Nuestra Casa: An advocacy initiative to reduce inequalities and tuberculosis along the US-Mexico border

Abstract

The US-Mexico border provides a rich learning environment for professional social workers and at the same time poses some challenges. This article explores some of the unique demographics and social and cultural characteristics in the border region. These characteristics have implications for social work teaching, research, policy and practice. The study of borders includes exploring social disparities and inequalities. Health risks and diseases travel fluidly between borders and kill indiscriminately. The US-Mexico border is at high-risk of elevated tuberculosis (TB) and HIV incidence due to socio-economic stress, rapid and dynamic population growth, mobility and migration, and the hybridization of cultures. Every minute, four people die from TB, and 15 more become infected worldwide. The number of deaths due to tuberculosis is unacceptable given that most cases of TB are preventable. Cross-border cooperation and collaboration among social workers, health professionals and public officials between communities and countries can reduce social injustices to move towards a healthier borderland, as demonstrated in the collaborative prevention of TB. Rather than limiting our work to define social inequalities, we seek to further the conversation and suggest social action to address TB. This article contributes ideas and examples of experiences to encourage innovative, community-academic engaged inter- and multidisciplinary interventions like the Nuestra Casa (Our House) initiative. Nuestra Casa is an advocacy, communication and social mobilization strategy to address TB and HIV health disparities and inequalities in underserved communities, which we argue provides a useful model for combating TB and other inequalities plaguing the US-Mexico borderland.

Introduction

The study of borders includes the study of social disparities. Borders create unique challenges and opportunities for social workers and public health professionals to address social inequalities and health disparities between groups. At borders, health risks and diseases travel and kill at will. These differences can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death. Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory and physical disability; sexual orientation; gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” (1). From a health equity standpoint, we have the ability and responsibility to advocate for and provide culturally and linguistically appropriate services, and to promote policies that improve community health (2).

The US-Mexico border region is a distinct geographic, economic, cultural and social area that is affected by systematic social and economic injustice. This is evidenced by social and economic problems that are apparent throughout the region, including poverty, health disparities, social inequities, and lowwage assembly, service, seasonal, and agricultural employment. Endemic poverty co-exists with institutional racism, gender violence and structural violence (systematic oppressions). The area, while populated by resilient families and communities that have confronted governmental neglect and social isolation, is at the periphery of the American and Mexican economies (3).

The border spans almost 2,000 miles from the Pacific Ocean to the Gulf of Mexico and includes four US states, six Mexican states, 44 U.S. counties, and 80 Mexican municipalities. The border region, defined as the area within 62.5 miles of either side of the boundary, is home to approximately 13 million individuals and to 26 US federally recognized Native American tribes (4). Each country has a distinct system of policies and health care practices, each with a disproportionate share of health, environmental risks, and diseases. It is unlikely that any other binational border has such variability in health status, services, and utilization. Lower socioeconomic and educational levels, migration, immigration, and rapid industrial development accompanied by population growth from the implementation of the North American Free Trade Agreement in 1994 helps to explain some of the present complexity in this particular borderland (5). The policies, norms, and regulations of one side of the border are not applicable to the other. On the border, the developed and developing regions merge and mix to combine some of the best and worst of both worlds.

In some places, only a sign or a fence marks the border. In other places, the border is reinforced with barbed wire or tall steel fences (6). Although each nation operates under distinct legal and political systems as well as different health care and public health systems, the U.S.-Mexico border region is mutually dependent, sharing environmental, social, economic, cultural, and epidemiologic characteristics. Extensive family and cultural ties are shared by many of the people in the borderland. Health inequalities along the border especially affect indigenous and immigrant populations, who are vulnerable as a result of low socio-economic status, lack of health insurance, linguistic and cultural barriers, and limited access to healthcare and social services (5,7). If the U.S.-Mexico border region were considered a state, the region would be comprised of the following characteristics: 1) rank last in access to health care; 2) second in death rates due to hepatitis; 3) third in deaths related to diabetes; 4) last in per capita income; 5) first in the number of school children living in poverty; and 6) first in the number of school children who are uninsured (8).

A semi-permeable membrane

The U.S.-Mexico border offers a stark context in cultural differences, social inequalities, and ever-present reminders of governmental power that limit individual opportunity by ascribing national identity. Although governed by different bodies, U.S. and Mexican border populations are highly connected through an integrated social and economic system. People on both sides of the border share similar cultures and are exposed to comparable environments. Population density and poverty in urban and rural areas near the border are high, and unincorporated communities-known as ‘colonias’-often have inadequate housing, roads, sewage systems, drainage, and lack a potable water supply. Transborder trade; maquiladora (twin plants) industry; migration, mobility and energy trade; drug, arms and human trafficking; smuggling and other modalities of transnational organized crime are core economic activities in the border region (9).

The US-Mexico border is open to the movement of risk and disease but closed to the free movement of people, services, and cures. Since the US-Mexico border separates rich and poor countries with different types of healthcare systems, inequalities in access to health care are created and reinforced for those living between these two nations. The distribution of communicable diseases like TB is associated with other social disparities (e.g., wealthy versus poor, majority versus minority) in both access to medical care and treatment. In addition, considerable research in public health on the US-Mexico border has increased focus on individual behavior and social determinants (1, 5, 7).

The border region also attracts migrants from other areas of Mexico, Central and South America, Europe and Asia who seek opportunities and safety (8) and, in many cases, migration to the United States. These goals are not always achieved once they arrive to the region, thus creating populations that are displaced and vulnerable. According to the U.S. Customs and Border Protection, 57,525 unaccompanied children were apprehended at the southwest border between October 1, 2013 and June 30, 2014. More than three-quarters of unaccompanied minors come from mostly poor and violent cities in El Salvador, Guatemala and Honduras. Children from Mexico, once the largest group, now make up less than a quarter of the total - a small number from the 43 other countries (10). It is important to note that some right wing groups and conservative elected officials (federal and state government) have defended increased enforcement of deportation measures by pointing to fears of disease epidemics, including tuberculosis. However, tuberculosis does not appear to be a serious concern at the moment for this group. For instance, Carrie Williams, a spokeswoman for the Texas Department of State Health Services, said there have been only three cases of tuberculosis reported among the undocumented children who have come into Texas. This is not the case among adult immigrants, where recently 89 new cases of TB were reported. For every case of active TB, there are between 10–15 more individuals infected (11).

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 the transmission of infectious diseases among residents of the US-Mexico border region (12). Also intriguing are the so-called ‘Hispanic or Latino health paradox’ and the ‘immigrant advantage,’ referring to the contradictory finding that indicates that Latinos and immigrants in the U.S. tend to have significantly better health and mortality outcomes than the average population despite generally low socioeconomic status (13, 14). Findings from the Tomas Rivera Policy Institute (15) suggest that the Latino health paradox exists for mental health issues, asthma, maternal-child health, and high blood pressure. Results from this study indicate that Hispanic immigrants are healthier in terms of these four health outcomes when they first arrive in the United States; however, they become less healthy with greater amounts of acculturation.

El Paso, Texas - Ciudad Juarez border metropolis

El Paso County is intersected by the Franklin Mountain Range and encompasses a portion of the Chihuahuan Desert as well as several communities such as the City of El Paso. Combined, the population of El Paso County and its neighboring Ciudad Juarez in the state of Chihuahua, Mexico is approximately two million. El Paso is the fourth largest city in Texas, with a population of 800,647 (16). Over 80 percent of El Paso residents are Hispanic of Mexican origin, with three quarters of the population speaking a language other than English at home. The median annual household income is $36,078. In El Paso, the unemployment rate in 2014 was 8.0 percent (17). The El Paso region experiences higher rates of unemployment, underemployment, and lower average wages than the rest of Texas. Texas, as a state, has the largest population of people who are uninsured, accounting for 28 percent of Texas’s population or 6.1 million people (18). El Paso’s uninsured rate is the highest in the state, with 30 percent being uninsured (19).

Ciudad Juarez is the largest city in the State of Chihuahua, Mexico, and the second most populated Mexican city on the US-Mexico border, after Tijuana in Baja California. Ciudad Juarez’s population for 2010 was 1,332,131, and its metropolitan area is the eighth largest in Mexico. Approximately forty percent of the state of Chihuahua’s population lives in Ciudad Juarez. More than 40 percent of the Juarez population lived in poverty in 2010 (20). Juarez borders with El Paso County in Texas, as well as Dona Ana County in New Mexico. In recent years, the national and international media have broadcast to the world examples of how violence, death, and organized crime have escalated in the border region and in particular in Juarez, naming the city as the most dangerous city in Mexico and among the most dangerous in the world (12).

The majority of people on either side of the border are permanent residents; some are ‘borderlanders’ (natives of the region that travel, live and work in both countries), others are bi-national, while others cross the border daily for work, school, business and to visit family members. Other individuals rarely cross the border, some have never crossed, and others are scared to cross. The public health consequences of these macro forces have been analyzed to some extent in conflict and transitional settings, but have not been considered in the context of Mexico’s violent struggle against drug cartels and organized crime (21). While there is a great need for service provision, care is not provided to those that need it the most. Some of the reasons for this have to do with people’s immigration status, border security and the enforcement of border laws, lack of linguistically appropriate services, and cultural understandings and misunderstandings (22).

The case of tuberculosis

In the United States, tuberculosis, HIV, viral hepatitis, and sexually transmitted infections (STI) are the most prevalent and most commonly reported infectious conditions. TB is described as a disease process resulting from the infection Mycobacterium tuberculosis. It is also understood as a social illness that causes great suffering, a disease of the “at-risk populations” and a sign of poverty and inequalities. TB is a medical and social condition that involves deep emotional experiences, narratives of illness, alienation from family members, isolation and stigmatization (23). TB remains a major global, social, and public health problem (24). Every minute, four people die from TB and 15 more become infected worldwide (25). In 2012, an estimated 8.6 million people developed TB and 1.3 million died from the disease, including 320,000 deaths among HIV-positive people (24). The number of deaths due to TB is unacceptable, especially given that most cases are preventable. While a myriad of communicable diseases exists in the U.S.-Mexico border region, TB, HIV and their co-morbidity are of upmost concern. TB and HIV account for substantial morbidity and mortality, with great social and financial costs to individuals, families, and societies. The US-Mexico border experiences a disproportionate burden of these conditions as compared to the rest of the countries and compared to other Western industrialized nations, with significant disparities observed across sub-groups and geographical regions (26).

There is recognition of the direct correlation between TB incidence and the prevalence of poverty (27). Although diseases like TB and HIV cross class lines and geographical locations, its highest toll has always been among immigrants, the foreign born, and the working class poor and their families. The patterns of diseases found in Hispanics, African Americans, Non-Hispanic Whites, Native Americans, Mexicans and foreign-born individuals along the border create unique challenges for social work and public health responses.

Poverty, increased violence, and family reunification are complex forces that move more poor people into the United States (from Mexico or any other underdeveloped countries like Honduras, El Salvador, Nicaragua, and Guatemala), and an increase in health risks and TB incidence is inevitable. The US-Mexico border is at high risk of elevated TB incidence and other health issues due to socioeconomic stress, rapid and dynamic population growth, mobility and migration, “cultural hybridization” and a young population (28). TB is a subtle and complex chronic infectious disease. The extent of the disease is likely to be underreported because of mobility and migration across the border as well as the long latency of the condition after infection occurs. The incidence of TB at the border far exceeds national incidence rates in both countries (see Figure 1).

Figure 1.

Incidence of TB at US and Mexican Border States

There is little discussion among health policymakers, researchers, social workers, and health practitioners about how to address tuberculosis and migration as well as its connection to poverty and other social inequalities (29). As shown in Figure 1, in 2012, TB rates on each side of the border were two times their respective national averages, according to published (30) and unpublished sources (31).

Ongoing transmission, prolonged infection, delayed diagnosis, increased mobility, increased drug resistance, limited access to health care, TB related stigma, increased mobility and migration make case management and completion of treatment difficult along the U.S.-Mexico border (5,24,32). TB presents unique characteristics that have their origin in the fact that society is divided into socioeconomic status-based groups or classes, and it is from these divisions that the resistance to the infection emerges. Mechanisms to reach out to educate and treat vulnerable populations for TB in both countries, including those that enter the US legally, need to be addressed and implemented.

In Mexico, every day there are 54 new TB cases, and every 6 hours a person dies from TB (31). TB continues to affect communities and individuals that are most vulnerable (e.g., the poor, underserved, malnourished, HIV positive, diabetic). Mexico’s national TB rate for 2013 was 13.6 per 100,000 (31); this is over four times the rate in the United States of 3.2 per 100,000. Mexico’s National TB prevalence rate for 2013 was 25.4 per 100,000; eight times higher than the United States rate of 3.2 per 100,000 (30).

Each of the six Mexican states that share a border with United States has higher TB rates compared to the national rate. Combined, they represent 29% of the total cases for Mexico in 2013, with the border municipalities of the states of Baja California, Nuevo Leon, and Tamaulipas having the largest concentration of TB cases (31). According to the Centers for Disease Control and Prevention (CDC), in the US in 2012, a total of 9,945 new TB cases were reported and the TB rate declined by 4.2% from 2006 to 3.2 cases per 100,000 (33). The national TB incidence rate in 2012 was the lowest since national reporting began in 1953. Despite this improvement, foreign-born persons and racial and ethnic minorities continue to bear a disproportionate burden of the disease in the US. TB rates among Mexican-origin individuals and other Hispanics, African Americans, Native Hawaiians and Other Pacific Islanders, and Asians were 5.3, 5.8, 12.3 and 18.9 times higher than among Non-Hispanic Whites respectively in 2012 (30).

We live in a society where risk and vulnerability have been globalized. At the same time and in seeming contradiction, the discourses of ‘nation’ (and assertions of ‘national identity’) are becoming more important in terms of globalization as an articulating device (34), which serves to distinguish ‘insiders’ from ‘outsiders’. This helps to create risk categories (e.g., foreign-born, Mexican-origin) to justify enhanced surveillance while also serving to separate those who can manage the risk from those whose risk requires management under supervision (35). Risk management consequently represents a localized response to the globalized problems of TB, HIV and poverty. The risk of TB then becomes associated with particular social categories defined in terms of national identity, such as foreign-born, rather than the structural inequalities and processes that place people at risk. For example, TB is associated with poor quality and overcrowded housing, and minority ethnic groups are more likely to experience housing inequalities as well as reside in areas that experience disadvantage (36).

TB often coexists with other comorbidities like diabetes mellitus, substance abuse, and HIV that, if not treated, can produce fatal consequences. People who are HIV positive and infected with TB are 20 to 40 times more likely to develop active TB than people not infected with HIV in the same country (24). The focus on TB and HIV in the US-Mexico border is timely, given the evidence of increasing burdens and worsening health disparities for these conditions, the evolution in the understanding of the social and structural influences of disease epidemiology, and the implications of the global economic downturn. The global trends and impacts on health of TB, HIV and STIs remain among the most urgent public health challenges of our time (24). In a world characterized by globalization, policies concerning health security, communicable diseases, and healthcare are increasingly important. The advent of TB drug resistance and the complexities of border population dynamics may cause a considerable threat to the population on either side (28). Health policies and health promotion actions tend to be unilateral in nature. Social workers, healthcare workers, and other professionals can help adapt and unify policies, actions, and interventions to address complex health disparities (37). We present a case study that describes the Nuestra Casa (Our House) Exhibit, an advocacy, communication and social mobilization strategy to increase the awareness of and social action for TB through public art as a medium for education and social engagement. This article describes the genesis and the evolution of this initiative.

Nuestra Casa

Phase 1: Cross-border cooperation and innovation in TB awareness

The Nuestra Casa exhibition was several years in development and grew from a unique partnership between Project Concern International (PCI), the US Agency for International Development (USAID), the Alliance of Border Collaborative (ABC), Dr. Eva Moya (author and bi-national social worker) and Damien Schumman (South African-based photographer and artist). In 2008, Moya met Schumann at the 2008 International AIDS Conference in Mexico City, where the two developed the idea of working together to bring greater public awareness to the social and public health issues of TB and HIV. Schumann had gained notoriety in South Africa for the creation of “TB/HIV Shack” installations focused on public health and social justice issues. One of Schumann’s Shack installations was on view in Mexico City, and there the two launched the idea of transforming the “The TB/HIV Shack” into the “Nuestra Casa” Initiative, focused on the issue of TB and HIV in the border region. In 2009, USAID awarded $20,000 to PCI to hire Schumann for the project and that same year the Nuestra Casa mobile exhibition began its tour in El Paso, Texas. The original house (see Photograph 1) was built by the artist with help from persons affected by TB in the El Paso and Ciudad Juarez border region.

Photograph 1.

Source: Nuestra Casa Exhibit (2009). Courtesy of Damien Schumann.

The Nuestra Casa exhibition was an interactive experience where individuals entered a living space- a literal “mobile home for TB” (38). It was conceived as a movable house built out of discarded particleboard, wood, and other scrap materials easily found in Mexican communities and colonias. Nuestra Casa included a living room, kitchen, bathroom, a hallway or Corridor of Hope (Camino de la Esperanza), and a small patio at the main entrance. Photographs developed as part of the Border Voices and Images of TB Project that Professor Moya directed in 2008–2009 were included along with some of Schumann’s photographic work.

The creation of “trapitos” (small pieces of cloth that were made available for visitors to write their thoughts about TB, the lives of people living with and dying from TB, and their reactions to the exhibit) were central to the experience of visitors since the first exhibition in 2009. As Nuestra Casa presents the life stories of persons affected by TB and other health disparities, it is a lens into the socioeconomic and environmental realities that help to create health disparities but also the stories of resilience, empowerment, and hope of those living with (and dying from) TB.

As visitors went through the house, they were immersed in hundreds of photographs and stories showing the reality of TB. Visitors frequently asked questions, received health information and interacted with people affected by TB and HIV, social workers, students, health care workers, advocates and decision makers. After being on display on an outdoor pedestrian friendly patio on the university campus, the house tour was moved to Mexico in partnership with the National TB Program and the support of the State TB Programs in Quintana Roo, Oaxaca, Tamaulipas, and Tijuana, before ending at the CDC Museum in Atlanta, Georgia in 2010. More than 1,500 trapitos were collected during the exhibit’s tour in 2009 to 2010 and included comments such as the following:

“I am now rethinking my career path so that I can do research to contribute to the efforts to combat TB. Also, I want to go abroad so that I can actively help out” - Atlanta, Georgia

“It is so real that my lungs hurt” - Cancun, Mexico

While on tour in 2010, Nuestra Casa became an international phenomenon at the 40th UNION Conference on Lung Health and Tuberculosis in Cancun, Mexico. At the end of its 2010 tour and with cooperation from the CDC, Nuestra Casa opened the National TB Conference in Atlanta and remained on exhibit at the CDC Museum for four months. Nuestra Casa became an advocacy, communication and social mobilization model in Mexico and inspired local, state, national, and international TB programs to integrate perspectives of persons affected by TB (and comorbidities) in advocacy efforts.

Phase 2: Returning Nuestra Casa to the university: The initiative

Shortly after the tour ended at the CDC, coauthors Moya and Wood (then Director of UTEP’s Centennial Museum) met to talk about how the exhibition’s tour might be used as a catalyst to reengage the El Paso, Texas and Ciudad Juarez, Mexico communities to use advocacy, communication, and social mobilization (ACMS) efforts in TB prevention. They invited Schumann back to the university to reassemble the Nuestra Casa in a gallery of the Centennial Museum and to highlight the 1,500 trapitos. Having visitors to this second phase engage with the heartfelt messages on many of the trapitos was, they felt, a must.

In the fall of 2011, Moya brought together the project team for what would soon come to be called the Nuestra Casa Initiative (NCI) that included Wood; coauthor Dr. Silvia Chávez-Baray (Dept. of Social Work), Dr. Guillermina Nuñez (Anthropology), Dr. Arvind Singhal (Communications Department and Social Justice Initiative), Dr. Lucia Durá (Rhetoric Department), Azuri Gonzalez (Center for Civic Engagement), and Raquel Orduño (social work student and TB Advocate).

The NCI became an ACMS strategy to increase TB awareness, detection, and cure rates; improve collaboration among TB, HIV, and Diabetes Mellitus Programs to reduce risk of infection and increase information and co-morbidity detection; promote a person-centered approach in health services and in the community; mitigate the impacts of stigma and discrimination; honor community resilience and the narratives of affected persons; and promote social action.

Through a series of workshops led by university faculty, service learning students worked mostly in pairs with the trapitos from the locations the traveling exhibition had visited, coding the data, finding major themes, and identifying trapitos that most poignantly expressed a significant theme to be highlighted through a tendedero (cloths line) of trapitos in the installation at the Museum. In the final workshop, faculty took the students through a series of exercises where they shared their experiences with the NCI. As they shared with their classmates their “favorite trapitos,” several of them were moved to tears as they explained just how profound the experience had been. The coding of the trapitos is posted online.

As faculty worked with students to code the trapitos and prepare them for installation, the Museum director worked with the artist, Museum staff and student interns to launch a web site and Facebook page, and to redesign the installation to include an art installation style display of Schumann’s photo narratives, web linked gallery content highlighting the 2009–10 tour, a computer kiosk to access online content (for those without handheld devises), a hands-on style trapito making station, and (of course) the tendederos of trapitos reconceptualized by Schumann as a forest that visitors would need to walk through as they approached Nuestra Casa.

In 2012, the project team launched the NCI at the UTEP Museum with the opening of a yearlong series of health and social programming developed by community advocates, faculty and students (see Photograph 2. The Museum’s involvement in the NCI was conceived in terms of emerging ideas about how to make museums more “participatory” (39, 40) and “person-centered” in their educational goals and strategy while the wider initiative sought to advocate, engage, and mobilize communities of scholars, researchers, advocates, professionals, students, and persons affected by TB to work for a world free of TB and HIV. Multiple modalities of education and health promotion were utilized, including visual media, presentations, lectures, social work student-guided interactions, candlelight vigils and communications technology and social media.

Photograph 2.

Nuestra Casa returns to UTEP as an Initiative (2012). Courtesy of the University of Texas at El Paso Centennial Museum.

The exhibition marked the first time in the Museum’s history that an exhibit of this nature involving students, faculty, community advocates and staff had been developed and it proved to be a richly rewarding experience for all those involved. Over the course of 2012, nearly 25,000 people visited the Museum and attended supporting programming.

The NCI was especially successful in engaging social work students and persons affected by tuberculosis as they participated in the initiative. Five graduate social work students became museum docents for the exhibit and regularly provided guided tours for visitors from Ciudad Juarez and El Paso. Twenty students volunteered as part of service learning projects. A Digital Media student produced two YouTube documentaries on TB and the Nuestra Casa exhibit (they can be also found on the It is: https://www.facebook.com/NuestraCasaInitiative2011/), while others have conducted outreach as volunteers for the 2011–2012 Dia de los Niños-Dia de los Libros (Children’s Day/Book Day), Binational Health Week, and community-wide events or through presentations in Ciudad Juarez and El Paso on TB and lung health. An NCI project dissemination guide (used by exhibit hosts to assist with assembly and dissemination), Tshirts and wristbands (For a world free of TB and HIV) were produced and disseminated.

In addition, Raquel Orduño, a person affected by TB, MSW graduate, activist and member of NCI, spoke about her experience in local, state, national and international forums. Her testimony reached hundreds of policy makers, advocates, and clinicians in the United States and Mexico, as well as officials during the 2013 World TB Day WHO Stop TB Partnership panel in Washington DC.

The legacy and continuing impacts of the NCI

The cross-border cooperation and innovation of the NCI was successful in terms of presentations, recognition, and publications. Nuestra Casa displayed at six principle venues: 1) the 40th and 42th International UNION Conferences on Lung Health and TB in Cancun, Mexico and Berlin, Germany respectively); 2) the 2010 National TB Conference (Atlanta, Georgia); 3) the 2011 National TB Conference in Mexico; 4) the 2012 International Social Work Conference in Stockholm; 5) the 2013 International Mental Health and Social Work Conference in Los Angeles; and 6) establishment of 20 academic, community and binational partnerships in the US-Mexico border supporting the 12-month display at the university.

Additionally, the exhibit was granted one of eight recognitions at the 2012 North American UNION Region Meeting and received notoriety at the 2011 Society for Applied Anthropology and the Western Social Science Association conferences. The exhibit was so successful that the Mexican Consulate in El Paso celebrated World TB Day 2012 by having the NCI team install several of Schumann’s photo narratives and trapitos, with an estimated viewership of 3,000. The 2012 World TB Day events were also launched at the university. At the event, the Pan American Health Organization released the 2012 TB and HIV/AIDS Comorbidity report for health care workers, which included an ACSM component highlighting the NCI. In 2013, NCI received the McGrath Community-University Engagement Regional award for innovation in interdisciplinary education and service.

Finally, this initiative has led to the publication of a book entitled Social Justice in the US-Mexico Border (Springer, 2012), authored by Moya in partnership with other scholars from the university. This publication features a chapter on TB and HIV, ACSM addressing challenges and opportunities for improving bi-national collaboration which include strategies like Nuestra Casa and the Border Voices and Images of TB (TB Photovoice Project). In 2013, the peer-reviewed article on the NCI was published in the journal Reflections, dedicated to scholarship on innovation in service learning. In 2014, the initiative was presented at the International Union Against Tuberculosis and Lung Disease Conference in Barcelona, Spain.

NCI fostered multi and interdisciplinary collaboration and capitalized upon the strengths of diverse professions and advocates to augment consciousness of tuberculosis. Faculty members used liberating structures and problem-based learning methods to work with students across disciplines. The participation of community members has also been critical to its success, as has re-conceptualizing museum gallery space as a public forum. The narratives of individuals affected by TB provide the human perspective necessary to contextualize the situation: namely, that all humans are vulnerable to the disease, and it is therefore imperative that policy be attentive to the challenges and needs of those affected.

The lessons learned that can be used to promote and strengthen macro social work practice and social mobilization efforts are as follows: 1) ACMS strategies are needed to effectively raise awareness, mobilize community members, leaders, and social workers; and to empower and engage persons affected by TB; to successfully prevent and care for those suffering from the diseases and its repercussions. 2) A person-centered approach to service delivery is required to improve detection, treatment, adherence, and cure, and to mitigate all forms of stigma related to TB. 3) NCI is a powerful ACMS intervention to increase social and political will to improve TB and HIV prevention and care and to mitigate stigma. 4) Macro social work interventions, community participation, as well as involvement of TB affected persons increased and is now fundamental for successful social mobilization. 5) Community academic engagement partnerships and collaborative action in the United States and Mexico are essential.

The NCI also led to a formal “call to action” for increasing the visibility of persons affected by TB, their stories, lives, worries, concerns, vulnerabilities, and aspirations; promoting inclusion, parity, and the participation of persons affected by TB across all levels; and sustaining permanent lines of funding through efficient distribution mechanisms. The next steps of the NCI include: seeking to share our innovative findings with other communities, venues, and locations beyond the US-Mexico Border; launching ACMS strategies to increase collaboration and cooperation across the two countries; capitalizing on the use of viral technology to share the lessons learned and innovation online; and identifying publication and dissemination venues that value and may help us incorporate the visual elements of this initiative beyond the social work, health and education fields.

Implications for social work

Implementing social determinant actions in health involves holistic understanding and interventions, identifying synergisms and antagonisms, and employing cost-effective strategies to achieve sustainable population coverage and scale (41).

The primary goal for local TB programs is to medically treat and eliminate TB in the jurisdiction that is being served. Social workers negotiate between multiple services and benefits within and across systems (42). Studies indicate that the rate of adherence to TB care continues to be low - approximately two thirds of all persons living with active TB and in treatment complete their medication regimen (24). TB interventions emphasize patient adherence with directly observed therapy (DOTS). Low adherence, stigma, TB comorbidities (i.e., HIV, diabetes, malnutrition, and substance abuse) significantly contribute to relapse rates, and may result in multidrug resistant TB. Social work, public health and medical literature point to factors associated with successful TB care: 1) medication regimen; 2) features of the health care system; and 3) features to the relationship between the person affected by TB, caregiver, and the health care provider (43,44).

Based on the lessons learned and the evidence cited, social workers: 1) identify social and medical services and help find housing for homeless individuals affected by health disparities (like TB); 2) counsel individuals and families to deal with the emotional and financial ramifications of their diagnosis; 3) advocate for policies, programs and services grounded on person-centered care; 4) convene and participate in multi and interdisciplinary teams that work in collaboration to improve access to care and increase adherence to treatment; 5) engage in activities that involve navigation of services; and 6) identify resources for the client population.

Addressing the high rate of poverty, poor health indicators, and overall living conditions in the USMexico border and other low income communities requires social workers who possess the leadership skills and have the in-depth linguistic and cultural knowledge to overcome the barriers to the receipt of services people need. Social work programs residing in the U.S.-Mexico border have the exceptional challenges of preparing graduates and practitioners in the border region, and must thus distinguish their education offerings from programs in other areas of the world.

Conclusion

The border region does not fare well in terms of socioeconomic measures. The socioeconomic disadvantages are particularly marked among Hispanic border populations. Combined, the demographic and social determinants present a number of challenges to improving health at the border. Our experience with the NCI shows that “person-centered education model” about TB for the persons affected by TB, the family members and their social support network, health and human service professionals and the wider community is essential (45). The traditional medical model continues to emphasize adherence by individual persons, absent of a person-centered model, which fails to acknowledge or address social and structural determinants of health (46). Social workers offer an ecological perspective on person-centered care, incorporating cultural factors in a biopsychosocial assessment of the individual. Failing to adopt a holistic perspective that incorporates cultural factors, and focusing primarily on medical adherence, may lead to the perception that lack of adherence is due primarily to individual characteristics. Addressing health disparities requires structural interventions. Interventions must address TB screenings and treatment of persons infected while also preventing persons at risk from acquiring the disease. The social work profession stands in a position to provide a holistic framework.

Evidence from the international community demonstrates that political commitment to implementing health policies and structural interventions combined with existing knowledge, observational evidence, and evidence based innovative practices, may yield health improvements (47). By focusing attention on capacity building, leadership and governance, strategic partnerships, and effective health communication, person-centered approaches can help generate awareness, stimulate new dialogue and disseminate promising practices. Policy and systems change is essential for reducing health inequalities like TB and HIV, and creating communities of opportunity that support health equity. Local partnerships and cross sector collaborations is a key part of ensuring that every individual has access to high quality education, housing, transportation, jobs, safe places and health care (48). Finally, we hope that this article contributes to promoting an expanding field of research and social action which is highly needed in order to develop advocacy, communication and social mobilization strategies to understand the mix of social determinants of TB infection and care, the perspectives of persons affected by TB, and promising intervention strategies.