 100,000 population, were found in four areas: San Diego 

County, California; two South Texas county clusters that include Laredo and 

Brownsville; and El Paso and neighboring counties in West Texas. The highest 

rates (ranging from 23.9 to 50 per 100,000) were in Cochise County, Arizona; 

western border counties of New Mexico; and a group of sparsely populated 

counties in West Texas. This last cluster had by far the highest death rate from 

motor vehicle crashes, 50.5 (CI=40.2, 60.7). These rates were based on deaths 

to border county residents; rates based on death by place of occurrence would 

provide slightly different results.

Motor vehicle crashes have their greatest impact on the young. As Table 5 shows, 

motor vehicle crashes are the leading cause of death for ages 1-4, 5-14, 15-24 

and 25-34 years, both nationally and for border counties. Motor vehicle crashes 

Figure 3: Motor vehicle crash rates by county clusters, U.S.-Mexico 

border, 2000-2004

Source: National mortality data, NCHS/CDC
 Chapter 9 - Injuries

281 

accounted for 20 percent or more of deaths for the age groups 5-14 and 15-24 

years. Among border Hispanics, motor vehicle crashes were even more important, 

representing more than 40 percent of all deaths in the 15-24 year age group.

The disproportionate impact of motor vehicle crashes on the young adds to the 

overall burden of this cause of death. The true impact of motor vehicle deaths 

is best illustrated using the YPLL measure. When the YPLL is used to rank 

causes of death, motor vehicle crashes are the third leading cause of death on 

the border. Figure 4 shows leading causes of death in border counties calculated 

using YPLL. Motor vehicle crashes are also the third leading cause of death 

among border Hispanics, based on the YPLL measure (data not shown).

Table 5: Motor vehicle deaths by age and ethnicity: proportion of all deaths and 

ranking, United States and U.S.-Mexico border counties, 2004

Figure 4: Leading causes of death based on years of potential life lost (YPLL), 

U.S.-Mexico border counties, 2004

Source: National mortality data, NCHS/CDC

 United States Border All Ethnicities Border Hispanic Border non-Hispanic White

 

Age Percent Ranking Percent Ranking Percent Ranking Percent Ranking

 

1-4 13.3 1 17.6 1 20.0 1 17.6 1

5-14 24.2 1 26.5 1 27.2 1 23.2 1

15-24 32.9 1 36.9 1 40.6 1 35.3 1

25-34 17.2 1 16.0 1 14.9 1 17.2 1

35-44 7.8 3 8.2 4 10.3 3 6.7 5

 

Source: National mortality data, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

282

Motor vehicle crash deaths also have a great impact on the elderly, as shown 

in Figure 5. In 2004, death rates were very high not only for teens and young 

adults 15-24 years of age, but also for the elderly, especially the population aged 

75 years or more. The pedestrian death rate, which is a component of the total 

motor vehicle crash death rate, was very low among the young but rose sharply 

after 64 years of age. Increased longevity, combined with an influx of retirees to 

the border states, is leading to significant growth in the elderly population of the 

border region. As a result, border traffic enforcement agencies are faced with the 

double challenge of ensuring the safety of two high-risk groups: the very young 

and the very old.

Risk Factors

A variety of factors, including behaviors, contribute to the risk of injury or death 

from motor vehicle crashes. Viewing motor vehicle crashes as a public health 

problem, however, makes it clear that many of these factors can be eliminated 

or mitigated through interventions (Bolen, 1997). The various risk factors and 

associated interventions are considered in turn.

Figure 5: Rates for motor vehicle crash deaths and pedestrian deaths by age, 

U.S.-Mexico border counties, 2004

Source: National mortality data, NCHS/CDC

Note: Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population. 

*MVC = Motor vehicle crash 
 Chapter 9 - Injuries

283 

Volume of traffic

As discussed in Chapter 1, “The U.S. Population at the Border,” the population 

of border counties and states is growing quickly. Rapid population growth in 

the border counties will clearly lead to a steady increase in vehicle miles driven. 

In addition, drivers in the border region are not limited to border residents. 

The population growth in non-border areas of border states will also add to the 

traffic load, as will drivers from other parts of the nation. Other contributing 

factors include population growth in the border areas of Mexico and the growth 

in cross-border traffic. Table 6 shows the number of incoming vehicle crossings 

for the U.S.-Mexico border during the years 1996, 2000, and 2003. The 

combined total of incoming trucks, buses and personal vehicles for the major 

ports of entry on the U.S.-Mexico border grew by more than 45 percent from 

1996 to 2000, although the number declined slightly in 2003. Nevertheless, 

more than 92 million vehicles entered the U.S. border region from Mexico in 

2003, an average of more than 250,000 incoming vehicles per day.

Table 6: Incoming vehicle crossings, U.S.-Mexico border 1996, 2000, and 2003

 1996 2000 2003

 

 Numbers in thousands

 

Personal vehicles 62,429 91,157 88,069

 Arizona 8,407 10,304 9,913

 California 11,116 30,018 32,675

 New Mexico 468 467 650

 Texas 42,438 50,368 44,831

 

Trucks 3,254 4,525 4,238

 Arizona 324 344 313

 California 755 1,032 1,020

 New Mexico 21 36 33

 Texas 2,154 3,113 2,872

 

Buses 120 270 319

 Arizona 4 14 13

 California 23 151 186

 New Mexico - - 1

 Texas 93 105 119

 

All vehicles 65,803 95,952 92,626

 Arizona 8,735 10,662 10,239

 California 11,894 31,201 33,881

 New Mexico 489 503 684

 Texas 44,685 53,586 47,822

Source: U.S-.Mexico Border Crossing Data, Bureau of Transportation Statistics, U.S. 

Department of Transportation. Based on data from U.S. Customs Service, Mission Support 

Services, Office of Field Operations, Operations management Database.
Border Lives: Health Status in the United States-Mexico Border Region

284

A useful measure of road traffic volume is the number of vehicle miles driven per 

year. The number of miles per vehicle has always been high in the border region 

due to urban sprawl and long distances between cities. The Federal Highway 

Administration (2000) estimates that the number of vehicle miles traveled in 

the four U.S. border states was nearly 500 million in 1990, a figure that rose 

to about 600 million miles in 2000. Projecting this trend forward produces an 

estimate of 900 million miles in 2020, or almost double the 1990 figure. The 

Federal Highway Administration also provides estimates of vehicle miles for the 

largest border counties. In these counties, vehicle miles increased by about three 

percent per year from 1995 to 2002. Assuming this rate of growth continues 

into the future, vehicle miles traveled in border counties will double by 2025.

Road traffic speed

Speed is a crucial factor in determining the likelihood of a motor vehicle crash, 

as well as the probability of injury or death. The higher the speed, the less time 

the driver has to react; high speed also greatly increases the chance of injury. As a 

rule of thumb, the probability of injury in a motor vehicle crash is proportional 

to the square of the speed, serious injury is proportional to the speed cubed, and 

fatal injury is proportional to speed to the fourth power (Andersson, 1997). In 

2005, the National Highway Transportation Safety Administration (NHTSA) 

estimated that about 30 percent of fatal crashes in the United States were speedrelated. For the border states this proportion was higher, ranging from about 34 

percent in California and New Mexico to about 40 percent in Arizona and Texas 

(NHTSA, 2006).

Speed is most important as a road safety factor among young drivers and 

highway drivers. Among young drivers, lack of experience and thrill-seeking 

behavior often lead to excessive speed and motor vehicle crashes that otherwise 

would be avoidable. Maximum speeds on highways have increased in recent 

years, adding to the risk of a crash, injury, and death for highway drivers. For 

both groups, enforcement of road safety rules is essential, although it is only part 

of the solution. Improvements in road design such as divided highways with 

restricted access, removal of roadside hazards, and appropriate lighting can also 

significantly reduce the risk of speed-related motor vehicle crashes (Peden, 2004).

Alcohol use

Alcohol consumption increases the likelihood of a motor vehicle crash and 

injury or death. A review of different blood alcohol limits in 16 states found that 

states with lower limits had seven percent fewer alcohol-related crashes (Shults, 

2001). Nationally, the estimated proportion of alcohol involvement (blood 

alcohol content >=80 mg/dL) in motor vehicle crash deaths was 34 percent 
 Chapter 9 - Injuries

285 

in 2004 (NHTSA, 2005). In Arizona and California, alcohol was involved in 

33 percent of motor vehicle crash deaths, a proportion similar to the national 

percentage. However, the proportion with alcohol involvement exceeded the 

national figure in the other two border states — particularly in Texas, where 

nearly 40 percent of fatalities occurred in alcohol-related crashes. Enforcement 

of blood alcohol limits is critical to reducing alcohol-related motor vehicle crash 

deaths, along with publicizing this enforcement and providing driver education 

via publicity campaigns.

Road design and rural roads

Road design is a key factor in determining the probability of motor vehicle 

crashes. The odds of road traffic crashes are raised by poorly designed roads that 

have blind intersections, inadequate lighting, poor signage, roadside hazards 

and other problems. Many rural roads include one or more of these design 

flaws. In addition, lower levels of traffic safety enforcement on these roads are 

exploited by many drivers, leading to excessive driver speed and/or alcohol use. 

Data from the state highway departments of the four border states indicated 

that a surprisingly high proportion of traffic fatalities occurred in rural areas, 

ranging from about 50 percent in California to about 60 percent in Arizona 

and Texas and nearly 75 percent in New Mexico (Arizona Department of 

Transportation, 2001; California Highway Patrol, 2001; New Mexico Highway 

and Transportation Safety Department, 2001; Texas Department of Public 

Safety, 2001).

Passenger restraints

Seat belts and child restraints can play a major part in preventing serious injury 

or death from motor vehicle crashes. Seat belts, especially in conjunction with 

airbags, can substantially enhance motor vehicle occupant safety. For drivers and 

front seat passengers, seat belts can reduce the risk of injury, serious injury, and 

death by 40 to 65 percent (Cummings, 2002). Child restraints reduce injury 

and fatalities in vehicle crashes by a similar amount (Traffic Safety Facts, 2002). 

Seatbelt and child restraint laws have greatly increased driver and passenger 

compliance, but usage varies greatly by state. On the basis of NHTSA data, seat 

belt use at the national level rose to 81 percent in 2006, up from 71 percent 

in 2000 (NHTSA, 2007). Seat belt use was above the national level in three 

of the four border states (90 percent in New Mexico and Texas; 93 percent in 

California) and below the national level in Arizona (79 percent). Seat belt use 

was far lower in fatal crashes: In 2005, more than half (52 percent) of all motor 

vehicle occupants killed in motor vehicle crashes were not using a seat belt or 

restraint (NHTSA, 2006). The proportion of fatal motor vehicle crashes in which 

seat belts were not used was similar in three of the four border states (Arizona, 54 
Border Lives: Health Status in the United States-Mexico Border Region

286

percent; New Mexico, 50 percent; Texas, 47 percent), while in California a much 

lower percentage of those killed were not using seat belts (34 percent).

Unintentional Poisoning

Poisoning is the second leading cause of unintentional injury death in both the 

United States and the U.S.-Mexico border region. Most poisoning deaths are due to 

drugs, as opposed to alcohol or other poisonous substances, and most of these are 

caused by abuse of prescription drugs, especially opioids, and various illegal drugs 

(Paulozzi, 2006). An increase in unintentional poisoning deaths in recent years has 

been reported for the United States (CDC, 2007; Paulozzi, 2006) and for New 

Mexico (CDC, 2005).

This section uses information on the underlying cause of death from the national 

vital statistics system to examine levels and recent trends in unintentional poisoning 

deaths in the U.S. border counties nearest to Mexico, the four border states, and 

the United States. In addition, this analysis also uses multiple cause of death data to 

determine the types of drugs used by decedents, including multiple drug use.

Between 2000 and 2004, unintentional poisoning deaths increased substantially 

along the U.S.-Mexico border, as Table 7 shows. The poisoning death rate 

increased in all four states during the four-year interval, although the change 

was not statistically significant for New Mexico. For the 44 border counties, 

the unintentional poisoning death rate also rose significantly during the same 

interval, from 6.4 to 8.0 deaths per 100,000 population. Poisoning death rates 

rose in the border counties of Arizona, California, and New Mexico during 

the four years, but the change was statistically significant only in California 

(from 5.7 to 8.4). In the border counties of Texas the poisoning death rate was 

unchanged during the interval.

Table 7: Unintentional poisoning death rates, United States and U.S.-

Mexico border, 2000 and 2004

 2000 2004

 

 Rate CI* Rate CI*

United States 4.5 (4.4, 4.6) 7.1 (7.0, 7.2)

Arizona 8.6 (7.8, 9.4) 10.7 (9.9, 11.6)

California 4.8 (4.5, 5.0) 7.2 (6.9, 7.4)

New Mexico 13.1 (11.4, 14.8) 15.3 (13.5, 17.1)

Texas 4.0 (3.7, 4.2) 6.6 (6.2, 6.9)

Border counties 6.4 (5.8, 7.1) 8.0 (7.3, 8.7)

Arizona border 13.2 (11.1, 15.4) 14.0 (11.8, 16.2)

California border 5.7 (4.8, 6.5) 8.4 (7.4, 9.4)

New Mexico border 8.2 (4.9, 11.6) 11.6 (7.7, 15.5)

Texas border 3.3 (2.5, 4.1) 3.3 (2.5, 4.1)

Notes: Rates are per 100,000 population, age-adjusted to the U.S. 2000 standard population 

*CI = 95% confidence interval 

Source: National mortality data, NCHS/CDC
 Chapter 9 - Injuries

287 

There were also large differences in the poisoning death rate across the border 

region in 2004. At the state level, New Mexico had the highest rate (15.3), while 

Texas and California had far lower rates (6.6 and 7.2, respectively). In the border 

counties, the highest rates were in Arizona and New Mexico (14.0 and 11.6, 

respectively), while the Texas border counties had by far the lowest rate (3.3).

Unintentional poisoning contributes to many injury deaths and it is a leading 

cause of death overall. For the border counties, unintentional poisoning was the 

thirteenth leading cause of death in 2004. However, when causes of death were 

ranked using the years of potential life lost (YPLL) methodology, unintentional 

poisoning emerged as the fifth leading cause of death in the border region.

Important differences were observed in unintentional poisoning death by age, 

sex, and ethnicity, as shown in Figure 6 and Table 8. First, unintentional 

poisoning virtually did not exist as a cause of death among young children on 

the border: In 2004 only two unintentional poisoning deaths occurred among 

children aged 0 to 14 years in the 44 border counties. Thereafter the death rate 

rose rapidly with age, peaked at ages 45 to 54 years, and fell sharply in older age 

groups. Second, major differences were observed in poisoning death rates by 

sex and by ethnicity. The male death rate was more than double the female rate 

(11.0 and 5.0), while the non-Hispanic white death rate was almost three times 

the rate for Hispanics (12.1 versus 4.2).

Figure 6: Unintentional poisoning death rates by age, U.S.-Mexico border counties, 2004

Source: National mortality data, NCHS/CDC

Note: Rates are per 100,000 population. 
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288

Types of drugs used

Most unintentional poisoning deaths are the result of drug abuse involving 

either illegal or prescription drugs, or poisoning from legal drugs taken in error 

or at the wrong dose. Abuse of illegal and prescription drugs, along with misuse 

of prescription drugs, accounted for nearly 80 percent of all unintentional 

poisoning deaths on the border in 2004. Multiple cause of death data provide 

some information on the types of drugs used by these decedents. The data 

in Table 9 are tabulated according to the first drug mentioned on the death 

certificate. Multiple drug use was reported in almost half (46 percent) of all 

such deaths; the largest number of illegal or prescription drugs used by a single 

decedent was seven. These deaths do not include deaths due to adverse effects 

of prescription drugs taken in the proper doses and as directed, which are 

coded elsewhere according to coding rules of the International Classification of 

Diseases, 10th Revision (ICD-10; WHO, 1992).

Of the 413 poisoning deaths caused by illegal and prescription drugs, more than 

one-third were caused by heroin and cocaine. Other opioids, which include 

many prescription analgesics such as codeine, oxycodone, and hydrocodone, 

accounted for nearly 31 percent of all unintentional deaths due to drug use. In 

addition, methadone, which is increasingly used as a prescription drug (Paulozzi, 

2006), caused a significant proportion of drug-related unintentional deaths. 

The total proportion of drug-poisoning deaths due to prescription drugs (other 

opioids and methadone) was almost 42 percent. Other studies have shown that 

most of the growth in unintentional poisoning deaths in the United States in 

recent years has been due to increased use of opioid analgesics (Paulozzi, 2006). 

A study of drug use in New Mexico demonstrated that deaths from illegal 

drug use were more likely to occur in larger urban areas of the state, while 

deaths from abuse or misuse of prescription drugs were most common in the 

smaller urban and rural areas of the state (CDC, 2005).

Table 8: Unintentional poisoning death rates by sex and ethnicity, U.S.-Mexico 

border counties, 2004

 Rate CI* Rate CI*

 

Both sexes 8.0 (7.3, 8.7) All ethnicities 8.0 (7.3, 8.7)

Male 11.0 (9.8, 12.1) Hispanic 4.2 (3.4, 4.9)

Female 5.0 (4.3, 5.8) non-Hispanic white 12.1 (10.4, 13.7)

 

Notes: Rates are per 100,000 population, age-adjusted to the US 2000 standard population.

CI* = 95% confidence interval

Source: National mortality data, NCHS/CDC 
 Chapter 9 - Injuries

289 

Falls

Falls are the third leading cause of unintentional injury death, both nationally 

and in the U.S.-Mexico border region. In 2004, falls caused 346 deaths in 

the 44 U.S. border counties, making falls the fifteenth leading cause of death 

on the border. Falls may lead to death both directly and indirectly. Falls are 

particularly important as a cause of injury among the elderly, as falls often lead 

to hip fracture. Among those aged 65 years or older, a hip fracture often results 

in an end to independent living and can begin the chain of events leading to 

death. Factors that contribute to falls among the elderly include difficulties in 

walking and balance, neurological and musculoskeletal disabilities, medications, 

dementia, and visual impairment (Tinetti, 1989).

Mortality due to unintentional falls rose slightly from 2000 to 2004 in the 

United States, increasing from 4.8 to 6.3 deaths per 100,000, but the rate did 

not change significantly in the border region. In 2004 the age-adjusted death 

rate due to falls on the U.S.-Mexico border was 5.4 per 100,000, slightly less 

than the national rate.

Table 10 provides 2004 fall mortality data for the United States, border states, 

border counties, and various subgroups. The border counties of Arizona and 

New Mexico had the highest fall death rates (7.9 and 8.2 per 100,000), while 

the rate was significantly lower in the border regions of California and Texas (5.2 

and 3.2). In both the United States and the border region, the fall death rate 

was significantly higher for men than for women. In both cases the male death 

rate exceeded the female rate by 70 percent. In general, fall death rates were 

Table 9: Unintentional drug poisoning deaths by cause, 

U.S.-Mexico border counties, 2004

Cause Number Percent

 

All causes 524 100.0

Illegal and prescription 

drugs 413 78.8

Other causes 111 21.2

 

 Drug poisoning deaths by type of drug used: 

All drugs 413 100.0

Heroin 43 10.4

Other opioids 127 30.8

Methadone 45 10.9

Other synthetic narcotics 24 5.8

Cocaine 109 26.4

Other and unspecified drugs 65 15.8

Source: National mortality data, NCHS/CDC 
Border Lives: Health Status in the United States-Mexico Border Region

290

higher for non-Hispanic whites than for Hispanics. For the United States as a 

whole, the fall death rate for non-Hispanic whites was 32 percent greater than 

for Hispanics (6.2 versus 4.7); in the border counties the rate for non-Hispanic 

whites was 80 percent above the Hispanic rate (6.3 versus 3.5).

Deaths due to falls increase significantly with age. Figure 7 provides the fall 

death rate by age for the total population of the U.S.-Mexico border counties in 

2004. The death rate from falls rose very gradually with age before age 65, but 

increased at an exponential rate for the older age groups.

Table 10: Unintentional drug poisoning deaths by cause, U.S.-Mexico border 

counties, 2004

Area and category Number Rate CI*

United States 18807 6.3 6.2, 6.4

Arizona 543 9.5 8.8, 10.5

California 1624 4.5 4.8, 5.2

New Mexico 225 11.8 11.0, 14.3

Texas 1051 4.7 5.6, 6.3

Border counties 346 5.4 4.8, 5.9

Arizona border 110 7.9 6.4, 9.4

California border 152 5.2 4.4, 6.1

New Mexico border 26 8.2 5.0, 11.3

Texas border 58 3.2 2.4, 4.0

 

United States 

 - Male 9856 8.2 8.0, 8.4

 - Female 8951 4.8 4.7, 4.9

 - Hispanic 978 4.7 4.4, 5.0

 - Non-Hispanic whites 16379 6.2 6.1, 6.3

 

Border counties 

 - Male 190 4.1 3.4, 4.8

 - Hispanic 73 3.5 2.4, 4.7

 - Non-Hispanic white 258 6.3 5.0, 7.6

 

Notes: Rates are per 100,000 population, age-adjusted to the US 2000 standard population.

CI* = 95% confidence interval

Source: National mortality data, NCHS/CDC 
 Chapter 9 - Injuries

291 

Violence: Homicide and Suicide

Violence, in the form of homicide and suicide, contributes notably to 

overall mortality both nationally and on the border. Homicides appear 

disproportionately among the young, and teenage suicide is a growing concern. 

The homicide death rate in the United States is by far the highest of any 

industrialized country. Based on data from the Organization for Economic 

Cooperation and Development (OECD; 2007), in 2002 the U.S. rate was 12 

times that in the United Kingdom, 10 times that in Italy, and more than double 

that in the next highest country, Finland. However, the United States has one of 

the lowest suicide rates of any industrialized country. Sixteen OECD member 

countries reported higher rates in 2002, with the highest rate (Hungary, 23.2) 

more than double the U.S. suicide death rate of 10.2.

Homicide

In 2004, homicide (death by assault) was the sixteenth leading cause of death in 

the U.S.-Mexico border counties and the fifteenth leading cause of death in the 

United States. There were 17,357 homicides in the United States in that year, 

326 of which occurred in the border region. In both areas, homicide was the 

second leading cause of death for the age group 15 to 24 years. The U.S. ageadjusted homicide death rate has remained at approximately 6.0 per 100,000 

population since 2000, with the exception of the spike in 2001 related to the 

September 11 events.

Figure 7: Unintentional fall death rates by age, U.S.-Mexico border counties, 

2004

Source: National mortality data, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

292

The homicide rate is generally higher for the border states than for the United 

States, while the border county rate is lower than the national rate, as shown 

in Table 11. Among border states, Arizona and New Mexico had the highest 

homicide death rates in 2004 (8.8 and 9.1), significantly higher than the 

statewide rates in California (6.7) and Texas (6.1). The homicide rate for 

the border counties was 4.6, significantly lower than the national rate (5.9). 

Among border counties, those in Arizona had the highest homicide rate (8.3), 

significantly higher than the border counties of the other states. The border 

area of Texas had by far the lowest homicide death rate (2.8). Significant 

differentials by sex and ethnicity also existed within the border region. The 

male homicide death rate was about three times the female rate for the border 

counties, somewhat less than the four-to-one ratio at the national level. The 

homicide death rate for Hispanics was higher than for non-Hispanic whites both 

nationally and on the border, although the disparity in homicide rates was much 

smaller in the border region.

Table 11: Homicide and suicide deaths and death rates, United States and U.S.-

Mexico border, 2004

 Homicides Suicides 

 

 Number Rate CI* Number Rate CI*

United States 17,357 5.9 5.8, 6.0 32,439 10.9 10.8, 11.1

Arizona 511 8.8 8.1, 9.6 880 15.7 14.7, 16.8

California 2,481 6.7 6.5, 7.0 3,366 9.6 9.3, 9.9

New Mexico 171 9.1 7.7, 10.5 360 18.9 16.9, 20.9

Texas 1,410 6.1 5.8, 6.5 2,301 10.7 10.2, 11.1

Border counties 326 4.6 4.1, 5.1 724 10.9 10.1, 11.7

Arizona border 101 8.3 6.7, 10.0 188 15.0 12.8, 17.1

California border 145 4.5 3.8, 5.3 329 10.9 9.7, 12.1

New Mexico border 16 ** ** 61 19.7 14.7, 24.7

Texas border 64 2.8 2.1, 3.4 146 7.2 6.0, 8.4

 

United States 

 - Male 13578 9.2 9.0, 9.3 25,566 17.5 17.3, 17.7

 - Female 3779 2.6 2.5, 2.6 6,873 4.5 4.4, 4.6

 - Hispanic 3271 7.2 6.9, 7.4 2,207 5.9 5.6, 6.2

 - Non-Hispanic white 5427 2.2 2.2, 2.3 27,001 11.0 10.8, 11.1

 

Border counties 

 - Male 257 7.2 6.3, 8.1 559 17.7 16.2, 19.2

 - Female 69 2.0 1.5, 2.5 165 4.9 4.1, 5.6

 - Hispanic 169 4.6 3.9, 5.3 177 5.5 4.7, 6.4

 - non-Hispanic white 89 3.2 2.5, 3.8 490 16.1 14.6, 17.5

 

Notes: Rates are per 100,000 population, age-adjusted to the US 2000 standard population

*CI = 95% confidence interval

** Figure does not meet standards for reliability or precision. 

Source: National mortality data, NCHS/CDC
 Chapter 9 - Injuries

293 

Prevention of homicides requires a variety of activities, many of which are 

proposed in Healthy People 2010, a national health education and health 

promotion program (U.S. Department of Health and Human Services [U.S. 

HHS], 2000). Implementing these strategies will require comparable data 

sources and standardized definitions. Without standardization, it is impossible 

to pursue strategies such as identifying and tracking subcategories of assault.

Suicides

Although the U.S. suicide death rate is lower than in many other countries, 

suicide remains the eleventh leading cause of death for the United States. Suicide 

is even more important on the U.S.-Mexico border, where it is the tenth leading 

cause of death. Suicide is a concern at any age, but teenage suicide represents a 

great loss not only to the individual but to society as well. When causes of death 

were ranked using the YPLL methodology, suicide was the fourth leading cause 

of death on the border.

Table 11 provides information on suicide death rates for the nation, border 

states, and border counties in 2004. Suicide death rates in the states of Arizona 

and New Mexico (15.7 and 18.9) were significantly higher than the national 

rate of 10.9. However, the suicide death rate for the 44 border counties was 

10.9, the same as the national rate. The border counties of Arizona and New 

Mexico had the highest suicide death rates in the border area (15.0 and 19.7), 

while the Texas border counties had the lowest rate (7.2). As with homicides, the 

male suicide rate was nearly four times the female rate, both nationally and in 

the border counties. The ethnic differences in suicide death rates, however, were 

the opposite of the homicide differentials, with the rate among non-Hispanic 

whites much higher than among Hispanics. Nationally, the non-Hispanic white 

suicide death rate was nearly two times the Hispanic rate, while on the border the 

non-Hispanic white rate was nearly three times the Hispanic rate. Nonetheless, 

suicide remains the twelfth leading cause of death among border Hispanics.

Suicide is uncommon among children under 10 years of age, but suicide deaths 

increase rapidly beginning at age 15. Teenage suicides are of particular concern 

as it is the third leading cause of death among the 15 to 24 year age group, 

both nationally and on the border. Figure 8 provides suicide death rates for 

15 to 24 year olds for the United States, border states, and border counties. To 

produce stable rates for the border counties, data were combined for the years 

2002-2004. The state rates for Arizona and New Mexico (16.8 and 20.1) were 

significantly higher than the national rate (10.0), and the same was true for the 

border counties of Arizona (14.3). The death rate for the New Mexico border 

counties (13.3) also exceeded the national rate, but the difference was not 

statistically significant.
Border Lives: Health Status in the United States-Mexico Border Region

294

Suicide is a preventable public health problem, although suicides and suicide 

attempts are difficult to predict. The most common risk factors for suicide 

include depression and other mental disorders, stressful life events, prior suicide 

attempt, a family history of mental disorder, a family history of suicide, and 

access to lethal suicide methods such as firearms (NIMH, 2006). The difficulty 

in predicting suicide means that most prevention programs focus on the known 

risk factors. Promising approaches to suicide prevention include recognition and 

treatment of mental disorders and drug abuse, along with reduction in access to 

lethal methods (Moscicki, 2001). Suicide prevention programs for the border 

need to use interventions targeted to the appropriate risk factors for various age, 

ethnic, and cultural groups. Chapter 10, “Mental Health” contains information 

for the border region on depression and other mental health problems that may 

be associated with suicide.

Injury Deaths in Early Childhood

In 2004, injury was the third leading cause of death in early childhood, defined 

as birth to four years of age. Beyond the first year of life however, intentional and 

unintentional injuries were the leading cause of death, accounting for nearly 40 

percent of all deaths among border children one to four years of age (data not 

shown). Injury causes a much smaller proportion of deaths during the first year of 

life (4 percent), but a surprising number of injury deaths occurred even in infants.

Figure 8: Suicide death rate for 15-24 year olds, United States, U.S.-Mexico 

border states, and border counties, 2002-2004

Source: National mortality data, NCHS/CDC
 Chapter 9 - Injuries

295 

Figure 9 provides the distribution of early childhood injury deaths by cause in 

2002-2004 separately for the United States and the border counties. As with 

other age groups, motor vehicle crashes were the leading cause of injury death 

for both areas (22 percent for the United States, 30 percent for the border). 

Homicides were the second leading cause of injury death in early childhood, 

accounting for nearly the same proportion of deaths as motor vehicle crashes: 20 

percent for the United States and for the border counties.

Drowning was the third leading cause of injury death for children under five 

years of age. Drowning caused 15 percent of early childhood injury deaths 

for the United States and 19 percent of those deaths in the border region. As 

mentioned earlier, poisoning was not an important cause of early childhood 

death. Homicides and drownings accounted for a much larger proportion of 

injury deaths in early childhood than at other ages, although the total number 

of injury deaths in early childhood was relatively small. The proportion of 

injury deaths due to motor vehicle crashes and drownings was larger on the 

border than for the United States as a whole. However, there was no statistically 

significant difference in the death rates due to these causes.

Conclusion and Recommendations

Unintentional and intentional injuries are a major health problem in the 

U.S.-Mexico border region and often go unmentioned in discussions of border 

health. Unintentional injuries account for five percent of all border deaths, and 

they are the fourth leading cause of death in the region — second if ranked in 

terms of the number of years of potential life lost. Combined with intentional 

injury deaths, these external causes represent 7.5 percent of all deaths in the 

border area, more than any other cause except heart disease and cancer. If 

Figure 9: Percent distribution of the leading causes of injury death in children 

0-4 years of age, United States and border counties, 2002-2004

Source: National mortality files, NCHS/CDC
Border Lives: Health Status in the United States-Mexico Border Region

296

considered separately, four external causes of death would be ranked among 

the 15 leading causes of death: motor vehicle crashes (eighth), suicides (tenth), 

unintentional poisoning (thirteenth), and falls (fifteenth). A fifth external cause 

of death, homicide, is the sixteenth leading cause of death in the border region.

While injury is a public health issue everywhere on the border, some causes 

of injury are more common in certain areas and in certain ethnic groups. 

In general, injury death rates are higher in Arizona and New Mexico, both 

statewide and in the border counties, than in California and Texas. This is true 

for both unintentional and intentional injuries. Regarding specific causes of 

injury, the death rate due to motor vehicle crashes is higher than the national 

rate in the border counties of Arizona and New Mexico. In one cluster of 

border counties in West Texas the motor vehicle crash death rate is more than 

three times the national rate. In the states of Arizona and New Mexico, as well 

as in their border counties, the death rate due to unintentional poisoning is 

substantially higher than the U.S. rate. Deaths due to falls are more common 

in the border area of Arizona than elsewhere on the border. The death rate 

from intentional injuries (homicide and suicide) is higher in Arizona and New 

Mexico, both statewide and on the border. For Hispanics, injury death rates 

are higher for motor vehicle deaths (among those 15 to 24 years of age) and for 

homicides. For non-Hispanic whites, death rates are higher for unintentional 

poisoning, falls, and suicides. For all the major causes of injury death, including 

falls, the rates are much higher for men than for women.

Unintentional injuries often are thought of as random events or accidents 

– outcomes that could not be prevented. Extensive research on injuries has 

demonstrated that many of these events are, in fact, predictable. Predictability 

implies that many injuries can be prevented, typically by addressing risk factors 

for various causes of injury. Other programs can mitigate the severity of injury, 

saving lives or reducing the medical or other costs that result from injury. 

Intentional injuries similarly can be prevented by addressing known risk factors 

for assault or suicide. 

Public health, mental health, and public safety groups need to work together 

in designing interventions that target known risk factors for various causes 

of injury. These intervention programs should be culturally and linguistically 

appropriate, and should be aimed at specific groups of the border population. 

Examples of these interventions include:

•	 Enforcement of existing laws, such as for road traffic safety.

•	 Enhanced supervision of high-risk groups, such as very young and elderly 

drivers, underprivileged youth, and others.

•	 Education programs related to proper driver and pedestrian behavior, injury 
 Chapter 9 - Injuries

297 

prevention for children (bicycle helmets), physician education regarding 

usage of drugs in the treatment of pain and psychiatric problems, and 

others.

•	 Outreach programs aimed at activities for underprivileged youth, exercise 

programs for the elderly, drug counseling, suicide prevention, treatment of 

mental health disorders, and poison control centers.
Border Lives: Health Status in the United States-Mexico Border Region

298

References

Andersson, G., & Nilsson, G. (1997) Speed management in Sweden. Linkoping, 

Sweden: Swedish National Road and Transport Institute.

Arizona Department of Transportation. (2001). Arizona motor vehicle crash facts 

2000. Phoenix, AZ: Author. Downloaded July 31, 2007, from http://

www.azdot.gov/mvd/Statistics/crash/PDF/00crashfacts.pdf

Baker, S.P., O’Neill, B., Ginsburg, M.J., Li, G. (1992) The injury fact book. New 

York: Oxford University Press.

Bolen, J., Sleet, D.A., Chorba, T. (1997). Overview of efforts to prevent motor 

vehicle-related injury. In: J. Bolen, D.A. Sleet, & V. Johnson, (Eds.), 

Prevention of motor vehicle-related injuries: a compendium of articles 

from the Morbidity and Mortality Weekly Report, 1985-1996. (pp. 1-7) 

Atlanta, GA: Centers for Disease Control and Prevention.

California Highway Patrol. 2000 Annual Report of Fatal and Injury Motor Vehicle 

Traffic Collisions. Retrieved July 31, 2007, from http://www.chp.ca.gov/

switrs/switrs2000.html

Centers for Disease Control and Prevention.(2005). Unintentional deaths from 

drug poisoning by urbanization of area – New Mexico, 1994–2003. 

Morbidity and Mortality Weekly Report, 54, 870-873.

Centers for Disease Control and Prevention. (2007). Unintentional poisoning 

deaths – United States, 1999–2004. Morbidity and Mortality Weekly 

Report, 56, 93-96.

Cummings, P., McKnight, B., Rivara, F.P., Grossman, D.C. (2002). Association 

of driver air bags with driver fatality: a matched cohort study. British 

Medical Journal, 324:1119-1122.

Federal Highway Administration. (2001). Highway Statistics 2000. Retrieved 

July 27, 2007, from http://www.fhwa.dot.gov/ohim/hs00.index.htm.

Moscicki, E.K. (2001). Epidemiology of completed and attempted suicide: 

toward a framework for prevention. Clinical Neuroscience Research, 1, 

310-323.

National Highway Transportation Safety Administration, National Center for 

Statistics and Analysis. (2002). Traffic safety facts 2002: Children. (DOT 

publication HS-809-607) Washington, DC: Author.
 Chapter 9 - Injuries

299 

National Highway Transportation Safety Administration, National Center for 

Statistics and Analysis. (2005, August). Traffic safety facts: Alcohol-related 

fatalities in 2004. (DOT publication no. HS-809-904). Washington, 

DC: Author.

National Highway Transportation Safety Administration, National Center 

for Statistics and Analysis. (2006). Traffic safety facts 2005. (DOT 

publication no. HS 810 631). Washington, DC: Author.

National Highway Transportation Safety Administration, National Center for 

Statistics and Analysis. (2007). Traffic safety facts: Seat belt use in 2006 

– Use rates in the states and territories. (DOT publication no. HS-810-

690). Washington, DC: Author.

National Institute of Mental Health. (2006). Suicide facts. (NIH Publication 

No. 03-4594). Bethesda, MD: Author. Retrieved July 24, 2007, from 

www.nih.gov/publicat/suicidefacts.pdf

National Safety Council. (1995). Accident Facts. (1995 ed.) Itaska, IL: Author.

National Safety Council. (2007). Injury facts. (2005-2006 ed.) Itaska, IL: 

Author.

New Mexico Highway and Transportation Safety Department. (2001). New 

Mexico traffic crash information, 2000. Retrieved July 31, 2007, from 

http://www.unm.edu/~dgrint/annual/annrept00.pdf

Organization for Economic Cooperation and Development. (2007). 

Organization for Economic Cooperation and Development Health 

Data. Retrieved July 23, 2007, from http://www.ecosante.org/index2.

php.

Paulozzi, L.J., Budnitz, D.S., Xi, Y. (2006). Increasing deaths from opioids 

analgesics in the United States. Pharmacoepidemiology and Drug Safety, 

15, 618-627.

Peden, M., Scurfield, R., Sleet, D., Mohan, D., Hyder, A.A., Jarawan, E., 

Mathers, C. (Eds.). (2004). World report on road traffic injury prevention: 

summary. Geneva, Switzerland: World Health Organization.

Pless, I.B., Hagel, B.E. (2005). Injury prevention: a glossary of terms. Journal of 

Epidemiology and Community Health; 59, 182-185.
Border Lives: Health Status in the United States-Mexico Border Region

300

Shults, R.A., Elder, R.W., Sleet, D.A., Nichols, J.L., Alao, M.O., CarandeKulis, V.G., et al. (2001). Reviews of evidence regarding interventions 

to reduce alcohol-impaired driving. American Journal of Preventive 

Medicine, 21(4S), :66-88.

Texas Department of Public Safety. (2001). Motor Vehicle Traffic Accidents 

2000. Retrieved July 31, 2007, from http://www.txdps.state.tx.us/

administration/driver_licensing_control/accident_records/mvta2000/

mvta2000.pdf

Tinetti, M.E., Speechley, M. (1989). Prevention of falls among the elderly. New 

England Journal of Medicine, 320, 1055-1059.

U.S. Department of Health and Human Services. (2000). Healthy People 2010. 

(Vols. 1-2, 2nd ed.). Washington, D.C.: U.S. Government Printing 

Office.

World Health Organization. (1992). International statistical classification of 

diseases and related health problems [Tenth revision]. Geneva: World 

Health Organization.
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Mental health is an essential component of health and well-being. 

Ensuring mental well-being has been identified as a public policy 

priority in the United States (New Freedom Commission on Mental 

Health, 2003; U.S. Department of Health and Human Services [HHS], 1999, 

2001). Poor mental health is associated with reduced quality of life, death, and 

a number of direct social costs. These include treatment costs, family resources 

(McGuire, 2002), reduced work hours and absenteeism, and lower productivity, 

(Ettner, 1997, 2000; Kessler, 1997, 1999). Similarly, substance use is associated 

with health and social burdens such as treatment, crime, reduced labor market 

participation and death (Office of National Drug Control Policy, 2004).

Poor mental health affects women and men of all racial and ethnic groups 

(Kessler, 2003a, 2003b, 2005a; Ojeda, 2006). Disparities in access to mental 

health and substance use treatment services by race/ethnicity, nativity (i.e., 

U.S.- vs. foreign-born), and socioeconomic status are well-documented (Alegria, 

2002; Kessler, 1999, 2005b; Ojeda 2006; Vega, 1999, 2001). Ethnic minorities, 

immigrants, and low-income persons face diverse barriers in accessing mental 

health services, including financial and health system barriers, psychosocial 

barriers such as stigma, or obstacles to timely or appropriate care due to 

language differences (HHS, 1999, 2001). However, effective treatments are 

available for many conditions (HHS, 2001), making it critical that individuals 

who need care are able to obtain timely, affordable, and culturally appropriate 

treatments.

The U.S.-Mexico Border Health Commission (2003) has identified mental 

health as a priority issue of Healthy Border 2010. The Healthy Border objective 

that directly focuses on mental health is: Reduce suicide mortality by 15 

percent, from 11.0 to 9.4 deaths per 100,000 population.

CHAPTER 10

MENTAL HEALTH
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302

Report Objectives

To date, numerous studies have reported on national and regional patterns of 

psychiatric morbidity, including by race and ethnicity (Alegria, 2007; Grant, 

2004; Ojeda, 2006; Vega, 1998). However, data on the prevalence of mental 

illness and substance use and on the prevalence of utilization of mental health 

and substance use services in the U.S.-Mexico border region have not been 

previously examined. This chapter aims to fill this gap by addressing these issues.

First, the prevalence of two mental health status indicators (i.e., Serious 

Psychological Distress and Major Depressive episode) and the use of any mental 

health services during the prior year was reported. The second section is devoted 

to examining the prevalence of illicit substance use and substance use treatment 

services. Where possible, the experiences of adult Hispanics and non-Hispanics 

and by nativity is reported.

Methods

This chapter investigates the relationships between ethnicity (Hispanic vs. nonHispanic) and nativity (U.S.- vs. foreign-born) and various mental health and 

substance use and treatment indicators, nationally and in U.S. counties on the 

U.S.-Mexico border. The U.S. border counties are defined as counties in the 

United States that are within the 100-kilometer limit of the U.S.-Mexico border.

Data are from aggregated waves of the 2004-2005 and 2002-2005 Substance 

Abuse and Mental Health Services Administration’s (SAMHSA) National Survey 

on Drug Use and Health (NSDUH), a population-based survey. The NSDUH 

is the primary source of information on the use of illicit drugs, alcohol, and 

tobacco by the civilian, noninstitutionalized population of the United States. 

The NSDUH interviews persons aged 12 years or older, although this chapter 

focused on adults aged 18 or older. The survey also collects data on mental 

illness, including serious psychological distress and major depression. Data 

from the survey can be used to examine the co-occurrence of substance use and 

mental health disorders. Since 1999, the NSDUH interview has been carried 

out using computer-assisted interviewing (CAI). Most of the questions are 

administered with audio computer-assisted self interviewing (ACASI). Data 

were analyzed with SUDAAN, a software package that accounts for the survey’s 

complex sample design. Statistical significance was assessed by examination of 

overlap of 95 percent confidence intervals. Since sample sizes were insufficient to 

report on individual counties and border states, data are reported for the nation 

and aggregated for all border counties, henceforth, the border region.
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Using the NSDUH data, the prevalence of serious psychological distress in 

the prior year, the prevalence of major depressive episode in the prior year, use 

of any mental health treatment in the prior year, and unmet need for mental 

health treatment in the prior year was examined. Lifetime use of any illicit drug, 

prior year use of any illicit drug, prior year use of substance use treatment, and 

lifetime use of substance use treatment was also examined.

This text provides a brief summary of the mental health and treatment measures 

analyzed. Serious psychological distress is defined as having a score of 13 or 

higher on the K6 Scale (Kessler, 2002, 2003c). Serious psychological distress is 

a non-specific measure of mental illness and refers to the presence, at some time 

in the prior year, of a diagnosable mental, behavioral, or emotional disorder 

meeting criteria described in the fourth edition of the Diagnostic and Statistical 

Manual of Mental Disorders (DSM-IV), excluding substance use disorder, and 

which also resulted in functional impairment or significant interference with or 

limitation of activities of daily living and instrumental activities of daily living.

Major depressive episode is defined as a period of at least two weeks in the 

previous year when a person experienced a depressed mood or loss of interest or 

pleasure in daily activities and had a majority of the symptoms for depression as 

described in DSM-IV.

Mental health treatment is defined as having received inpatient or outpatient 

care or having used psychotropic medications for problems with emotions, 

nerves, or mental health. Unmet need for mental health treatment is defined as a 

perceived need for treatment that was not received.

This chapter also reports on illicit drug use and treatment. Illicit drugs are 

defined as: marijuana/hashish, cocaine (including crack), heroin, hallucinogens, 

inhalants, and prescription-type psychotherapeutics used nonmedically. 

Substance use treatment refers to treatment received in order to reduce or stop 

illicit drug or alcohol use, or for medical problems associated with illicit drug 

or alcohol use. It includes treatment received at any location, such as a hospital, 

rehabilitation facility (inpatient or outpatient), mental health center, emergency 

room, private doctor’s office, self-help group, or prison/jail (SAMSHA, 2006).

Mental Health Status

Mental health status can be assessed through clinical interviews, validated scales 

in population-based surveys, mortality rates due to suicide, and in other ways. 

Two indicators of mental health status occurring within the prior 12 months 

were examined: Serious Psychological Distress (Kessler, 2002, 2003c), which is 

a nonspecific measure of mental illness, and occurrence of a Major Depressive 
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304

Episode, also referred to as major depression. The prevalence of these two 

measures for adults only as they were unmeasured in youths was reported.

Nationally, one of every eight (11.6 percent) adults experienced serious 

psychological distress (Figure 1). When data are examined by ethnicity, a 

slightly lower proportion of non-Hispanics (10.2 percent) and slightly higher 

proportion of Hispanics (12.8 percent) had experienced serious psychological 

distress in the prior year. Nevertheless, rates for border counties or by Hispanic 

status were not statistically different from national rates.

Compared to serious psychological distress, the prevalence of major depression 

was significantly lower for Hispanics and non-Hispanics, both nationally and in 

border counties. For example, 5.8 percent of non-Hispanics in border counties had 

experienced an episode of major depression in the prior year, as had 5.5 percent of 

Hispanics; these differences are not statistically different.

When data were disaggregated by Hispanic status and nativity, greater variation 

in rates of psychological distress were observed, both nationally and in border 

counties, as shown in Figure 2. Nationally, U.S.-born Hispanics exhibited the 

highest rate (15.4 percent) of psychological distress in the prior year compared 

to other groups. Among immigrant populations, national rates of psychological 

distress were similar for Hispanics and non-Hispanics (8.8 percent and 8.2 percent, 

respectively). Border county rates were within the range of national rates and 

confidence intervals were wide, hence differences were not statistically significant. 

Nevertheless, the data suggest that a greater proportion of immigrant Hispanics 

residing in the border region had experienced psychological distress in the prior year 

compared to immigrants nationwide (12.4 percent vs. 8.8 percent, respectively).

Figure 1: Prevalence of serious psychological distress and major depression 

during previous 12 months, 18 years and older, United States and all border 

counties, 2004-2005
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Data on major depression by Hispanic status and nativity suggest that rates for 

border counties are within the range of national data, as depicted in Figures 

1 and 3. Nationally, native-born Hispanics and non-Hispanics reported 

similar rates of major depression, about 8 percent each (Figure 3). Immigrant 

Hispanics and non-Hispanics also exhibited similar rates of major depression 

(approximately 5 percent for each). However, immigrants’ rates of major 

depression were slightly lower than those of their native-born counterparts. Data

Figure 2: Prevalence of serious psychological distress by Hispanic ethnicity 

and nativity, United States and all border counties, 18 years and older, 2004-

2005

Figure 3: Prevalence of major depression, past year, by Hispanic status and 

nativity, United States and all border counties, ages 18 and older, 2004-2005

Percent
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306

for major depression among Hispanics and non-Hispanics residing in border 

counties had wide confidence intervals and thus did not appear to be statistically 

different from national rates.

Utilization of Mental Health Services

Individuals with mental disorders can benefit from timely treatment (HHS, 

1999, 2001). We examined the prevalence of use of mental health services by all 

adults in the United States, disaggregating data by Hispanic status and nativity 

where possible. In addition, we report on the proportion of adults reporting 

unmet need for mental health care. Unmet need refers to persons who believed 

they needed mental health treatment but did not receive it.

Nationally, Hispanics were less likely to have obtained any mental health care 

than non-Hispanics (7.8 percent vs. 13.7 percent, respectively), as shown in 

Figure 4. This pattern is consistent with previously published literature which 

identifies gaps in mental health service use among Hispanics (Alegria, 2002; 

Ojeda, 2006; Wells, 2001). The gap in mental health service use between 

Hispanics and non-Hispanics is even greater and statistically significant in 

border counties: Only 6.6 percent of Hispanics obtained any mental health 

care, compared to 14.5 percent of non-Hispanics. Fewer persons reported 

unmet need for mental health care and differences between Hispanics and nonHispanics were statistically nonsignificant. For example, in the border region, 

3.9 percent of Hispanics reported unmet need for mental health treatment, 

compared to 3.5 percent of non-Hispanics.

Figure 4: Mental health service use and unmet need for mental health treatment 

during previous 12 months by Hispanic status, ages 18 and older, United States 

and all border counties, 2002-2005
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 Chapter 10 - Mental Health

Figure 5 depicts clear differences in use of mental health services by both ethnic 

group and nativity. Mental health treatment rates were higher for U.S.-born 

Hispanics and U.S.-born non-Hispanics, nationally. In the border region, 

U.S.-born non-Hispanics were most likely to obtain mental health treatment 

(14.8 percent). Notably, U.S.-born Hispanics were twice as likely as immigrant 

Hispanics in border counties to obtain mental health treatment (8.6 percent vs. 

4.4 percent, respectively).

Report of unmet need for mental health care also varied by nativity, as shown 

in Figure 6. Nationwide, U.S.-born adults, both Hispanic and non-Hispanic, 

were approximately twice as likely to report not receiving needed mental health 

care as were immigrants, regardless of ethnicity (about six percent for U.S.–born 

adults vs. about three percent for immigrants). Rates of perceived unmet need 

for mental health care were undifferentiated among border county residents.

Figure 5: Use of any mental health treatment during previous 12 months, by 

Hispanic status and nativity, 18 years and older, United States and all border 

counties, 2002-2005
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308

Mental Health Service Use by Adults with Probable Need for Care

It is also important to know whether adults with mental health service needs 

accessed mental health services. Data from the 2004-2005 waves of the National 

Survey of Drug Use and Health indicate that 27.7 percent of Hispanics who 

met criteria for serious psychological distress in the prior year obtained mental 

health care during that time period versus 46.4 percent of non-Hispanics (data 

not shown). Among adults experiencing a major depressive episode in the prior 

year, 37.6 percent of Hispanics obtained mental health care compared to 55.9 

percent of non-Hispanics (data not shown).

Differences by nativity in mental health service use by adults with symptoms 

of poor mental health were also observed. For example, 48.1 percent of U.S.-

born non-Hispanics experiencing serious psychological distress obtained mental 

health care as compared to 22.5 percent of foreign-born non-Hispanics (data 

not shown).

For adults experiencing major depression, differences by nativity remained 

stark: 57.0 percent for U.S.-born non-Hispanics vs. 37.8 percent for immigrant 

non-Hispanics. Among Hispanics, differences in mental health service use 

were less pronounced by nativity, yet overall use was lower for both immigrants 

and natives. For example, among Hispanic adults meeting criteria for serious 

psychological distress, 32.8 percent of natives obtained mental health care 

compared to 21.0 percent of immigrants. Figures were slightly higher among 

those with major depression: 42.4 percent among U.S.-born Hispanics vs. 31.0 

percent of immigrant Hispanics (data not shown).

Figure 6: Unmet need for mental health treatment during previous 12 months 

by Hispanic status and nativity, ages 18 and older, United States and all border 

counties, 2002-2005
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 Chapter 10 - Mental Health

Illicit Substance Use

Use of illicit drugs is a pervasive national concern because of the great social, 

economic, and other costs associated with this behavior (Office of National 

Drug Control Policy, 2004). This section addresses drug use behaviors by 

Hispanic and non-Hispanic adults in the United States and border counties.

Figure 7 provides data on the self-reported use of any illicit drugs during the 

previous 12 months and during the person’s lifetime. Nationwide and in the 

border region, Hispanics were less likely to report having used any illicit drug at 

any point during their lives than were non-Hispanics. For example, nationally 

49.3 percent of non-Hispanics reported using any illicit drugs during their 

lifetime compared to 38.2 percent of Hispanics. In the border region, ethnic 

group differences were similar (35.2 percent for Hispanics vs. 50 percent of nonHispanics). Data on prior-year drug consumption indicate that there were no 

significant differences between Hispanics and non-Hispanics, either nationally 

or in border counties; furthermore, rates between border counties and the 

United States did not differ.

There were important differences in illicit drug use behaviors by immigrant 

status, as shown in Figure 8. U.S.-born adults were approximately twice as likely 

to have used illicit drugs during their lifetime compared to immigrants. At the 

national level, 56.1 percent of U.S.-born Hispanics reported illicit drug use vs. 

24.9 percent of immigrant Hispanics. Among the non-Hispanic population, 

51.3 percent of U.S.-born non-Hispanics reported illicit drug use at some 

Figure 7: Lifetime and past year use of illicit drugs by Hispanic status, United 

States and all border counties, 2002-2005
Border Lives: Health Status in the United States-Mexico Border Region

310

point in their lives, vs. 28.8 percent of immigrant non-Hispanics. Significantly, 

U.S.-born Hispanics in the border region were less likely to have used any illicit 

drugs during their lifetime compared to the national rate (43.9 percent vs. 56.1 

percent, respectively). In the border region, U.S.-born Hispanics exhibited a 

lower rate of lifetime drug use compared to U.S.-born non-Hispanics; however, 

the difference was not statistically significant (43.9 percent vs. 52.3 percent). In 

contrast, immigrant non-Hispanics reported a lifetime drug use rate that was 

7.1 percentage points higher than that of immigrant Hispanics (32.8 percent vs. 

25.7 percent respectively), yet this difference was nonsignificant.

In the United States, use of illicit drugs in the prior year varied by Hispanic 

ethnicity and nativity, as illustrated in Figure 9. Nationally, U.S.-born Hispanics 

consumed illicit drugs at a statistically higher rate than non-Hispanics in the 

prior year (20.6 percent vs. 14.6 percent). Additionally, U.S.-born Hispanics 

were statistically more likely to have consumed illicit drugs in the prior year 

compared to their immigrant peers. For example, in border counties 17.2 

percent of U.S.-born Hispanics reported any illicit drug use in the prior year 

compared to 7.7 percent of immigrant Hispanics. U.S.-born non-Hispanics 

were twice as likely to report any illicit drug use in the prior year compared to 

immigrant non-Hispanics (14.3 percent vs. 7.0 percent, respectively). Notably, 

however, differences between immigrant Hispanics and immigrant nonHispanics were not statistically different nationally or in border counties.

Figure 8: Any lifetime use of illicit drugs, by Hispanic status and nativity, ages 

18 and older, United States and all border counties
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 Chapter 10 - Mental Health

Utilization of Substance Use Treatment Services

Lifetime consumption of any substance use treatment services was low among 

both Hispanics and non-Hispanics. Nationally, Hispanics were significantly less 

likely to have obtained substance use treatment compared to non-Hispanics 

(4.9 percent vs. 6.5 percent), as shown in Figure 10. There was roughly a two 

percentage point difference in the use of drug treatment services by Hispanic 

and non-Hispanic residents of the border region (5 percent vs. 7.4 percent), 

however, this difference was not statistically significant.

Figure 9: Any past year use of illicit drugs by Hispanic status and nativity, ages 

18 and older, United States and all border counties, 2002-2005

Figure 10: Lifetime and past-year utilization of substance use treatment 

services by Hispanic status, ages 18 and older, United States and all border 

counties, 2002-2005
Border Lives: Health Status in the United States-Mexico Border Region

312

Prior year use of drug treatment services was lower than lifetime use rates. 

Nationally and in the border region, roughly two percent of Hispanics and 

non-Hispanics had obtained substance use treatment in the prior year, and no 

differences were observed by ethnic group.

Disaggregating substance use treatment data by nativity indicates important gaps 

in access, especially among immigrant subgroups (Figure 11). In the United 

States, native-born adults were at least twice as likely to obtain substance use 

treatment as their immigrant peers. Among Hispanics, 7.4 percent of the U.S.-

born obtained substance treatment compared to 3.1 percent of immigrants; 

among non-Hispanics, 6.9 percent of the U.S.-born obtained treatment versus 

2.3 percent of immigrants. Nationally, U.S.-born Hispanics and non-Hispanics 

consumed substance use treatment services at a similar rate (about 7 percent 

for each), while differences between immigrants were modest. Border county 

data suggest that use of substance use treatment services was similar for U.S.-

born Hispanics (5.0 percent) and non-Hispanics (7.6 percent) and immigrant 

Hispanics (5.0 percent). Data for immigrant non-Hispanics residing in the 

border were unavailable due to insufficient sample sizes.

Consumption of substance use treatment services are low nationally and 

especially low in the border region, where data display wide confidence intervals 

(see Figure 12). Only 2.5 percent of U.S.-born Hispanics, 1.6 percent of U.S.-

born non-Hispanics, 1.1 percent of immigrant Hispanics, and 0.6 percent of 

immigrant non-Hispanics in the United States obtained substance use treatment 

in the prior year. Rates were not statistically different for border county 

residents.

Figure 11: Any lifetime utilization of substance use treatment services, by 

Hispanic status and nativity, ages 18 and older, United States and all border 

counties, 2002-2005
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 Chapter 10 - Mental Health

Conclusions and Recommendations

Poor mental health affects all residents of all regions, including communities on 

the U.S.-Mexico border, as evidenced by the data presented in this chapter. To 

our knowledge this is the first effort to examine the mental health status and use 

of mental health and substance use services in the U.S.-Mexico border region.

There were many similarities in mental health status across ethnic groups. 

However, important differences emerged when data were disaggregated by 

nativity. Nationally, a greater proportion of U.S.-born Hispanics and nonHispanics reported psychological distress and major depression compared to 

their immigrant peers. Data on mental health service use indicated that, both 

nationally and in the border region, Hispanics in particular were underserved 

by mental health providers. Therefore, improving access to culturally competent 

mental health services for Hispanics, including immigrants, is critical for 

ensuring the health of this population.

Economic factors, including access to health insurance coverage, may influence 

timing and use of health services, including mental health care. Given the 

pervasiveness of uninsurance among Hispanics in the United States, (DeNavasWalt, 2006) it is important to facilitate access to safety-net mental health care 

providers by reducing administrative and economic barriers that may reduce 

the use of needed care by the most vulnerable populations. Additionally, it is 

essential that culturally diverse mental health providers are available to treat 

Figure 12: Past year utilization of substance use treatment services by Hispanic 

status and nativity, ages 18 and older, United States and all border counties, 

2002-2005
Border Lives: Health Status in the United States-Mexico Border Region

314

populations with diverse linguistic needs (e.g., Spanish-speakers, indigenous 

populations, etc).

One recent study (Ortega, 2006) identified that Puerto Ricans and Mexicans 

experiencing anxiety or depressive disorders were also likely to experience 

comorbid asthma and cardiovascular illness. Ortega and colleagues’ analyses 

should be further expanded to the border region in order to shed light on the 

physical health-care needs of individuals experiencing comorbid mental illness.

The examination of illicit substance use and corresponding use of substance 

use treatment services revealed important differences in lifetime substance use 

by ethnicity and nativity. Significantly, Hispanics were less likely to report any 

lifetime use of illicit substances, though there were few prior-year differences; 

immigrant Hispanics in particular were least likely to have used illicit substances 

during their lives. In contrast, U.S.-born Hispanics and non-Hispanics

exhibited similar lifetime and 12-month patterns of illicit substance use. Research 

literature suggests that sociocultural factors (e.g., family cohesion, attitudes 

towards drugs, abstention by siblings and parents; Grant, 2004; Hawkins, 1992) 

play an important role in shaping drug behaviors. However, greater access to 

drugs and increased peer pressure for engaging in risky behaviors also influence 

youths’ and young adults’ consumption of illicit drugs. The mere presence 

or absence of any of these factors will not predict substance use behaviors 

immediately or during the course of their lives. Therefore, additional efforts are 

needed to elucidate the protective mechanisms that result in immigrants’ lower 

drug use prior to and following migration to the United States.

With respect to substance use treatment services, the data demonstrated that 

service use was low regardless of region, ethnicity, or nativity. For example, less 

than 10 percent of adults had ever used services and less than 5 percent had used 

services in the prior year, nationally and in the border region. The prevalence 

of substance use treatment services was lower for Hispanics compared to nonHispanics, while immigrants in both ethnic groups fared similarly. While not all 

individuals may need to access professional substance use treatment services, it 

is important that those who need attention receive it in a timely, efficient, and 

affordable manner.

The data provided in this chapter provide a first view of the mental health needs 

of Hispanics, including immigrants, in the United States and its four-state U.S.-

Mexico border-region. The data suggest that policy and health system factors 

may contribute to improved access to mental health and substance use treatment 

services by populations especially in the border region.
315 

 Chapter 10 - Mental Health

References

Alegria, M., Canino, G., Rios, R., Vera, M., Calderon, J., Rusch, D., & Ortega, 

A.N. (2002). Inequalities in Use of Specialty Mental Health Services 

Among Latinos, African Americans, and Non-Latino Whites. Psychiatric 

Services, 53(12), 1547-1555.

Alegria, M., Mulvaney-Day, N., Torres, M., Polo, A., Cao, Z., & Canino, G. 

(2007). Prevalence of Psychiatric Disorders Across Latino Subgroups in 

the United States. American Journal of Public Health, 97(1), 68-75.

DeNavas-Walt, C., Proctor, B., & Lee, C. (2006). Income, Poverty, and Health 

Insurance Coverage in the United States: 2005 (Current Population 

Reports, P60-231). Washington, DC: Government Printing Office.

Ettner, S.L., Frank, R.G., & Kessler, R.C. (1997). The Impact of Psychiatric 

Disorders on Labor Market Outcomes. Industrial and Labor Relations 

Review, 51(1), 64-81.

Ettner, S.L. (2000). The Relationship Between Labor Market Outcomes and 

Physical and Mental Health: Exogenous Human Capital or Endogenous 

Health Production? In D.S. Salkever, & A. Sorkin (Eds.), The Economics 

of Disability (pp. 1-31). Stamford, CT.: JAI Press Inc.

Grant, B.F., Stinson, F.S., Hasin, D.S., Dawson, D.A., Chou, S.P., & Anderson, 

K. (2004). Immigration and Lifetime Prevalence of DSM-IV Psychiatric 

Disorders Among Mexican Americans and Non-Hispanic Whites in 

the United States: Results from the National Epidemiologic Survey 

on Alcohol and Related Conditions. Archives of General Psychiatry, 61, 

1226-1233.

Hawkins, J.D., Catalano, R.F., & Miller, J.Y. (1992). Risk and Protective 

Factors for Alcohol and Other Drug Problems in Adolescence and Early 

Adulthood: Implications for Substance Abuse Prevention. Psychological 

Bulletin, 112(1), 64-105.

Kessler, R., & Frank, R.G. (1997). The Impact of Psychiatric Disorders on Work 

Loss Days. Psychological Medicine, 27, 861-873.

Kessler, R., Barber, C., Birnbaum, H.G., Frank, R.G., Greenberg, P.E., Rose, 

R.M., Simon, G.E., & Wang, P. (1999a). Depression in the Workplace: 

Effects on Short-Term Disability. Health Affairs, 18(5), 163-171.
Border Lives: Health Status in the United States-Mexico Border Region

316

Kessler, R. (2003a). Epidemiology of Women and Depression. Journal of 

Affective Disorders, 74, 5-13.

Kessler, R., Berglund, P., Demler, O., Jin, R., Koretz, D., KR, M., Rush, 

J.A., Walters, E.E., & Wang, P. (2003b). The Epidemiology of Major 

Depressive Disorder: Results From the National Comorbidity Survey 

Replication (NCS-R). Journal of the American Medical Association, 

289(23), 3095-3105.

Kessler, R., Berglund, P., Demler, O., Jin, R., & Walters, E.E. (2005a). Lifetime 

Prevalence and Age-of-Onset Distributions of DSM-IV Disorders 

in the National Comorbidity Survey Replication. Archives of General 

Psychiatry, 62, 593-602.

Kessler, R.C., Zhao, S., Katz, S.J., Kouzis, A.C., Frank, R.G., Edlund, M., & 

Leaf, P. (1999). Past-Year Use of Outpatient Services for Psychiatric 

Problems in the National Comorbidity Study. American Journal of 

Psychiatry, 156, 115-123.

Kessler, R.C., Andrews, G., Colpe, L.J., Hiripi, E., Mroczek, D.K., Normand, 

S.-L.T., Walters, E.E., & Zaslavsky, A.M. (2002). Short Screening 

Scales to Monitor Population Prevalences and Trends in Non-Specific 

Psychological Distress. Psychological Medicine, 32, 959-976.

Kessler, R.C., Barker, P.R., Colpe, L.J., Epstein, J.F., Gfroerer, J.C., Hiripi, E., 

Howes, M.J., Normand, S.-L.T., Manderscheid, R.W., Walters, E.E., 

& Zaslavsky, A.M. (2003c). Screening for Serious Mental Illness in the 

General Population. Archives of General Psychiatry, 60, 184-189.

Kessler, R.C., Demler, O., Frank, R.G., Olfson, M., Pincus, H.A., Walters, 

E.E., Wang, P., Wells, K.B., & Zaslavsky, A.M. (2005b). Prevalence and 

Treatment of Mental Disorders, 1990-2003. New England Journal of 

Medicine, 354(24), 2515-2523.

McGuire, T., Wells, K.B., Bruce, M.L., Miranda, J., Scheffler, R., Durham, 

M., Ford, D.E., & Lewis, L. (2002). Burden of Illness. Mental Health 

Services Research, 4(4), 170-185.

New Freedom Commission on Mental Health (2003). Achieving the Promise: 

Transforming Mental Health Care in America. Final Report. Rockville, 

MD: Department of Health and Human Services.
317 

 Chapter 10 - Mental Health

Office of National Drug Control Policy (2004). The Economic Costs of Drug 

Abuse in the United States, 1992-2002 (Publication No. 207303). 

Washington, DC: Executive Office of the President.

Ojeda, V.D., & McGuire, T.G. (2006). Gender and Racial/Ethnic Differences 

in Use of Outpatient Mental Health and Substance Use Services by 

Depressed Adults. Psychiatric Quarterly.

Ortega, A.N., Feldman, J.M., Canino, G., Steinman, K., & Alegria, M. (2006). 

Co-occurrence of mental and physical illness in US Latinos. Soc 

Psychiatry Psychiatr Epidemiol, 41(12), 927-934.

Substance Abuse and Mental Health Services Administration (2006). Results 

From the National Survey on Drug Use and Health: National Findings 

(Office of Applied Studies, NSDUH Series H-30; HHS Publication 

No. SMA 06-4194). Rockville, MD.

U.S. Department of Health and Human Services (1999). Mental Health: A 

Report of the Surgeon General. Rockville, MD: U.S. Department of 

Health and Human Services, Substance Abuse and Mental Health 

Services Administration, Center for Mental Health Services, National 

Institutes of Health, National Institute of Mental Health

U.S. Department of Health and Human Services (2001). Mental Health: 

Culture, Race, and Ethnicity–A Supplement to Mental Health: A Report 

of the Surgeon General Rockville, MD: U.S. Department of Health and 

Human Services

United States-Mexico Border Health Commission (2003). Healthy Border 2010. 

El Paso, TX and Mexico, DF.

Vega, W., Alderete, E., Kolody, B., & Aguilar-Gaxiola, S. (1998). Illicit drug use 

among Mexicans and Mexican Americans in California: the effects of 

gender and acculturation. Addiction, 93(12), 1839-1850.

Vega, W.A., Kolody, B., Aguilar-Gaxiola, S., & Catalano, R. (1999). Gaps 

in Service Utilization by Mexican-Americans with Mental Health 

Problems. American Journal of Psychiatry, 156, 928-934.

Vega, W.A., Kolody, B., & Aguilar-Gaxiola, S. (2001). Help-Seeking for Mental 

Health Problems Among Mexican Americans. Journal of Immigrant 

Health, 3(3), 133-140.
Border Lives: Health Status in the United States-Mexico Border Region

318

Wells, K.B., Klap, R., Koike, A., & Sherbourne, C.D. (2001). Ethnic Disparities 

in Unmet Need for Alcoholism, Drug Abuse, and Mental Health Care. 

American Journal of Psychiatry, 158(12), 2027-2032.
319 

As the data in this report clearly show, challenges to improving health in 

the U.S.-Mexico border region are numerous and complex. A highly 

urbanized population – more than 90 percent of border residents live 

in urban areas – lives next to rural and frontier communities, separated by 

long stretches of rural, desert landscapes and open spaces. Two critical factors 

affecting health status – overall levels of poverty and unemployment – are 

very high in the border area. Yet the homicide rate in U.S. border counties is 

substantially below the national level, and violent crime reports for the four U.S. 

border states mirror the national decline in violent crime since 1990 (Bureau 

of Justice Statistics, 2007). Environmental hazards, including high levels of 

atmospheric ozone and particulate matter, have been linked to the rapid rise in 

asthma cases among border inhabitants. The daily mixing of large numbers of 

U.S. and Mexican residents has been linked with high levels of communicable 

diseases in the border region. Yet for many communicable diseases, incidence 

rates in the border counties are lower than in the non-border areas of the four 

states and lower than national levels. 

The border region is sorely lacking in health facilities and health workforce, 

and many border residents suffer from poor access to health care. Border 

residents have high levels of obesity and diabetes, among other health problems. 

Nevertheless, the border population does surprisingly well on many health 

measures including infant mortality, overall mortality, and deaths from two 

of the nation’s leading causes, heart disease and cancer. Hispanics, the border 

residents who suffer the most from poverty and poor access to care, do nearly as 

well, and in some cases do better, than their non-Hispanic neighbors on many 

health measures.

Burgeoning population growth in the border region has increased the demand 

for both preventive and clinical health services. Population growth and 

increased cross-border traffic also call for increased epidemiological tracking and 

CONCLUSION 
Border Lives: Health Status in the United States-Mexico Border Region

320

surveillance of infectious diseases, environmental health hazards, and chronic 

diseases. At the same time, government expenditures dedicated to public health 

are not keeping pace with population growth, and public health—the essential 

pillar of economic growth and prosperity—is at risk of reversing the positive 

gains for the last two decades. 

In this complex landscape of people, places, cultures, and economic factors, 

many public and private agencies are working to address border health 

problems. These agencies include federal, state, and local government agencies, 

academic institutions, private and non-profit health-services providers, nongovernmental advocacy organizations, and transnational institutions. 

As pointed out in several chapters of this report, efforts to improve health in 

the border region are limited by lack of adequate systems for gathering and 

analyzing comparable data. While state and federal agencies maintain sizeable 

databases concerning demographics, morbidity and mortality, and other vital 

statistics, data are rarely germane to the sub-county level. Only in rare cases 

are data geo-coded by zip code, census tract, or geo-referenced coordinates. 

Very few health indicator databases for border populations are stratified by 

socioeconomic, cultural, or ethnic characteristics. This limitation makes it 

difficult to assess health conditions by particular cohorts. In other words, we 

do not really know our border population. While certain research projects do 

stratify such populations, studies are usually limited to a particular community 

or county that may not be representative of other areas along the border. 

Obtaining data from and among different federal, state, or county health 

authorities can be difficult for different reasons. Some cite privacy concerns, 

while others worry about the quality of the data. Also, the frequency for entering 

and updating data files differs for many of these authorities, with two or more 

years of data pending processing at any one time. As a result, the datasets 

that are available are not routinely used effectively to target public health 

expenditures in the geographic areas or demographic sectors of greatest need. 

This inaugural Border Health Status Report indicates that there are continuing 

and serious health disparities among residents of the U.S. side of the 

U.S.-Mexico border. Nonetheless, the collective of health authorities and 

organizations along the border is vibrant, capable, and dedicated. It is likely that 

such efforts are linked to many of the positive health outcomes identified in 

this report, including unexpectedly positive birth outcomes, low rates of some 

infectious diseases, and lower rates of breast cancer in the border region. 

This report should be used as a tool for focusing border health efforts, such as in 

the following areas:

•	 Utilizing the Healthy Border 2010 framework and the forthcoming Healthy 
321 

 Conclusion

Border 2020 report under development as the basis for the development of 

plans and actions focused on particular border health issues. 

•	 Improving interstate and binational communication among state 

health authorities and local medical service providers to facilitate better 

management of binational disease cases (for example, tuberculosis and 

sexually transmitted diseases), including improvement of the efficiency of 

intrastate and binational procedures for reporting of infectious diseases.

•	 Gearing research and evaluation frameworks to improving health systems 

at the local, state, and federal levels, with emphasis on providing access to 

care and reducing health disparities. Monitoring and evaluation frameworks 

should be based on an epidemiological information platform that uses geocoding to permit analysis of health conditions at the sub-county level. Such 

a platform would provide a foundation for improved targeting of public 

health resources. Baselines should be established considering stratified 

demographic cohorts among different segments of the border population 

based on socio-cultural, ethnic, and economic parameters. Data should be 

made available to all legitimate users in the public and private sector for 

research, planning, monitoring, and evaluation. 

•	 Synthesizing, analyzing, and making data publicly available on a regular 

basis through the production of periodic reports on the impact of border 

health activities.

The United States-Mexico Border Health Commission (BHC) will seek to 

publish periodic border health status updates similar to this first report. Future 

publications will include emerging issues impacting border residents such as 

adolescent health, environmental and occupational health, and elderly health 

care issues, among others. The BHC welcomes input on topics, issues, and 

actions from all border health stakeholders.

323 

APPENDICES 

Appendix to Chapter 3..................................................325

Appendix to Chapter 7..................................................349 

325 

 Appendix to Chapter 3

Methodology

The NHIS is a household multistage1 probability sample interview that is 

conducted continuously throughout the year on behalf of the National Center 

for Health Statistics2 through a contract with interviewers from the U.S. 

Census Bureau. The NHIS is conducted through a face-to-face interview survey 

protocol that relies on self-report and proxy report status. Therefore, the answer 

to each survey question relies on the best recall effort of the survey participant 

on a specific topic. The main goal of the NHIS is to monitor the health of the 

U.S. population through the collection and analysis of data on a broad range of 

health topics.

The target population for the NHIS is the civilian non-institutionalized 

population in the United States. Individuals excluded from the survey are 

patients in long-term care institutions (e.g. nursing homes, hospitals for the 

chronically ill, disabled, or wards for abused or neglected children); correctional 

facilities (e.g. prisons, jails, juvenile detention centers, halfway houses); active 

duty Armed Forces personnel, and U.S. nationals living in foreign countries. 

The NHIS has been used extensively in the past to estimate health insurance 

coverage status, self-reported health outcomes, and self-reported health care 

utilization (IOM 1993, Cohen 2004, Seid 2003). The NHIS has a welldocumented low non-response rate (about one percent) for the insurance 

section, which greatly minimized the need to use techniques to compensate for 

missing data.

Because published health insurance estimates from the NHIS are limited to 

national, regional, or state levels3

, we used the in-house version of the NHIS 

1 For an explanation of the multistage concept, see Richard M Single (2000), “52,467 + 57,204 = 

254,281,227? Using the National Health Interview Survey and the 2000 Census to Introduce Statistical Sampling and Weights.” Journal of Statistics Education 8(1). Retrieved from http://www.amstat.org/publications/

jse/secure/v8n1/single.cfm

2 For more technical information concerning NHIS, visit the NHIS website at www.cdc.gov/nchs/

nhis.htm.

3 In 2001, the Census Bureau released 2000 insurance coverage estimates at the county level. But 

such estimates are neither stratified by ethnicity nor contain any other self-reported health care variable of 

APPENDIX TO CHAPTER 3

 
Border Lives: Health Status in the United States-Mexico Border Region

326

to generate point estimates for a specific geographical region such as the U.S.-

Mexico border4. To identify the counties that belong to the U.S.-Mexico border 

and the primary sampling unit (PSU) that the NHIS used to represent them, we 

first identified the federal information processing standard (FIPS) code5

 for each 

county. The same steps were taken to identify the PSU that represent the nonborder counties and the border states. Subsequently, PSUs representing border 

counties were merged to develop a mutually-exclusive epidemiological unit.

Rate Calculation

Because NHIS data come from a complex multistage sample survey, statistics 

presented in this study are subject to sampling error. To compensate for this, 

standard errors adjusted for the complex sample frame are also reported to 

indicate the reliability of the estimates performed. Estimates and standard errors 

were calculated using the SPSS 13.0 complex sample module (SPSS). The SPSS 

complex sample module allows the computation of point estimates while taking 

into consideration the complexity of the survey design and weight assignment. The 

Taylor series linearization method was chosen for variance estimation.

Estimates were calculated by using in-house NHIS survey weights, which are 

calibrated to census totals for age, sex, race/ethnicity of the U.S. civilian noninstitutionalized population. One caveat to this approach is that the weight used 

for the development of this report accurately reflects the national configuration, but 

may not expressly address the border age structure. To compensate for this, and to 

investigate the difference between standard error estimations for the United States 

and the border, a specific area re-weighting research project is underway at the 

NCHS.

The statistics provided in this report are based on data from the NHIS adult sample 

and family core components. For statistical purposes, each section was weighted 

according to its source file (e.g. the family core weight was specifically used for the 

questions belonging to the family core section).

Estimates presented in this report are adjusted percentages and their corresponding 

standard errors. Estimates presented have a relative standard error (RSE) of 30 

percent or less. Cohen and Bloom have shown that estimates with such properties 

at the NHIS are statistically reliable. Estimates that do not comply with this 

requirement are identified as not statistically reliable and flagged with an asterisk (*).

interest. For more information, visit the Census Bureau website at www.census.gov/hhes/www/sahie/.

4 Results of this work can be replicated using the in-house NHIS.

5 FIPS codes are a standardized set of numeric or alphabetic codes issued by the National Institute 

of Standards and Technology (NIST) to ensure uniform identification of geographic entities through all 

federal government agencies. The entities covered include: states and statistically equivalent entities, counties 

and statistically equivalent entities, named populated and related location entities such as places and county 

subdivisions, and American Indian and Alaska Native areas.
327 

 Appendix to Chapter 3

Statistical tests for measuring significance of difference between two point 

estimates were performed using a two-tail Z test at the 0.05 level, assuming 

independence. For multiple comparisons, statistical significance was assessed 

by judging the overlap of 95 percent confidence intervals for calculated rates. 

The use of terms such as “greater than,” more likely than,” or “less likely than” 

indicates a statistically significant difference. The use of terms such as “no 

difference” or “equivalent rates” indicates that the estimates being compared 

were not statistically different. Overlapping confidence intervals represent a nonstatistically significant relationship. Lack of comments regarding the difference 

between two estimates does not necessarily imply that the difference was tested 

and found to be not significant.

U.S.-Mexico Border

For 2000-2003, a group of 5,139 subjects from the adult population (18 years 

of age and older) of the U.S.-Mexico border region was identified. The Cluster 

selected corresponds to the number of individuals who also completed the adult 

and family components of the NHIS. More than half of the border population 

(53 percent) was identified as Hispanic. The majority of the individuals were 

females (56 percent). Three out of every four individuals were between 25 and 

69 years of age.

The border region consists of counties within the 100 kilometer area north of the 

U.S.-Mexico border. The border counties include the 44 counties designated by 

the U.S.-Mexico Border Health Commission, plus Maricopa County, Arizona.
Border Lives: Health Status in the United States-Mexico Border Region

328

List of Tables

Footnotes:

1 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, 

state-sponsored or other government sponsored health program, or military plan at the time of the interview. This 

classification also includes individuals who have only Indian Health Services coverage or hand only a private plan that paid for 

one type of service such as accidents or dental care.

2

 Border states: Arizona, California, New Mexico, and Texas.

3

 Counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the 

US portion of the US-Mexico border region. This includes 44 border counties identified by US-Mexico Border Health 

Commission, plus Maricopa County, Arizona.

4 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined 

under La Paz agreement (1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona.5 

Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or 

Latino” refers to all persons who are not of Hispanic or Latino origin, regardless of race. 

 

Data source: National Health Interview Survey, 2000-2003 (In-house version) 

 

Table 1. Percent of the total population without health insurance coverage1 by selected 

characteristics: 2000-2003 

 

Region Percent 

 

United States 14.7 0.15 14.4-15.0 

Border States2 20.6 0.37 19.9-21.3 

 Border Counties3

 22.9 0.96 21.0-24.8 

 Non-Border Counties4 20.1 0.39 19.3-20.9 

 

Region by Ethnicity5 

United States 

 Hispanic 32.7 0.47 31.80-33.63 

 Non-Hispanic 12.0 0.14 11.75-12.29 

 

Border States 

 Hispanic 33.4 0.61 32.22-34.65 

 Non-Hispanic 13.2 0.34 12.50-13.87 

 

Border Counties 

 Hispanic 38.2 1.33 33.54-40.85 

 Non-Hispanic 12.0 1.11 9.96-14.39 

 

Non-Border Counties 

 Hispanic 32.3 0.69 30.94-33.71 

 Non-Hispanic 13.4 0.34 12.72-14.09 

 

Standard

Error

Confidence 

Interval
329 

 Appendix to Chapter 3

Table 2. Percent of the total uninsured1 population: Short2 and Long3 term lack of health insurance 

cover age by selected characteristics: 2000-2003

 

 Region Percent Standard Error Confidence Interval 

United States 

 Short term 27.2 0.34 26.6-27.9 

 Long term 72.8 0.34 72.1-73.4 

 

Border States4

 

 Short term 21.4 0.58 20.2-22.5 

 Long term 78.6 0.58 77.5-79.8 

 

 Border Counties5

 

 Short term 17.9 1.65 14.9-21.4 

 Long term 82.1 1.65 78.6-85.1 

 

Non-Border Counties6

 

 Short term 22.2 0.60 21.0-23.4 

 Long term 77.8 0.60 76.6-79.0 

 

 Region by Ethnicity7

United States 

 Hispanic 

 Short Term 17.6 0.48 16.6-18.5 

 Long Term 82.5 0.48 81.4-83.3 

 Non-Hispanic 

 Short Term 31.6 0.40 30.7-32.3 

 Long Term 68.5 0.40 67.6-69.2 

 

Border States 

 Hispanic 

 Short Term 16.6 0.60 15.4-17.8 

 Long Term 83.4 0.60 82.1-84.5 

 Non-Hispanic 

 Short Term 29.4 0.97 27.4-31.3 

 Long Term 70.6 0.97 68.6-72.5 

 

 Border Counties 

 Hispanic 

 Short Term 13.1 1.23 10.8-15.7

 Long Term 86.9 1.23 84.2-89.2 

 Non-Hispanic 

 Short Term 31.4 3.60 24.7-39.0 

 Long Term 68.6 3.60 60.9-75.2 

 

 Non-Border Counties 

 Hispanic 

 Short Term 17.6 0.68 16.2-18.9 

 Long Term 82.4 0.68 81.0-83.7 

 Non-Hispanic 

 Short Term 29.1 0.98 27.1-31.0 

 Long Term 70.9 0.98 68.9-72.8

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards 

of reliability or precision.

Footnotes: 

1 A person was defined “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other government 

sponsored health program, or military plan at the time of the interview. 

2

 Short Term Lack of Health Insurance- Less than 1 year without health insurance. A year was defined as the 12 months prior of the interview.

3

 Long Term Lack of Health Insurance- More than 1 year without health insurance.

4 Border states: Arizona, California, New Mexico, and Texas. 

5 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico border 

region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 6 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement (1987) as the US 

portion of the US-Mexico border, except Maricopa County, Arizona as the US portion of the US-Mexico border region. 7

Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons who are not of 

Hispanic or Latino origin, regardless of race. 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 

 

 

 
Border Lives: Health Status in the United States-Mexico Border Region

330

Table 3. Percent of the adult population (18 years and over) who did not get medical care because they 

can not afford it1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 4.8 0.06 4.6-4.9 Border States2

 4.7 0.13 4.5-5.0 Border Counties3

 5.0 0.27 4.4-5.5 Non-Border Counties4 4.7 0.14 4.4-4.9 

 Region by Ethnicity5 

United States Hispanic 5.4 0.13 5.1-5.6 Non-Hispanic 4.7 0.06 4.5-4.8 

Border States Hispanic 5.2 0.17 4.8-5.5 Non-Hispanic 4.5 0.15 4.1-4.7 

 Border Counties Hispanic 6.0 0.35 5.3-6.7 Non-Hispanic 4.3 0.33 3.6-4.9 

 Non-Border Counties Hispanic 5.0 0.2 4.6-5.4 Non-Hispanic 4.5 0.17 4.1-4.8 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 2.7 0.10 2.5-2.8 

 Uninsured 11.2 0.31 10.5-11.7 

 Non-Hispanic 

 Insured 2.7 0.05 2.5-2.7 

 Uninsured 19.8 0.32 19.1-20.4 

 

Border States 

 Hispanic 

 Insured 2.6 0.13 2.3-2.8 

 Uninsured 10.3 0.37 9.6-11.1 

 Non-Hispanic 

 Insured 2.4 0.12 2.1-2.6 

 Uninsured 18.3 0.57 17.1-19.4 

 

 Border Counties 

 Hispanic 

 Insured 2.7 0.17 2.4-3.1 

 Uninsured 11.3 0.70 9.9-12.7 

 Non-Hispanic 

 Insured 2.4 0.22 1.9-2.8 

 Uninsured 18.4 1.82 15.0-22.2 

 

 Non-Border Counties 

 Hispanic 

 Insured 2.6 0.15 2.3-2.9 

 Uninsured 10.1 0.44 9.2-10.9 

 Non-Hispanic 

 Insured 2.4 0.13 2.1-2.7 

 Uninsured 18.2 0.60 17.0-19.4 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

Footnotes: 

1

Question: DURING THE PAST 12 MONTHS, was there any time when{person} needed medical care, but did not get it because {person} 

couldn’t afford it?

2Border states: Arizona, California, New Mexico, and Texas.

3 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the 

US-Mexico border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz 

agreement (1987).

5 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all 

persons who are not of Hispanic or Latino origin, regardless of race. 6 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or 

other government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have 

only Indian Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care.

7

 Without insurance coverage at the time of the interview.

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
331 

 Appendix to Chapter 3

Table 4. Percent of the adult population (18 years and over) who could not afford dental care in the past 

12 months1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 9.4 0.13 9.2-9.7 

Border States2 10.4 0.27 9.9-10.9 Border Counties3

 11.5 0.61 10.3-12.8 Non-Border Counties4 10.2 0.29 9.6-10.8 

 Region by Ethnicity

 

United States Hispanic5

 11.5 0.31 10.8-12.0 Non-Hispanic 9.2 0.14 8.9-9.4 

Border States2 Hispanic 12.3 0.48 11.4-13.3 Non-Hispanic 9.4 0.34 8.7-10.1 

 Border Counties3 Hispanic 16.8 0.99 14.9-18.8 Non-Hispanic 8.1 0.86 6.5-9.9 

 Non-Border Counties4 Hispanic 11.2 0.54 10.1-12.2 Non-Hispanic 9.7 0.36 8.9-10.4 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 7.0 0.28 6.5-7.6 

 Uninsured 18.7 0.60 17.5-19.9 

Non-Hispanic 

 Insured 6.3 0.11 6.0-6.5 

 Uninsured 29.3 0.51 28.2-30.3 

 

Border States 

 Hispanic 

 Insured 7.7 0.44 6.8-8.6 

 Uninsured 19.7 0.80 18.1-21.3 

 Non-Hispanic 

 Insured 6.2 0.29 5.6-6.8 

 Uninsured 30.3 1.26 27.8-32.9 

 

 Border Counties 

 Hispanic 

 Insured 8.5 1.05 6.6-10.8 

 Uninsured 27.0 1.98 23.2-31.0 

 Non-Hispanic 

 Insured 6.0 0.83 4.4-7.8 

 Uninsured 25.5 2.18 21.4-30.0 

 

 Non-Border Counties 

 Hispanic 

 Insured 7.5 0.48 6.6-8.5 

 Uninsured 17.4 0.85 15.7-19.1 

 Non-Hispanic 

 Insured 6.3 0.30 5.7-6.9 Uninsured 31.1 1.40 28.3-33.9 

* Estimates preceded by an asterisk have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

Footnotes: 

1 Question: DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn’t get it because you couldn’t 

afford it? ..... Dental care (including check-ups). 

2

 Border states: Arizona, California, New Mexico, and Texas. 

3 Counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico 

border region.This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona.

4

Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico Border, defined under La Paz agreement (1987) as 

the US portion of the US-Mexico border region, except Maricopa County, Arizona.

5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race.

6 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other government 

sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian Health Services coverage or 

hand only a private plan that paid for one type of service such as accidents or dental care.

7 Without insurance coverage at the time of the interview.

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
Border Lives: Health Status in the United States-Mexico Border Region

332

Table 5. Percent of the adult population (18 years and over) who could not afford mental/care counsel 

for the past 12 months1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 1.9 0.05 1.8-2.0 

Border States2 2.1 0.11 1.9-2.3 Border Counties3

 2.7 0.32 2.1-3.4 Non-Border Counties4 2.0 0.12 1.8-2.2 

 Region by Ethnicity5

United States Hispanic 2.3 0.14 2.0-2.5 Non-Hispanic 1.9 0.05 1.7-1.9 

Border States Hispanic 2.5 0.2 2.1-2.9 Non-Hispanic 2.0 0.14 1.6-2.2 

 Border Counties Hispanic 4.2 0.61 3.1-5.5 Non-Hispanic 1.7 0.28 1.2-2.3 

 Non-Border Counties Hispanic 2.1 0.19 1.7-2.5 Non-Hispanic 2.0 0.15 1.7-2.3 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 1.1 0.11 0.9-1.3 

 Uninsured 4.2 0.29 3.6-4.8 

 Non-Hispanic 

 Insured 1.2 0.04 1.1-1.2 

 Uninsured 6.6 0.26 6.1-7.1 

 

Border States 

 Hispanic 

 Insured 1.1 0.15 0.8-1.4 

 Uninsured 4.7 0.39 4.0-5.5 

 Non-Hispanic 

 Insured 1.2 0.11 0.9-1.4 

 Uninsured 7.0 0.72 5.7-8.5 

 

 Border Counties 

 Hispanic 

 Insured 1.3* 0.44 0.6-2.5 

 Uninsured 7.7 0.96 5.9-9.8 

 Non-Hispanic 

 Insured 1.1* 0.23 0.7-1.6 

 Uninsured 6.5* 1.91 3.5-11.4 

 

 Non-Border Counties 

 Hispanic 

 Insured 1.1 0.15 0.8-1.4 

 Uninsured 3.8 0.39 3.0-4.6 

 Non-Hispanic 

 Insured 1.2 0.12 0.9-1.4 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

 

1

 DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn’t get it because you couldn’t afford it? ..... 

Mental health care or counseling.

2

 Border states: Arizona, California, New Mexico, and Texas. 3

 Counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico 

border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
333 

 Appendix to Chapter 3

Table 6. Percent of the adult population (18 years and over) who do not have a place to go when they 

are sick1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 13.6 0.16 13.3-13.9 

Border States2 18.2 0.40 17.4-18.9 Border Counties3

 18.6 0.86 16.9-20.3 Non-Border Counties4 18.1 0.45 17.2-19.0 

 Region by Ethnicity5 

United States Hispanic 28.4 0.56 27-3-29.4 Non-Hispanic 11.8 0.15 11.4-12.0 

Border States Hispanic 29.5 0.73 28.0-30.9 Non-Hispanic 12.5 0.38 11.7-13.3 

 Border Counties Hispanic 31.9 1.05 29.7-33.9 Non-Hispanic 10.0 0.89 8.4-11.9 

 Non-Border Counties Hispanic 28.8 0.89 27.0-30.6 Non-Hispanic 13.0 0.41 12.2-13.8 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 10.6 0.40 9.8-11.3 

 Uninsured 57.4 0.80 55.8-58.9 

 Non-Hispanic 

 Insured 7.5 0.13 7.2-7.7 

 Uninsured 40.8 0.56 39.6-41.8 

 

Border States 

 Hispanic 

 Insured 10.6 0.45 9.7-11.5 

 Uninsured 58.7 1.06 56.5-60.8 

 Non-Hispanic 

 Insured 6.8 0.27 6.3-7.3 

 Uninsured 49.8 1.39 47.0-52.5 

 

 Border Counties 

 Hispanic 

 Insured 11.2 1.16 9.0-13.7 

 Uninsured 57.1 1.36 54.3-59.7 

 Non-Hispanic 

 Insured 4.8 0.40 4.0-5.6 

 Uninsured 52.4 3.56 45.2-59.3 

 

 Non-Border Counties 

 Hispanic 

 Insured 10.5 0.49 9.5-11.5 

 Uninsured 59.2 1.33 56.5-61.8 

 Non-Hispanic 

 Insured 7.2 0.31 6.6-7.8 Uninsured 49.4 1.51 46.4-52.4 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

1 Is there a place that you USUALLY go to when you are sick or need advice about your health (No responses)? 2Border states: Arizona, California, New Mexico, and Texas. 3Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the 

US-Mexico border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico Border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all 

persons who are not of Hispanic or Latino origin, regardless of race. 6A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
Border Lives: Health Status in the United States-Mexico Border Region

334

 

Region Percent Standard Confidence

 Error Interval

United States 

 Clinic/Health Center 16.0 0.31 15.4-16.6

 Dr. Office/HMO 79.7 0.33 79.0-80.3

 Hospital ER/Outpatient Facility/Other Places 4.3 0.09 4.0-4.4

 

Border States2

 

 Clinic/Health Center 14.9 0.48 13.9-15.8

 Dr. Office/HMO 80.7 0.56 79.6-81.6

 Hospital ER/Outpatient Facility/Other Places 4.4 0.22 3.9-4.8

 

 Border Counties3

 

 Clinic/Health Center 16.1 1.33 13.6-18.9

 Dr. Office/HMO 79.8 1.36 76.9-82.3

 Hospital ER/Outpatient Facility/Other Places 4.1 0.46 3.2-5.1

 

 Non-Border Counties4

 

 Clinic/Health Center 14.6 0.49 13.6-15.5

 Dr. Office/HMO 81.0 0.59 79.7-82.1

 Hospital ER/Outpatient Facility/Other Places 4.5 0.25 3.9-5.0

 

 Region by Ethnicity5

United States 

 Hispanic 

 Clinic/Health Center 24.5 0.58 23.3-25.6

 Dr. Office/HMO 68.2 0.64 66.6-69.4

 Hospital ER/Outpatient Facility/Other Places 7.3 0.26 6.8-7.8

 Non-Hispanic 

 Clinic/Health Center 15.1 0.33 14.5-15.8

 Dr. Office/HMO 80.9 0.35 80.2-81.6

 Hospital ER/Outpatient Facility/Other Places 3.9 0.10 3.7-4.1

 

Border States 

 Hispanic 

 Clinic/Health Center 23.9 0.84 22.2-25.5

 Dr. Office/HMO 70.1 0.93 68.1-71.8

 Hospital ER/Outpatient Facility/Other Places 6.1 0.34 5.4-6.7

 Non-Hispanic 

 Clinic/Health Center 11.2 0.53 10.1-12.3

 Dr. Office/HMO 85.1 0.61 83.8-86.2

 Hospital ER/Outpatient Facility/Other Places 3.7 0.26 3.2-4.2

 

Border Counties 

 Hispanic 

 Clinic/Health Center 24.0 2.21 19.8-28.6

 Dr. Office/HMO 70.3 2.41 65.3-74.8

 Hospital ER/Outpatient Facility/Other Places 5.7 0.74 4.4-7.3

 Non-Hispanic 

 Clinic/Health Center 12.3 1.61 9.4-15.8

 Dr. Office/HMO 84.4 1.63 80.8-87.3

 Hospital ER/Outpatient Facility/Other Places 3.3 0.57 2.3-4.6

 

Non-Border Counties 

 Hispanic 

 Clinic/Health Center 23.9 0.89 22.1-25.6

 Dr. Office/HMO 70.0 1.00 67.9-71.9

 Hospital ER/Outpatient Facility/Other Places 6.1 0.38 5.4-6.9

 Non-Hispanic 

 Clinic/Health Center 11.0 0.52 9.9-12.0

 Dr. Office/HMO 85.2 0.63 83.8-86.4

 Hospital ER/Outpatient Facility/Other Places 3.8 0.29 3.2-4.4

 Region by Ethnicity and Insurance Coverage Status 6,7

United States 

 Hispanic 

 Insured

 Clinic/Health Center 18.5 0.53 17.4-19.5

 Dr. Office/HMO 77.0 0.58 75.8-78.1

 Hospital ER/Outpatient Facility/Other Places 4.5 0.23 4.0-4.9

Table 7. Percent of the adult population (18 years and over) who have a place to go when they are sick1

by selected characteristics: 2000-2003
335 

 Appendix to Chapter 3

 

Region by Ethnicity and Insurance Coverage Status 6,7 Continued

 

Region Percent Standard Confidence

 Error Interval

 Uninsured 

 Clinic/Health Center 45.2 1.29 42.6-47.7

 Dr. Office/HMO 37.7 1.08 35.5-39.8

 Hospital ER/Outpatient Facility/Other Places 17.2 0.85 15.5-18.8

 Non-Hispanic 

 Insured 

 Clinic/Health Center 14.0 0.33 13.4-14.6

 Dr. Office/HMO 83.0 0.34 82.2-83.6

 Hospital ER/Outpatient Facility/Other Places 3.0 0.09 2.8-3.1

 Uninsured 

 Clinic/Health Center 26.8 0.79 25.3-28.4

 Dr. Office/HMO 59.2 0.86 57.5-60.8

 Hospital ER/Outpatient Facility/Other Places 14.0 0.53 12.9-15.0

 

Border States 

 Hispanic 

 Insured 

 Clinic/Health Center 17.0 0.71 15.6-18.4

 Dr. Office/HMO 79.3 0.8 77.6-80.8

 Hospital ER/Outpatient Facility/Other Places 3.8 0.35 3.1-4.5

 Uninsured 

 Clinic/Health Center 46.9 1.78 43.4-50.4

 Dr. Office/HMO 39.2 1.53 36.2-42.3

 Hospital ER/Outpatient Facility/Other Places 13.8 0.97 12.0-15.8

 Non-Hispanic 

 Insured 

 Clinic/Health Center 9.9 0.52 8.9-10.9

 Dr. Office/HMO 87.3 0.61 86.0-88.4

 Hospital ER/Outpatient Facility/Other Places 2.8 0.26 2.3-3.3

 Uninsured 

 Clinic/Health Center 26.6 1.79 23.2-30.3

 Dr. Office/HMO 58.1 2.20 53.6-62.4

 Hospital ER/Outpatient Facility/Other Places 15.3 1.42 12.6-18.3

 

Border Counties 

 Hispanic 

 Insured 

 Clinic/Health Center 17.3 1.81 14.0-21.2

 Dr. Office/HMO 79.8 1.95 75.6-83.3

 Hospital ER/Outpatient Facility/Other Places 2.9 0.52 2.0-4.1

 Uninsured 

 Clinic/Health Center 40.9 3.48 34.1-47.9

 Dr. Office/HMO 46.2 3.10 40.0-52.3

 Hospital ER/Outpatient Facility/Other Places 12.9 1.67 9.9-16.6

 Non-Hispanic 

 Insured 

 Clinic/Health Center 11.5 1.60 8.6-15.0

 Dr. Office/HMO 86.4 1.60 82.8-89.2

 Hospital ER/Outpatient Facility/Other Places 2.2 0.48 1.3-3.3

 Uninsured 

 Clinic/Health Center 25.0 4.98 16.4-36.1

 Dr. Office/HMO 53.0 9.46 34.6-70.6

 Hospital ER/Outpatient Facility/Other Places 22.0 * 6.47 11.7-37.4

 

Non-Border Counties 

 Hispanic 

 Insured 

 Clinic/Health Center 16.9 0.78 15.4-18.5

 Dr. Office/HMO 79.1 0.88 77.3-80.8

 Hospital ER/Outpatient Facility/Other Places 4.0 0.41 3.2-4.8

 Uninsured 

 Clinic/Health Center 48.9 2.08 44.7-53.0

 Dr. Office/HMO 37.0 1.77 33.5-40.5

 Hospital ER/Outpatient Facility/Other Places 14.1 1.16 11.9-16.6

 Non-Hispanic 

 Insured 

 Clinic/Health Center 9.6 0.52 8.5-10.6

 Dr. Office/HMO 87.5 0.64 86.1-88.7

 Hospital ER/Outpatient Facility/Other Places 2.9 0.29 2.3-3.5

 Uninsured 

 Clinic/Health Center 26.9 1.89 23.2-30.7

 Dr. Office/HMO 58.8 2.14 54.5-63.0

 Hospital ER/Outpatient Facility/Other Places 14.3 1.35 11.8-17.2

Table 7. Percent of the adult population (18 years and over) who have a place to go when they are sick 

by selected characteristics: 2000-2003 (Continued) 
Border Lives: Health Status in the United States-Mexico Border Region

336

* Estimates have a relative standard error of greater than 30 and should be used with caution as 

they do not meet the standards of reliability or precision.

Footnotes:

1 Question: What kind of place do you go to most often when (person) is sick? 2 Border states: Arizona, California, New Mexico, and Texas. 3

 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La 

Paz agreement (1987) as the US portion of the US-Mexico border region. This includes 44 border 

counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the 

US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico 

border region, except Maricopa County, Arizona. 5 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the 

category “Non-Hispanics or Latino” refers to all persons who are not of Hispanic or Latino origin, 

regardless of race. 6 A person was defined as “uninsured” if he or she did not have any private health insurance, 

Medicare, Medicaid, SCHIP, state-sponsored or other government sponsored health program, 

or military plan at the time of the interview. This classification also includes individuals who have 

only Indian Health Services coverage or hand only a private plan that paid for one type of service 

such as accidents or dental care. 7 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 

 

 
337 

 Appendix to Chapter 3

Table 8. Percent of the adult population (18 years and over) who have visited an emergency room in 

the past 12 months1 by selected characteristics: 2000-2003 

 

 Region Percent Standard Error Confidence Interval

 

United States 20.1 0.15 19.8-20.4

Border States2 17.8 0.34 17.1-18.4 

 Border Counties3 14.7 0.75 13.3-16.2 

 Non-Border Counties4 18.4 0.38 17.7-19.2 

 

 Region by Ethnicity5 

 

United States 

 Hispanic 17.5 0.33 16.8-18.1 

 Non-Hispanic 20.4 0.16 20.0-20.7 

 

Border States 

 Hispanic 15.8 0.4 15.0-16.6 

 Non-Hispanic 18.7 0.45 17.8-19.6 

 

 Border Counties 

 Hispanic 13.1 0.69 11.8-14.5 

 Non-Hispanic 15.7 0.98 13.8-17.7 

 

 Non-Border Counties 

 Hispanic 16.5 0.46 15.6-17.4 

 Non-Hispanic 19.3 0.5 18.3-20.3 

 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 20.3 0.41 19.5-21.1 

 Uninsured 13.1 0.47 12.1-14.0 

 Non-Hispanic 

 Insured 20.2 0.17 19.8-20.5 

 Uninsured 22.0 0.43 21.1-22.8 

Border States 

 Hispanic 

 Insured 18.7 0.50 17.7-19.7 

 Uninsured 11.4 0.59 10.2-12.6 

 Non-Hispanic 

 Insured 18.9 0.47 18.0-19.8 

 Uninsured 17.5 0.93 15.6-19.3 

 

 Border Counties 

 Hispanic 

 Insured 16.0 1.20 13.7-18.5 

 Uninsured 9.4 0.69 8.1-10.8

 Non-Hispanic 

 Insured 15.9 1.18 13.7-18.4 

 Uninsured 13.7 2.63 9.2-19.7 

 

 Non-Border Counties 

 Hispanic 

 Insured 19.3 0.54 18.2-20.4 

 Uninsured 12.0 0.72 10.6-13.5 

 Non-Hispanic 

 Insured 19.5 0.51 18.5-20.5 Uninsured 18.1 1.01 16.1-20.1 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

 

1

DURING THE PAST 12 MONTHS, HOW MANY TIMES have you gone to a HOSPITAL EMERGENCY ROOM about your own health? 

(This includes emergency room visits that resulted in a hospital admission.) 2

 Border states: Arizona, California, New Mexico, and Texas. 3

 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the USMexico border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
Border Lives: Health Status in the United States-Mexico Border Region

338

Table 9. Percent of the total population who spent at least one night in hospital in the past 12 months1

by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 8.5 0.06 8.4-8.6 

Border States2 7.6 0.12 7.3-7.8 Border Counties3

 7.9 0.29 7.4-8.5 Non-Border Counties4 7.5 0.12 7.3-7.8 

 Region by Ethnicity5

United States Hispanic 7.4 0.11 7.1-7.5 Non-Hispanic 8.7 0.07 8.5-8.8 

Border States Hispanic 7.1 0.15 6.8-7.4 Non-Hispanic 7.8 0.15 7.5-8.1 

 Border Counties Hispanic 7.6 0.31 7.0-8.2 Non-Hispanic 8.2 0.32 7.5-8.8 

 Non-Border Counties Hispanic 7.0 0.17 6.6-7.3 Non-Hispanic 7.8 0.17 7.4-8.1 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 8.7 0.15 8.3-8.9 

 Uninsured 4.8 0.16 4.4-5.1 

 Non-Hispanic 

 Insured 9.2 0.07 9.0-9.3 

 Uninsured 5.4 0.14 5.1-5.7 

 

Border States 

 Hispanic 

 Insured 8.4 0.22 8.0-8.8 

 Uninsured 4.5 0.20 4.1-4.9 

 Non-Hispanic 

 Insured 8.4 0.17 8.0-8.7 

 Uninsured 4.4 0.32 3.8-5.0 

 

 Border Counties 

 Hispanic 

 Insured 9.5 0.58 8.4-10.7 

 Uninsured 4.5 0.40 3.8-5.4 

 Non-Hispanic 

 Insured 8.8 0.35 8.0-9.4 

 Uninsured 4.0 0.70 2.8-5.6 

 

 Non-Border Counties 

 Hispanic 

 Insured 8.2 0.23 7.7-8.6 

 Uninsured 4.5 0.23 4.0-4.9 

 Non-Hispanic 

 Insured 8.3 0.18 7.9-8.6 Uninsured 4.5 0.35 3.8-5.2 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

1

DURING THE PAST 12 MONTHS was {person} a patient in a hospital OVERNIGHT? (Do not include an overnight stay in the emergency 

room.) Remember to include any new mothers and/or babies who where hospitalized for the baby’s birth. 2 Border states: Arizona, California, New Mexico, and Texas. 3

 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the 

US-Mexico border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all 

persons who are not of Hispanic or Latino origin, regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7 Without insurance coverage at the time of the interview.

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
339 

 Appendix to Chapter 3

Table 10. Percent of the adult population (18 years and over) who have seen/talked to a General Doctor 

in the past 12 months1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 68.2 0.21 67.8-68.6 

Border States2 63.4 0.47 62.4-64.3 Border Counties3

 56.7 1.43 53.9-59.5 Non-Border Counties4

 64.8 0.5 63.8-65.8 

 Region by Ethnicity5 

United States Hispanic 54.7 0.49 53.7-55.6 Non-Hispanic 69.9 0.22 69.4-70.3 

Border States Hispanic 53.3 0.63 52.0-54.5 Non-Hispanic 68.5 0.51 67.4-69.4 

 Border Counties Hispanic 45.2 1.38 42.4-47.9 Non-Hispanic 64.2 1.64 60.8-67.3 

 Non-Border Counties Hispanic 55.4 0.71 54.0-56.8 Non-Hispanic 69.3 0.51 68.2-70.2 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 67.2 0.52 66.1-68.1 

 Uninsured 34.5 0.73 33.0-35.9

 Non-Hispanic 

 Insured 73.6 0.21 73.1-79.9 

 Uninsured 45.3 0.56 44.1-46.3 

 

Border States 

 Hispanic 

 Insured 65.3 0.73 63.8-66.7 

 Uninsured 34.7 0.88 32.9-36.5 

 Non-Hispanic 

 Insured 72.9 0.55 71.7-73.9 

 Uninsured 40.1 1.29 37.5-42.7 

 

 Border Counties 

 Hispanic 

 Insured 57.1 1.41 54.2-59.8 

 Uninsured 30.4 1.77 27.0-34.0 

 Non-Hispanic 

 Insured 68.2 2.08 63.9-72.2 

 Uninsured 32.2 2.67 27.1-37.7 

 

Non-Border Counties 

 Hispanic 

 Insured 67.2 0.82 65.5-68.8 

 Uninsured 36.1 1.01 34.1-38.1 

 Non-Hispanic Insured 73.8 0.52 72.7-74.8 Uninsured 41.4 1.40 38.6-44.2 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

 

1 DURING THE PAST 12 MONTHS, that is since {12 monthref date}, have you seen or talked to any of the following health care providers about 

your own health? ..... A general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine) 2

 Border states: Arizona, California, New Mexico, and Texas. 3

 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the 

US-Mexico border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7

 Without insurance coverage at the time of the interview.

Data source: National Health Interview Survey, 2000-2004 (In-house version) 

 
Border Lives: Health Status in the United States-Mexico Border Region

340

Table 11. Percent of the adult population (18 years and over) who have seen/talked to a Medical 

Specialist in the past 12 months1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 25.7 0.18 25.3-26.0 

Border States2 23.3 0.39 22.5-24.0 Border Counties3

 19.9 0.93 18.2-21.8 Non-Border Counties4

 24.0 0.43 23.1-24.8 

 Region by Ethnicity5 

United States Hispanic 15.1 0.33 14.4-15.7 Non-Hispanic 27.0 0.19 26.6-27.3 

Border States Hispanic 14.1 0.41 13.2-14.9 Non-Hispanic 27.9 0.46 26.9-28.7 

 Border Counties Hispanic 11.7 0.56 10.6-12.9 Non-Hispanic 25.2 1.12 23.0-27.5 Non-Border Counties Hispanic 14.7 0.5 13.7-15.7 Non-Hispanic 28.4 0.5 27.4-29.3 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 20.3 0.45 19.4-21.2 

 Uninsured 6.6 0.34 6.0-7.3 

 Non-Hispanic 

 Insured 29.3 0.20 28.8-29.6 

 Uninsured 11.9 0.34 11.2-12.5 

 

Border States 

 Hispanic 

 Insured 19.0 0.56 19.9-20.1 

 Uninsured 6.4 0.51 5.4-7.5 

 Non-Hispanic 

 Insured 30.3 0.49 29.3-31.2 

 Uninsured 12.5 1.04 10.5-14.6 

 

 Border Counties 

 Hispanic 

 Insured 17.2 0.87 15.5-18.9 

 Uninsured 5.0 0.78 3.6-6.7 

 Non-Hispanic 

 Uninsured 11.9 1.99 8.4-16.4 

 Insured 26.7 1.21 24.6-29.4 

 

 Non-Border Counties 

 Hispanic 

 Insured 19.5 0.66 18.1-20.8 

 Uninsured 6.8 0.62 5.7-8.1 

 Non-Hispanic 

 Insured 31.0 0.54 29.8-32.0 

 Uninsured 12.6 1.17 10.4-15.0 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

Footnotes: 

 

1 DURING THE PAST 12 MONTHS, that is since {12 monthref date}, have you seen or talked to any of the following health care providers about 

your own health? ..... A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist 

orophthalmologist)? 2

 Border states: Arizona, California, New Mexico, and Texas.

3

 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the 

US-Mexico border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race. 6 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7

 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
341 

 Appendix to Chapter 3

Table 12. Percent of the female adult population (18 years and over) who have seen/talked to a OB/

GYN in the past 12 months1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 45.6 0.28 45.1-46.2 

Border States2 42.5 0.58 41.3-43.7 Border Counties3

 40.8 1.52 37.8-43.9 Non-Border Counties4

 42.9 0.62 41.6-44.1 

 Region by Ethnicity5 

United States Hispanic 43.9 0.65 42.6-45.2 Non-Hispanic 45.8 0.3 45.2-46.4 

Border States Hispanic 39.8 0.9 38.0-41.6 Non-Hispanic 43.8 0.76 42.3-45.3 

 Border Counties Hispanic 35.1 1.26 32.6-37.6 Non-Hispanic 44.5 2.41 39.8-49.3 

 Non-Border Counties Hispanic 41.1 1.09 38.9-43.2 Non-Hispanic 43.7 0.79 42.14-45.2 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 50.1 0.79 48.5-51.6 

 Uninsured 32.2 1.03 30.2-34.2 

 Non-Hispanic 

 Insured 47.4 0.32 46.7-48.0 

 Uninsured 34.3 0.69 32.9-35.6 

 

Border States 

 Hispanic 

 Insured 45.7 1.09 43.5-47.8 

 Uninsured 29.9 1.19 27.5-32.3 

 Non-Hispanic 

 Insured 45.5 0.90 43.7-47.2 

 Uninsured 31.8 1.72 28.4-35.2 

 

 Border Counties 

 Hispanic 

 Insured 40.7 1.57 37.5-43.8 

 Uninsured 27.5 1.81 24.0-31.2 

 Non-Hispanic 

 Insured 45.2 2.78 39.6-50.7 

 Uninsured 38.9 5.95 27.8-51.1 

 

 Non-Border Counties 

 Hispanic 

 Insured 46.8 1.29 44.2-49.4 

 Uninsured 30.6 1.48 27.7-33.6 

 Non-Hispanic 

 Insured 45.6 0.93 43.7-47.4 Uninsured 30.8 1.78 27.3-34.4 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

 

1 DURING THE PAST 12 MONTHS, that is since {12 monthref.date}, have you seen or talked to any of the following health care providers about 

your own health? ..... A doctor who specializes in women’s health (an obstetrician/gynecologist)?

2 Border states: Arizona, California, New Mexico, and Texas. 3 Border counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the USMexico border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race.

6 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care.

7 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
Border Lives: Health Status in the United States-Mexico Border Region

342

Table 13. Time since last saw/talked to a dentist1 for respondents age 18 years and over by selected 

characteristics: 2000-2003

 Region Percent Standard Confidence 

 Error Interval

United States 

 6 months or less 46.4 0.24 45.9-46.8

 More than 6 mo., but no more than a year ago 17.5 0.14 17.2-17.7

 More than 1 year 36.2 0.23 35.7-36.6

 

Border States2

 

 6 months or less 43.1 0.55 42.0-44.2

 More than 6 mo., but no more than a year ago 17.5 0.31 16.9-18.2

 More than 1 year 39.4 0.5 38.4-40.4

 

Border Counties3

 

 6 months or less 43.9 1.26 41.4-46.4

 More than 6 mo., but no more than a year ago 16.3 0.75 14.8-17.8

 More than 1 year 39.8 1.34 37.2-42.5

 

Non-Border Counties4

 

 6 months or less 42.9 0.61 41.7-44.2

 More than 6 mo., but no more than a year ago 17.8 0.34 17.1-18.5

 More than 1 year 39.3 0.53 38.2-40.3

 

 Region by Ethnicity

 

United States 

 Hispanic5

 

 6 months or less 33.4 0.51 32.4-34.3

 More than 6 mo., but no more than a year ago 18.0 0.36 17.3-18.7

 More than 1 year 48.6 0.5 47.6-49.6

 Non-Hispanic 

 6 months or less 47.9 0.26 47.4-48.4

 More than 6 mo., but no more than a year ago 17.4 0.15 17.0-17.7

 More than 1 year 34.7 0.24 34.2-35.1

 

4 Border States 

 Hispanic 

 6 months or less 31.7 0.72 30.2-33.1

 More than 6 mo., but no more than a year ago 17.6 0.51 16.6-18.6

 More than 1 year 50.7 0.69 49.3-52.1

 Non-Hispanic 

 6 months or less 48.6 0.6 47.4-49.8

 More than 6 mo., but no more than a year ago 17.5 0.36 16.7-18.2

 More than 1 year 33.9 0.58 32.7-35.0

 

Border Counties 

 Hispanic 

 6 months or less 28.8 1.62 25.7-32.1

 More than 6 mo., but no more than a year ago 14.9 1.19 12.6-17.4

 More than 1 year 56.2 1.43 53.5-59.0

 Non-Hispanic 

 6 months or less 53.2 1.71 49.7-56.5

 More than 6 mo., but no more than a year ago 17.1 0.78 15.5-18.7

 More than 1 year 29.8 1.71 26.4-33.2

 

Non-Border Counties 

 Hispanic 

 6 months or less 32.4 0.83 30.7-34.0

 More than 6 mo., but no more than a year ago 18.3 0.56 17.2-19.4

 More than 1 year 49.3 0.79 47.7-50.8

 Non-Hispanic 

 6 months or less 47.8 0.64 46.4-49.0

 More than 6 mo., but no more than a year ago 17.6 0.39 16.7-18.3

 More than 1 year 34.7 0.62 33.4-35.9

 

Region by Ethnicity and Insurance Coverage Status 6,7

 

United States 

 Hispanic 

 Insured 

 6 months or less 41.3 0.59 40.1-42.5

 More than 6 mo., but no more than a year ago 19.7 0.44 18.8-20.6

 More than 1 year 39.0 0.53 38.0-40.0

 Uninsured 

 6 months or less 19.3 0.63 18.1-20.6
343 

 Appendix to Chapter 3

 Region Percent Standard Confidence 

 Error Interval

 More than 6 mo., but no more than a year ago 14.9 0.53 13.9-16.0

 More than 1 year 65.8 0.77 64.3-67.3

 Non-Hispanic 

 Insured 

 6 months or less 51.4 0.27 50.8-51.9

 More than 6 mo., but no more than a year ago 17.5 0.17 17.2-17.9

 More than 1 year 31.1 0.24 30.6-31.6

 Uninsured 

 6 months or less 24.2 0.45 23.3-25.0

 More than 6 mo., but no more than a year ago 16.3 0.39 15.6-17.1

 More than 1 year 59.5 0.51 58.5-60.5

 

4 Border States 

 Hispanic 

 Insured 

 6 months or less 39.5 0.83 37.8-41.1

 More than 6 mo., but no more than a year ago 19.5 0.64 18.2-20.8

 More than 1 year 41.1 0.70 39.7-42.5

 Uninsured 

 6 months or less 18.9 0.87 17.2-20.7

 More than 6 mo., but no more than a year ago 14.4 0.72 13.1-15.9

 More than 1 year 66.7 1.02 64.6-68.7

 Non-Hispanic 

 Insured 

 6 months or less 52.8 0.69 51.4-54.2

 More than 6 mo., but no more than a year ago 17.4 0.40 16.6-18.2

 More than 1 year 29.8 0.70 28.4-31.2

 Uninsured 

 6 months or less 21.0 1.04 19.0-23.2

 More than 6 mo., but no more than a year ago 18.2 0.90 16.4-20.0

 More than 1 year 60.8 1.05 58.7-62.9

 

Border Counties 

 Hispanic 

 Insured 

 6 months or less 37.5 1.86 33.8-41.3

 More than 6 mo., but no more than a year ago 17.4 1.66 14.3-21.0

 More than 1 year 45.1 1.75 41.7-48.6

 Uninsured 

 6 months or less 17.4 2.10 13.6-22.0

 More than 6 mo., but no more than a year ago 11.7 1.12 9.7-14.2

 More than 1 year 70.8 2.13 66.4-74.9

 Non-Hispanic 

 Insured 

 6 months or less 57.1 2.10 52.9-61.2

 More than 6 mo., but no more than a year ago 17.4 1.01 15.5-19.6

 More than 1 year 25.5 2.35 21.1-30.4

 Uninsured 

 6 months or less 21.5 3.02 16.1-28.1

 More than 6 mo., but no more than a year ago 13.6 2.23 9.7-18.7

 More than 1 year 64.9 2.34 60.1-69.4

 

Non-Border Counties 

 Hispanic 

 Insured 

 6 months or less 39.9 0.96 38.0-41.8

 More than 6 mo., but no more than a year ago 19.9 0.68 18.6-21.3

 More than 1 year 40.2 0.79 38.6-41.7

 Uninsured 

 6 months or less 19.3 0.92 17.6-21.2

 More than 6 mo., but no more than a year ago 15.3 0.86 13.6-17.1

 More than 1 year 65.4 1.13 63.1-67.6

 Non-Hispanic 

 Insured 

 6 months or less 52.0 0.72 50.5-53.4

 More than 6 mo., but no more than a year ago 17.4 0.43 16.5-18.2

 More than 1 year 30.7 0.69 29.3-32.1

 Uninsured 

 6 months or less 20.9 1.10 18.8-23.2

 More than 6 mo., but no more than a year ago 18.9 0.97 17.0-20.9

 More than 1 year 60.2 1.17 57.8-62.5

Table 13. Time since last saw/talked to a dentist1 for respondents age 18 years and over by selected 

characteristics: 2000-2003 (Continued)
Border Lives: Health Status in the United States-Mexico Border Region

344

* Estimates have a relative standard error of greater than 30 and should be used with caution as 

they do not meet the standards of reliability or precision. 

 

Footnotes: 

 

1

 Question: About how long has it been since you last saw a dentist? Include all types of dentists, 

such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

2

 Border states: Arizona, California, New Mexico, and Texas. 3

 Counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz 

agreement (1987) as the US portion of the US-Mexico border region. This includes 44 border 

counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the 

US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico 

border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the 

category “Non-Hispanics or Latino” refers to all persons who are not of Hispanic or Latino origin, 

regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, 

Medicare, Medicaid, SCHIP, state-sponsored or other government sponsored health program, 

or military plan at the time of the interview. This classification also includes individuals who have 

only Indian Health Services coverage or hand only a private plan that paid for one type of service 

such as accidents or dental care. 7 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 

 
345 

 Appendix to Chapter 3

Table 14. Percent of the adult population (18 years and over) who have seen/talked with a mental 

health professional in the past 12 months1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 6.2 0.08 6.0-6.3 

Border States2 5.5 0.17 5.1-5.8 Border Counties3

 4.7 0.37 4.0-5.5 Non-Border Counties4

 5.6 0.19 5.3-6.0 

 Region by Ethnicity5 

United States Hispanic 3.8 0.16 3.5-4.1 Non-Hispanic 6.5 0.09 6.2-6.6 

Border States Hispanic 3.0 0.17 2.7-3.4 Non-Hispanic 6.7 0.23 6.2-7.1 

 Border Counties Hispanic 2.7 0.53 1.7-3.9 Non-Hispanic 6.0 0.59 4.8-7.2 

 Non-Border Counties Hispanic 3.1 0.17 2.8-3.5 Non-Hispanic 6.8 0.25 6.3-7.3 

 Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 5.3 0.23 4.9-5.7 

 Uninsured 1.4 0.15 1.1-1.7 

 Non-Hispanic 

 Insured 6.5 0.10 6.3-6.7 

 Uninsured 5.8 0.23 5.3-6.2 

 

Border States 

 Hispanic 

 Insured 4.3 0.26 3.7-4.8 

 Uninsured 1.1 0.19 .79-1.5 

 Non-Hispanic 

 Insured 6.8 0.24 6.3-7.3 

 Uninsured 5.7 0.54 4.6-6.8 

 

 Border Counties 

 Hispanic 

 Insured 3.8 0.76 2.5-5.6 

 Uninsured 1.1* 0.49 0.4-2.6 

 Non-Hispanic 

 Insured 5.9 0.59 4.7-7.1 

 Uninsured 6.8 1.34 1.3-4.5 

 Non-Border Counties 

 Hispanic 

 Insured 4.4 0.26 3.8-4.9 

 Uninsured 1.1 0.20 0.7-1.5 

 Non-Hispanic 

 Insured 7.0 0.26 6.5-7.5 Uninsured 5.5 0.59 4.4-6.7 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

1

 DURING THE PAST 12 MONTHS, that is since {12 monthref. date}, have you seen or talked to any of the following health care providers about 

your own health? ..... A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker.

2

 Border states: Arizona, California, New Mexico, and Texas.

3

 Counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico 

border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico Border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7

 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
Border Lives: Health Status in the United States-Mexico Border Region

346

Table 15. Percent of the adult population (18 years and over) who have received a flu shot in the past 

12 months1 by selected characteristics: 2000-2003 

 

 Region Percent Standard Error Confidence Interval 

 

United States 27.9 0.19 27.5-28.3 

 

Border States2 24.8 0.44 23.9-25.7 

 Border Counties3 24.2 1.31 21.7-26.9 

 Non-Border Counties4 24.9 0.45 24.0-25.8 

 

 Region by Ethnicity5 

 

United States 

 Hispanic 17.4 0.38 16.7-18.2 

 Non-Hispanic 29.2 0.21 28.8-29.6 

 

Border States 

 Hispanic 17.1 0.46 16.1-17.9 

 Non-Hispanic 28.7 0.59 27.5-29.8 

 

 Border Counties 

 Hispanic 16.5 0.81 14.9-18.1 

 Non-Hispanic 29.2 1.95 25.4-33.2 

 

 Non-Border Counties 

 Hispanic 17.2 0.54 16.1-18.2 

 Non-Hispanic 28.6 0.59 27.4-29.7 

 

 Region by Ethnicity and Insurance Coverage Status 6,7 

United States Hispanic Insured 23.0 0.53 21.9-24.0 Uninsured 8.3 0.36 7.6-9.0 Non-Hispanic Insured 31.8 0.22 31.4-32.2 Uninsured 11.6 0.32 10.9-12.2 

Border States Hispanic Insured 22.8 0.67 21.5-24.2 Uninsured 8.0 0.44 7.14-8.8 Non-Hispanic Insured 31.3 0.62 30.0-32.5 Uninsured 11.9 0.85 10.3-13.7 

 Border Counties Hispanic Insured 23.6 1.31 21.0-26.2 Uninsured 7.7 0.63 6.5-9.0 Non-Hispanic Insured 31.6 1.93 27.8-35.5 Uninsured 10.9 2.36 7.0-16.5 

 Non-Border Counties Hispanic Insured 22.7 0.77 21.1-24.2 Uninsured 8.0 0.54 7.0-9.1 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

 

1 DURING THE PAST 12 MONTHS, have you had a flu vaccine sprayed in your nose by a doctor or other health professional? A health professional 

may have let you spray it. This vaccine is usually given in the fall and protects against influenza for the flu season. [This influenza vaccine is called 

FluMist.] 2

 Border states: Arizona, California, New Mexico, and Texas. 3

 Counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico 

border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico Border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5

 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, State-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7

 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 
347 

 Appendix to Chapter 3

Table 16. Percent of the adult population (18 years and over) who have received a pneumonia shot in 

the past 12 months1 by selected characteristics: 2000-2003 

 Region Percent Standard Error Confidence Interval 

United States 15.6 0.16 15.3-16.0 

Border States2 13.8 0.45 12.9-14.7 Border Counties3

 14.9 1.73 11.8-18.7 Non-Border Counties4

 13.5 0.38 12.8-14.3 

Region by Ethnicity 

United States Hispanic5

 7.2 0.27 6.6-7.6 Non-Hispanic 16.7 0.18 16.3-17.0 

Border States Hispanic 6.9 0.35 6.2-7.6 Non-Hispanic 17.2 0.6 16.0-18.4 

 Border Counties Hispanic 6.2 0.71 4.9-7.7 Non-Hispanic 20.6 2.57 15.9-26.2 

 Non-Border Counties Hispanic 7.1 0.39 6.4-7.9 Non-Hispanic 16.6 0.49 15.6-17.5 

Region by Ethnicity and Insurance Coverage Status 6,7 

 

United States 

 Hispanic 

 Insured 9.4 0.38 8.6-10.1 

 Uninsured 3.6 0.25 3.1-4.0 

 Non-Hispanic 

 Insured 18.2 0.19 17.8-18.5 

 Uninsured 6.8 0.27 6.3-7.4 

 

Border States 

 Hispanic 

 Insured 9.6 0.54 8.6-10.7 

 Uninsured 2.8 0.28 2.2-3.3 

 Non-Hispanic 

 Insured 19.1 0.66 17.1-20.4 

 Uninsured 5.7 0.65 4.4-7.0 

 

 Border Counties 

 Hispanic 

 Insured 9.1 1.15 7.0-11.6 

 Uninsured 2.5 0.57 1.5-3.9 

 Non-Hispanic 

 Insured 22.6 2.65 17.7-28.3 

 Uninsured 5.2 1.40 3.0-8.8 

 

 Non-Border Counties 

 Hispanic 

 Insured 9.8 0.60 8.6-11.0 

 Uninsured 2.9 0.33 2.2-3.5 

 Non-Hispanic 

 Insured 18.4 0.56 17.2-19.4 Uninsured 5.7 0.72 4.4-7.3 

* Estimates have a relative standard error of greater than 30 and should be used with caution as they do not meet the standards of reliability or precision.

 

Footnotes: 

 

1

 Question: Have you EVER had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. 

It is also called the pneumococcal vaccine.

2

 Border states: Arizona, California, New Mexico, and Texas.

3 Counties that are within 100 kilometers (62 miles) of US-Mexico border, defined under La Paz agreement (1987) as the US portion of the US-Mexico 

border region. This includes 44 border counties identified by US-Mexico Border Health Commission, plus Maricopa County, Arizona. 4

 Counties that belong to the 4 border states that are more than 100 kilometers (62 miles) of the US-Mexico border, defined under La Paz agreement 

(1987) as the US portion of the US-Mexico border region, except Maricopa County, Arizona. 5 Person of Hispanic or Latino origins may be of any race or combination of races. Similarly, the category “Non-Hispanics or Latino” refers to all persons 

who are not of Hispanic or Latino origin, regardless of race. 6

 A person was defined as “uninsured” if he or she did not have any private health insurance, Medicare, Medicaid, SCHIP, state-sponsored or other 

government sponsored health program, or military plan at the time of the interview. This classification also includes individuals who have only Indian 

Health Services coverage or hand only a private plan that paid for one type of service such as accidents or dental care. 7 Without insurance coverage at the time of the interview. 

 

Data source: National Health Interview Survey, 2000-2004 (In-house version) 

349 

APPENDIX TO CHAPTER 7

 

 

 

 Rate SE CI - CI+

Border 26.0 0.37 25.27 26.72

Arizona border 21.0 0.72 19.57 22.40

 Cochise 21.7 2.34 17.09 26.26

 Pima 20.7 0.84 19.09 22.38

 Santa Cruz 18.5 4.16 10.31 26.61

 Yuma 23.5 2.07 19.42 27.53

California border 19.4 0.48 18.47 20.37

 Imperial 28.5 2.83 23.00 34.08

 San Diego 19.0 0.49 18.05 19.97

New Mexico border 37.9 1.98 33.98 41.73

 Doña Ana 50.0 3.29 43.59 56.50

 Otero 28.2 3.87 20.60 35.78

Texas border 38.1 0.84 36.48 39.78

 Cameron 40.1 2.09 36.03 44.23

 El Paso 45.3 1.66 42.08 48.60

 Hidalgo 34.5 1.57 31.44 37.58

 Maverick 35.4 5.55 24.51 46.26

 Starr 19.1 3.92 11.39 26.77

 Val Verde 27.2 4.56 18.27 36.13

 Webb 43.2 3.30 36.74 49.67

Number of deaths per 100,000 population age-adjusted to the 2000 

U.S. standard
Border Lives: Health Status in the United States-Mexico Border Region

350

CT USA_2000 std err

TT_BRD_44 CT 25.2 0.626472618

AZ_TT_BRD_44_CT 21.4 1.251202418

CA_TT_BRD__44_CT 20.3 0.850756622

NM_TT_BRD__44_CT 39.0 3.468365077

TX_TT_BRD_44_CT 33.5 1.351106963

 CT USA_2000 std err

Border Total 25.2 0.626472618

Border Counties Arizona 21.4 1.251202418

 California 20.3 0.850756622

 New Mexico 39.0 3.468365077

 Texas 33.5 1.351106963

2004 <25 25-34 35-44 45-54 55-64 65-74 75-84 85+

 AZ 0.0 2.0 5.5 13.2 38.4 67.7 135.0 256.2

 CA 0.4 1.2 3.7 12.2 33.1 84.2 165.1 248.8

 NM 0.0 3.8 7.5 16.7 50.8 112.8 209.9 395.3

 TX 0.2 1.4 4.5 16.3 46.0 104.4 219.1 388.6
351 

 Appendix to Chapter 7

 Diabetes Mortality Rates US-MX Border 

2004

 

CT <25 25-34 35-44 45-54 55-64 65-74 75-84 85+

Total Border 0.19 1.71 4.61 12.04 36.33 103.14 172.28 311.87 

Arizona Border - 1.82 7.33 16.08 37.28 80.77 105.91 289.14 

California Border 0.44 1.91 3.18 9.71 26.04 87.28 147.62 226.86 

New Mexico Border - 4.94 14.53 17.01 47.53 142.68 207.51 696.71 

Texas Border - 0.94 4.00 12.45 49.13 134.08 254.40 420.02 
Border Lives: Health Status in the United States-Mexico Border Region

352

2004 Border HSP Diabetes Mortality Rates

CT Race ICD Sex All <1 01T04 5T14Y 15t24Y 25t34Y 35t44 45t54Y 55t64T 65t74Y 75t84Y 85+ USA va std err LCL UCL

 2000

TT_BRD_44 CT HSP 52) E10-E14 DIABETES MELLITUS TT 22.22 - - - - 1.47 3.73 15.18 50.92 160.73 282.14 506.78 38.42 2.5773 1.61 35.27 41.57AZ_TT_BRD_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 19.51 - - - - 1.44 8.18 21.20 40.76 157.98 194.85 614.20 36.63 22.3269 4.73 27.37 45.89CA_TT_BRD_Male_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 15.26 - - - - 1.21 2.13 16.35 38.14 160.99 241.55 408.58 33.84 12.1484 3.49 27.01 40.67NM_TT_BRD_MALE_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 33.75 - - - - 8.16 4.30 24.86 63.55 188.39 339.39 720.98 49.54 57.9560 7.61 34.62 64.46TX_TT_BRD_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 25.19 - - - - 1.06 3.51 12.39 56.32 158.39 304.48 500.61 39.17 4.4888 2.12 35.02 43.33TT_BRD_44 CT NHW 52) E10-E14 DIABETES MELLITUS TT 25.07 - - - 0.59 2.05 6.20 6.95 24.36 66.58 116.85 242.52 17.83 0.8632 0.93 16.01 19.65AZ_TT_BRD_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 25.53 - - - - 2.50 7.90 10.68 30.18 53.02 88.65 235.67 6.83 2.8846 1.70 13.50 20.16CA_TT_BRD_Male_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 20.68 - - - 0.99 2.27 4.45 4.72 20.96 66.84 117.71 199.99 16.43 1.4504 1.20 14.07 18.79NM_TT_BRD_MALE_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 49.77 - - - - - 25.18 10.37 33.50 114.97 145.41 708.08 33.51 25.4825 5.05 23.62 43.40TX_TT_BRD_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 37.16 - - - - - 5.59 9.83 21.99 74.89 157.53 278.61 20.48 7.2756 2.70 15.20 25.77

CT Race ICD Sex All <1Y 01T04 5T14Y 15t24Y 25t34Y 35t44 45t54Y 55t64T 65t74Y 75t84Y 85+ 

TT_BRD_44 CT HSP 52) E10-E14 DIABETES MELLITUS TT 22.22 - - - - 1.47 3.73 15.18 50.92 160.73 282.14 506.78 

AZ_TT_BRD_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 19.51 - - - - 1.44 8.18 21.20 40.76 157.98 194.85 614.20 

CA_TT_BRD_Male_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 15.26 - - - - 1.21 2.13 16.35 38.14 160.99 241.55 408.58 NM_TT_BRD_MALE_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 33.75 - - - - 8.16 4.30 24.86 63.55 188.39 339.39 720.98 

TX_TT_BRD_44_CT HSP 52) E10-E14 DIABETES MELLITUS TT 25.19 - - - - 1.06 3.51 12.39 56.32 158.39 304.48 500.61 TT_BRD_44 CT NHW 52) E10-E14 DIABETES MELLITUS TT 25.07 - - - 0.59 2.05 6.20 6.95 24.36 66.58 116.85 242.52 

AZ_TT_BRD_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 25.53 - - - - 2.50 7.90 10.68 30.18 53.02 88.65 235.67 

CA_TT_BRD_Male_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 20.68 - - - 0.99 2.27 4.45 4.72 20.96 66.84 117.71 199.99 NM_TT_BRD_MALE_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 49.77 - - - - - 25.18 10.37 33.50 114.97 145.41 708.08 

TX_TT_BRD_44_CT NHW 52) E10-E14 DIABETES MELLITUS TT 37.16 - - - - - 5.59 9.83 21.99 74.89 157.53 278.61 
353 

 Appendix to Chapter 7

Border Total HSP 38.42 1.61

 NHW 17.83 0.93

Border Counties Arizona HSP 36.63 4.73

 NHW 16.83 1.70

 California HSP 33.84 3.49

 NHW 16.43 1.20

 New Mexico HSP 49.54 7.61

 NHW 33.51 5.05

 Texas HSP 39.17 2.12

 NHW 20.48 2.70

 

 Hispanic Non-Hispanic White HSP_CI NHSP_CI

Border Total 38.4 17.8 1.61 0.93

Border Counties Arizona 36.6 16.8 4.73 1.70

 California 33.8 16.4 3.49 1.20

 New Mexico 49.5 33.5 7.61 5.05

 Texas 39.2 20.5 2.12 2.70
Border Lives: Health Status in the United States-Mexico Border Region

354

CT <25 25-34 35-44 45-54 55-64 65-74 75-84 85+

Total BRD HSP 0.0 1.5 3.7 15.2 50.9 160.7 282.1 506.8

AZ BRD HSP 0.0 1.4 8.2 21.2 40.8 158.0 194.8 614.2

CA BRD HSP 0.0 1.2 2.1 16.3 38.1 161.0 241.5 408.6

NN BRD HSP 0.0 8.2 4.3 24.9 63.5 188.4 339.4 721.0

TX BRD HSP 0.0 1.1 3.5 12.4 56.3 158.4 304.5 500.6

TT BRD NHW 0.6 2.0 6.2 6.9 24.4 66.6 116.8 242.5

AZ BRD NHW 0.0 2.5 7.9 10.7 30.2 53.0 88.6 235.7

CA BRD NHW 1.0 2.3 4.5 4.7 21.0 66.8 117.7 200.0

NM BRD NHW 0.0 0.0 25.2 10.4 33.5 115.0 145.4 708.1

TX BRD NHW 0.0 0.0 5.6 9.8 22.0 74.9 157.5 278.6
355 

 Appendix to Chapter 7

 Diabetes Mortality Rates US-MX Border

 

 USA_2000 std err SD

4 Border States 24.7 0.21 0.41

National USA 24.5 0.09 0.18

Border States AZ 20.8 0.60 1.18

 CA 22.2 0.26 .52

 NM 31.4 1.31 2.56

 TX 29.9 0.41 0.80
Border Lives: Health Status in the United States-Mexico Border Region

356

 Mortality Rate per 100,000 PP _04 Sex All ages <1Yr 01T04 5T14yR 15T24YR 25T34YR 35T44YR 45T54YR 55T64YR 65T74YR 75T84YR 85+ Old New USA_2000

4 States 52) E10-E14 DIABETES MELLITUS TT 21.76 0.00 0.00 0.10 0.28 1.39 4.21 13.81 38.44 90.07 180.12 293.45 14.03 16.39 24.72

AZ 52) E10-E14 DIABETES MELLITUS TT 20.77 0.00 0.00 0.12 0.00 2.05 5.50 13.22 38.37 67.72 134.96 256.15 12.18 14.09 20.82CA 52) E10-E14 DIABETES MELLITUS TT 19.82 0.00 0.00 0.07 0.37 1.16 3.70 12.20 33.11 84.20 165.06 248.83 12.60 14.74 22.18NM 52) E10-E14 DIABETES MELLITUS TT 30.74 0.00 0.00 0.00 0.00 3.81 7.53 16.74 50.78 112.75 209.86 395.27 18.10 21.02 31.41TX 52) E10-E14 DIABETES MELLITUS TT 24.34 0.00 0.00 0.15 0.23 1.41 4.49 16.30 46.01 104.42 219.10 388.63 16.73 19.60 29.94

 Mortality Rate per 100,000 PP _04 Sex <1Year 01T04 5-14Yr 15T24Yr 25T34yr 35T44Yr 45T54Yr 55T64Yr 65T74Yr 75T84Yr 85+ Var STD ERROR LCL UCL

4 States 52) E10-E14 DIABETES MELLITUS TT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.01 0.01 0.01 0.04 0.21 24.31 25.12

AZ 52) E10-E14 DIABETES MELLITUS TT 0.00 0.00 0.00 0.00 0.00 0.02 0.03 0.05 0.07 0.11 0.0 0.36 0.60 19.63 22.00CA 52) E10-E14 DIABETES MELLITUS TT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.01 0.02 0.02 0.01 0.07 0.26 21.66 22.69NM 52) E10-E14 DIABETES MELLITUS TT 0.00 0.00 0.00 0.00 0.03 0.07 0.11 0.19 0.39 0.55 0.35 1.70 1.31 28.86 33.97TX 52) E10-E14 DIABETES MELLITUS TT 0.00 0.00 0.00 0.00 0.00 0.00 0.01 0.02 0.04 0.06 0.04 0.17 0.41 29.14 30.73

 Diabetes Mortality Rates US-MX Border

 2004 US_Mortality Rates_2004 Sex All Ages <1Year 01T04 5-14Yr 15T24Yr 25T34yr 35T44Yr 45T54Yr 55T64Yr 65T74Yr 75T84Yr 85+ USA_2000 var std err LCL UCL

US 52) E10-E14 DIABETES MELLITUS TT 24.91 0.02 0.05 0.09 0.39 1.50 4.59 13.38 37.07 87.16 176.90 306.98 24.51 .0082 0.09 24.33 24.68
357 

 Appendix to Chapter 7

 Diabetes Mortality Rates US-MX Border

 

2004 USA_2000 std err SD

AZ 20.82 0.60 1.18

CA 22.18 0.26 0.52

NM 31.41 1.31 2.56

TX 29.94 0.41 0.80

All 4 States 4.72 0.21 0.41

US 24.51 0.09 0.18

359 

This list provides a starting place for those interested in health issues in 

the U.S.-Mexico border region. It is a non-exhaustive list of suggested 

further reading, conceived as a guide to essential writings and resources 

that can be used by policy makers, public health officials, students, and others 

interested in the health challenges faced by those working in the U.S.-Mexico 

border region. 

Books 

Bruhn, J.G. & Brandon, J.E. (Eds.). (1997). Border Health: Challenges for the 

United States and Mexico. New York: Garland Publishing. 

A collection of essays that seeks to describe the challenges presented 

by the amalgam of two cultures relative to health issues resulting from 

pollution, economic development, and social contact. 

Curiel, H., & Land, H. (2007) Outreach and care approaches to HIV/AIDS along 

the U.S.-Mexico border. Binghamton, NY: Haworth Press. 

This book provides insight into the complex factors influencing the 

control of HIV/AIDS along the U.S.-Mexico border. The book presents 

in-depth insights into the problems of language differences, lack of 

resources, poverty, culture, social stigma, fear of rejection, and other 

pressing issues. Practical approaches and strategies are detailed, with an 

emphasis on culturally sensitive health-care practices.

Power, J.G., Byrd, T. (1998). U.S.-Mexico border health: Issues for regional and 

migrant populations. Thousand Oaks, CA: Sage Publications.

FURTHER READING 
Border Lives: Health Status in the United States-Mexico Border Region

360

A compilation of fifteen research studies and practitioner reports on 

health concerns in the border region.

Warner, D.C. & Scheider, P.G., (2004). Cross-border health insurance: Options 

for Texas. U.S.-Mexican Policy Reports Series 12. New York: Sage 

Publications. 

This book examines the development of new cross-border health 

insurance programs in California that provide coverage in Mexico to 

U.S. enrollees and considers the potential use of such models in Texas, 

the state with the highest percentage of uninsured persons in the nation. 

Journal Articles

Belson, M., S. Kieszak, W Watson, K.M.. Blindauer, K. Phan, L. Backer, & 

Carol Rubin. (2003). Childhood pesticide exposures on the TexasMexico border: clinical manifestations and poison center use. American 

Journal of Public Health, 93,(8). pp 1310-1315. 

Preventing Chronic Disease, Volume 5: No. 4, October 2008. http://www.

cdc.gov/pcd/issues/2008/oct/toc.htm. Methods, results and binational 

commentary on reproductive health surveillance in the border region 

are the theme of this issue of the journal.

Stephen, G., M.K. O’Rourke, McRill, C., Flood, T., Mack, M., & M. Lebowitz. 

(2003). Assessment of respiratory symptoms and asthma prevalence in 

a U.S.-Mexico Border Region, Archives of Environmental Health 58(3): 

156-162.

Varady, R., & Mack, M. (1995). Transboundary water resources and public 

health in the U.S.-Mexico Border Region,” Journal of Environmental 

Health 57(8): 8-14. 

Conference Proceedings and Reports

Dutton, R.J., Weldon, M., Shannon, J., Bowcock, C., Tackett-Gibson, M., 

Blakely, C., et al. (2000). Survey of health and environmental conditions 

in Texas border counties and colonias. Austin TX: Texas Department of 

Health, Office of Border Health. 

The results of Survey of Health and Environmental Conditions in 

Texas Border Counties and Colonias are presented in this report. This 
361 

 Further Reading 

population-based household survey was the first comprehensive 

description of health and environmental conditions facing Texas 

families living near the U.S.-Mexico border. The results provide a 

baseline of information for development of targeted interventions by 

agencies working with border residents to improve the quality of life 

and health. The baseline can be used to evaluate the success of followup interventions and to identify high-risk subgroups.

Perkins, J.L.., Zavaleta, A.N. Mudd, G., Bollinger, M., Muirhead, Y., & 

Cisneros, J. (2001). The Lower Rio Grande Valley Community Health 

Assessment. Houston, TX: University of Texas, Health Science Center 

at Houston, School of Public Health. Retrieved September 10, 2007 

from http://www.sph.uth.tmc.edu/uploadedFiles/Regional_Campuses/

Brownsville/LRGV_ASSESSMENT.pdf

This report summarizes the results of the Lower Rio Grande Valley 

Community Health Assessment, which was conducted from 2000-

2001. The main goals of the assessment were to determine health 

status of residents in the Lower Rio Grande Valley, assess the capacity 

of the public health infrastructure in the region, and assist with the 

implementation of the University of Texas MPH program. The counties 

of Cameron, Hidalgo, Starr, and Willacy constituted the assessment 

region for this project.

Warner, D.C. (Project Director). (2003). Health workforce needs: opportunities 

for U.S.-Mexico collaboration, Vols I and II. Austin and San Antonio, 

TX: Center for Health and Social Policy, Lyndon B. Johnson School of 

Public Affairs, University of Texas at Austin and the Regional Center 

for Health Workforce Studies, Center for Health Economics and Policy, 

University of Texas at San Antonio. Retrieved September 9, 2007 from 

http://www.utexas.edu/lbj/faculty/warner/prp0203/papers.pdf 

This publication is the product of a year-long policy research project 

at the Lyndon B. Johnson School of Public Affairs at the University 

of Texas at Austin. As Mexico and the United States have become 

increasingly economically integrated, and as many Mexicans live and 

work in the United States on a temporary or permanent basis, it has 

become important that social services such as education and health also 

become more interconnected and responsive. 

A conference was held on March 28, 2003, at the Lyndon B. Johnson 

School of Public Affairs in Austin, Texas, to bring together a number 

of experts in the field from Mexico and the United States. The 

title of the conference was “Responding to Unmet Needs through 
Border Lives: Health Status in the United States-Mexico Border Region

362

International Collaboration for Health Professionals: The Case of the 

U.S. and Mexico.” Both the conference proceedings (Section I) and the 

background papers (Section II) identify barriers to and opportunities 

for increased cross-border collaboration in training, licensure, and 

practice of physicians, dentists, and nurses.

Warner, D.C., & Reed, K. (1993). Health care across the border: The experience of 

U.S. citizens in Mexico. U.S.-Mexican Policy Report no. 4. Austin TX: 

Lyndon B. Johnson School of Public Affairs, The University of Texas. 

This exploratory report examines cross-border use of health services in the 

U.S.-Mexico border region. It is one of the few available reports on the use 

of health services in Mexico by U.S. citizens and residents and, conversely, 

the use of U.S. health services by citizens and residents of Mexico.

Centers for Disease Control and Prevention. (2001, Jan 19). Preventing and 

controlling tuberculosis along the U.S.-Mexico border: work group 

report. Morbidity and Mortality Weekly Report 50,No. RR-1). Retrieved 

September 09, 2007 from http://www.dshs.state.tx.us/borderhealth/pdf/

CDC_TB_inborder_RR5001.pdf

In June 1999, to facilitate future discussions with Mexican 

counterparts, the Centers for Disease Control and Prevention (CDC) 

convened a meeting of tuberculosis control officials from the four U.S. 

states bordering Mexico (i.e., California, Arizona, New Mexico, and 

Texas) to address TB prevention and control in the border area. Focus 

areas included a) surveillance needs, b) case management and therapy 

completion, c) performance indicators and program evaluation, and 

d) research needs. Meeting participants’ deliberations and resulting 

proposals for action by CDC and state and local tuberculosis control 

programs are detailed in this report.

Internet Resources

U.S.-Mexico Border Health Commission

www.borderhealth.org

www.saludfronteriza.org.mx

USA-Mexico Border Health Rural Assistance Center

http://borderhealth.raconline.org

Pan American Health Organization, United States-Mexico Border Office

http://www.fep.paho.org


365 

In the United States

211 N. Florence, Suite 101

El Paso, TX 79901

Tel. (915) 532-1006

Fax: (915) 532-1697

Toll Free: (866) 785-9867

www.borderhealth.org

In México

Avenida Durango No. 247, 

4o piso

Col. Roma, Delegación Cuauhtémoc

C.P. 06700 México, D.F.

Tel. and Fax: (01152-55) 3611-0765 al 67

www.saludfronteriza.org.mx