Revista Panamericana de Salud Pública/Pan American Journal of Public Health

Health needs in marginalized urban areas in Mexico

Objective. To understand the health needs of the population living in Mexico’s marginalized urban areas.
Methods. A population-based survey of families residing in poor, urban neighborhoods, in five geographic areas in Mexico (northern, central, southern, south-east, and Mexico City), selected through multistage sampling. Interviews were conducted and anthropometric measurements were taken in the home, and included all members of the participating family. Analysis was carried out on positive health factors, nutrition, reproductive health, health problems, and mental health, and results were disaggregated by age and sex.
Results. In all, 24 707 individuals participated. The interviewees were found to have minimal schooling (6 years or less). Only 46.8% had health care coverage, be it public or private. Among the children, 19.8% were malnourished; overweight was prevalent from adolescence onwards. Of adolescents 12–19 years of age, 15.7% were sexually active, but only 57.7% of the males and 41.9% of the females in this age group were using some method of contraception. Of the adults, 5.9% suffered from diabetes and 11.5%, from high blood pressure. In the sample of adolescents, adults, and elderly adults, tobacco use was 21.2%; alcohol consumption, 36.0%; illicit drug use, 9.5%; and depression, 20.2%.
Conclusions. The health needs of people living in Mexico’s marginalized urban areas proliferate in the context of a young population with weak ties and little support from family and health services. They face crisis and disease—infant malnutrition, high-risk pregnancy, and addictions—the byproducts of disparities in social progress. The rate of chronic conditions was similar to that of the general population of Mexico.

Objetivo. Evaluar las necesidades de salud de la población residente en áreas urbanas marginadas de México.
Métodos. Encuesta poblacional a familias residentes en colonias urbanas pobres de cinco regiones geográficas de México (Norte, Centro, Sur, Sureste y Ciudad de México), seleccionadas mediante un muestreo polietápico. Se realizaron entrevistas y mediciones antropométricas en sus domicilios a todos los integrantes de las familias seleccionadas y se analizaron las características de salud positiva, nutrición, salud reproductiva, daños a la salud y salud mental por grupos de análisis formados por edad y sexo.
Resultados. Participaron 24 707 personas. En los entrevistados se observó una baja escolaridad (6 años o menos) y solo 46,8% tuvo cobertura de servicios de salud, ya fuera en instituciones públicas o privadas. De los niños, 19,8% presentaba desmedro y el sobrepeso predominó a partir de la adolescencia. En los adolescentes de 12 a 19 años, 15,7% tenía vida sexual activa, pero solo 57,7% de los hombres y 41,9% de las mujeres de ese grupo de edad usaban algún método anticonceptivo. De los adultos, 5,9% padecía diabetes y 11,5% hipertensión arterial. En la muestra de adolescentes, adultos y adultos mayores, el tabaquismo fue de 21,2%, el consumo de alcohol de 36,0%, el uso de drogas de 9,5% y la depresión de 20,2%.
Conclusiones. La vulnerabilidad sanitaria de las personas que viven en las áreas urbanas marginadas de México se manifiesta en la existencia de una población joven, con pocas redes de apoyo familiar y de servicios de salud, que sufre trastornos y enfermedades, como la desnutrición infantil, el alto riesgo reproductivo y las adicciones en adolescentes y adultos, producto del rezago en el desarrollo social. La prevalencia de enfermedades crónicas fue similar a la de la población mexicana no marginada.

Health risk behaviors among adolescents in the south of Brazil: prevalence and associated factors

Objective. To determine the prevalence of health risk behaviors and to analyze factors associated with exposure to such behaviors among adolescents in the state of Santa Catarina in the south of Brazil.
Methods. Adolescents attending 240 high school classes at the state’s public schools answered a questionnaire that collected demographics (sex, age, area of residence, and day versus night classes), social and economic data (working status and monthly family income), and information on health risk behaviors (insufficient levels of physical activity, low intake of fruits/vegetables, smoking, alcohol abuse, illicit drug use, involvement in physical fights, and irregular use of condoms).
Results. The completed questionnaires of 5 028 adolescents (2 984 females and 2 044 males), 15–19 years of age (mean = 17.0; standard deviation = 1.12), were considered valid. The most prevalent health risk behaviors were insufficient levels of physical activity (36.5%), low intake of fruits/vegetables (46.5%), and irregular use of condoms (38.3%). Approximately 7 of 10 adolescents (64.7%) were exposed to two or more risk behaviors simultaneously. The following risk subgroups were identified: male adolescents, adolescents from 18–19 years of age, living in urban areas, studying at night, and having a higher family income.
Conclusions. The percentage of adolescents exposed to health risk behaviors was high, especially when simultaneous exposure to different behaviors was considered. These results can contribute to developing health promotion campaigns for the school setting that are specifically aimed at the risk subgroups identified.

Objetivo. Determinar a prevalência de comportamentos de risco à saúde e analisar fatores associados à exposição a esses comportamentos em adolescentes do Estado de Santa Catarina, Brasil.
Método. Adolescentes escolares de 240 turmas do ensino médio da rede pública estadual responderam a um questionário para a coleta de informações demográficas (sexo, idade, região de residência e período de estudo), socioeconômicas (trabalho e renda familiar mensal) e de comportamentos de risco à saúde (níveis insuficientes de atividade física, baixo consumo de frutas/ verduras, tabagismo, consumo abusivo de bebidas alcoólicas, consumo de drogas ilícitas, envolvimento em brigas e não utilizar preservativos regularmente nas relações sexuais).
Resultados. Foram considerados válidos os questionários de 5 028 adolescentes (2 984 do sexo feminino e 2 044 do sexo masculino), com idade entre 15 e 19 anos (média = 17,0; desvio padrão = 1,12). Os comportamentos de risco mais prevalentes na amostra foram níveis insuficientes de atividade física (36,5%), baixo consumo de frutas/verduras (46,5%) e não utilizar preservativos regularmente nas relações sexuais (38,3%). Aproximadamente sete em cada 10 adolescentes (64,7%) estavam expostos a dois ou mais comportamentos de risco de forma simultânea. Os seguintes subgrupos de risco foram identificados: adolescentes do sexo masculino, adolescentes de 18 a 19 anos de idade, que residem em área urbana, que estudam no período noturno e que têm maior renda familiar.
Conclusões. A proporção de adolescentes expostos a comportamentos de risco à saúde foi elevada, principalmente ao se considerar a exposição simultânea a diferentes comportamentos. Os resultados encontrados podem contribuir para o desenvolvimento de programas de promoção da saúde no ambiente escolar, direcionados principalmente aos subgrupos de risco.

Barriers to interventions aimed at promoting the health of health care workers in Brazil

Objective. To search the literature for circumstances that impede injury and disease prevention and other activities intended to improve the health of the health care worker.
Methods. The SciELO database was searched for articles published in 1967–2008. This was supplemented by a PubMed search for the period 1950–2008. The following key words were used to identify articles in English, Portuguese, and Spanish: work, health personnel, occupational, risks, diseases, ergonomics, work ability, quality of life, organization, accidents, work conditions, intervention, and administration. Articles on injury and disease prevention and occupational health in a health care setting in Latin America were selected, along with articles focused on health promotion in the health sector.
Results. The following shortcomings were identified: activities lacked a sound theoretical foundation and were not integrated with the health services management; a failure to evaluate the effectiveness of the activity; health surveillance focused solely on a specific disease or injury; management not committed to the proposed activity; miscommunication; inability of workers to participate, or control the work environment; and, programs or efforts that were limited to changing the workers’ behaviors.
Conclusions. The literature shows that all the barriers identified by this study affect both the health care workers’ health as well as their productivity.

Objetivo. Identificar na literatura situações que possam impedir ou prejudicar as ações de prevenção de acidentes e doenças ou de promoção da saúde de trabalhadores do setor saúde.
Método. Foi realizada uma revisão da literatura utilizando a base SciELO para o período de 1967 a 2008, complementada por busca na base PubMed para o período de 1950 a 2008. Os seguintes termos foram utilizados para identificar artigos em português, inglês e espanhol: trabalho, trabalhador, ocupacional, riscos, doenças, ergonomia, capacidade para o trabalho, qualidade de vida, organização, acidentes, condições de trabalho, intervenção e administração. Foram selecionados artigos sobre prevenção de doenças e acidentes e sobre promoção da saúde no trabalho em serviços de saúde latino-americanos. Também foram selecionados artigos sobre intervenções em ambientes de trabalho no setor saúde.
Resultados. Foram identificadas as seguintes situações desfavoráveis: programas de intervenção sem boa base teórica e não integrados à gestão do serviço como um todo; falhas em avaliar a eficácia das intervenções; vigilância da saúde restrita a doenças e agravos específicos; falta de compromisso da gestão com as intervenções; falhas na comunicação; falta de participação e controle por parte dos trabalhadores sobre o ambiente de trabalho; e programas e intervenções baseados exclusivamente na mudança comportamental dos trabalhadores.
Conclusões. A literatura mostra que todas as barreiras citadas afetam tanto a melhoria do estado de saúde dos trabalhadores em saúde quanto a sua capacidade para o trabalho.

The effects of a rural environment on the prevalence of allergic rhinitis among schoolchildren in Mexicali, Baja California, Mexico

Objectives. To assess the prevalence of allergic rhinitis symptoms among schoolchildren in Mexicali, Baja California, Mexico, and determine what impact a rural environment might have on this condition.
Methods. A population-based, cross-sectional study using a standardized questionnaire administered to a random sample of 2 087 schoolchildren 6–7 years of age (1 078 girls and 1 009 boys) living in the city of Mexicali, Baja California, Mexico. The study analyzed associations between exposure variables and personal and family health history, and two dependent variables—nasal symptoms and nasal and ocular symptoms, in the absence of a cold or flu–using odd ratios (OR) and 95% Confidence Intervals (95%CI). The study took place in February–July 2004 and followed the methodology of the International Study of Asthma and Allergies in Childhood (ISAAC).
Results. The general prevalence of nasal symptoms and nasal and ocular symptoms was 25.0% and 10.5%, respectively. The boys and girls who had ever lived on a farm or in a rural area had a lower probability, adjusted for confounding variables, of presenting nasal symptoms (OR = 0.43; 95%CI: 0.24–0.77), or nasal and ocular symptoms (OR = 0.39; 95%CI: 0.16–0.93).
Conclusions. In the study population, exposure to a rural environment in early childhood decreased the risk of developing allergic rhinitis, regardless of a family history of asthma.

Objetivos. Determinar la prevalencia de síntomas de rinitis alérgica en escolares de Mexicali, Baja California, México, y evaluar la influencia del medio ambiente rural sobre esta afección.
Métodos. Estudio transversal poblacional mediante la aplicación de un cuestionario estandarizado en una muestra aleatoria de 2 087 escolares de 6 a 7 años (1 078 niñas y 1 009 niños) residentes en la ciudad de Mexicali, Baja California, México. Se evaluó la asociación entre variables de exposición y antecedentes clínicos personales y familiares, y dos variables dependientes: síntomas nasales y síntomas nasales y oculares, en ausencia de catarro o gripe, con sus razones de posibilidades (OR, odds ratios) e intervalos de confianza de 95% (IC95%). El estudio, realizado entre febrero y julio de 2004, utilizó la metodología del Estudio Internacional de Asma y Alergia en la Infancia (ISAAC).
Resultados. Las prevalencias generales de síntomas nasales y síntomas nasales y oculares fueron de 25,0% y 10,5%, respectivamente. Los niños y las niñas que habían vivido en el campo o zona rural en algún momento presentaron menor probabilidad de padecer síntomas nasales (OR = 0,43; IC95%: 0,24 a 0,77) y síntomas nasales y oculares (OR = 0,39; IC95%: 0,16 a 0,93), después de ajustar por factores de confusión.
Conclusiones. El contacto con el medio rural en los primeros años de vida disminuyó el riesgo de presentar rinitis alérgica en la población estudiada, independientemente de los antecedentes familiares de asma.

The state of mental health primary care in the social services of El Alto, La Paz, Bolivia

Objectives. To determine the mental health and behavioral disorders (MHBD) treated by a Bolivian health network; and to gauge the perspective of the health professionals, community members, and care-providers in order to identify ways to better handle the issues.
Methods. A descriptive cross-sectional study was conducted from January to December 2005 in 15 public health centers in districts 2 and 3 of the Corea Network, one of four urban networks in the municipality of El Alto, province of Murillo, department of La Paz, Bolivia. The research and active participation methodology was employed through interviews, focus group sessions, review of external consultation logs and clinical histories, and active observation.
Results. Only 0.05% of primary care visits were for MHBD. Among the barriers identified by doctors were: lack of a specialized reference center (60.0%), not enough time (40.0%), a shortage of specialized personnel (33.3%), the drug supply (20.0%), and undertrained staff (16.6%). The departmental and federal programs have limited human resources training, standards of care are nonexistent, and the information system does not collect data on MHBD. Community members amply identified the mental health problems and care needs that, to date, have not been met by the social services.
Conclusiones. Training and development of primary care services staff must be expanded so as to provide the proper care for mental health disorders. Improvements must be made in the management of health care services and the reporting of behavioral and mental health disorders. Another recommendation is to incorporate community participation in the model approach to mental health within the framework of primary health care.

Objetivos. Caracterizar los trastornos de salud mental o conductuales (TSMC) atendidos en una red de salud boliviana y conocer la percepción de profesionales sanitarios, representantes de la comunidad y responsables de brindar los servicios a fin de identificar los elementos necesarios para mejorar la respuesta a estos problemas.
Método. Se realizó un estudio transversal descriptivo entre enero y diciembre de 2005 en los 15 centros públicos de salud de los distritos 2 y 3 pertenecientes a la Red Corea, una de las cuatro redes urbanas del municipio de El Alto, provincia de Murillo, departamento de La Paz, Bolivia. Se utilizó la metodología de investigación y acción participativa mediante entrevistas, sesiones en grupos focales, análisis de los cuadernos de registros de consultas externas e historias clínicas y la observación participante.
Resultados. Solo 0,05% de las consultas en los servicios de primer nivel correspondían a TSMC. Entre las dificultades percibidas por los médicos para la atención de esos pacientes están la falta de un centro de referencia especializado (60,0%), la falta de tiempo (40,0%), la ausencia de personal especializado (33,3%), la carencia de medicamentos (20,0%) y la insuficiente capacitación del personal (16,6%). Los programas departamentales y nacionales tienen limitaciones para la capacitación de los recursos humanos, no existen normas de atención y el sistema de información no registra variables sobre TSMC. Las personas de la comunidad identificaron adecuadamente los problemas de salud mental y las necesidades de atención que a la fecha no tienen respuesta de los servicios.
Conclusiones. Se deben fortalecer la formación y la capacitación del personal de los servicios de atención primaria de salud para lograr una adecuada atención de los trastornos de salud mental. Se debe mejorar la gestión de los servicios y el registro de los trastornos de comportamiento y de salud mental. También se recomienda integrar la participación comunitaria al modelo de abordaje de la salud mental dentro del marco de la atención primaria de salud.

Global public health: international health is tested to its limits by the human influenza A epidemic

This article comes from the intense international pressure that follows a near-catastrophy, such as the human influenza A H1N1 epidemic, and the limited resources for confronting such events. The analysis covers prevailing 20th century trends in the international public health arena and the change-induced challenges brought on by globalization, the transition set in motion by what has been deemed the “new” international public health and an ever-increasing focus on global health, in the context of an international scenario of shifting risks and opportunities and a growing number of multinational players.

Global public health is defined as a public right, based on a new appreciation of the public, a new paradigm centered on human rights, and altruistic philosophy, politics, and ethics that undergird the changes in international public health on at least three fronts: redefining its theoretical foundation, improving world health, and renewing the international public health system, all of which is the byproduct of a new form of governance. A new world health system, directed by new global public institutions, would aim to make public health a global public right and face a variety of staggering challenges, such as working on public policy management on a global scale, renewing and democratizing the current global governing structure, and conquering the limits and weaknesses witnessed by international health.

La sociedad mundial se ha declarado en alerta por la que se ha considerado la mayor amenaza biológica para la humanidad en el siglo XXI: la epidemia de influenza que se viene pronosticando hace más de dos años (1) e iniciada recientemente por el virus de la influenza humana A H1N1, ad portas de convertirse en una pandemia. Surge así una fuerte presión internacional para considerar las limitaciones que presenta el enfoque de salud pública internacional actual para enfrentar eventos cuasicatastróficos como este.

Objective. To assess risk factors for chronic noncommunicable disease (CND) and to identity social inequalities in their distribution among the adult Brazilian population.
Methods. Study of CND risk factors (including tobacco use, overweight and obesity, low fruit and vegetable intake (LFVI), insufficient leisure-time physical activity (LTPA), sedentary lifestyle, and alcohol abuse, among other risks) in a probabilistic sample of 54 369 individuals from Brazil’s 26 state capitals and Federal District, in 2006, using the Surveillance System of Risk and Protective Factors for Chronic Non-Communicable Diseases through Telephone Interviews (VIGITEL), a computer-assisted telephone interviewing (CATI) survey system, and calculated age-adjusted prevalence ratios for trends in education levels using Poisson regression with linear models.
Results. Men reported higher tobacco use, overweight, LFVI, sedentary lifestyle, and alcohol abuse versus women, but lower insufficient LTPA. In men, education was associated with increased overweight and sedentary lifestyle, but decreased tobacco use, LFVI, and insufficient LTPA. Among women, education was associated with decreased tobacco use, overweight, obesity, LFVI, and insufficient LTPA, but increased sedentary lifestyle.
Conclusion. In Brazil, prevalence of CND risk factors (except insufficient LTPA) is higher in men. For both sexes, the CND risk factor prevalence ratio is influenced by level of education.

Prevalencia y distribución social de los factores de riesgo de enfermedades crónicas no transmisibles en Brasil

Objetivos. Evaluar los factores de riesgo de enfermedades crónicas no transmisibles (ECNT) e identificar las desigualdades sociales relacionadas con su distribución en la población adulta brasileña.
Métodos. Se estudiaron los factores de riesgo de ECNT (entre ellos el consumo de tabaco, el sobrepeso y la obesidad, el bajo consumo de frutas y vegetales [BCFV], la insuficiente actividad física en el tiempo de ocio [IAFTO], el estilo de vida sedentario y el consumo excesivo de alcohol) en una muestra probabilística de 54 369 adultos de 26 capitales estatales de Brasil y el Distrito Federal en 2006. Se utilizó el Sistema de Vigilancia de los Factores Protectores y de Riesgo para Enfermedades Crónicas No Transmisibles por Entrevistas Telefónicas (VIGITEL), un sistema de encuestas telefónicas asistido por computadora, y se calcularon las prevalencias ajustadas por la edad para las tendencias en cuanto al nivel educacional mediante la regresión de Poisson con modelos lineales.
Resultados. Los hombres informaron mayor consumo de tabaco, sobrepeso, BCFV, estilo de vida sedentario y consumo excesivo de alcohol que las mujeres, pero menos IAFTO. En los hombres, la educación se asoció con un mayor sobrepeso y un estilo de vida sedentario, pero con un menor consumo de tabaco, BCFV e IAFTO. En las mujeres, la educación se asoció con un menor consumo de tabaco, sobrepeso, obesidad, BCFV e IAFTO, pero aumentó el estilo de vida sedentario.
Conclusiones. En Brasil, la prevalencia de factores de riesgo para ECNT (excepto IAFTO) es mayor en los hombres que en las mujeres. En ambos sexos, el nivel de educación influye en la prevalencia de los factores de riesgo para ECNT.

Cuba, a relatively poor, socialist, developing country has the lowest rate of HIV infection in the Caribbean subregion and a rate among the lowest in the world. Yet when we look at the published explanations for this, outside Cuba, we face a wall of controversy and disdain. A fair amount of the criticism seems due to ideological wars and the economic blockade by the United States of America (US) imposed on Cuba. The latter certainly undermines communication, scientific exchange, and understanding.

La infección por el VIH/sida en Cuba: lecciones y retos

Cuba presenta la tasa más baja de infección por el VIH en el Caribe. Este análisis toma en cuenta diferentes puntos de vista acerca de cómo Cuba alcanzó ese estatus y busca identificar los elementos clave de su éxito relativo. Contrario a lo expresado por una buena parte de la literatura extranjera, el aislamiento de los pacientes desempeñó un papel menor. Desde la perspectiva de los cubanos, los elementos de mayor peso fueron: la cooperación intersectorial, la vigilancia epidemiológica, la educación, la búsqueda dirigida y el tamizaje de los contactos, la cobertura gratuita de la salud pública y la solidaridad social. Los enfoques desarrollados más recientemente han sido la promoción de salud, la inclusión sexual, el programa llamado “hospital de día”, la educación continua de los pacientes, un mayor papel de los pares educadores y la cobertura de 100% de los seropositivos con el tratamiento antirretroviral.

Response to AIDS in Brazil: contributions of social movements and the sanitary reform

This paper briefly outlines how the political scenario and the mobilization of different actors have contributed to the construction of a public health policy in response to the AIDS epidemics in Brazil. Three factors are presented and discussed: the political context of the 1980s, characterized by redemocratization, growth of social movements, and consolidation of the Brazilian health care reform; the socio-cultural context of the 1970s and 1980s, characterized by achievement of individual freedom, which was key to the organization of the AIDS movement; and finally the actions carried out in the international scenario to support the sustainability of the Brazilian domestic policy and the reinforcement of a global response to face the epidemics in lower-middle income economies.

Desde o surgimento da aids no Brasil, em 1983, mais de 205 mil mortes e 506 mil casos foram registrados no país (1, 2). No mundo, somente no ano de 2007, foram 2,7 milhões de novas infecções e 2 milhões de mortes, a maior parte em países de média e baixa renda (3). Para traçar um paralelo, buscando situações semelhantes, com um número tão grande de vítimas, é preciso voltar a outras épocas — como a idade média, quando a peste negra dizimou cerca de 20 milhões de vidas, o que representava uma parcela expressiva da população europeia, ou o início do século XX, quando a gripe espanhola matou entre 20 e 50 milhões de pessoas em todo o mundo (4, 5).

Objectives. To determine what proportion of El Paso (Texas, United States of America) residents access health care services in Mexico, which services they use, and why they cross for care.
Methods. A cross-sectional, telephone survey of El Paso County residents was conducted from October–November 2007 to determine use of health care services in Mexico. At total of 2 560 telephone interviews were completed. Descriptive statistics and Chi-square analysis were used to determine the proportion crossing the US-Mexico border for care and identify correlates of crossing.
Results. The proportion of El Paso residents that had crossed into Mexico for some type of health care service during the two years prior to the survey interview was 32.5%. Of border crossers, 27.1% used health services; 63.2%, dental services; 82.0%, pharmacy; and 9.8%, traditional healers. Reasons given were cost, lack of health insurance, language barriers, and convenience. Hispanic ethnicity, having lived in Ciudad Juárez, being uninsured, and younger age were associated with crossing. The majority were satisfied with the health services received.
Conclusions. Crossing the border to access health care services in Mexico is not uncommon for US residents living in El Paso County, Texas. Given the high rate of uninsured in the United States and the increasingly stringent security requirements, health policies may be needed that allow for cross-border care, making use of this alternative health care system easier and safer.

Utilización transfronteriza de los servicios de salud por residentes en los Estados Unidos que viven cerca de la frontera con México

Objetivos. Determinar la proporcion de habitantes de El Paso (Texas, Estados Unidos de America) que acceden a los servicios de salud de Mexico, los servicios utilizados y las razones para buscar atencion del otro lado de la frontera.
Metodos. Se realizo un estudio transversal mediante encuesta telefonica a personas residentes en el condado de El Paso. La encuesta se aplico a 2 560 personas entre octubre y noviembre de 2007 para determinar el uso de servicios de salud en Mexico. Se utilizaron metodos de estadistica descriptiva y la prueba de la ƒÔ2 para determinar la proporcion de personas que cruza la frontera de los Estados Unidos hacia Mexico en busca de atencion sanitaria e identificar los factores relacionados con ello.
Resultados. La proporcion de habitantes de El Paso que han cruzado a Mexico en busca de algun tipo de atencion sanitaria en los 2 anos previos al estudio fue de 32,5%. De los que cruzaron la frontera, 27,1% utilizaron servicios medicos; 63,2% servicios estomatologicos; 82,0% farmaceuticos y 9,8% curanderos. Las razones ofrecidas fueron: el costo, no tener seguro de salud, las barreras idiomaticas y la conveniencia. Los factores asociados con el cruce de la frontera fueron ser hispano, haber vivido en Ciudad Juarez, no tener seguro y una menor edad. La mayoria se manifesto satisfecha con los servicios de salud recibidos.
Conclusiones. Entre los residentes del condado de El Paso, Texas, es frecuente el cruce de la frontera para acceder a los servicios de salud de Mexico. Dada la elevada proporcion de personas sin seguro medico en los Estados Unidos y los requisitos cada vez mas rigurosos para obtener un seguro, se necesitarian politicas de salud que permitan la atencion sanitaria transfronteriza, con el uso de un sistema alternativo de salud mas facil y seguro.