Health and human security in border regions
Maria Teresa Cerqueira
United StatesMexico Border Office, Pan Amer-ican Health Organization, El Paso, Texas, United States of America. Send correspondence to email@example.com
The Region of the Americas has a very large equity gap, and the United StatesMexico border is no exception, as indicated by the gradient between the two countries and between communities along both sides of the border. For example, the average household income in San Diego, California, United States (US$ 60 000), is about double that in McAllen, Texas, United States (US$ 30 000), and there is an abysmal difference between the average household income along the northern Mexican border states (US$ 10 000) and the southern U.S. border states (US$ 40 000) (1).
With release of the Human Development Report 1994: New Dimensions of Human Security (2), it became increasingly clear that external aggression is not the only danger menacing the world today. The report introduced a new concept of human security centered on people and the elements that affect their quality of life. Thus, a broader vision of human security is seen to underlie the health determinants and take into account the interdependence of the risk and protective factors that affect people and communities everywhere. This perspective recognizes the multidimensional relationships between these factors as well as the interaction between economic development, poverty reduction, sustainable development, democratic governance, and the rule of law, including respect for human rights, peace, and security (3).
The broader concept of human security should draw on input from both the public and private sectors, including government organizations and civil society groups, and calls for states to ensure the survival, livelihood, and dignity of their inhabitants. The new paradigm centers on the security of people and on the responsibility of states to "protect the vital core of all human lives in ways that enhance human freedoms and human fulfillment" (4).
This idea is of vital importance for U.S.Mexico border communities, nestled between two countries, two cultures, and two governmental systems. Many are dealing with new threats such as climate change, environmental deterioration, and food insecurity as well as with epidemics and diseases such as tuberculosis, HIV/AIDS, and diabetes. This complex health scenario poses serious challenges for communities struggling to provide an integrated, well-coordinated response.
The human security concept calls for strategies to protect people from critical and pervasive threats and to empower them to take charge of their lives. This is a fundamentally new way of thinking about a range of challenges that include hunger, poverty, ill health, poor education, armed conflict, forced migration, and human trafficking. Addressing these issues will require multinational and multisectoral collaboration among diverse stakeholders in order to bridge the gap between human security, humanitarian assistance, human rights, and local development.
Violence and injuries as a major human security challenge
In border regions, violence and injuries of external causes are the major human security problem facing public health. Epidemiologic surveillance for preventing and controlling violence in cities and urban areas has become a priority on the public health agenda of many countries. Every day, the lives of more than 15 000 people are cut short as a result of an injury. Among the causes of injury are acts of violence against others or oneself, road traffic crashes, burns, drownings, falls, poisonings, and wars. The deaths caused by injuries have an immeasurable impact on the affected families and communities, whose lives are often changed irrevocably by these tragedies.
Injuries and violence have been neglected on the global health agenda for many years, despite being predictable and largely preventable. Evidence from many countries shows that dramatic successes in the prevention of injuries and violence can be achieved through concerted efforts that involve, but are not limited to, the health sector. The international community needs to work with governments and civil society around the world to implement these evidence-based interventions and reduce the unnecessary loss of life that occurs each day as a result of injuries and violence. Approximately 5.8 million deaths annually are attributable to injuries, accounting for 10% of the global mortality (5).
Approximately a quarter of the annual injuries death toll is the result of suicides and homicides, while road traffic injuries account for another quarter. Injuries are a growing problem: the three leading causes of death globally from injuriesroad traffic crashes, homicides, and suicidesare all predicted to rise in rank compared with other mortality causes, placing them among the top 20 leading causes by 2030. Road traffic crashes are predicted to become the fifth leading cause of death by that year, with suicides and homicides rising to become the 12th and 18th leading causes of death, respectively (5).
Despite the problem's magnitude, attention to injury and violence prevention and control among policy-makers and those funding global public health remains disproportionately low. This is particularly alarming given that a broad range of strategies based on sound scientific evidence has been shown to be ef-fective, yet these interventions have not been widely implemented. The increase in violence as a public health problem has consolidated the commitment of governments at all levels, public and private sectors, and civil society to establish policies and national plans and to mobilize resources for preventing violence and injuries.
Declines in injuries have been seen mainly in high-income countries, many of which have steadily decreased the burden of injury by applying proven prevention and treatment strategies. For example, Sweden has successfully managed to reduce the rate of child injuries over the past few decades by about 80% among boys and about 75% among girls (5). Similarly, covering wells and reducing exposure to large bodies of water (for example, by building safe bridges and by erecting fences around swimming pools) have shown their effectiveness in reducing drowning rates in a number of countries.
Many countries have also managed to reduce their road traffic fatality rates in recent decades. However, in some high-income countries the downward trend that began in the 1970s and 1980s has started to plateau, suggesting that new approaches are needed in order to preserve progress to date and continue the decline in mortality rates.
Measures to prevent injuries and violence
Increasingly, governments around the world are coming to recognize and gain a better understanding of the problem as a basis for designing, implementing, and monitoring effective national prevention strategies. A body of measures that have helped lower the rates of injuries and their consequences now exists. Furthermore, cost-benefit analyses of selected prevention measures show that these yield significant value for money, making investment in them of enormous societal benefit. For example, a study in the United States found that every dollar spent on smoke detectors saves US$ 28 in health-related expenditures (5). However, much of the evidence of these measures' effectiveness comes from high-income countries; therefore, low- and middle income countries should seek to adapt and implement these strategies to specific circumstances within their own environments. By doing soand by rigorously evaluating the outcomes of these effortsthe current, unacceptably high global burden of injury can be reduced.
Border health: violence and injury prevention
Along the U.S.Mexico border, thousands of lives are lost annually to road injuries and violence; many more individuals and their families suffer the consequences of violence in the form of physical disabilities, mental illness and psychological disorders, drug and alcohol abuse, reproductive health problems, and sexually transmitted infections. Furthermore, violence affects human health across the lifespan: child abuse and neglect; domestic and interfamily violence; sexual violence, especially against women; elderly abuse; homicide; and suicide.
The contents of this special issue present on-the-ground experiences in preventing and controlling injuries and violence, strategies for implementing effective prevention programs, and the methods used to address causes and evaluate the effects of these strategies. It also addresses the need to integrate related mental health services within the primary health care strategy. Some articles focus on risk factor identification and surveillance, while others present research on the causes of specific injuries and types of violence and the use of data to understand the nature and extent of the particular injury or violence problem.
The evidence to date clearly points to the importance of creating healthy and supportive environments. The first step toward reaching this goal will be for border communities to conduct the necessary health situation analyses and then seek to raise awareness of the findings among policymakers, researchers, schoolteachers, and health care practitioners, among others. The adoption of an ecological framework to evaluate experiences in violence and injury prevention and control, including those at the individual level, relationship and interpersonal level, school and community level, and social level, encourages the participation of key stakeholders, leads to a distillation of best practices, and motivates all members of the community to work together to overcome the environmental conditions that perpetuate violence and injuries and to shape public policies that nurture the development of safe and secure border areas.
For far too long, the critical role of capacity-buildingdespite increased awareness of the problem and growing political commitment to its solutionhas been overlooked. When people and institutions at all ecological levels are empowered as agents for positive change, comprehensive and sustainable improvements will result.
It is the desire of all those who collaborated in the production of this special issue that its contents will provide valuable and practical guidance to communities everywhere seeking to improve the social conditions that lead to securing, protecting, and preserving human security.
Acknowledgments. The guest editorial committee for this special issue was comprised of Arturo Cervantes, Maria Teresa Cerqueira, Marcelo Korc, and Jorge Rodríguez. Special recognition to Victor Aparicio, Lorely Ambriz, and Guillermo Padron for their technical and editorial support.
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2. Programa de las Naciones Unidas para el Desarrollo. Informe sobre desarrollo humano 1994. Nueva York: Oxford University Press; 1994. Capítulo 2: Nuevas dimensiones de la seguridad humana. Disponible en: http://hdr.undp.org/es/informes/mundial/idh1994/ Acceso el 8 de junio de 2012
3. Organización Panamericana de la Salud (OPS). Salud, seguridad humana y bienestar [Internet]. 50.o Consejo Directivo, 62.ª Sesión del Comité Regional de la OMS para las Américas; del 27 de septiembre al 1 de octubre del 2010; Washington, DC, US. Washington, DC: OPS; 2010 (documento CD50/17). Disponible en: http://new.paho.org/hq/dmdocuments/2010/CD50-17-s.pdf Acceso el 8 de junio de 2012.
4. Commission on Human Security. Human security now: protecting and empowering people. New York: Commission on Human Security; 2003. Disponible en: http://ochaonline.un.org/humansecurity/CHS/finalreport/English/FinalReport.pdf Acceso el 4 de mayo de 2012.
5. Organización Mundial de la Salud. Traumatismos y violencia: datos. Ginebra: Organización Mundial de la Salud; 2010. Disponible en: http://whqlibdoc.who.int/publications/2010/9789243599373_spa.pdf Consultado el 5 de junio de 2012.