Water, sanitation, and hygiene access among people who inject drugs in Tijuana and San Diego in 2020-2021: a cross-sectional study.

BACKGROUND: Water, sanitation, and hygiene (WASH) access is critical to public health and human dignity. People who inject drugs (PWID) experience stigma and structural violence that may limit WASH access. Few studies have assessed WASH access, insecurity, and inequities among PWID. We describe WASH access, social and geographic inequalities, and factors associated with WASH insecurity among PWID in the Tijuana-San Diego metropolitan area. METHODS: In this cross-sectional binational study, we interviewed PWID (age 18+) in 2020-2021 about WASH access and insecurity. City of residence (Tijuana/San Diego) and housing status were considered as independent variables to describe key WASH access outcomes and to assess as factors associated with WASH insecurity outcomes. Measures of association between outcomes and independent variables were assessed using log modified-Poisson regression models adjusting for covariates. RESULTS: Of 586 PWID (202 Tijuana; 384 San Diego), 89% reported basic access to drinking water, 38% had basic hand hygiene, 28% basic sanitation, and 46% access to bathing, and 38% reported recent open defecation. Participants residing in Tijuana reported significantly higher insecurity in accessing basic drinking water (aRR: 1.68, 95%CI: 1.02-2.76), basic hygiene (aRR: 1.45, 95%CI: 1.28-1.64), and bathing (aRR: 1.21, 95%CI: 1.06-1.39) than those living in San Diego. Participants experiencing unsheltered homelessness experienced significantly higher insecurity in accessing basic drinking water (aRR: 2.03, 95%CI: 1.07-3.86), basic sanitation (aRR: 1.68, 95%CI: 1.48, 1.92), bathing (aRR: 1.84, 95%CI: 1.52-2.22), and improved water sources for cleaning wounds (aRR: 3.12, 95%CI: 1.55-6.29) and for preparing drugs (aRR: 2.58, 95%CI: 1.36-4.89) than participants living in permanent housing. CONCLUSION: WASH access among PWID in the Tijuana-San Diego metropolitan area was low by international standards and lower than the national averages in both countries. Homelessness was significantly associated with WASH insecurity in this population. Concentrated efforts are needed to guarantee continuously available WASH services for PWID-especially those who are unsheltered.

WaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region.

BACKGROUND: Water, sanitation, and hygiene (WaSH) insecurity increases the risk of water-related diseases. However, limited research has been conducted on psychosocial distress as it relates to WaSH insecurity, especially among people who inject drugs (PWID). We examined the relationship between WaSH insecurity and related anxiety among PWID living in different housing conditions along the US-Mexico border region. METHODS: From 2020-2021, a cross-sectional study was conducted among 585 people who injected drugs within the last month in Tijuana (N = 202), San Diego (N = 182), and in both Tijuana and San Diego (N = 201). Participants underwent interviewer-administered surveys related to WaSH access, substance use, and generalized anxiety disorder (GAD-7). Quasi-Poisson regressions were used to assess associations between WaSH insecurity and anxiety in the prior 6-months. RESULTS: Participants were 75% male, 42% were unhoused and 91% experienced WaSH insecurity in the prior 6-months. After adjusting for housing status, gender, and age, lack of access to basic drinking water (Adj RR: 1.28; 95% CI: 1.02-1.58), sanitation (Adj RR:1.28; 95% CI: 1.07-1.55), and a daily bath/shower (Adj RR: 1.38; 95% CI: 1.15-1.66) were associated with mild-severe anxiety. The number of WaSH insecurities was independently associated with a 20% increased risk of experiencing anxiety per every additional insecurity experienced (Adj RR: 1.20; CI: 1.12-1.27). We also found a significant interaction between gender and housing status (p = 0.003), indicating that among people experiencing sheltered/unsheltered homelessness, women had a higher risk of mild-severe anxiety compared to men (Adj RR: 1.55; 95% CI: 1.27-1.89). At the same time, among women, those who are unhoused have 37% increased risk of anxiety than those who live in stable housing conditions (Adj RR: 1.37; 95% CI: 1.01-1.89). CONCLUSION: The lack of specific WaSH services, particularly lack of drinking water, toilets, and daily showers were associated with higher levels of anxiety among PWID in the Tijuana-San Diego border region. Women experiencing homelessness were especially vulnerable. WaSH interventions that provide safe, 24-h access may help to reduce anxiety and health risks associated with WaSH insecurity.

An Ethnographic Assessment of COVID-19‒Related Changes to the Risk Environment for People Who Use Drugs in Tijuana, Mexico.

Objectives. To characterize the effects of the onset of the COVID-19 pandemic on the risk environment of people who use drugs (PWUD) in Tijuana, Mexico. Methods. We used intensive participant-observation ethnography among street-based PWUD and key informants, such as frontline physicians and harm reductionists. Results. PWUD described an unprecedented cessation of police violence and extortion during the initial pandemic-related lockdown, though this quickly reversed and police violence worsened. Government-provided housing and medical treatment with methadone were temporarily provided to PWUD in a dedicated clinic, yet only for PWUD with COVID-19 symptoms. Concurrently, non‒COVID-19‒related hospital care became virtually inaccessible, and many PWUD died of untreated, chronic illnesses, such as hepatitis C, and soft-tissue infections. Border closures, decreases in social interaction, and reduced drug and sex tourism resulted in worsening food, income, and housing insecurity for many PWUD. By contrast, potent illicit drugs remained easily accessible in open-air drug markets. Conclusions. The pandemic exacerbated health risks for PWUD but also offered profound glimpses of beneficial structural changes. Efforts are needed in Tijuana and elsewhere to institutionalize positive pandemic-related shifts and ameliorate novel harms for PWUD. (Am J Public Health. 2022;112(S2):S199-S202. https://doi.org/10.2105/AJPH.2022.306796).

Social and geographic inequalities in water, sanitation and hygiene access in 21 refugee camps and settlements in Bangladesh, Kenya, Uganda, South Sudan, and Zimbabwe.

INTRODUCTION: Many refugees face challenges accessing water, sanitation, and hygiene (WASH) services. However, there is limited literature on WASH access for refugee populations, including for menstrual health services. Unmet WASH access needs may therefore be hidden, amplifying morbidity and mortality risks for already vulnerable refugee populations. The aim of this study was therefore to quantitatively analyze WASH access among refugee camps, with a focus on households with women of reproductive age. METHODS: This was a cross-sectional study that utilized the Standardized WASH Knowledge, Attitude and Practice (KAP) Survey. A total of 5632 household questionnaires were completed by the United Nations Refugee Agency in 2019 in 21 refugee camps and settlements in Bangladesh, Kenya, South Sudan, Uganda, and Zimbabwe. WASH access (14 items) and social and geographic stratifiers were analyzed at the household-level including the refugee camp, country of the settlement, having women of reproductive age, members with disability/elderly status, and household size. We calculated frequencies, odds ratios, and performed bivariate and multivariate analyses to measure inequalities. We developed a Female WASH Access Index to characterize WASH access for households with women of reproductive age. RESULTS: Most refugee households had high levels of access to improved water (95%), low levels of access to waste disposal facility (64%) and sanitation privacy (63%), and very low access to basic sanitation (30%) and hand hygiene facility (24%). 76% of households with women of reproductive age had access to menstrual health materials. WASH access indicators and the Female WASH Access Index showed large inequalities across social and geographic stratifiers. Households with disabled or elderly members, and fewer members had poorer WASH access. Households with women of reproductive age had lower access to basic sanitation. CONCLUSIONS: Large inequalities in WASH access indicators were identified between refugee sites and across countries, in all metrics. We found high levels of access to improved water across most of the refugee camps and settlements studied. Access to basic hygiene and sanitation, sanitation privacy, waste disposal, and menstrual health materials, could be improved across refugee sites. Households with women of reproductive age, with 4+ members, and without members with disability/elderly status were associated with higher WASH access. The female WASH access index piloted here could be a useful tool to quickly summarize WASH access in households with women of reproductive age.

Excess Out-of-Hospital Mortality and Declining Oxygen Saturation: The Sentinel Role of Emergency Medical Services Data in the COVID-19 Crisis in Tijuana, Mexico.

STUDY OBJECTIVE: Emergency medical services (EMS) may serve as a key source of real-time data about the evolving health of coronavirus disease 2019 (COVID-19)-affected populations, especially in low- and middle-income countries with less rapid and reliable vital statistics registration systems. Although official COVID-19 statistics in Mexico report almost exclusively inhospital mortality events, excess out-of-hospital mortality has been identified in other countries, including 1 EMS study in Italy that showed a 58% increase. Additionally, EMS and hospital reports from several countries have suggested that silent hypoxemia-low Spo2 in the absence of dyspnea-is associated with COVID-19. It is unclear, however, how these phenomena can be generalized to low- and middle-income countries. We assess how EMS data can be used in a sentinel capacity in Tijuana, a city on the Mexico-United States border with earlier exposure to COVID-19 than many low- and middle-income country settings. METHODS: In this observational study, we calculated numbers of weekly out-of-hospital deaths and respiratory cases handled by EMS in Tijuana, and estimated the difference between peak epidemic rates and expected trends based on data from 2014 to 2019. Results were compared with official COVID-19 statistics, stratified by neighborhood socioeconomic status, and examined for changing demographic or clinical features, including mean Spo2. RESULTS: An estimated 194.7 excess out-of-hospital deaths (95% confidence interval 135.5 to 253.9 deaths) occurred during the peak window (April 14 to May 11), representing an increase of 145% (95% CI 70% to 338%) compared with expected levels. During the same window, only 5 COVID-19-related out-of-hospital deaths were reported in official statistics. This corresponded with an increase in respiratory cases of 236.5% (95% CI 100.7% to 940.0%) and a decrease in mean Spo2 to 77.7% from 90.2% at baseline. The highest out-of-hospital death rates were observed in low-socioeconomic-status areas, although respiratory cases were more concentrated in high-socioeconomic-status areas. CONCLUSION: EMS systems may play an important sentinel role in monitoring excess out-of-hospital mortality and other trends during the COVID-19 crisis in low- and middle-income countries. Using EMS data, we observed increases in out-of-hospital deaths in Tijuana that were nearly 3-fold greater than increases reported in EMS data in Italy. Increased testing in out-of-hospital settings may be required to determine whether excess mortality is being driven by COVID-19 infection, health system saturation, or patient avoidance of health care. We also found evidence of worsening rates of hypoxemia among respiratory patients treated by EMS, suggesting a possible increase in silent hypoxemia, which should be met with increased detection and clinical management efforts. Finally, we observed social disparities in out-of-hospital death that warrant monitoring and amelioration.

Social inequalities and prevalence of depressive symptoms: a cross-sectional study of women in a Mexican border city, 2014.

OBJECTIVE: To assess the association between intersectional disadvantage and clinically significant depressive symptoms (CSDS), describing the magnitude of social inequalities in the prevalence of symptoms among adult women in Tijuana, Mexico. METHODS: This was a cross-sectional study. CSDS were assessed using the Centers for Epidemiological Studies Depression Scale among a probability sample of 2 345 women from 18 - 65 years of age in 2014. CSDS prevalence was calculated according to categories of three social stratifiers: socioeconomic status (SES), educational attainment, and fertility (number of children). Social inequality was measured with the slope index of inequality (SII) and the concentration index (CIx). Intersectionality among stratifiers was explored descriptively and with multivariable regression analysis. RESULTS: CSDS prevalence was 17.7% (95%CI: 15.1% - 21.0%). The SII and CIx showed inequity in all social stratifiers. The absolute difference in CSDS prevalence between the lowest and highest ends of the SES gradient was 21.9% (95%CI: 21.5% - 22.4%). Among the most disadvantaged women, i.e., those at the intersection of lowest SES, lowest educational attainment, and highest fertility, the CSDS prevalence was 39.5% (95% CI: 26.0% - 52.9%). CONCLUSIONS: Disadvantage along multiple axes was associated with CSDS. Efforts to improve the mental health of women should include equity-oriented policies that address its social determinants.

Taxing women's bodies: the state of menstrual product taxes in the Americas.

The taxation of menstrual products has been identified as unfair, imposing economic burden on people who menstruate based simply on a biological difference. These taxes have been described as major contributors to menstrual poverty. Although they have been debated among governments, and a focus of political activism, academic literature has largely neglected the issue. Here I comprehensively reviewed the status of menstrual product taxes for all countries and populated territories in the Americas in 2022. Data from 57 countries and territories, and 78 states (those of the United States and Brazil) were included. Since 2012, 10 countries and territories have eliminated taxation on menstrual products-Jamaica, Canada, Saint Kitts & Nevis, Trinidad & Tobago, Guyana, Colombia, Puerto Rico, Mexico, Ecuador, and Barbados. Nevertheless, menstrual product taxes were still applied in 63.2% of locations in 2022, with an average tax rate of 11.2% (ranging from 1.0% in Costa Rica to 22.0% in Uruguay). The average woman of reproductive age in the Americas experienced a menstrual product tax rate of 5.8% in 2022. In sum, despite activism and progress, most of the region continues to employ discriminatory taxation against people who menstruate, with particularly high taxation rates concentrated in South America.

Correlation between tobacco control policies and tobacco prevention in Mexico: a sub-national analysis.

This study aims to determinate the correlation between tobacco control policies (TCP) and the prevalence of tobacco use in the 32 Mexican states during the 2016-2017 period. This is an ecological study that measured TCP by the Tobacco Control Scale (TCS) which assigns a score (0-100) based on the level of these component's implementation: price, prohibition in public spaces, expenditures of public information campaigns, publicity prohibitions, health warnings, and treatments. We analyzed the associations between the TCS scores and prevalence of tobacco use extracted from the National Survey of Drug, Alcohol and Tobacco Consumption using Spearman correlations. Prevalence of daily smokers is negatively correlated with global TCS scores for adolescents (p = 0.026). Price showed similar negative correlations with daily prevalence in adolescents (p = 0.003), adults (p = 0.040), men (p < 0.006), and women (p = 0.040). Many Mexican states need to improve on tobacco control policies, especially targeting a key population: adolescents.

A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs.

BACKGROUND: Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages-such as homelessness or drug injection practices-often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel 'MH WASH Domain Scale-12' among people who menstruate and who inject drugs in the Tijuana-San Diego region and identified correlates of MH access using this scale. METHODS: We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0-12 points and higher scores indicating better MH access. We assessed the scale's reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020-2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates. RESULTS: Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our 'MH WASH Domain Scale-12' was reliable (Cronbach's alpha = 0.81, McDonald's Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing 'WASH availability' and Factor-2 contained items related to 'WASH security'-encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing. CONCLUSION: We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region.

Water, sanitation and hygiene insecurity predict abscess incidence among people who inject drugs in a binational US-Mexico metropolitan area: A longitudinal cohort study.

INTRODUCTION: People who inject drugs (PWID) are at high risk of developing injection-related infections, including abscesses. Access to water, sanitation, and hygiene (WASH) are key human rights and services; yet these services have been underexplored as predictors of abscesses among PWID. METHODS: Longitudinal analysis was employed among a cohort of PWID to determine if WASH insecurity (lack of access) was associated with abscess incidence in the Tijuana, Mexico and San Diego, United States metropolitan area during 24-months of follow-up survey data from 2020 to 2023. We calculated abscess prevalence at baseline and tracked the incidence of new abscesses among individuals without an abscess during the previous visit. Time dependent Cox regression modeling was employed with variance clustered by participant to characterize the relationship between WASH insecurity and abscess incidence. RESULTS: At baseline, hand hygiene insecurity, bathing insecurity in the previous six months and open defecation in the last week, were reported by 60 %, 54 % and 38 % of participants, respectively; 21 % reported an abscess in the last six months. The incidence of abscesses was 24.4 (95 %CI: 21.1-27.6) per 100 person-years. After adjusting for covariates, the hazard of developing an abscess remained significantly elevated among individuals using non-improved (with risk of contamination) water sources (e.g., surface water) for preparing drugs (adjusted HR [adjHR]: 1.49 [95 %CI: 1.01-2.21], experiencing bathing insecurity (adjHR: 1.59 [95 %CI: 1.12-2.24]) and open defecation (adjHR: 1.65 [95 %CI: 1.16-2.35]). CONCLUSIONS: PWID in the Tijuana-San Diego metropolitan area reported facing high rates of insecurity accessing WASH services. Abscess incidence was higher (four to nine times) than observed rate among PWID cohorts in other settings. Access to continuously available toilet facilities, bathing infrastructure, and safe water sources for preparing drugs for injection could prevent abscesses among PWID. Accessible WASH infrastructure should be ensured among PWID communities and promoted as a key component of harm reduction infrastructure.

Popular education to improve water quality and hygiene in a Mexican indigenous community.

Long-term research has identified significant water contamination and associated poor health outcomes in the indigenous community of Alpuyeca, located in south-central Mexico. We set out to develop a popular education initiative in this community to improve water, sanitation and hygiene (WaSH) knowledge and practices. In order to avoid recreating hierarchical power dynamics in this vulnerable community, a participatory action research (PAR) design was used, wherein the community took leadership and facilitation roles in each stage of the research process. In qualitative interviews and design sessions, community members identified unsatisfied WaSH needs in households and community institutions and articulated a clear worldview of the spiritual role of water, which guided the development of a series of popular education-based workshops and discussions. The popular education initiative process was documented with a mixed methods framework, using before-and-after surveys, semi-structured interviews and participatory observation. Increases in knowledge and practices related to water purification, water consumption and hand hygiene were noted in the community. The community identified locally installed and managed ecotechnologies as a key opportunity for sustainable development, community participation and the adoption of water and sanitation systems, compatible with public imaginaries of the role of water.

Accompaniment on the edge: What can the US learn from Latin America about contested abortion care?

The US has stood as a reference point for abortion rights in the Americas since 1973, however in 2022, the US Supreme Court revoked the constitutional right to abortion. Facing similar circumstances, a huge number of grass roots accompanist networks have arisen throughout Latin America. These collectives are typically organized loosely within state and national networks that provide training and medication/supplies and promote advocacy and the expansion of new collectives. Extensive evidence and lived experience support the safety and effectiveness of self-managed medication abortion. Much can be learned from the Latin American accompanist model in the modern struggle for reproductive justice in the US. Accompaniment networks in Mexico have provided transborder abortion services-via misoprostol delivery-to US-based women living in states that required long travel or high costs to access services. Now, these transborder services will take on a new level of significance. Guaranteeing safe and low-cost access to abortion services is a key tenet of reproductive justice. Instead of relying on the political process alone to eventually provide abortion access through legal channels, an accompanist model provides an icon of resistance to oppressive legal shifts, and directly provides services to women.

Progress and challenges in tobacco control policies in Mexico, 2003-2017: an approach using the Tobacco Control Scale.

The study aims to assess the implementation of tobacco control policies in Mexico from 2003 through 2017 using the Tobacco Control Scale (TCS). The TCS is a research tool widely used in the European region. It facilitates assessment of tobacco control policy implementation based on six cost-effective interventions: tobacco taxes, smoke-free policies, advertising bans, public spending on the information campaign, health warnings, and smoking cessation treatment, reflecting results in a total score between 0 and 100. From 2003 through 2017, Mexico's total score improved from 24/100 to 55/100, with substantial progress in raising tobacco taxes, 11 subnational smoke-free laws, and with placement on cigarette packs of large health warnings with pictograms. Progress in tobacco control policies implemented in this period corresponds with a decrease in smoking prevalence across Mexico. This tool is useful for monitoring tobacco policy implementation in low- and middle-income countries and be used for advocacy purposes to enforce and improve tobacco control legislation.

The feminization of medicine in Latin America: 'More-the-merrier' will not beget gender equity or strengthen health systems.

This viewpoint addresses the lack of gender diversity in medical leadership in Latin America and the gap in evidence on gender dimensions of the health workforce. While Latin America has experienced a dramatic change in the gender demographic of the medical field, the health sector employment pipeline is rife with entrenched and systemic gender inequities that continue to perpetuate a devaluation of women; ultimately resulting in an under-representation of women in medical leadership. Using data available in the public domain, we describe and critique the trajectory of women in medicine and characterize the magnitude of gender inequity in health system leadership over time and across the region, drawing on historical data from Mexico as an illustrative case. We propose recommendations that stand to disrupt the status quo to more appropriately value women and their representation at the highest levels of decision making for health. We call for adequate measurement of equity in medical leadership as a matter of national, regional, and global priority and propose the establishment of a regional observatory to monitor and evaluate meaningful progress towards gender parity in the health sector as well as in medical leadership.

Deported, homeless, and into the canal: Environmental structural violence in the binational Tijuana River.

INTRODUCTION: The US deports more Mexicans to Tijuana than any other borderland city. Returning involuntarily as members of a stigmatized underclass, many find themselves homeless and de-facto stateless. Subject to routinized police victimization, many take refuge in the Tijuana River Canal (El Bordo). Previous reports suggest Tijuana River water may be contaminated but prior studies have not accessed the health effects or contamination of the water closest to the river residents. METHODS: A binational, transdisciplinary team undertook a socio-environmental, mixed methods assessment to simultaneously characterize Tijuana River water quality with chemical testing, assess the frequency of El Bordo residents' water-related diseases, and trace water contacts with epidemiological survey methods (n = 85 adults, 18+) in 2019, and ethnographic methods in 2019-2021. Our analysis brings the structural violence framework into conversation with an environmental injustice perspective to documented how social forces drive poor health outcomes enacted through the environment. RESULTS: The Tijuana River water most proximate to its human inhabitants fails numerous water-quality standards, posing acute health risks. Escherichia coli values were ∼40,000 times the Mexican regulatory standard for directly contacted water. Skin infections (47%), dehydration (40%) and diarrhea (28%) were commonly reported among El Bordo residents. Residents are aware the water is contaminated and strive to minimize harm to their health by differentially using local water sources. Their numerous survival constraints, however, are exacerbated by routine police violence which propels residents and other people who inject drugs into involuntary contact with contaminated water. DISCUSSION: Human rights to drinking water, sanitation and hygiene are routinely violated among El Bordo inhabitants. This is exacerbated by violent policing practices that force unhoused deportees to seek refuge in waterways, and drive water contacts. Furthermore, US-Mexico 'free-trade' agreements drive rapid growth in Tijuana, restrict Mexican environmental regulation enforcement, and drive underinvestment in sewage systems and infrastructure.

COVID-19 and the Nordic Paradox: a call to measure the inequality reducing benefits of welfare systems in the wake of the pandemic.

The Nordic Paradox of inequality describes how the Nordic countries have puzzlingly high levels of relative health inequalities compared to other nations, despite extensive universal welfare systems and progressive tax regimes that redistribute income. However, the veracity and origins of this paradox have been contested across decades of literature, as many scholars argue it relates to measurement issues or historical coincidences. Disentangling between potential explanations is crucial to determine if widespread adoption of the Nordic model could represent a sufficient panacea for lowering health inequalities, or if new approaches must be pioneered. As newfound challenges to welfare systems continue to emerge, evidence describing the benefits of welfare systems is becoming ever more important. Preliminary evidence indicates that the COVID-19 pandemic is drastically exacerbating social inequalities in health across the world, via direct and indirect effects. We argue that the COVID-19 pandemic therefore represents a unique opportunity to measure the value of welfare systems in insulating their populations from rising social inequalities in health. However, COVID-19 has also created new measurement challenges and interrupted data collection mechanisms. Robust academic studies will therefore be needed-drawing on novel data collection methods-to measure increasing social inequalities in health in a timely fashion. In order to assure that policies implemented to reduce inequalities can be guided by accurate and updated information, policymakers, academics, and the international community must work together to ensure streamlined data collection, reporting, analysis, and evidence-based decision-making. In this way, the pandemic may offer the opportunity to finally clarify some of the mechanisms underpinning the Nordic Paradox, and potentially more firmly establish the merits of the Nordic model as a global example for reducing social inequalities in health.

Health policies for international migrants: A comparison between Mexico and Colombia.

Objective: The aim of this study was to compare the health policies for international migrants in Mexico and Colombia. Methods: A descriptive comparative study of the documents issued by the national-level government of the most recent past administrations in each country (2012-2018 for Mexico, 2013-2018 for Colombia) was conducted. We identified the documents' objectives, strategies, and evaluation of results, and the representation of international migrants and migrant health in the policy. Results: Both countries situate health care policies for international migrants in a human rights framework. In both, migrants are entitled to health care, but access is limited by migration status. The main contrasts are the focus on different migrant populations (Mexican migrants in the Mexico-US migration circuit in Mexico; Venezuelan immigrants and Colombians returning from Venezuela in Colombia), and the discursive framing of policies as a response to the crisis in Colombia. As a result, while concrete actions are detailed in the Colombian policies, most documents in Mexico are limited to general strategies. These differences can be explained by the context in which each set of policies was issued: a relatively stable Mexico-US migration flow in Mexico, and the reception of hundreds of thousands of migrants from Venezuela in a very short time in Colombia. Conclusions: Tradition in matters of migration, and the current migration context, influence health policies for migrant populations.

Excess Out-Of-Hospital Mortality and Declining Oxygen Saturation: The Sentinel Role of EMS Data in the COVID-19 Crisis in Tijuana, Mexico.

OBJECTIVE: Emergency medical services (EMS) may serve as a key source of real-time data about the evolving health of COVID-19 affected populations, especially in low-and-middle-income countries (LMICs) with less rapid and reliable vital statistic registration systems. Although official COVID-19 statistics in Mexico report almost exclusively in-hospital mortality events, excess out-of-hospital mortality has been identified in other settings, including one EMS study in Italy that showed a 58% increase. EMS and hospital reports from several countries have suggested that silent hypoxemia--low oxygen saturation (SpO2) in the absence of dyspnea--is associated with COVID-19 outbreaks. It is unclear, however, how these phenomena can be generalized to LMICs. We assess how EMS data can be used in a sentinel capacity in Tijuana, a city on the Mexico-United States border with earlier exposure to COVID-19 than many LMIC settings. METHODS: We calculated numbers of weekly out-of-hospital deaths and respiratory cases seen by EMS in Tijuana, and estimate the difference between peak-epidemic rates (during April 14th-May 11th) and forecasted 2014-2019 trends. Results were compared with official COVID-19 statistics, stratified by neighborhood socioeconomic status (SES), and examined for changing demographic or clinical features, including mean (SpO2). RESULTS: An estimated 194.7 (95%CI: 135.5-253.9) excess out-of-hospital deaths events occurred, representing an increase of 145% (70%-338%) compared to forecasted trends. During the same window, only 8 COVID-19-positive, out-of-hospital deaths were reported in official statistics. This corresponded with a rise in respiratory cases of 274% (119%-1142%), and a drop in mean SpO2 to 77.7%, from 90.2% at baseline. The highest out-of-hospital death rates were observed in low-SES areas, although respiratory cases were more concentrated in high-SES areas. CONCLUSIONS: EMS systems may play an important sentinel role in monitoring excess out-of-hospital mortality and other trends during the COVID-19 crisis in LMICs. Using EMS data, we observed increases in out-of-hospital deaths in Tijuana that were nearly threefold greater magnitude than increases reported using EMS data in Italy. Increased testing in out-of-hospital settings may be required to determine if excess mortality is being driven by COVID-19 infection, health system saturation, or patient avoidance of healthcare. We also found evidence of worsening rates of hypoxemia among respiratory patients seen by EMS, suggesting a rise in silent hypoxemia, which should be met with increased detection and clinical management efforts. Finally, we observed that social disparities in out-of-hospital death that warrant monitoring and amelioration.