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Int Public Health J 2016;8(2):107-119 ISSN: 1947-4989
© 2016 Nova Science Publishers, Inc.
Nuestra Casa: An advocacy initiative to reduce inequalities
and tuberculosis along the US-Mexico border
Eva M Moya1,, PhD, LMSW,
Silvia M. Chávez-Baray1, PhD,
William W. Wood2, PhD, and
Omar Martinez3, JD, MPH, MS
1The University of Texas at El Paso College of Health
Sciences Department of Social Work, El Paso, Texas,
United States of America
2University of Wisconsin-Milwaukee Department of
Anthropology, Milwaukee, Wisconsin, United States of
America
3School of Social Work, College of Public Health,
Temple University, Philadelphia, Pennsylvania, United
States of America
Correspondence: Eva M Moya, PhD, LMSW, Associate Dean
College of Health Sciences and Assistant Professor, The
University of Texas at El Paso College of Health Sciences
Department of Social Work, 500 W University Ave, El
Paso, Texas 79968, United States. E-mail:
emmoya@utep.edu.
Abstract
The US-Mexico border provides a rich learning
environment for professional social workers and at the
same time poses some challenges. This article explores
some of the unique demographics and social and cultural
characteristics in the border region. These characteristics
have implications for social work teaching, research, policy
and practice. The study of borders includes exploring social
disparities and inequalities. Health risks and diseases travel
fluidly between borders and kill indiscriminately. The US-
Mexico border is at high-risk of elevated tuberculosis (TB)
and HIV incidence due to socio-economic stress, rapid and
dynamic population growth, mobility and migration, and
the hybridization of cultures. Every minute, four people die
from TB, and 15 more become infected worldwide. The
number of deaths due to tuberculosis is unacceptable given
that most cases of TB are preventable. Cross-border
cooperation and collaboration among social workers, health
professionals and public officials between communities and
countries can reduce social injustices to move towards a
healthier borderland, as demonstrated in the collaborative
prevention of TB. Rather than limiting our work to define
social inequalities, we seek to further the conversation and
suggest social action to address TB. This article contributes
ideas and examples of experiences to encourage innovative,
community-academic engaged inter- and multidisciplinary
interventions like the Nuestra Casa (Our House) initiative.
Nuestra Casa is an advocacy, communication and social
mobilization strategy to address TB and HIV health
disparities and inequalities in underserved communities,
which we argue provides a useful model for combating TB
and other inequalities plaguing the US-Mexico borderland.
Keywords: tuberculosis, health disparities, social work,
U.S.-Mexico border
Introduction
The study of borders includes the study of social
disparities. Borders create unique challenges and
opportunities for social workers and public health
professionals to address social inequalities and health
Eva M Moya, Silvia M Chávez-Baray, William W Wood et al.
108
disparities between groups. At borders, health risks
and diseases travel and kill at will. These differences
can affect how frequently a disease affects a group,
how many people get sick, or how often the disease
causes death. Healthy People 2020 defines a health
disparity as “a particular type of health difference that
is closely linked with social, economic, and/or
environmental disadvantage. Health disparities
adversely affect groups of people who have
systematically experienced greater obstacles to health
based on their racial or ethnic group; religion;
socioeconomic status; gender; age; mental health;
cognitive, sensory and physical disability; sexual
orientation; gender identity; geographic location; or
other characteristics historically linked to
discrimination or exclusion” (1). From a health equity
standpoint, we have the ability and responsibility to
advocate for and provide culturally and linguistically
appropriate services, and to promote policies that
improve community health (2).
The US-Mexico border region is a distinct
geographic, economic, cultural and social area that is
affected by systematic social and economic injustice.
This is evidenced by social and economic problems
that are apparent throughout the region, including
poverty, health disparities, social inequities, and low-
wage assembly, service, seasonal, and agricultural
employment. Endemic poverty co-exists with
institutional racism, gender violence and structural
violence (systematic oppressions). The area, while
populated by resilient families and communities that
have confronted governmental neglect and social
isolation, is at the periphery of the American and
Mexican economies (3).
The border spans almost 2,000 miles from the
Pacific Ocean to the Gulf of Mexico and includes four
US states, six Mexican states, 44 U.S. counties, and
80 Mexican municipalities. The border region,
defined as the area within 62.5 miles of either side of
the boundary, is home to approximately 13 million
individuals and to 26 US federally recognized Native
American tribes (4). Each country has a distinct
system of policies and health care practices, each with
a disproportionate share of health, environmental
risks, and diseases. It is unlikely that any other
binational border has such variability in health status,
services, and utilization. Lower socioeconomic and
educational levels, migration, immigration, and rapid
industrial development accompanied by population
growth from the implementation of the North
American Free Trade Agreement in 1994 helps to
explain some of the present complexity in this
particular borderland (5). The policies, norms, and
regulations of one side of the border are not
applicable to the other. On the border, the developed
and developing regions merge and mix to combine
some of the best and worst of both worlds.
In some places, only a sign or a fence marks the
border. In other places, the border is reinforced with
barbed wire or tall steel fences (6). Although each
nation operates under distinct legal and political
systems as well as different health care and public
health systems, the U.S.-Mexico border region is
mutually dependent, sharing environmental, social,
economic, cultural, and epidemiologic characteristics.
Extensive family and cultural ties are shared by many
of the people in the borderland. Health inequalities
along the border especially affect indigenous and
immigrant populations, who are vulnerable as a result
of low socio-economic status, lack of health
insurance, linguistic and cultural barriers, and limited
access to healthcare and social services (5,7). If the
U.S.-Mexico border region were considered a state,
the region would be comprised of the following
characteristics: 1) rank last in access to health care; 2)
second in death rates due to hepatitis; 3) third in
deaths related to diabetes; 4) last in per capita income;
5) first in the number of school children living in
poverty; and 6) first in the number of school children
who are uninsured (8).
A semi-permeable membrane
The U.S.-Mexico border offers a stark context in
cultural differences, social inequalities, and ever-
present reminders of governmental power that limit
individual opportunity by ascribing national identity.
Although governed by different bodies, U.S. and
Mexican border populations are highly connected
through an integrated social and economic system.
People on both sides of the border share similar
cultures and are exposed to comparable environments.
Population density and poverty in urban and rural
areas near the border are high, and unincorporated
communities—known as ‘colonias’—often have
Nuestra Casa 109
inadequate housing, roads, sewage systems, drainage,
and lack a potable water supply. Transborder trade;
maquiladora (twin plants) industry; migration,
mobility and energy trade; drug, arms and human
trafficking; smuggling and other modalities of
transnational organized crime are core economic
activities in the border region (9).
The US-Mexico border is open to the movement
of risk and disease but closed to the free movement of
people, services, and cures. Since the US-Mexico
border separates rich and poor countries with different
types of healthcare systems, inequalities in access to
health care are created and reinforced for those living
between these two nations. The distribution of
communicable diseases like TB is associated with
other social disparities (e.g., wealthy versus poor,
majority versus minority) in both access to medical
care and treatment. In addition, considerable research
in public health on the US-Mexico border has
increased focus on individual behavior and social
determinants (1, 5, 7).
The border region also attracts migrants from
other areas of Mexico, Central and South America,
Europe and Asia who seek opportunities and safety
(8) and, in many cases, migration to the United States.
These goals are not always achieved once they arrive
to the region, thus creating populations that are
displaced and vulnerable. According to the U.S.
Customs and Border Protection, 57,525
unaccompanied children were apprehended at the
southwest border between October 1, 2013 and June
30, 2014. More than three-quarters of unaccompanied
minors come from mostly poor and violent cities in El
Salvador, Guatemala and Honduras. Children from
Mexico, once the largest group, now make up less
than a quarter of the total - a small number from the
43 other countries (10). It is important to note that
some right wing groups and conservative elected
officials (federal and state government) have
defended increased enforcement of deportation
measures by pointing to fears of disease epidemics,
including tuberculosis. However, tuberculosis does
not appear to be a serious concern at the moment for
this group. For instance, Carrie Williams, a
spokeswoman for the Texas Department of State
Health Services, said there have been only three cases
of tuberculosis reported among the undocumented
children who have come into Texas. This is not the
case among adult immigrants, where recently 89 new
cases of TB were reported. For every case of active
TB, there are between 10-15 more individuals
infected (11).
The large-scale movement of people, closeness of
social interactions, large volume of trade, limitations
of public health infrastructure, and environmental
conditions are all factors that facilitate the
transmission of infectious diseases among residents of
the US-Mexico border region (12). Also intriguing are
the so-called ‘Hispanic or Latino health paradox’ and
the ‘immigrant advantage,’ referring to the
contradictory finding that indicates that Latinos and
immigrants in the U.S. tend to have significantly
better health and mortality outcomes than the average
population despite generally low socioeconomic
status (13, 14). Findings from the Tomas Rivera
Policy Institute (15) suggest that the Latino health
paradox exists for mental health issues, asthma,
maternal-child health, and high blood pressure.
Results from this study indicate that Hispanic
immigrants are healthier in terms of these four health
outcomes when they first arrive in the United States;
however, they become less healthy with greater
amounts of acculturation.
El Paso, Texas - Ciudad Juarez
border metropolis
El Paso County is intersected by the Franklin
Mountain Range and encompasses a portion of the
Chihuahuan Desert as well as several communities
such as the City of El Paso. Combined, the population
of El Paso County and its neighboring Ciudad Juarez
in the state of Chihuahua, Mexico is approximately
two million. El Paso is the fourth largest city in
Texas, with a population of 800,647 (16). Over 80
percent of El Paso residents are Hispanic of Mexican-
origin, with three quarters of the population speaking
a language other than English at home. The median
annual household income is $36,078. In El Paso, the
unemployment rate in 2014 was 8.0 percent (17). The
El Paso region experiences higher rates of
unemployment, underemployment, and lower average
wages than the rest of Texas. Texas, as a state, has the
largest population of people who are uninsured,
accounting for 28 percent of Texas’s population or 6.1
Eva M Moya, Silvia M Chávez-Baray, William W Wood et al.
110
million people (18). El Paso’s uninsured rate is the
highest in the state, with 30 percent being uninsured
(19).
Ciudad Juarez is the largest city in the State of
Chihuahua, Mexico, and the second most populated
Mexican city on the US–Mexico border, after Tijuana
in Baja California. Ciudad Juarez’s population for
2010 was 1,332,131, and its metropolitan area is the
eighth largest in Mexico. Approximately forty percent
of the state of Chihuahua’s population lives in Ciudad
Juarez. More than 40 percent of the Juarez population
lived in poverty in 2010 (20). Juarez borders with El
Paso County in Texas, as well as Dona Ana County in
New Mexico. In recent years, the national and
international media have broadcast to the world
examples of how violence, death, and organized crime
have escalated in the border region and in particular in
Juarez, naming the city as the most dangerous city in
Mexico and among the most dangerous in the world
(12).
The majority of people on either side of the
border are permanent residents; some are
‘borderlanders’ (natives of the region that travel, live
and work in both countries), others are bi-national,
while others cross the border daily for work, school,
business and to visit family members. Other
individuals rarely cross the border, some have never
crossed, and others are scared to cross. The public
health consequences of these macro forces have been
analyzed to some extent in conflict and transitional
settings, but have not been considered in the context
of Mexico’s violent struggle against drug cartels and
organized crime (21). While there is a great need for
service provision, care is not provided to those that
need it the most. Some of the reasons for this have to
do with people’s immigration status, border security
and the enforcement of border laws, lack of
linguistically appropriate services, and cultural
understandings and misunderstandings (22).
The case of tuberculosis
In the United States, tuberculosis, HIV, viral hepatitis,
and sexually transmitted infections (STI) are the most
prevalent and most commonly reported infectious
conditions. TB is described as a disease process
resulting from the infection Mycobacterium
tuberculosis. It is also understood as a social illness
that causes great suffering, a disease of the “at-risk
populations” and a sign of poverty and inequalities.
TB is a medical and social condition that involves
deep emotional experiences, narratives of illness,
alienation from family members, isolation and
stigmatization (23). TB remains a major global,
social, and public health problem (24). Every minute,
four people die from TB and 15 more become
infected worldwide (25). In 2012, an estimated 8.6
million people developed TB and 1.3 million died
from the disease, including 320,000 deaths among
HIV-positive people (24). The number of deaths due
to TB is unacceptable, especially given that most
cases are preventable. While a myriad of
communicable diseases exist in the U.S.-Mexico
border region, TB, HIV and their co-morbidity are of
upmost concern. TB and HIV account for substantial
morbidity and mortality, with great social and
financial costs to individuals, families, and societies.
The US-Mexico border experiences a disproportionate
burden of these conditions as compared to the rest of
the countries and compared to other Western
industrialized nations, with significant disparities
observed across sub-groups and geographical regions
(26).
There is recognition of the direct correlation
between TB incidence and the prevalence of poverty
(27). Although diseases like TB and HIV cross class
lines and geographical locations, its highest toll has
always been among immigrants, the foreign born, and
the working class poor and their families. The patterns
of diseases found in Hispanics, African Americans,
Non-Hispanic Whites, Native Americans, Mexicans
and foreign-born individuals along the border create
unique challenges for social work and public health
responses.
Poverty, increased violence, and family
reunification are complex forces that move more poor
people into the United States (from Mexico or any
other underdeveloped countries like Honduras, El
Salvador, Nicaragua, and Guatemala), and an increase
in health risks and TB incidence is inevitable. The
US-Mexico border is at high risk of elevated TB
incidence and other health issues due to
socioeconomic stress, rapid and dynamic population
growth, mobility and migration, “cultural
hybridization” and a young population (28). TB is a
Nuestra Casa 111
subtle and complex chronic infectious disease. The
extent of the disease is likely to be underreported
because of mobility and migration across the border
as well as the long latency of the condition after
infection occurs. The incidence of TB at the border
far exceeds national incidence rates in both countries
(see Figure 1).
2012
TB Cases
2012
TB Rate
Arizona (AZ) 211 3.2
California (CA) 2,191 5.8
New Mexico (NM) 40 2.4
Texas (TX) 1,233 4.7
U.S. Border States 3,675 6.1
U.S. Total 9,945 3.2
Baja California (BC) 1,853 54.8
Chihuahua (CHIH) 692 19.0
Coahuila (COAH) 614 21.2
Nuevo Leon (NL) 1,237 25.0
Sonora (SON) 855 30.0
Tamaulipas (TAMS) 1,109 32.0
Mexican border states 6,360 30.1
Mexican National 19,738 16.7
a Border area is defined as the area extending 100 kilometers (62 miles) north-south of the U.S.-Mexico border.
b Sources: Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 2013. U.S. Department
of Health and Human Services, 2013.
Preliminar 2013/Secretaria de Salud/Dirección General de Epidemiologia/Sistema Nacional de Vigilancia Epidemiológica.
March 28, 2014.
There is little discussion among health
policymakers, researchers, social workers, and health
practitioners about how to address tuberculosis and
migration as well as its connection to poverty and
other social inequalities (29). As shown in Figure 1, in
2012, TB rates on each side of the border were two
times their respective national averages, according to
published (30) and unpublished sources (31).
Ongoing transmission, prolonged infection,
delayed diagnosis, increased mobility, increased drug-
resistance, limited access to health care, TB related
stigma, increased mobility and migration make case
Eva M Moya, Silvia M Chávez-Baray, William W Wood et al.
112
management and completion of treatment difficult
along the U.S.-Mexico border (5,24,32). TB presents
unique characteristics that have their origin in the fact
that society is divided into socioeconomic status-
based groups or classes, and it is from these divisions
that the resistance to the infection emerges.
Mechanisms to reach out to educate and treat
vulnerable populations for TB in both countries,
including those that enter the US legally, need to be
addressed and implemented.
In Mexico, every day there are 54 new TB cases,
and every 6 hours a person dies from TB (31). TB
continues to affect communities and individuals that
are most vulnerable (e.g., the poor, underserved,
malnourished, HIV positive, diabetic). Mexico’s
national TB rate for 2013 was 13.6 per 100,000 (31);
this is over four times the rate in the United States of
3.2 per 100,000. Mexico’s National TB prevalence
rate for 2013 was 25.4 per 100,000; eight times higher
than the United States rate of 3.2 per 100,000 (30).
Each of the six Mexican states that share a border
with United States has higher TB rates compared to
the national rate. Combined, they represent 29% of
the total cases for Mexico in 2013, with the border
municipalities of the states of Baja California, Nuevo
Leon, and Tamaulipas having the largest
concentration of TB cases (31). According to the
Centers for Disease Control and Prevention (CDC), in
the US in 2012, a total of 9,945 new TB cases were
reported and the TB rate declined by 4.2% from 2006
to 3.2 cases per 100,000 (33). The national TB
incidence rate in 2012 was the lowest since national
reporting began in 1953. Despite this improvement,
foreign-born persons and racial and ethnic minorities
continue to bear a disproportionate burden of the
disease in the US. TB rates among Mexican-origin
individuals and other Hispanics, African Americans,
Native Hawaiians and Other Pacific Islanders, and
Asians were 5.3, 5.8, 12.3 and 18.9 times higher than
among Non-Hispanic Whites respectively in 2012
(30).
We live in a society where risk and vulnerability
have been globalized. At the same time and in
seeming contradiction, the discourses of ‘nation’ (and
assertions of ‘national identity’) are becoming more
important in terms of globalization as an articulating
device (34), which serves to distinguish ‘insiders’
from ‘outsiders’. This helps to create risk categories
(e.g., foreign-born, Mexican-origin) to justify
enhanced surveillance while also serving to separate
those who can manage the risk from those whose risk
requires management under supervision (35). Risk
management consequently represents a localized
response to the globalized problems of TB, HIV and
poverty. The risk of TB then becomes associated with
particular social categories defined in terms of
national identity, such as foreign-born, rather than the
structural inequalities and processes that place people
at risk. For example, TB is associated with poor
quality and overcrowded housing, and minority ethnic
groups are more likely to experience housing
inequalities as well as reside in areas that experience
disadvantage (36).
TB often coexists with other comorbidities like
diabetes mellitus, substance abuse, and HIV that, if
not treated, can produce fatal consequences. People
who are HIV positive and infected with TB are 20 to
40 times more likely to develop active TB than people
not infected with HIV in the same country (24). The
focus on TB and HIV in the US-Mexico border is
timely, given the evidence of increasing burdens and
worsening health disparities for these conditions, the
evolution in the understanding of the social and
structural influences of disease epidemiology, and the
implications of the global economic downturn. The
global trends and impacts on health of TB, HIV and
STIs remain among the most urgent public health
challenges of our time (24). In a world characterized
by globalization, policies concerning health security,
communicable diseases, and healthcare are
increasingly important. The advent of TB drug-
resistance and the complexities of border population
dynamics may cause a considerable threat to the
population on either side (28). Health policies and
health promotion actions tend to be unilateral in
nature. Social workers, healthcare workers, and other
professionals can help adapt and unify policies,
actions, and interventions to address complex health
disparities (37). We present a case study that
describes the Nuestra Casa (Our House) Exhibit, an
advocacy, communication and social mobilization
strategy to increase the awareness of and social action
for TB through public art as a medium for education
and social engagement. This article describes the
genesis and the evolution of this initiative.
Nuestra Casa 113
Nuestra Casa
Phase 1: Cross-border cooperation
and innovation in TB awareness
The Nuestra Casa exhibition was several years in
development and grew from a unique partnership
between Project Concern International (PCI), the US
Agency for International Development (USAID), the
Alliance of Border Collaborative (ABC), Dr. Eva
Moya (author and bi-national social worker) and
Damien Schumman (South African-based
photographer and artist). In 2008, Moya met
Schumann at the 2008 International AIDS Conference
in Mexico City, where the two developed the idea of
working together to bring greater public awareness to
the social and public health issues of TB and HIV.
Schumann had gained notoriety in South Africa for
the creation of “TB/HIV Shack” installations focused
on public health and social justice issues. One of
Schumann’s Shack installations was on view in
Mexico City, and there the two launched the idea of
transforming the “The TB/HIV Shack” into the
“Nuestra Casa” Initiative, focused on the issue of TB
and HIV in the border region. In 2009, USAID
awarded $20,000 to PCI to hire Schumann for the
project and that same year the Nuestra Casa mobile
exhibition began its tour in El Paso, Texas. The
original house (see Photograph 1) was built by the
artist with help from persons affected by TB in the El
Paso and Ciudad Juarez border region.
The Nuestra Casa exhibition was an interactive
experience where individuals entered a living space—
a literal “mobile home for TB” (38). It was conceived
as a movable house built out of discarded
particleboard, wood, and other scrap materials easily
found in Mexican communities and colonias. Nuestra
Casa included a living room, kitchen, bathroom, a
hallway or Corridor of Hope (Camino de la
Esperanza), and a small patio at the main entrance.
Photographs developed as part of the Border Voices
and Images of TB Project that Professor Moya
directed in 2008-2009 were included along with some
of Schumann’s photographic work.
The creation of “trapitos” (small pieces of cloth
that were made available for visitors to write their
thoughts about TB, the lives of people living with and
dying from TB, and their reactions to the exhibit)
were central to the experience of visitors since the
first exhibition in 2009. As Nuestra Casa presents the
life stories of persons affected by TB and other health
disparities, it is a lens into the socioeconomic and
environmental realities that help to create health
disparities but also the stories of resilience,
empowerment, and hope of those living with (and
dying from) TB.
As visitors went through the house, they were
immersed in hundreds of photographs and stories
showing the reality of TB. Visitors frequently asked
questions, received health information and interacted
with people affected by TB and HIV, social workers,
students, health care workers, advocates and decision
makers. After being on display on an outdoor
pedestrian friendly patio on the university campus, the
house tour was moved to Mexico in partnership with
the National TB Program and the support of the State
TB Programs in Quintana Roo, Oaxaca, Tamaulipas,
and Tijuana, before ending at the CDC Museum in
Atlanta, Georgia in 2010. More than 1,500 trapitos
were collected during the exhibit’s tour in
2009 to 2010 and included comments such as the
following:
“I am now rethinking my career path so that I can
do research to contribute to the efforts to combat TB.
Also, I want to go abroad so that I can actively help out”
- Atlanta, Georgia
“It is so real that my lungs hurt” - Cancun, Mexico
While on tour in 2010, Nuestra Casa became an
international phenomenon at the 40th UNION
Conference on Lung Health and Tuberculosis in
Cancun, Mexico. At the end of its 2010 tour and with
cooperation from the CDC, Nuestra Casa opened the
National TB Conference in Atlanta and remained on
exhibit at the CDC Museum for four months. Nuestra
Casa became an advocacy, communication and social
mobilization model in Mexico and inspired local,
state, national, and international TB programs to
integrate perspectives of persons affected by TB (and
comorbidities) in advocacy efforts.
Eva M Moya, Silvia M Chávez-Baray, William W Wood et al.
114
Photograph 1. Source: Nuestra Casa Exhibit (2009). Courtesy of Damien Schumann.
Nuestra Casa Exhibition.
Photograph 2. Nuestra Casa returns to UTEP as an Initiative (2012). Courtesy of the University of Texas at El Paso
Centennial Museum.
Phase 2: Returning Nuestra Casa to the
university: The initiative
Shortly after the tour ended at the CDC, coauthors
Moya and Wood (then Director of UTEP’s Centennial
Museum) met to talk about how the exhibition’s tour
might be used as a catalyst to reengage the El Paso,
Texas and Ciudad Juarez, Mexico communities to use
advocacy, communication, and social mobilization
(ACMS) efforts in TB prevention. They invited
Schumann back to the university to reassemble the
Nuestra Casa in a gallery of the Centennial Museum
Nuestra Casa 115
and to highlight the 1,500 trapitos. Having visitors to
this second phase engage with the heartfelt messages
on many of the trapitos was, they felt, a must.
In the fall of 2011, Moya brought together the
project team for what would soon come to be called
the Nuestra Casa Initiative (NCI) that included Wood;
coauthor Dr. Silvia Chávez-Baray (Dept. of Social
Work), Dr. Guillermina Nuñez (Anthropology), Dr.
Arvind Singhal (Communications Department and
Social Justice Initiative), Dr. Lucia Durá (Rhetoric
Department), Azuri Gonzalez (Center for Civic
Engagement), and Raquel Orduño (social work
student and TB Advocate).
The NCI became an ACMS strategy to increase
TB awareness, detection, and cure rates; improve
collaboration among TB, HIV, and Diabetes Mellitus
Programs to reduce risk of infection and increase
information and co-morbidity detection; promote a
person-centered approach in health services and in the
community; mitigate the impacts of stigma and
discrimination; honor community resilience and the
narratives of affected persons; and promote social
action.
Through a series of workshops led by university
faculty, service learning students worked mostly in
pairs with the trapitos from the locations the traveling
exhibition had visited, coding the data, finding major
themes, and identifying trapitos that most poignantly
expressed a significant theme to be highlighted
through a tendedero (clothsline) of trapitos in the
installation at the Museum. In the final workshop,
faculty took the students through a series of exercises
where they shared their experiences with the NCI. As
they shared with their classmates their “favorite
trapitos,” several of them were moved to tears as they
explained just how profound the experience had been.
The coding of the trapitos is posted online.
As faculty worked with students to code the
trapitos and prepare them for installation, the Museum
director worked with the artist, Museum staff and
student interns to launch a web site and Facebook
page, and to redesign the installation to include an art
installation style display of Schumann’s photo-
narratives, web linked gallery content highlighting the
2009-10 tour, a computer kiosk to access online
content (for those without handheld devises), a hands-
on style trapito making station, and (of course) the
tendederos of trapitos reconceptualized by Schumann
as a forest that visitors would need to walk through as
they approached Nuestra Casa.
In 2012, the project team launched the NCI at the
UTEP Museum with the opening of a yearlong series
of health and social programming developed by
community advocates, faculty and students (see
Photograph 2. The Museum’s involvement in the NCI
was conceived in terms of emerging ideas about how
to make museums more “participatory” (39, 40) and
“person-centered” in their educational goals and
strategy while the wider initiative sought to advocate,
engage, and mobilize communities of scholars,
researchers, advocates, professionals, students, and
persons affected by TB to work for a world free of TB
and HIV. Multiple modalities of education and health
promotion were utilized, including visual media,
presentations, lectures, social work student-guided
interactions, candlelight vigils and communications
technology and social media.
The exhibition marked the first time in the
Museum’s history that an exhibit of this nature
involving students, faculty, community advocates and
staff had been developed and it proved to be a richly
rewarding experience for all those involved. Over the
course of 2012, nearly 25,000 people visited the
Museum and attended supporting programming.
The NCI was especially successful in engaging
social work students and persons affected by
tuberculosis as they participated in the initiative. Five
graduate social work students became museum
docents for the exhibit and regularly provided guided
tours for visitors from Ciudad Juarez and El Paso.
Twenty students volunteered as part of service
learning projects. A Digital Media student produced
two YouTube documentaries on TB and the Nuestra
Casa exhibit (they can be also found on the It is:
https://www.facebook.com/NuestraCasaInitiative2011
/), while others have conducted outreach as volunteers
for the 2011-2012 Dia de los Niños-Dia de los Libros
(Children’s Day/Book Day), Binational Health Week,
and community-wide events or through presentations
in Ciudad Juarez and El Paso on TB and lung health.
An NCI project dissemination guide (used by exhibit
hosts to assist with assembly and dissemination), T-
shirts and wristbands (For a world free of TB and
HIV) were produced and disseminated.
In addition, Raquel Orduño, a person affected by
TB, MSW graduate, activist and member of NCI,
Eva M Moya, Silvia M Chávez-Baray, William W Wood et al.
116
spoke about her experience in local, state, national
and international forums. Her testimony reached
hundreds of policy makers, advocates, and clinicians
in the United States and Mexico, as well as officials
during the 2013 World TB Day WHO Stop TB
Partnership panel in Washington DC.
The legacy and continuing impacts of
the NCI
The cross-border cooperation and innovation of the
NCI was successful in terms of presentations,
recognition, and publications. Nuestra Casa displayed
at six principle venues: 1) the 40th and 42th
International UNION Conferences on Lung Health
and TB in Cancun, Mexico and Berlin, Germany
respectively); 2) the 2010 National TB Conference
(Atlanta, Georgia); 3) the 2011 National TB
Conference in Mexico; 4) the 2012 International
Social Work Conference in Stockholm; 5) the 2013
International Mental Health and Social Work
Conference in Los Angeles; and 6) establishment of
20 academic, community and binational partnerships
in the US-Mexico border supporting the 12-month
display at the university.
Additionally, the exhibit was granted one of eight
recognitions at the 2012 North American UNION
Region Meeting and received notoriety at the 2011
Society for Applied Anthropology and the Western
Social Science Association conferences. The exhibit
was so successful that the Mexican Consulate in El
Paso celebrated World TB Day 2012 by having the
NCI team install several of Schumann’s photo-
narratives and trapitos, with an estimated viewership
of 3,000. The 2012 World TB Day events were also
launched at the university. At the event, the Pan
American Health Organization released the 2012 TB
and HIV/AIDS Comorbidity report for health care
workers, which included an ACSM component
highlighting the NCI. In 2013, NCI received the
McGrath Community-University Engagement
Regional award for innovation in interdisciplinary
education and service.
Finally, this initiative has led to the publication of
a book entitled Social Justice in the US-Mexico
Border (Springer, 2012), authored by Moya in
partnership with other scholars from the university.
This publication features a chapter on TB and HIV,
ACSM addressing challenges and opportunities for
improving bi-national collaboration which include
strategies like Nuestra Casa and the Border Voices
and Images of TB (TB Photovoice Project). In 2013,
the peer-reviewed article on the NCI was published in
the journal Reflections, dedicated to scholarship on
innovation in service learning. In 2014, the initiative
was presented at the International Union Against
Tuberculosis and Lung Disease Conference in
Barcelona, Spain.
NCI fostered multi and interdisciplinary
collaboration and capitalized upon the strengths of
diverse professions and advocates to augment
consciousness of tuberculosis. Faculty members used
liberating structures and problem-based learning
methods to work with students across disciplines. The
participation of community members has also been
critical to its success, as has re-conceptualizing
museum gallery space as a public forum. The
narratives of individuals affected by TB provide the
human perspective necessary to contextualize the
situation: namely, that all humans are vulnerable to
the disease, and it is therefore imperative that policy
be attentive to the challenges and needs of those
affected.
The lessons learned that can be used to promote
and strengthen macro social work practice and social
mobilization efforts are as follows: 1) ACMS
strategies are needed to effectively raise awareness,
mobilize community members, leaders, and social
workers; and to empower and engage persons affected
by TB; to successfully prevent and care for those
suffering from the diseases and its repercussions. 2) A
person-centered approach to service delivery is
required to improve detection, treatment, adherence,
and cure, and to mitigate all forms of stigma related to
TB. 3) NCI is a powerful ACMS intervention to
increase social and political will to improve TB and
HIV prevention and care and to mitigate stigma. 4)
Macro social work interventions, community
participation, as well as involvement of TB affected
persons increased and is now fundamental for
successful social mobilization. 5) Community-
academic engagement partnerships and collaborative
action in the United States and Mexico are essential.
The NCI also led to a formal “call to action” for
increasing the visibility of persons affected by TB,
Nuestra Casa 117
their stories, lives, worries, concerns, vulnerabilities,
and aspirations; promoting inclusion, parity, and the
participation of persons affected by TB across all
levels; and sustaining permanent lines of funding
through efficient distribution mechanisms. The next
steps of the NCI include: seeking to share our
innovative findings with other communities, venues,
and locations beyond the US-Mexico Border;
launching ACMS strategies to increase collaboration
and cooperation across the two countries; capitalizing
on the use of viral technology to share the lessons
learned and innovation online; and identifying
publication and dissemination venues that value and
may help us incorporate the visual elements of this
initiative beyond the social work, health and
education fields.
Implications for social work
Implementing social determinant actions in health
involves holistic understanding and interventions,
identifying synergisms and antagonisms, and
employing cost-effective strategies to achieve
sustainable population coverage and scale (41).
The primary goal for local TB programs is to
medically treat and eliminate TB in the jurisdiction
that is being served. Social workers negotiate between
multiple services and benefits within and across
systems (42). Studies indicate that the rate of
adherence to TB care continues to be low -
approximately two thirds of all persons living with
active TB and in treatment complete their medication
regimen (24). TB interventions emphasize patient
adherence with directly observed therapy (DOTS).
Low adherence, stigma, TB comorbidities (i.e., HIV,
diabetes, malnutrition, and substance abuse)
significantly contribute to relapse rates, and may
result in multidrug resistant TB. Social work, public
health and medical literature point to factors
associated with successful TB care: 1) medication
regimen; 2) features of the health care system; and 3)
features to the relationship between the person
affected by TB, caregiver, and the health care
provider (43,44).
Based on the lessons learned and the evidence
cited, social workers: 1) identify social and medical
services and help find housing for homeless
individuals affected by health disparities (like TB); 2)
counsel individuals and families to deal with the
emotional and financial ramifications of their
diagnosis; 3) advocate for policies, programs and
services grounded on person-centered care; 4)
convene and participate in multi and interdisciplinary
teams that work in collaboration to improve access to
care and increase adherence to treatment; 5) engage in
activities that involve navigation of services; and 6)
identify resources for the client population.
Addressing the high rate of poverty, poor health
indicators, and overall living conditions in the US-
Mexico border and other low income communities
requires social workers who possess the leadership
skills and have the in-depth linguistic and cultural
knowledge to overcome the barriers to the receipt of
services people need. Social work programs residing
in the U.S.-Mexico border have the exceptional
challenges of preparing graduates and practitioners in
the border region, and must thus distinguish their
education offerings from programs in other areas of
the world.
Conclusion
The border region does not fare well in terms of
socioeconomic measures. The socioeconomic
disadvantages are particularly marked among
Hispanic border populations. Combined, the
demographic and social determinants present a
number of challenges to improving health at the
border. Our experience with the NCI shows that
“person-centered education model” about TB for the
persons affected by TB, the family members and their
social support network, health and human service
professionals and the wider community is essential
(45). The traditional medical model continues to
emphasize adherence by individual persons, absent of
a person-centered model, which fails to acknowledge
or address social and structural determinants of health
(46). Social workers offer an ecological perspective
on person-centered care, incorporating cultural factors
in a biopsychosocial assessment of the individual.
Failing to adopt a holistic perspective that
incorporates cultural factors, and focusing primarily
on medical adherence, may lead to the perception that
lack of adherence is due primarily to individual
Eva M Moya, Silvia M Chávez-Baray, William W Wood et al.
118
characteristics. Addressing health disparities requires
structural interventions. Interventions must address
TB screenings and treatment of persons infected while
also preventing persons at risk from acquiring the
disease. The social work profession stands in a
position to provide a holistic framework.
Evidence from the international community
demonstrates that political commitment to
implementing health policies and structural
interventions combined with existing knowledge,
observational evidence, and evidence based
innovative practices, may yield health improvements
(47). By focusing attention on capacity building,
leadership and governance, strategic partnerships, and
effective health communication, person-centered
approaches can help generate awareness, stimulate
new dialogue and disseminate promising practices.
Policy and systems change is essential for reducing
health inequalities like TB and HIV, and creating
communities of opportunity that support health
equity. Local partnerships and cross sector
collaborations is a key part of ensuring that every
individual has access to high quality education,
housing, transportation, jobs, safe places and health
care (48). Finally, we hope that this article contributes
to promoting an expanding field of research and
social action which is highly needed in order to
develop advocacy, communication and social
mobilization strategies to understand the mix of social
determinants of TB infection and care, the
perspectives of persons affected by TB, and
promising intervention strategies.
Acknowledgments
Special thanks to the participants of this intervention
and the organizations that contributed to the
development, funding and the dissemination of the
Nuestra Casa Initiative. We also want to thank Ethan
C. Levine for proof-reading the article and Dr.
Kathleen Curtis, Dean of the College of Health
Sciences, the University of Texas at El Paso for her
support.
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Submitted: January 07, 2015. Revised: February 08, 2015.
Accepted: February 18, 2015.
