Improving Health Security Along the US - Mexico Border

TIER ONE PROGRAM “SCIENCE & POLICY” CLASS WHITE PAPER • 2021

Improving Health Security

The views expressed and opinions presented in this paper are those of the students and their instructor. They do not necessarily reflect the positions of the Scowcroft Institute of International Affairs, The Bush School of Government & Public Service or Texas A&M University.

Scowcroft Institute of International Affairs | The Bush School of Government & Public Service Texas A&M University | College Station, Texas, USA | bushschoolscowcroft@tamu.edu | bush.tamu.edu/scowcroft

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along the US - Mexico Border Contents

IMPROVING HEALTH SECURITY ALONG THE US - MEXICO BORDER Tier One Program “Science & Policy” Class White Paper • 2021 What is Health Security?.................................................................................................................................................................. 4 The Impact of Economic Policies on the Border Region............................................................................................................. 6 The Unique Health Security Challenge of the Border Region.................................................................................................... 7 American Defense Infrastructure and Health Security.............................................................................................................. 8 Protecting Military Personnel.................................................................................................................................................... 8 The Growing Challenge of Cyberbiosecurity........................................................................................................................... 9 Drug Cartels and the Intersection of Violence, Health, and Economic Enterprise...........................................................11 Health Inequities and Health Security..........................................................................................................................................13 Inadequate Health Insurance Coverage in the Border Region............................................................................................13 The Healthcare Worker Shortage and Its Impact on Access to Care................................................................................. 14 The Health Security Implications of Health Disparities and Inequities in Latinx Populations along the Border.................................................................................................................................. 16 Conclusion........................................................................................................................................................................................19 Recommendations.....................................................................................................................................................................19 References....................................................................................................................................................................................... 23 Authors............................................................................................................................................................................................ 32 In Memoriam................................................................................................................................................................................... 34 The Scowcroft Vision...................................................................................................................................................................... 34

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The US-Mexico border is a 2,000 mile stretch with significant cultural, political, and economic importance to the United States. Since the earliest days of American expansion into the Mexican state of Tejas, the region has offered both challenges and opportunities. While the earliest battles in the border region centered on land ownership, economic development, and defining the physical border itself, the medicalization of the border beginning in the early 1900s, has shaped American ideas of national security and public health over the course of the last century. Beginning with the establishment of the first disinfectant plant in El Paso, Texas to the recent restrictions on the movement of refugees during COVID-19, the conceptualization of health security in the border region overlooks the complexity and interconnectedness of communities along the border and of the US and Mexico as a whole.

In this paper we seek to expand the common understanding of health security along the US-Mexico

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border to encompass both traditional national security considerations and border health issues that are rarely viewed through this lense. We will examine national security challenges such as disease threats to US military personnel stationed in the border region, the growing world of cyberbiosecurity, and the impact of drug cartels and cartel violence. We will also discuss the national security and health security threats posed by health inequities and a lack of access to care. By taking a holistic view of health at the US-Mexico border we will challenge the traditional notion of national security and provide recommendations for improving health security in the border region.

What is Health Security?

Health security is defined as, "the activities required, both proactive and reactive, to minimize the danger and impact of acute public health events that endanger people’s health across geographical regions and

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international boundaries” (World Health Organization, 2021). The Centers for Disease and Control (CDC) outlines today's global health security risks as, “the emergence and spread of infectious diseases, increase in globalization (travel and trade), growth of drug-resistant pathogens, and accidental release of dangerous pathogens” (Center for Disease Control and Prevention, 2021). This is a global challenge that both intergovernmental organizations and state governments have sought to address with varying degrees of success.

The largest and most comprehensive program addressing global health security is the World Health Organization’s International Health Regulations (IHR) framework (World Health Organization, 2021). This legal framework encourages countries to strengthen their national capacity to prevent and respond to infectious disease outbreaks or natural disasters.

IHR requires nations to have or build an effective alert and response system and prevent or contain public health threats (World Health Organization, 2021). Additionally, IHR encourages countries to accomplish these goals without making significant disruptions to travel and transportation. Despite its intentions, IHR fails to properly hold countries accountable for the implementation of the criteria listed within the framework. Additionally, the tools used to measure countries' capacity to deal with international emergencies rely on self-reported data.

Self-reported data can be inaccurate due to the gaps and vulnerabilities which are not transparent or are overlooked. For example, a recent report on the implementation of the IHRs released on March 29th, 2021, reported the United States scored 100 percent in its capacity 9.3 assessment (World Health Organization, 2021). This specific capacity measures access to essential services. However, more than 28 million people in the US lack access to basic healthcare (Damico et al., 2020). This disparity is intensified along the US-Mexico border.

Another international framework which was developed to address global health security is the Global Health Security Agenda (GHSA). GHSA is a group of nations, international organizations, non-governmental organizations, and private sector companies (Global Health Security Agenda, 2021). Their mission is to find the gaps in global health security preparedness and response and address them through a multisector,

multilateral partnership approach (Global Health Security Agenda, 2021). These partnerships enable nations within GHSA to enhance their global health security through the development of laboratory systems, strengthening disease surveillance, tracking diseases, and preventing them from spreading. These are goals that can only be met through global cooperation and consistent funding.

In addition to international-level efforts, the US has established a number of programs and organizations directed at understanding and addressing binational health security in the US-Mexico border region. One such program is a binational partnership between the US and Mexico titled the Binational Border Infectious Disease Surveillance Program (BIDS). The program aims to enhance cooperation between US states along the border (Texas, Arizona, New Mexico, and California) in the detection, reporting, and prevention of infectious diseases at the local, state, and federal levels (Center for Disease Control and Prevention, 2021). Under BIDS, the US and Mexico established guidelines and protocols to exchange epidemiological information and coordinate timely responses which directly affect both nations.

Since the health systems within the US and Mexico are structured differently, BIDS plays an important role in facilitating bilateral communication and cooperation (Center for Disease Control and Prevention, 2021).

Lastly, the US – Mexico Border Health Commission is an organization of international leaders from both the US and Mexico who work to improve the health of communities in the US – Mexico border region (U.S. Department of Health and Human Services, 2021).

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Using the Healthy Border Initiative to focus on public health issues directly affecting the border populations, the commission seeks to understand the root causes of infectious and chronic diseases along the border (Healthy Border 2020, 2021). Broadly, the commission oversees binational health challenges and aims to expose the underlying causes of heightened infectious and chronic disease risk along the US –Mexico border.

The Impact of Economic Policies on the Border Region As previously mentioned, the US-Mexico border region is a vital cultural and economic hub for the United States.

Despite its importance, it is also one of the lowestincome areas of the country with some of the largest health disparities (Weinberg et al., 2003). In recent decades, the border region has been defined within the US government and public consciousness largely by the North American Free Trade Agreement (NAFTA) and migration. NAFTA led to a massive expansion of economic opportunities for the United States, and to a lesser extent Mexico, but had devastating impacts on many of Mexico’s citizens. The implementation of NAFTA led to increased pollution in northern Mexico, the devastation of Mexico’s rural farmers, and the rise of

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maquiladoras (manufacturing plants) along the Mexican side of the border (Relinger, 2010; Gallagher, 2002). These factors, in turn, contributed to an increased pressure to migrate, both internally within Mexico and across the US-Mexico border. Importantly, while the relationship between the US and Mexico has had a positive impact on the US economy as a whole, it has weakened the health security of communities on both sides of the border through deepening poverty, inadequate living conditions, and political and social exclusion.

In the border region, one of the primary contributing factors to both infectious and chronic diseases is poverty. The rise of maquiladoras in northern Mexico, high unemployment rates along the US side of the border, low educational attainment, and a lack of jobs that pay a living wage on both sides of the US – Mexico border have all contributed to the extreme poverty of the region. The maquiladoras have drawn attention recently due to the large role they play in the health and outcomes of individuals in the border region.

Employees in the maquiladoras are often citizens from southern Mexico who migrated to the northern border states in search of jobs at the plants. Although these manufacturing plants are located in Mexico, most of them are owned by US companies and, while

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the plants are state-of-the-art, most plant employees live in surrounding colonias, which are unincorporated communities generally lack basic necessities, including clean drinking water, sanitation systems, electricity, road development, and safe housing (Taylor, 2015). Many of the individuals working at the maquiladoras live in nearby colonias because their average wage is just over $1/hour. Maquiladora workers also lack access to health services and education.

Colonias are not just a challenge on the Mexican side of the border. An estimated 400,000 Texans live in rural colonias. More than 129,880 people live in 868 colonias within Hidalgo County alone (Federal Reserve Bank of Dallas, 2021). Additionally, levels of environmental pollution and agricultural pesticide exposure are higher in these areas, which are linked to numerous health issues (Rios & Meyer, 2009). Colonia residents on both sides of the border often have greater need for healthcare access, but are generally isolated from critical healthcare resources due to geographic distance, limited or non-existent public transportation, and low economic stability (Manusov et al., 2019).

The colonias living conditions and maquiladora working conditions exacerbate the threat of infectious diseases. During the COVID-19 pandemic, Mexico allowed states to decide on what kind of restrictions they placed on their citizens’ ability to work or gather. However, since the maquiladoras are US-owned, laborers were still required to come into work (Sieff, 2021). Workers reported that the plants did not provide masks to wear and, within the plants, laborers were unable to practice proper social distancing (Sieff, 2021). This experience not only further highlighted the US economy’s dependence on foreign workforces, but also elevated binational health policies within business relationships.

The Unique Health Security Challenge of the Border Region The border region of today is not just driven by the impacts of NAFTA and migration. It is also a region where defense infrastructure co-exists side-by-side with some of the most deadly criminal organizations in the world. The formation and growth of Mexico’s drug cartels over the last four decades has altered both the traditional national security and health security landscape in the border region. Vast health inequities,

a lack of medical professionals or access to care, cartel violence, and the opportunity cartels offer to escape poverty rushes headlong into US military personnel training for deployment, billions of dollars in US GDP, and the growing military-industrial complex that has been deployed in response to immigration. Nowhere else in the US do so many factors not only converge, but come intertwined and dependent on one another. It is this convergence which makes the US-Mexico border region a unique health security challenge. This convergence also necessitates addressing the traditional elements of health security and broadening our understanding of what constitutes health security in order to truly improve American health security as a whole.

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AMERICAN DEFENSE INFRASTRUCTURE AND HEALTH SECURITY Protecting Military Personnel The threat of infectious disease in the border region results from the combination of a sub-tropical environment, extensive binational human and animal movement, and the large quantity of trade that comes across America’s southern border. This threat impacts both civilian residents of the border region and military personnel stationed there. The threat of infectious disease to America’s defense infrastructure and health security presents itself in two ways: 1) the risk that military personnel will become infected with dangerous infectious diseases, and 2) that troop movement will facilitate disease spread both domestically and internationally.

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Regarding the risk of infection for military personnel, there are several military installations along the southern border. Most notable of these are large bases located in the major metropolitan areas of San Diego, CA and El Paso, TX. Both cities experience substantial cross-border human movement. Nearly 50 million border crossings occur annually at ports of entry in the San Diego-Tijuana metropolitan area, followed by the El Paso-Ciudad Juárez area with more than 10 million crossings annually (U.S. Department of Transportation, 2019). At the same time, interactions between military and civilian populations on and around bases are frequent, meaning that military personnel experience an infection risk that is similar to the surrounding community.

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Diseases of great concern for military personnel stationed in the border region are some of the region’s most worrisome neglected tropical diseases (NTDs), such as Chagas disease and Dengue fever. Military populations in this region are particularly at-risk for exposure to Chagas disease during night-time field training, when they are generally not protected from triatomine bugs (Harris, et al., 2017). As an estimated 60-70 percent of kissing bugs in Texas are infected with T. cruzi (the parasite that causes Chagas) and these insects are increasingly common around major installations, including Joint Base San Antonio, a major training hub for multiple branches, appropriate actions must be taken to mitigate the risk of Chagas infection in military populations (Blaschke, 2021). In the case of Dengue, a recent study determined that close to 8 percent of US military personnel recently returned from deployment tested positive for dengue antibodies. The same study found this rate was closer to 12.4 percent for those returning from South America and there were consistent issues with application of DEET and wearing of permethrin-treated uniforms (Hesse, et al., 2017). As Dengue becomes more common in the US, these challenges could be exacerbated and occur at installations within the continental US. Prolonged periods outdoors, inadequate protection against vectors, and lack of education all contribute to the risks diseases like Chagas and Dengue pose to military populations in the southern border region.

Regarding the second threat, troop movement facilitating the spread of disease, past pandemics provide excellent examples of how troop movements can present both a domestic and international health security threat. One of the most notable examples of military populations spreading diseases globally is that of the 1918 flu pandemic. The first reported death occurred on March 4, 1918 at Camp Funston, KS, though there were likely flu deaths at the camp prior to this date (Spinney, 2018). This first wave spread to New York City by March 11th and, given Camp Funston’s role as a major American Expeditionary Forces training post and processing center for as many as 20,000 troops annually at the time, the flu soon cropped up across the American Midwest and East Coast and in the ports of France (Spinney, 2018, pp. 36). The spread continued as Allied units moved across Europe, the Japanese re-

entered the war in Russia, and the US Navy carried the disease globally (Farley, 2020). Though the first wave was not particularly remarkable, subsequent waves wreaked havoc globally, leaving at least 50 million dead. In the US it killed an estimated 675,000 Americans (CDC, 2019). At one point, the entire Royal Navy was unable to deploy for months as it struggled with more than 10,000 severely ill sailors (Kolata, 2019, pp. 9-11). This, of course, was not just a problem for the Allies, as even the German General, Erich von Ludendorff, complained multiple times that it was stalling his battle plans (Kolata, pp. 11).

What started as an unremarkable flu spiraled into one of the deadliest pandemics in recorded history largely because of military movements globally. This had severe ramifications for both military and civilian populations and the efficacy of great powers’ militaries during, what was at the time, the deadliest conflict in history.

Emergence of future pandemics could also have severe ramifications for the military in the border region. For example, the 2009 H1N1 pandemic was first identified in Veracruz, Mexico before entering the US (Perez-Padilla, et al., 2009). This pandemic, while not particularly threatening for the US military, did trigger implementation for force health protection measures while the military struggled to acquire vaccines. These measures included social distancing and alternate work locations, which can be disruptive for the armed services (Peitersen, Levin, & Jones, 2011). Additionally, the 2009 H1N1 pandemic highlighted the critical nature of the southern border for force health protection.

Most recently, the COVID-19 pandemic has demonstrated, particularly early in 2020 when an outbreak was identified aboard the USS Reagan, infectious diseases are capable of severely hampering US global reach and power projection. While threats posed to military readiness are just one element of the overall issue of binational health, it is a critical one that has immediate and potentially dire impacts for US national security if appropriate precautions and plans are not put in place.

The Growing Challenge of Cyberbiosecurity Aside from traditional defense infrastructure and protection of force readiness, there are additional elements within the American defense infrastructure

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that threaten health security if not properly addressed.

One of the most critical is the strengthening of US and binational cyberbiosecurity. Cyberbiosecurity is defined as “understanding the vulnerabilities to unwanted surveillance, intrusions, and malicious and harmful activities which can occur within or at the interfaces of commingled life and medical sciences, cyber, cyberphysical, supply chain and infrastructure systems, and developing instituting measures to prevent, protect against, mitigate, investigate and attribute such threats as it pertains to security, competitiveness, and resilience” (Murch et al., 2018). Its importance extends from protecting the health records of ordinary Americans to preventing terrorist organizations from obtaining digitally stored genetic information on deadly pathogens.

The importance of protecting the personal health information of Americans is often underappreciated.

The healthcare sector, in general, is an attractive target for cyber attacks due to the low difficulty of accessing information and the high probability that the goals of the attack will be achieved. Additionally, cyberattacks on the healthcare sector have a high potential for benefits.

Many healthcare organizations continue to employ outdated systems that lower the difficulty of attacks (Martin et al., 2017).

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Simultaneously, healthcare devices continue to be developed to both increase their access to patient information and improve their network integration capabilities which increase the potential benefits. Cyber attackers’s access to patient information makes the healthcare sector an attractive target for financial gain (Martin et al., 2017). The patient information targeted can range from identification data to detailed health records, so healthcare institutions will pay ransom to try to regain access quickly.

Cybersecurity for America’s healthcare infrastructure has lagged behind other cyber defense measures. This is due, in part, to the many overlapping healthcare-related laws in the US that establish ambiguous and inconsistent expectations and mechanisms. For example, the Cyber Disclosure Acts - 2015, 2017, 2019 - are vague and the Health Insurance Portability and Accountability Act of 1996 guidance for the cybersecurity framework is only mandated for healthcare institutions that are part of the federal government (Abraham et al., 2019).

In addition to the lack of sufficient cyberbiosecurity for personal health records, cyberbiosecurity must be improved to better protect health research data including, but not limited to, genomic and viromic sequences. Microbial next generation sequencing (NGS)

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is vulnerable to attacks and could target personal/ institutional data, the integrity of pathogens, and sequencing services. The risks involved with attackers targeting pathogenic sequencing and already sequenced pathogens also pose a major risk that must be addressed (Fayans et al., 2020).

While cyberbiosecurity is an international problem, it is equally a challenge in the border region where research data and personal health information is often exchanged between nations. The US and Mexico should focus on establishing cyberbiosecurity measures that address the weaknesses in cyberbiosecurity along the border region. This could be modeled on the 2010 Canada-US Action Plan for Critical Infrastructure and the 2012 Cybersecurity Action Plan Between Public Safety Canada and the Department of Homeland Security.

Despite Mexico only establishing a national cybersecurity strategy in 2017, a cooperative action plan should be prioritized and could likely be addressed quickly; Canada established its first cybersecurity plan in 2010 and within the year established the US-Canada cooperative action plan.

Drug Cartels and the Intersection of Violence, Health, and Economic Enterprise Illegal narcotics and counterfeit pharmaceuticals fund cartels, and some corrupt American and Mexican officials, while wreaking havoc upon border communities.

According to a 2020 Fiscal Year report, US Customs and Border Protection seized 42,645 pounds of cocaine, 156,901 pounds of methamphetamine, and 3,967 pounds of fentanyl (Sinclair, 2021). The heavy presence of drug trafficking, the federal law enforcement presence aimed at curtailing such trafficking, and the economic incentives provided by drug cartels to help facilitate transport of illegal substances and supplies, leaves border communities to serve as the frontlines for fights between traffickers and law enforcement, storage centers for drug shipments, and makes them particularly vulnerable to illegal drug use or exposure to counterfeit supplies. For example, during the COVID-19 pandemic, residents of border communities, like other communities throughout the nation, flocked to stores to stock up on medical and disinfectant supplies causing a shortage of goods throughout the US and Mexico. This scarcity presented an additional opportunity for profit and cartels started

to traffic watered down cleaning supplies and falsely labeled Mexican cold and flu medicine (Borunda, 2020).

Additionally, the makers of Pfizer recently reported that fake COVID-19 vaccines were distributed throughout Mexico (Hopkins, 2021). The flood of illegal drugs and counterfeit supplies exploits and exacerbates the existing disparities in border communities.

The high level of illegal drugs and the large presence of drug smugglers in the border region has created a crisis of drug dependency, alcoholism, and mental health issues. The National Survey on Drug Use and Health regarding Hispanics (2019) shows the intersection of substance use and mental health issues stating that among the US Hispanic population, serious mental illness continues to increase, and suicidal thoughts and behaviors continue to increase in Hispanic adults ages 18-49 between 2009 and 2019. Additionally, substance use disorder significantly increased suicidality among Hispanic adults ages 18 and older. During the COVID-19 pandemic, loss of jobs and lack of social gatherings resulted in migrants and residents alike suffering from anxiety and depression (Leanos, 2020). Anxiety and depression can put people at greater risk of substance abuse and the increase in mental health issues may be partly responsible for the increase in drugs being trafficked across the southern border. For example, fentanyl seizure has considerably accrued over the last five years (Sinclair, 2021).

Many people in the border region who suffer from addiction cannot get help because of lack of health insurance coverage or availability of treatment. A recent study found that 59 percent of those suffering addiction on the United States side of the US-Mexico border region lacked health insurance while only 8 percent of Mexicans lacked health insurance on the Mexican side of the USMexico border region (Wallisch et al., 2017). However, only 58.4 percent of those on the US-side received help if they wanted it, and 43 percent of those of those suffering addiction received help if they wanted it on the Mexican side of the border (Wallisch et al., 2017). Growing levels of addiction and the barriers to seeking help, have contributed to the increase of drug trafficking at the USMexico border.

With this increased level of drug trafficking comes increasing levels of violence on the Mexican side of the border. More than 34,500 homicides were reported

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in 2019 by Mexico’s national public security system (Beittel, 2020). Mexico City reported that 2019 marked the highest homicide rate it has seen in the last 25 years (Beittel ,2020). Cartel violence in Mexico has helped to create a cross-border gun smuggling market. Fabian Hernandez, Chief of the Office of Ministry of Foreign Affairs in Mexico, exclaims that almost 3 million guns were smuggled into the US over the past ten years (Resendiz, 2021). In addition, around forty-one percent of the crimes committed in Mexico are a result of guns from Texas (Resendiz, 2021). The increased gun violence resulted in ten women killed each day in 2018 (Beatley, 2020). Aside from the physical health impacts of violence, such as death or disability, there are also extensive mental health impacts that result from experiencing regular violence. Along the border, migrants face anti-immigrant policies and sentiments and the lived experiences of discrimination, which have a damaging effect on the mental health of immigrants and children of immigrants (Williams & Mohammed, 2009). Additionally, existing US policies contribute to deteriorating mental health conditions including increased fear and lack of safety among these US-Mexico border communities.

The extensive reach of the drug cartels and their ability to move drugs throughout Mexico and into the US relies on the complacency and/or support of corrupt officials on both sides of the border. For example, HSBC, an American bank, is notorious for laundering money for the Mexican cartels. Starting in 2008, HSBC allowed two cartels in Mexico and Columbia to launder $881 million in drug proceeds through the bank (White, 2017). Additionally, many police officers in Mexico turn a blindeye to crime due to bribes from the cartels.

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One example is the arrest of a former Mexican Federal Police Officer and Commander of the Mexican Federal Police’s Sensitive Investigative Units for drug-trafficking conspiracy and receiving thousands of dollars in bribes (US. Attorney's 2020). Furthermore, corrupt US Customs officials sometimes assist cartels in moving their products into the US (Archibold, 2009). This systemic corruption allows for the health security impacts of drug trafficking, such as violence, anxiety, depression, and substance abuse, to continue.

For increased binational health cooperation in preventing drug trafficking, the US and Mexico established intelligence agencies for thwarting drug trafficking. Intelligence agencies can combat narcotics trafficking through possible surveillance from satellites and drones, cybersurveillance, and penetration by clandestine operatives. The El Paso Intelligence Center, established in 1974, brings together various agencies such as Drug Enforcement Administration (DEA), Federal Bureau of Investigation (FBI), and Immigration and Customs Enforcement (ICE) to cooperate on various matters, such as cartel issues (DEA, 2021). The National Southwest Border Counternarcotics strategy focuses on improving the flow of communication between tribal, local, and federal intelligence programs (Best, 2010). While much of the interstate communication between Mexico and US intelligence agencies are classified, universities provide another avenue to share information. Arizona State University created a partnership with the Mexican Biosafety Association (Amexbio) to strengthen biosecurity initiatives and collaborate on research (ASU, 2021). While interstate initiatives exist to increase collaboration and communication, Mexico recently passed a Foreign Agent Law, which would limit the ability for US law enforcement agents to operate in Mexico (Stevenson, 2020). As Mexico’s distrust towards US intelligence and enforcement agencies grows, the security cooperation between the two states diminishes. Addressing the health security impacts of drug trafficking will require a multi-faceted approach to health that incorporates access to mental health and addiction services.

Addressing the supply side of drug trafficking on its own cannot solve the problem, however. The US must recognize the role it plays through its large demand for illegal narcotics.

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HEALTH INEQUITIES AND HEALTH SECURITY Inadequate Health Insurance Coverage in the Border Region Those living in the US-Mexico border region experience an array of barriers to health insurance coverage, which hampers their ability to seek healthcare. From a binational health perspective, the inability of many people to acquire health insurance presents a challenge to policy makers as an underinsured population is an unhealthier one (KFF, 2019 B). One study found that, in South Texas, 40.8 percent of Hispanics and 50 percent of 18-29 year olds were uninsured (Ramirez et al., 2013). In contrast, the nationwide uninsured rate was 15 percent (Ramirez et al., 2013). The situation for both documented and undocumented immigrants shows an even starker picture. The Affordable Care Act (ACA) currently excludes undocumented immigrants from eligibility for health

insurance coverage, contributing to the 7.1 million undocumented immigrants who lack health insurance in the United States (Page et al., 2020). Undocumented immigrants can purchase private health insurance outside of the ACA marketplace, but many cannot afford this coverage due to limited incomes and lack of subsidies (KFF, 2019 B).

In addition to the challenges faced by undocumented immigrants, recent changes to the public charge law threatens the ability of lawfully present immigrants in the United States to procure health insurance and other benefits. In August 2019 the federal government announced that individuals can be denied US citizenship or adjustment to legal permanent resident (LPR) status if he or she is likely to be classified as a public charge (KFF, 2019 A). While the former public charge policies excluded

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use of Medicaid, the Children’s Health Insurance Program (CHIP), or other non-cash programs in public charge determinations, the current rule now considers the use of certain previously excluded programs, including non-emergency Medicaid for non-pregnant adults, the Supplemental Nutrition Assistance Program (SNAP), and several housing programs, in public charge determinations (KFF, 2019 A). According to one study, 8.3 million children live in a household with at least one noncitizen and risk losing CHIP, Medicaid benefits, or household nutritional assistance due to the fear and confusion surrounding these changes (Page et al., 2020).

As more and more people disenroll from Medicaid and CHIP programs in fear of becoming a public charge, the health security of the US-Mexico border region is under threat.

While the changes in the public charge law threatens the health security of immigrants, as well as binational health more broadly, the Legal Immigrant Children’s Health Improvement Act (ICHIA) provides another avenue for immigrant children and pregnant women to obtain health insurance. However, Texas currently only offers the option to lawfully present immigrant children and excludes pregnant women (KFF, 2021). While Texas does not offer the option to pregnant women, other border states, such as California, do. Additionally, California offers income-eligible undocumented children health insurance coverage using state-only funds (KFF, 2021). Many states across the US have expanded health insurance coverage to elderly undocumented immigrants. Illinois was the first state to offer low-

income immigrant seniors, who previously did not have access, health insurance coverage no matter their documentation status (NBC News, 2021). Policies like the ones of California and Illinois will improve healthcare access for immigrants in their states and these policies could benefit binational health if further expanded.

Due to the high rates of uninsured individuals in the border region and the high costs of healthcare in the US, many people travel to Mexico to receive healthcare.

According to a recent study, approximately 400,000 people have travelled from the United States to Mexico for healthcare purposes per year (Bustamante, 2019).

Healthcare costs in Mexico range from 36 percent to 89 percent less compared to costs in the US, making it a viable option for those who would otherwise go without care due to financial barriers (Bustamante, 2019). The primary group of travellers to Mexico for healthcare are Mexican and Hispanic immigrants. Seventy percent of those travelling to Mexico for healthcare belong to this group (Bustamante, 2019). There are still many individuals living in the border region who are not able to travel to Mexico for care and, therefore, have no access to care outside of emergency services. In order to provide these individuals with proper healthcare, policymakers should look to increase health insurance coverage in the US-Mexico border region. Doing so will increase the overall health of the communities in the border region and increase American health security.

The Healthcare Worker Shortage and Its Impact on Access to Care Many health issues have been linked to the lack of adequate infrastructure experienced by residents living along the US-Mexico border. Studies have uncovered associations between the region’s lack of resources and several diseases, including respiratory infections, neurological problems, and birth defects (Rios & Meyer, 2009). The lack of access to care experienced by many residents of the border region stems from a lack of health insurance, as discussed previously, an inability to access clinics and hospitals, or a lack of available and/ or qualified medical professionals in the region. For colonia residents, rural outreach programs have been successful in engaging residents with health services. For example, the Colonia Care Project featured integrated, interprofessional primary care by teams of providers

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through incorporating a mobile health clinic named UniMóvil (Manusov et al., 2019). The project provides primary care services, mental health evaluations and treatment, social services, medication advice and reconciliation, and health and quality-of-life education to colonia residents. In order to provide colonia residents with proper healthcare, policymakers should look towards increasing infrastructural development through bridging the urban-rural divide in the South Texas border region.

One major problem compounding infrastructural issues in South Texas is a healthcare system that remains insufficiently staffed and unequipped to meet the region’s needs. Statewide, there exists a critical shortage of healthcare workers, with fewer physicians per 100,000 Texans than the national average, lagging behind the ten most populous states (The Graduate Medical Education (GME) Report, 2020). This physician shortage is projected to worsen over the coming decade;

by 2033, the Association of American Medical Colleges projects that there will be a shortage of up to 139,000 physicians nationally, including 55,200 primary care physicians (The Complexities of Physician Supply and Demand, 2020). Of these shortages, the most significant deficits are projected to be in primary care specialties most accessible to rural Texans; namely, general internal medicine, family medicine, pediatrics, and psychiatry (Texas Physician Supply and Demand Projections, 2020). For example, in South Texas in 2018, only 79.9 percent of the demand for general internal medicine was met and this is expected to decrease to 76.4 percent by 2032 (Texas Physician Supply and Demand Projections, 2018-2032, 2020).

The current physician shortage crisis can be attributed to several factors, but is primarily due to insufficient funding for residency programs. Before being licensed and able to practice independently, medical school graduates must enter a three-to-seven year

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residency program, during which they receive intensive training in specialties, including pediatrics or psychiatry.

Training new residents is crucial to replace retiring physicians, address growing population numbers, and increase physicians in rural and historically excluded communities. In Texas, residency programs are mainly funded through a federal $10 billion Medicare appropriation distributed nationally each year. However, despite large increases in medical school enrollment, such as UTRGV School of Medicine enrolling its first class of 55 students in July 2017, this funding has not significantly changed over the past two decades.

In 1997, Congress passed the Balanced Budget Act, which artificially capped the number and geographic distribution of Medicare-funded residencies among existing training programs. This has created a bottleneck by preventing existing teaching hospitals from receiving Medicare funding for any new residency positions added after 1996, severely limiting these programs from keeping pace with increased medical school enrollment (Salsberg, 2008). Additionally, Texas has not historically supplemented these federal funds and has occasionally limited additional state funding. For example, in 2011, Texas lawmakers reduced the budget for training family medicine doctors by 72 percent (Collins & Novack, 2019).

This lack of funding has resulted in a shortage of over 200 residency slots in the state, as of 2018. Without sufficient funds, rural communities’ residency programs are especially vulnerable, such as when the 40-year old Wichita Falls Family Medicine Residency Program was shut down in 2018 due to financial constraints (Choate 2018).

The shortage in healthcare workers also extends to other fields, including community health workers or

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promotores. Studies have found promotores to be a vital resource for reaching rural residents and residents in colonias (Zuniga et al, 2011). Indeed, promotores generally are able to deliver health education, while cognizant of culturally-sensitive, social needs of community members they work with. The effectiveness of promotores has financial benefits: every dollar spent on community health workers yields $2.47 in healthcare savings (Kangovi et al., 2020). Providing sufficient funding for residency programs, thereby increasing the number of practicing physicians in the region, as well as funding training programs for promotores and community health workers would be cost-effective measures to expand the healthcare workforce, a dire need for the people of South Texas.

The Health Security Implications of Health Disparities and Inequities in Latinx Populations along the Border Health disparities and inequities are a significant health security challenge in the border region. This is particularly true for immigrants. Eighty-eight percent of immigrants experienced their first trauma during their immigration process, and 11.67 percent experienced trauma after immigration. Exposure to traumatic events such as those experienced by immigrants increases the risks of mental health problems including PTSD, depression, and substance use (Fortuna et al., 2008). At the US-Mexico border region, the need for mental health is even more apparent, especially for young children.

According to MacLean et al. (2020) immigrant children who suffered forced separation from their families are at an increased risk for developing mental health disorders, including depression, post-traumatic stress disorder (PTSD), and anxiety disorders. Researchers explain that regardless of length of separation, children who experienced family separation would benefit from comprehensive mental health treatment (MacLean et al., 2020).

As previously mentioned, migrants’ mental health also suffers due to issues created by immigration enforcement policy. Militarization of the US-Mexico border, particularly around major cities or traditional crossing points, has shifted the immigration routes, making the migration process more dangerous and often leading to dehydration and sometimes death. Due to

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the changes in enforcement policy, migrants are utilizing increasingly dangerous routes through treacherous waterways, deserts, and mountains (Orrenius, 2004).

According to Fulginiti (2008), coyotes, people who smuggle immigrants across the border, operating in the last 20 years have been associated with organized crime groups and drug cartels in the border region. These smugglers sometimes hold victim’s hostage throughout the dangerous trips to extort ransoms from their family members, who have already paid high-cost fees to guide them across. Fulginiti (2008) explain that in Arizona thirty-six percent of the deaths among nonresidents from Mexico or Central America were related to circumstances of unsafe undocumented border crossing.

The expansion of cartels into human trafficking has diversified and increased their profit streams, while causing further violence and harm to residents and migrants in the border region.

US asylum and deportation policies also play a distinct role in the trauma experienced by migrants.

Residents of the region who suffer deportation are frequently deported into unsafe locations. The system does not consider different cartel-controlled areas when determining where to deport an individual. The US practice of deporting people to geographical areas different from where they were initially apprehended makes them especially vulnerable to opposing cartels who often think they are working for other organized crime groups. Those who are not deported often encounter anti-immigrant policies and sentiments and many face discrimination, which has been found to have damaging effects on the physical and mental health of immigrants and children of immigrants (Williams & Mohammed, 2009). Existing US policies contribute to deteriorating mental health conditions including increased fear and lack of safety among Hispanic, Latino and/or Latinx communities. The Pew Hispanic Center found that six in ten Hispanic, Latino and/or Latinx members worry that they themselves or a family member or close friend will be deported (Pew Hispanic Center, 2007). One way that addresses this impact on mental health is to provide early intervention. The US Department of Health and Human Services (HHS) currently facilitates block grants to states and local public and private agencies who administer preschool programs for children such as Head Start and Child Care

Programs. These programs include direct aid to lowincome families for preschool attendance and childcare services and can help address some of the mental health impacts felt by immigrant children.

Another issue contributing to the deteriorating physical health of immigrants is their nutritional environment. While the definition of food deserts is contested, federal standards are very low and oftentimes locations such as Dollar Stores or convenience stores qualify as availability of nutritious foods (De Master, 2019). Poor residents have limited options to purchase fresh fruits or vegetables in these areas and often struggle to maintain a healthy diet because they do not live-in close proximity to supermarkets, especially those that sell healthy food (Salinas, 2015). In the Rio Grande Valley, a food desert covers 52% of the area on the TexasMexico border, according to a recent assessment by the Working on Wellness project at Texas A&M University (Capucion, 2018). The high prevalence of obesity and related health disorders has been documented in a population that is predominantly poor and Hispanic, Latino and/or Latinx who lack knowledge of and access

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to healthy food options. At the same time, obesity rates in some areas of the region are well-above comparative national averages.

Beyond the direct impact to nutritional intake, additional disparities among health outcomes are a direct result of these conditions. High rates of chronic disease such as obesity and diabetes among border populations are higher than state averages and significantly higher than national averages (CDC, 2006). Hispanic, Latino and/or Latinx people living with these types of chronic diseases are also more likely to be unaware of their status, which can be attributed to inadequate access to healthcare. Consequently, diabetic amputations occur at an increased rate and have a lasting effect on the lives of patients and families (MacRury, 2018). According to the CDC (2006) rates of diabetes-related lower extremity amputation (LEAs) in the general population were higher along the TexasMexico border compared with non-border counties.

In Texas, the prevalence of diabetes is higher near the Mexico border. Residents in this area are more likely to have lower levels of education, lower incomes, no health insurance, and other barriers to obtaining healthcare (CDC, 2006). Food insecurity and SNAP participation is also a contributor to the nutritional environment conditions of the US-Mexico border region, which requires attention. Kaushal (2014) found that children in

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Mexican immigrant families are at greater risk of being food insecure than children in native families in the US. Despite this stark difference, they are less likely to participate in SNAP. Finally, according to the Agency for Healthcare Research and Quality, quality of care continues to be an unaddressed issue along the US-Mexico border. The high prevalence of use of healthcare services in Mexico

by Texas border residents implies an unmet need in healthcare on the US side of the border. Focusing on the unmet needs calls for a binational approach to improve the affordability, accessibility, and quality of healthcare in the US–Mexico border region (Bustamente, 2019).

Texas is far from average, ranking 50 out of the 50 states and the District of Columbia in terms of quality of care received by Hispanic, Latino and/or Latinx people.

The health disparities and inequities that exist within the immigrant communities and the Hispanic, Latino and/or Latinx population along the border region more broadly, have significant implications for our overall health security. A lack of access to care and nutritious food leads individuals to live unhealthier lives. This increases their risk of chronic diseases and can make them higher risk for some infectious diseases such as COVID-19. Improving the mental and physical health of our most vulnerable communities in the border region will help improve overall health security in our country.

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CONCLUSION The COVID-19 pandemic has demonstrated that threats to national security expand beyond the conventional ideas of warfare and terrorism. Health security is a central component to the overall well-being of those residing in the US and throughout the world. In order to address the existing gaps in our health security we must address them in the realm of traditional defense and the realm of public health. This requires understanding the infectious disease threat that the border region poses to force readiness, but also understanding how a lack of access to physical and mental health services can put our population more at-risk for serious health consequences, including making it more difficult to control a pandemic like COVID-19. To address these gaps and strengthen US health security in the border region and more broadly, we have outlined 11 recommendations below.

RECOMMENDATIONS 1) Improve vector control and disease prevention in military populations by taking steps such as distributing educational pamphlets, DEET,

and permethrin-treated uniforms prior to field exercises in addition to deployments.

DEET and permethrin-treated uniforms are already distributed prior to certain field activities. However, ensuring that they are consistently distributed before any outings in the southern border region of the United States will help better familiarize service members with them and ensure they are more consistently protected against vector-borne illnesses. Furthermore, increasing education on such illnesses will help ensure service members understand what insects to watch out for, what signs and symptoms to be cautious of, and how they can best protect themselves from these diseases.

2) Establish a US-Mexico cooperative cyberbiosecurity action plan to reduce the risks and costs associated with cyber-attacks on the healthcare sector on the US-Mexico border.

To reduce the attractiveness of cyber-attacks on the healthcare sector, the action plan should require all healthcare infrastructure to be upgraded once per year to the highest standard at that time. Upgrading the systems regularly will better protect the incredibly

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sensitive patient information including health records, personal information, and genomic data. The value of patient information makes ransomware an attractive option for cyber-attacks, so the action plan should also include a strategy to develop and implement better methods over time to prevent ransomware attacks and to better address successful attacks at the speed necessary to protect patient information.

3) Continue the use of, and increase resources for, organizations like BIDS, the Border Health Commission, and NCMI that report, prevent, and respond to potential health threats in the US-Mexico border region.

The agencies in place are tasked with ensuring the health security of the US, but are often not given resources consistently. These agencies see an increase in funding only in times of great crisis or emergencies. The National Center of Medical Intelligence (NCMI) office is currently based in Fort Detrick, Maryland. The US should provide satellite NCMI offices along the border region to monitor health security threats and serve a liaison between various agencies, such as EPIC, and US-Mexico. Although many intelligence services act to protect the nation, little attention has been paid towards biosecurity. This points to a reactive, rather than proactive, attempt to avoid health crises at the border. This is not sustainable when considering the impact of funding on response capabilities to health crises. For these reasons, consistent and adequate funding should be allocated to relevant border US agencies.

4) Strengthen the enforcement system of those inculpitated with the cartels and promote workplace accountability.

The current enforcement system is ineffective and corrupt officials are prosecuted when it is too late.

Both the US and Mexico must promote individual responsibility and have a reporting mechanism when a coworker is suspected of working with the cartels.

Police officials should conduct “integrity campaigns” that promote working against the cartels to protect their loved ones and their fellow countrymen.

5) Revert to the former public charge law.

Federal policymakers should exclude programs such

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as Medicaid, the Children’s Health Insurance Program (CHIP), or other non-cash programs in public charge determinations as done before August 2019. The current public charge law has led to the disenrollment of many immigrants and US citizen children and has threatened the health security of many people in the US-Mexico border region.

6) Allow years spent under transitional status apply to any waiting period for federal benefits for legal immigrants, such as the five-year moratorium on access to Medicaid benefits.

Policies such as this one could garner bipartisan support as organizations such as the Catholic Health Association of the United States support this approach. By enacting such a policy, policymakers could contribute to increased healthcare access in the US-Mexico border region while also following a humane and beneficial immigration approach.

7) Allow undocumented immigrants the option to apply for insurance coverage on ACA marketplaces.

Extending access to the ACA marketplace to undocumented immigrants would lead to higher rates of insurance among the undocumented population and improve binational health at the state and federal level. Additionally, policymakers in Texas should look to expand health insurance coverage through the ICHIA to include pregnant women. Enacting a program similar to that in Illinois, which offers low-income immigrant seniors health insurance regardless of their documentation status, could also strengthen the health of the border region by protecting the most vulnerable population.

8) Create and fund a variety of programs and initiative to address the specific need of the undocumented or immigrant population.

Creating a program similar to the Intervention Research to Improve Native American Health (IRINAH), which focuses on undocumented or immigrant populations to address the lack of multilevel and community-level interventions, or the National Institutes of Health created the Intervention Research to Improve Native American Health (IRINAH) program, which solicits proposals that

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develop, adapt, and test strategies to address these challenges and create interventions appropriate for Native populations. Similarly, a program could be created focused on undocumented or immigrant population.

Additionally, creating community gardens available to these populations could also lead to greater community involvement and healthier eating habits.

Head Start should also be expanded and early identification and interventions for young children, including adjusting eligibility to provide access to undocumented families, should be introduced. This should be established as part of a larger network of community service providers and aim to provide appropriate and culturally competent screening tools, assessments, interventions and referrals. Additionally, this will provide efficient and economical early intervention and prevention for high-risk children and

families and address targeted behavior management strategies, such as self-control, problem solving, and social skills and provide access to integrated treatment (Mental health & substance abuse) for those who need it in the community regardless of legal status.

Finally, communities along the border would benefit from reducing amputations among people with diabetes, potentially using the evidence-based RAPID model. This could be done with a focus on training and managing interdisciplinary diabetes teams, which has been shown to reduce amputation rates. Accordingly, creating a database of patients, who may be at an increased risk and managing proactive, preventative interventions for these vulnerable community members would be beneficial. Following the RAPID guidelines could also include introducing protocols for home visiting programs, establishing pathways for knowledge transfer of expert

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advice in the treatment of diabetic foot ulcers could be refined and disseminated. Obesity prevention initiatives and improved primary care management of obesity also should be prioritized effectively addressing the obesity epidemic, by prioritizing access to primary care.

Improving primary care management of obesity includes expanding the role of PCP or NPs in the community (Bowen et. al, 2018).

9) Expand the healthcare workforce to develop rural healthcare infrastructure.

Policymakers should allocate funding towards health agencies in rural South Texan communities, prioritizing recruitment of community health workers who can staff outreach programs and mobile health clinics.

Additionally, expanding residency training positions in Texas for medical school graduates should be a priority in combating the physician shortage. For example, S.348 - Resident Physician Shortage Reduction Act of 2019 would increase the number of residency positions eligible for graduate medical education payments under Medicare for qualifying hospitals, with an aggregate increase of 3,000 positions per fiscal year for five years.

Supporting primary care specialities will also help alleviate physician geographic maldistribution.

10) Expand the use of SNAP benefits and implement it as an official federal government initiative,

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including “doubling up” use of SNAP benefits at farmers markets.

Expanded use of SNAP benefits is already occurring in many neighborhoods. Making SNAP expansion an official federal government initiative could lead to healthier eating options, specifically for those at risk for obesity.

Doubling up on these SNAP benefits at farmers markets would jump start healthy behaviors as community members would become more inclined to eat healthier options. Not only would this benefit the people using SNAP benefits, but it could also benefit farmers.

11) Establish a humane immigration enforcement system in an adequate, responsible, and transparent way.

Finally, establishing a humane immigration enforcement system that protects the health and well-being of detained persons, would improve both health security and national security. Current ICE facilities have inadequate medical care, continued reports of sexual abuse against detainees, and insufficient budget justifications to Congress. Essential functions carried out by a more humane immigration enforcement system, which will allow a commission to look at transitioning essential functions and employees to prioritize accountability, transparency and oversight, would improve the health and well-being of detainees and the American public.

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64. Salinas, J.J., & Sexton, K. (2015). A border versus non-border comparison of food environment, poverty, and ethnic composition in Texas urban settings. Frontiers in public health, 3, 63.

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AUTHORS

*

Anna Gibson Adriel Arguelles

Adriel Arguelles is a Master of International Affairs student attending the Bush School of Government and Public Service at Texas A&M University. He focuses his studies on China and Asia-Pacific security, and is also interested in U.S. biodefense policy. He was previously a U.S. Indo-Pacific Command Student Fellow and a Research Assistant for the CoronaNet Research Project. After graduating from New Mexico State University in 2017 with a BS in genetics, he taught English as a second language for one year in Shenzhen, China.

Yarielka Arrieta Batista Yarielka Arrieta Batista is a second-year graduate student pursuing a joint master’s degree between the School of Public Health and the Bush School of Government and Public Service.

Yarielka received a bachelor’s degree in Sociology in May 2019.

Upon completing her joint degree program in May 2022, Yarielka will receive a Masters of Public Health in Health Policy & Management and a Masters of International Affairs, with concentrations in Women, Peace, and Security and American Diplomacy. Last summer, Yarielka worked as an intern for the Department of Health and Human Services in the Office of Global Affairs. Specifically, Yarielka worked within the Office of Pandemics and Emerging Threats. This experience fueled her excitement to advocate for international cooperation and research on modern public health threats. Yarielka hopes to work in the global health security and diplomacy field. Although Yarielka hopes to work in the global health sector, she is also passionate about domestic health policy. Yarielka hopes that in the future, she will have the opportunity to work at a think tank that focuses on affordable health care for all in the United States.

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Anna Gibson is a first-year student in the Masters of International Affairs Program at the Bush School of Government and Public Service. Her areas of concentration are intelligence and biosecurity. She received her Bachelor of Science in Biomedical Sciences at Texas A&M University. She currently works as a student assistant/researcher in the Paul de Figueiredo Lab in the Department of Microbial Pathogenesis and Immunology. After graduation, Anna Gibson aims for a career in biosecurity and biodefense.

Danyale C. Kellogg Danyale is an MIA student on the national security and diplomacy track with concentrations in China studies and biosecurity at the Bush School. She is also in the Global Health Graduate Certificate program in the Texas A&M School of Public Health.

She has internship experience in the Departments of Defense, Health and Human Services, and Homeland Security, as well as other organizations, and is a current Women in Defense Scholar with the National Defense Industrial Association. She will begin her PhD in biodefense this fall at the Schar School at George Mason University.

Alexander Lê Alexander Lê is a masters degree student at the Texas A&M School of Public Health, and an MD Plus student at the Texas A&M College of Medicine. His focus centers around community health, preventative medicine, and immigrant and refugee health. He graduated from the University of Houston in 2019, and is currently involved with the Vietnamese Culture and Science Association as a VP of Community Health Programs.

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Chandler Molpus Chandler Molpus is currently a student at the Bush School of Government and Public Service at Texas A&M University.

Chandler is pursuing a Master in International Affairs with concentrations in International Development and Pandemic Preparedness and Disaster Response. Before attending the Bush School, Chandler graduated from the University of Mississippi with a BA in International Studies.

Chandler is interested in furthering his research on the intersection between public health and development.

Sanny Rivera MPH, M.Ed, CPST Sanny Rivera is a second-year Doctoral student at Texas A&M University and works at Texas Children's Hospital with Injury Prevention efforts.

She works on communitybased projects and is actively involved in several efforts with the Greater Houston Area community. Her work and interests focus on health disparities, community health interventions, mental health programs, stress, the Latin American population, the U.S. immigrant population, asthma disparities, the adolescent experience, qualitative research methods,

and family dynamics. She has extensive experience in health education and health promotion in Texas, especially addressing disparities among different racial/ ethnic populations. Sanny is particularly passionate about serving the Latinx community and identifying culturally responsive practices to promote health behaviors. Sanny is originally from Queens, New York and is a first generation student and proud daughter of immigrants from Ecuador and Uruguay. She graduated from Oak Ridge High School in Conroe ISD then attended the University of Houston where she received her BS in Health, BS in Psychology, and ultimately her M.Ed in Health Education. Then she earned her MPH at The George Washington University. She is currently a secondyear pursuing her Doctoral degree in Public Health at Texas A&M University in the Health Promotion and Community Health Sciences Department. *All authors contributed equally to this white paper

About “Science & Policy” “Science & Policy” is a class funded through the Tier One Program by the Office of the President at Texas A&M University. It’s an interdisciplinary graduate level course designed to bring together Masters and PhD students from the social sciences and sciences from across the university. Students are challenged to work together over the course of the semester on a research topic within the scope of the course.

The George H.W. Bush Presidential Library & Museum and The Bush School of Government & Public Service at Texas A&M University, College Station, Texas, USA

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In Memoriam/The ImprovingScowcroft Health Security Vision

In Memoriam Lieutenant General

Brent Scowcroft (March 19, 1925 - August 6, 2020)

President George H.W. Bush & Lt. Gen. Brent Scowcroft “We live in an era of tremendous global change. Policy makers will confront unfamiliar challenges, new opportunities, and difficult choices in the years ahead.

I look forward to the Scowcroft Institute supporting policy-relevant research that will contribute to our understanding of these changes, illuminating their implications for our national interest, and fostering lively exchanges about how the United States can help shape a world that best serves our interests and reflects our values.”

— Lt. Gen. Brent Scowcroft, USAF (Ret.)

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The views expressed and opinions presented in this paper are those of the students and their instructor. They do not necessarily reflect the positions of the Scowcroft Institute of International Affairs, The Bush School of Government & Public Service or Texas A&M University.

Scowcroft Institute of International Affairs | The Bush School of Government & Public Service Texas A&M University | College Station, Texas, USA | bushschoolscowcroft@tamu.edu | bush.tamu.edu/scowcroft

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