The symptoms were common enough. But the boy’s condition worsened.

Eventually the doctors in Douglas, Arizona, diagnosed him with Rocky Mountain Spotted Fever (RMSF), a tick borne disease. RMSF is easily treated with antibiotics when detected early. But the delay in diagnosis landed the boy in an intensive care unit in Tucson.

The staff at Chiricahua Community Health Clinics Inc. (CCHCI) wondered how he contracted the disease, which was unheard of in Douglas.

Then they found out Agua Prieta, Sonora, just across the border, had 40 cases of RMSF. Six children had died.

“It was a real wakeup call,” said Dr. Jonathan Melk, a pediatrician and CCHCI chief executive officer in Cochise County, Arizona. “It’s unthinkable that in a town like Douglas we would have people extremely ill or even dying of an illness and a mile away the health care providers wouldn’t even have heard of it. But that was the case.”

The boy survived, but CCHCI set out to improve coordination with Agua Prieta so other infectious diseases wouldn’t catch them off guard.

CCHCI, often just referred to as Chiricahua, started a binational infectious disease monitoring program just as the COVID-19 pandemic was taking hold. Two staff members now coordinate with hospitals in Sonora to track and treat infectious diseases on both sides of the border. Chiricahua hopes to provide a binational disease surveillance model for other border communities.

“We will never optimize the health of Americans who live in border communities unless we work with our Mexican colleagues,” Dr. Melk said.

Health for all

Chiricahua already faces a monumental task: serving 30,000 patients across rural Cochise County, from the artsy enclave of Bisbee to the vast farms surrounding Willcox.

Chiricahua staff provide care regardless of immigration status, nationality or ability to pay. As a federally qualified health center, services are available to anyone for a sliding fee. That’s important in a county with a large undocumented population and a 14.6% poverty rate.

But Chiricahua staff knew their work couldn’t stop at the border with Mexico. In the 2020 census, Douglas’s population was 16,534. Agua Prieta is home to 91,000.

They form a binational community: family members live on both sides, children go back and forth across the border for school, workers commute from Mexico to jobs in the U.S.

Infectious diseases cross back and forth, too.

“Viruses, mosquitoes, dog ticks and other vectors don’t stop for U.S. Customs and Border Patrol,” said Dr. Melk.

The new binational infectious disease program, which began with a grant from the non-profit Direct Relief, set out to improve coordination with health officials in Sonora. They hired Alexandra, or Alex, Boneo to be the binational liaison and Emily Harris as infectious disease program manager. Harris is now public health programs manager.

Building a lasting framework for cross-border collaboration

On a brisk February morning, Boneo drives south into Agua Prieta, passing a migrant resource center run by the Catholic church serving people recently deported. She continues across the Agua Prieto River to the city’s general hospital.

Boneo lives in Douglas now, but she grew up in Agua Prieta, or AP as locals call it. With years of community development experience on both sides, Boneo was well-positioned to recruit Mexican health professionals to the project.

At the Agua Prieta General Hospital she greets Dr. Brianda González Gutiérrez, from the hospital’s infectious disease unit, like an old friend. Together they have organized four binational committee meetings to discuss recent disease data in Douglas and Agua Prieta and any concerning trends.

“It is one single community,” Dr. González said. “People are constantly crossing back and forth.”

Boneo said doctors like Brianda quickly understood the importance of collaboration.

“But we got started in the most difficult time possible: the pandemic,” Boneo said.

She prioritized in-person meetings to build relationships between U.S. and Mexican health professionals. But with the border closed to nonessential travel from March 2020 to Nov. 2021, the Mexican doctors needed special permission to cross into Douglas for meetings. 

“Once we were stopped at the border for extra revision,” Boneo said. But they made it “across the line” and the meeting went forward.

Chiricahua now coordinates with hospitals in Sonora to ensure doctors on both sides have up to date information on infectious disease trends and can take preventative, not just reactive, measures.

“Health shouldn’t have borders,” Dr. González said.

Putting health before politics

Doctors in Agua Prieta were on board to address binational public health. But the pandemic set off debates among Cochise County officials on the role of government in health care.

Now county officials disagree over the government’s role in the pandemic. In January 2022, the Republican-controlled board of supervisors rejected $1.9 million in federal pandemic aid, which among other programs, would have helped Chiricahua keep a COVID-19 testing site in Bisbee open to the general public. 

Responding to a request for comment, supervisor Tom Crosby shared his notes in preparation for the vote, which outline, “my stance is to get the county out of the vaccine business.”

He has not been vaccinated and said he opposes “socialist medicine.” The notes say he does not want the county health department “influencing” people to get the vaccine.

Ann English, the sole supervisor who voted to accept the funds, said, “Many of the requests were for increasing mandated services we have to provide and would have taken some of the burden off our county budget. Why would I not vote for enhanced health services and lowering the local budget for mandated services?”

Dr. Alicia Thompson, director of Cochise County Health and Social Services, knew county leadership was resistant to some pandemic funding opportunities.

“But when that $1.9 million grant was turned down, it was such a shock,” she said. “The night before, I thought we had the votes.”

After the funding was voted down, on Feb. 25 Chiricahua had to end free COVID-19 testing for the general public in Bisbee.

“You would think public health would not be embroiled in politics,” Thompson said. “But the way it is structured in the United States, there has always been a political component to the work that we do because we are part of county government.”

Thompson and Chiricahua staff said federal programs are essential to serving this rural county and they will continue to advocate for the health care needs of Cochise County residents.

“The culture of our county is that we always think about our neighbors,” Dr. Thompson said. “Because they are part of who we are.”

Data informs decision making

While policy debates over the pandemic dragged into a third year, from Cochise County to Washington D.C., health professionals in Douglas and Agua Prieta were busy working to make sure that political and physical boundaries don’t impede patient care.

With the support of doctors like Brianda González, Chiricahua and Agua Prieta health professionals shared data and established priorities. A key tool is the Arizona Department of Health Services’ Medical Electronic Disease Surveillance Intelligence System (MEDSIS), a secure disease reporting system.

With MEDSIS, doctors in Arizona can notify colleagues in Sonora about binational cases.

For example, if a tuberculosis patient seeks cares in Arizona and then returns to Sonora, Dr. González can access secure patient information in the MEDSIS system. Then her team can continue the course of treatment. If a Douglas resident tests positive for chlamydia and a sexual partner in Agua Prieta needs to be contacted, that information is also shared.

The Chiricahua team said they are learning new strategies from their Mexican colleagues. Contact tracers in Agua Prieta go directly to people’s homes — instead of relying on phone calls — to notify them of potential exposure to an infectious disease.

“Frankly, I think their system works better,” Dr. Melk said. “Based on what we’ve learned from them, we want to repeat what they’re doing through a community health worker program.”

Shared disease surveillance information helps health professionals on both sides plan preventative measures.

“Data really helps us move forward with informed decisions and removed us from the subjective area of anecdotal cases,” Chiricahua’s Emily Harris said. “As a group we can look at that surveillance data and say, ‘This is what we need to focus on next.'”

Their next step is a deeper dive into STIs, including chlamydia.

“Chlamydia is at least two people,” Dr. Melk said. “Unless both people are treated, then the disease persists. In this case, the two people may be on different sides of an iron fence, in two different political systems.”

Alex Boneo finishes her meetings in Agua Prieta and drives to the port of entry. In her childhood, crossing back and forth was easier. Now sometimes she is stuck waiting over an hour to cross into Douglas.

Luckily the line to cross is short. But her to-do list today is still long.

Figuring out how two vastly different health systems can work together, in the midst of a pandemic, was no easy feat. But she believes they are creating the framework for ongoing communication and cooperation.

“We were really lucky to find the people (in Mexico) who are passionate to make a change,” she said. “They could have said no, I’m really busy, COVID is taking over my life and job.”

While the pandemic has tested the health systems of both countries to their limits, communities such as Douglas and Agua Prieta are coming together to improve public health with the tools they have at hand.

“We are here together, regardless of COVID, regardless of the border, regardless of the limitations,” Boneo said. “The No. 1 lesson is binational work is possible.”