Establishing A Binational Student-Run Free-Clinic In Tijuana, Mexico: A Model for U.S.-Mexico Border States

Abstract

In 2011, a bi-national student-run free clinic for the underserved, known as “Health Frontiers in Tijuana” (HFiT), was created in Tijuana, Mexico. Students and faculty from one Mexican and one U.S. medical school staff the clinic and attend patients on Saturdays. Students from both medical schools enroll in a didactic course during the quarter/semester that they attend the free clinic. The course addresses clinical, ethical, cultural, population-specific issues and the structure, financing and delivery of medical care in Mexico. The clinic implements an electronic medical record and is developing telemedicine for consulting on complex cases. Despite challenges related to sustaining adequate funding, this program may be replicated in other border communities.

Background

Tijuana, Baja California, Mexico borders San Diego, California and is home to ≥1.6 million residents.(1) The northern Tijuana area, Zona Norte, lacks a government sponsored health center. The closest government health center near downtown is not fully operational as it was closed for renovation in 2009. The Zona Norte is home to large populations of homeless persons, deportees, substance users, and sex workers given the proximity of Tijuana’s red light district. Prevalence of HIV and latent TB infection are elevated among these vulnerable populations, many of whom lack access to timely and affordable healthcare. (2, 3)^,(4) These populations are often stigmatized,(5, 6) further exacerbating financial and health system barriers to care. Efforts to provide healthcare to vulnerable populations residing in the Zona Norte are needed. We describe a binational, free student-run clinic which aims to promote healthcare access in the Northern border region while also providing training opportunities for medical school students and other professionals.

Creation of a Binational Student-Run Free Clinic

On April 30, 2011 a new bi-national student-run community free clinic known as Health Frontiers in Tijuana (HFiT) was established in Tijuana’s Zona Norte. HFiT serves vulnerable persons, including sex workers, substance users, deportees, homeless, and indigent patients. HFiT patients often reside in the Zona Norte, although persons residing >60 miles from the clinic have also received care. HFit was established as a partnership between the University of California, San Diego School of Medicine (UCSD) and Tijuana’s Autonomous University of Baja California School of Medicine (UABC) (Facultad de Medicina de la Universidad Autónoma de Baja California), which is the only publicly funded medical school in Tijuana. The obvious need for healthcare for marginalized populations coupled with a desire by both universities to ‘give back’ to the community resulted in the planning and implementation of the HFiT clinic. Start-up funding was procured from multiple sources including the United States Agency for International Development (USAID), PrevenCasa, a local non-governmental organization operating in the Zona Norte, and Baja California’s Secretariat of Health (La Secretaría de Salud de Baja California: ISESALUD). HFiT also receives in-kind support (e.g., medications, supplies) from the State of Baja California’s HIV/AIDS program and PrevenCasa, which provides the site for the clinic. Donations enable the clinic to provide medications, basic laboratory tests, social services and refreshments to patients, most of whom live in extreme poverty.

HFiT Training Opportunities

First through third-year medical school students interested in attending the clinic must first enroll at their medical school, in an HFiT course consisting of two components: (1) didactic classroom-based training and (2) primary care medicine internships under the direct supervision of clinical faculty from UCSD or UABC. The classroom curriculum was developed by UCSD and UABC faculty and is implemented concurrently at both universities (UCSD Course website: http://gph.ucsd.edu/education/courses). The didactic course addresses provision of healthcare in Mexico among disadvantaged populations who typically seek care at the clinic (Table 1). The clinic also trains students in cultural competency issues and aims to improve their understanding of factors that contribute to health disparities and barriers to healthcare access in Mexico. UCSD students seeking to improve their Spanish language skills in clinical settings may do so through the HFiT course. All students are trained in personal safety measures.

Table 1.

Didactic Curriculum for Health Frontiers in Tijuana (HFiT), A Binational Student Run Free Clinic in Tijuana, Mexico

COURSE TOPICS
• Course Overview, requirements and outline
• Scheduling clinic rotations
• Travel Safety
• Student safety and travel requirements for Tijuana Mexico [U.S. students]
• Question answer panel with (repeat) students
• Electronic Medical Record
• Medical history/ SOAP Notes/ Confidentiality/Safety
• Physical Exam
• Cultural competency [U.S. students]
• Substance abuse in the Zona Norte, Tijuana.
• Congenital syphilis in Hospital General de Tijuana
• Health care and health policy in Mexico
• Provider cultural competency
• Social resources in Mexico
• The Binational patient
• Infection Control in health care settings in the US and Mexico
• Case studies: TB outbreak at Hospital General de Tijuana
• Legal aspects of clinical practice in Mexico
• Case studies
• Migration and Health
• Deportation and substance use and HIV risk behaviors
• Cross-border collaboration between clinician-researchers for better patient outcomes: Case studies.
• Student as Teacher
• Community health
• The community as Teacher
• Course Wrap up
• Case studies
• Lessons learned
• Look to the future

Medical school faculty from UCSD and UABC volunteer their time and provide medical and social services. Faculty mentors advise students in clinical history taking, medical exams, and triaging patients to health and social services (e.g., HIV/AIDS care, obtaining health insurance coverage). HFiT provides a broad range of free medical services to adults including diagnosis and care for sexually transmitted infections including HIV testing and linkage to care, abscesses resulting from injection drug use, prenatal services, diabetes and other conditions. A telemedicine The clinic uses an electronic medical record (EMR) which facilitates the administrative oversight and long-term care provision.(7, 8) The use of free EMR software (http://www.practicefusion.com/) has proved critical given the clinic’s limited resources. Due to academic schedules and resource constraints, the HFiT clinic is open every Saturday, serving all who seek care.

Since April 2011, the clinic has provided care to >500 unique patients, many of whom return for follow-up care. Patients needing specialized care (e.g., surgeries, testing, medical devices) are referred to the Tijuana General Hospital. Anecdotally, students from both universities report increased familiarity with the presentation of diverse health conditions among patients with multiple comorbidities as well as a greater sensitivity to working with disadvantaged populations.

Lessons Learned

Several challenges have emerged during the HFiT clinic’s first year, particularly in the areas of resource access and staffing. A steady stream of financial resources is needed for the clinic to achieve its mission of providing desperately needed primary health care services and ‘front-line’ medications (e.g., aspirin, antibiotics, prenatal vitamins, insulin). Mental health services constitute an emergent need in the HFiT patient population. Clinic directors are exploring collaborations with other universities and disciplines (e.g., social work; dentistry; nutrition, pediatrics) to provide increased supervised training opportunities and a broader range of services. While the EMR software implemented is free, it is only available in English, and it is used inconsistently due to lack of familiarity and language barriers by volunteer physicians. Ongoing training and implementing a procedural checklist will ensure consistent use of the EMR. Since the HFiT clinic is staffed by volunteers, student schedules and long-border waits (i.e., >1.5 hours) pose barriers to long-term commitments for U.S.-based students and faculty. It is recommended that U.S.-based HFiT affiliates apply for a U.S. SENTRI border crossing card,(9) which expedites U.S. re-entry.

Anecdotally, the clinic has been well received in the community and among both Mexican and American students and faculty. HFiT may be an important first contact with healthcare for some patients. Evaluation of services is being implemented to understand HFiT’s role in healthcare access among vulnerable patients. This clinic model may be replicated in other U.S.-Mexico border states given appropriate partnerships with governmental and non-governmental organizations and access to reliable funding streams for clinic supplies and operational costs.