The County of San Diego Health and Human Services Agency (HHSA) serves a diverse population of 3.3 million individuals. Thirty-four percent of the San Diego County population is Latino[1], there is a large immigrant community, and it is reported that over 450,000[2] individuals speak a language other than English at home. San Diego is also home to an international border crossing, and it is believed to be one of the busiest in the world with over 150,000 individuals crossing the border northbound in a single day[3]. People cross for work, recreation, shopping, education, to see family, to access healthcare, etc.

Baja California is also home to a large US citizen population. According to the US Consulate in Tijuana, there are about 265,000 US Citizens living in Baja California and according to the Mexican Institute on Statistics and Geography (INEGI), there are approximately 50,000 US citizen children living in Baja California. There is also a large proportion of the San Diego essential workforce that live in Baja California and cross the border every day to work in agricultural fields, retail, the hospitality industry, and healthcare facilities.

This fluidity creates an interconnectedness and interdependence between California and Baja California and from a public health perspective, this region is considered one with a shared community and shared health challenges. It is apparent that diseases do not recognize borders and with the constant fluidity, diseases can spread quickly, in both directions as is proving evident with the COVID-19 pandemic. For these reasons, it is critical for leaders on both sides of the border to communicate regularly and work together to support the shared binational community.

At the beginning of the COVID-19 pandemic, it became evident that the challenges facing San Diego were the same challenges shared by Tijuana and globally. It was essential to implement a formal structure to facilitate regular binational communication, coordination and collaboration in order to jointly and effectively respond to COVID-19. Simultaneously, the County of San Diego was activating its incident command structure and assigned 9 sectors and 13 sub-sectors to coordinate critical communication with stakeholders. HHSA leaders who regularly work with Mexico, noted the urgency of activating a binational response and advocated for developing and dedicating staff to support a binational focus within the Government Sector. It garnered immediate support and the Binational (San Diego-Tijuana) sub sector was implemented to share data, updates, response strategies and offer support to partners on both sides of the border. In partnership with ISESALUD, Health Services Jurisdiction of Tijuana, Tecate and Rosarito, Baja California, the Binational sector began hosting virtual biweekly meetings with key binational partners (primarily government agencies) to address COVID-19 in the border region. Over the last 11 months, 19 calls have taken place, in addition to various other activities including facilitating cross-border medical care support, and large personal protective equipment donations. The Binational sector is the only formal cross-border structure formed in response to the COVID-19 pandemic along the entire US-Mexico border region.

[1] https://www.census.gov/quickfacts/fact/table/sandiegocountycalifornia,CA/PST045219

[2] https://www.census.gov/quickfacts/fact/table/sandiegocitycalifornia,US/PST045219

[3] https://www.sandag.org/uploads/projectid/projectid_451_27426.pd

When the COVID-19 pandemic began in early 2020, regional public health leaders in San Diego, California and Tijuana, Baja California immediately began communicating and sharing data, updates, response strategies and offering support to one another. Due to existing and longstanding cross-border collaboration and partnerships, this effort unfolded quickly and seamlessly through traditional communication channels.  It was not long before the County of San Diego established a larger incident command structure to respond to the pandemic and to address coordination across disciplines. The County created 9 sectors and 13 sub-sectors to facilitate regular communication, coordination, resource allocation and address other needs. HHSA leaders who regularly work with Mexico, noted the urgency of activating a binational response and advocated for developing and dedicating staff to support a binational focus within the government sector. It garnered immediate support and the Binational (San Diego-Tijuana) sub sector was implemented to share data, updates, response strategies and offer support to partners on both sides of the border. The Binational sector is led by two bilingual County HHSA leaders who facilitate cross-border exchanges in multiple areas related to public health and emergency preparedness. The binational sector is innovative in that it is the only formal cross-border structure formed in response to the COVID-19 pandemic along the entire US-Mexico border region.

The Binational (San Diego-Tijuana) sector began hosting biweekly calls on March 26, 2020 in partnership with ISESALUD, Health Services Jurisdiction of Tijuana, Tecate and Rosarito, Baja California and other key binational partners (primarily government agencies). To meet the needs of the bilingual audience, the sector hired a company that offered simultaneous English-Spanish interpretation via the Zoom platform. Nineteen calls have been held to date between March 26, 2020 - Dec 17,2020. The calls address COVID-19 at the local level with San Diego and Tijuana providing epidemiological and general updates from both the County of San Diego HHSA and ISESALUD Tijuana. General updates include testing, tracing and treatment strategies, review of new guidelines, border testing data and cross-border collaborative efforts. Following these general updates is a participant discussion and an occasional special presentation. For instance, a speaker from the Baja California Secretary of Health presented their business safe reopening guidelines and the UN Refugee Agency in Tijuana provided an update on how the COVID-19 pandemic impacted Tijuana’s migrant shelters. In addition to the calls, the Binational sector produces a biweekly COV19 Binational bilingual newsletter highlighting epidemiological data at the local, state and federal levels in the US and Mexico, the latest local updates (e.g. business reopening plans and guidelines), donation opportunities to support Tijuana hospitals, and other helpful and timely resources such as free flu vaccine and COVID-19 testing sites on both sides of the border.

Furthermore, the Binational sector responds to daily complex inquiries and requests and coordinates with internal and external partners to develop guidance and responses. Examples include connecting physicians in Tijuana and San Diego to provide cross-border medical care, providing specific data reports to the Mexican Consulate in San Diego, and facilitating philanthropic activities. One substantial request involved the sector’s coordination of a large Personal Protective Equipment donation from the County of San Diego to the Baja California Health Services, ISESALUD Health Jurisdiction of Tijuana, Rosarito and Tecate who disseminated items to public hospitals, fever clinics, Tijuana Red Cross and Civil Protection. This request involved coordinating with local and state officials in California as well as the Mexican Consulate, the Baja California Secretary of Health, and the revenue service of the Mexican federal government. After a few months of communication, permit processing and inventory accounting, the request was approved by the Mexican federal government and on November 12, 2020, 83 pallets of PPE were transported by 4 semi-trucks from a warehouse in San Diego to a warehouse in Tijuana.

The County of San Diego supports forming strong partnerships with Baja California counterparts as it aligns with the County’s Live Well San Diego vision of building better systems and improving collaboration through regional partnerships and collective impact to achieve a healthy, safe and thriving region. The region is fortunate to have several longstanding binational partnerships that enable regular cross-border communication, coordination, and collaboration which have existed for decades outside of the COVID-19 pandemic.

The County of San Diego has partnerships with governmental agencies at the local, State and Federal levels on both sides of the border as well as with academic, medical and nonprofit organizations. Within HHSA, there are certain departments that work binationally and oversee the coordination of large binational initiatives. For instance, HHSA Central and South Regions, in collaboration with the US-Mexico Border Health Commission, coordinate the annual binational Love Your Heart campaign in all states along the US-Mexico border to raise awareness about heart health by offering free blood pressure screenings. Also within HHSA, the Public Health Services, Office of Border Health has existed for 27 years with the role of facilitating communication and collaboration among the health departments at the local level in San Diego and Tijuana. When emergencies or situations requiring immediate response arise, HHSA utilizes their established communication pathways to communicate with their counterpart, ISESALUD, representing the jurisdiction of Tijuana, Tecate and Rosarito and other key binational partners. The San Diego County’s Public Health Officer sees it as a priority to have regular communication with her counterpart, the Tijuana Health Jurisdiction ISESALUD Director.

Due to these existing partnerships, COVID-19 collaboration happened quickly and organically.

Further, coming together during this challenging time has only strengthened the existing cross-border network, bringing various agencies and entities together in a more profound way. For example, HHSA and its counterpart ISESALUD have always had a strong relationship and have met regularly for various events and meetings. During the pandemic, there has often been daily communication between the two entities further solidifying their commitment to work together and support one another. 

The Binational Sector is also in regular communication with the California Department of Public Health, Office of Binational Border Health and their Border Infectious Disease Surveillance Program which has a strong partnership with ISESALUD at the State level in Baja California. They communicate daily with their counterparts in Baja California regarding COVID-19 and they work closely on binational surveillance efforts and cases. They also work in close collaboration with the County of San Diego’s and Imperial County’s Epidemiology programs on binational case investigation and reporting, which has been a longstanding partnership for over 15 years. This collaboration among the CDPH Office of Binational Border Health, the State of Baja California, the County of San Diego, and Imperial County is essential for prompt notification of new cases in border counties as well as coordinating binational case investigations, containment and mitigation strategies.

The Binational Sector has maintained a level of flexibility, adaptability and quality improvement throughout the pandemic. One day is different from the next and inquiries are frequent, varied and complex requiring constant solutions-based thinking. Learning of heightened challenges in Tijuana hospitals led to a group of University of California, San Diego physicians wanting to lend support and resulting in daily visits by a group of doctors to the main Tijuana hospital to build capacity among their healthcare workforce. The Binational Sector played a key role by connecting the appropriate individuals to coordinate this effort.

Another example of a successful quality improvement effort was the need for streamlining a notification pathway for individuals with COVID-19 who are released from a hospital in San Diego County and returning to their home in Mexico. Ensuring that each entity involved is informed prior to their interaction with the individual is essential for preparedness, to take the necessary precautions and to ensure the patient is supported along their journey and when they reach their destination. The Binational sector facilitated meetings among the County Emergency Medical Services leadership, the County Epidemiology program, the California Department of Public Health, Office of Binational Border Health, Centers for Disease Control and Prevention and the Tijuana Health Jurisdiction to develop a notification pathway for Mexico-bound discharged patients who are traveling via ambulance. Once all participating entities provided input and agreed on a process, the pathway was finalized and implemented across the San Diego County hospital system.

The daily border crossings decreased when the Department of Homeland Security implemented restrictions, limiting trips for only essential reasons and for U.S. Citizens and Lawful Permanent residents only. Still, the number of crossings per day hovers around 100,000 creating much attention and concern around cross-border disease transmission. With leadership support from the County of San Diego, Board of Supervisors Chairman and in partnership with the Binational Sector lead, a testing site was implemented at the Port of Entry to allow border crossers quick, free and easy access to testing.

Plans are currently underway to implement a testing location close to the San Ysidro Port of Entry to facilitate COVID-19 testing for H2 Agricultural visa holders who cross the border into San Diego, prior to traveling to their destination which includes sites in California as well as other states across the country. This innovative practice is being planned and coordinated in partnership with the State of California and the County of San Diego. Other opportunities in discussion include adopting a formal process for binational contact tracing and case notification, vaccine dispensing sites at the ports of entry and a continual effort to streamline and create consistent messaging for the shared binational population.

Recognizing the interconnectivity of the region, the reality that San Diego County and Tijuana share a population and many essential workers cross the border every single day, and the fact that disease spread is multi-directional, the need for a Binational Sector to coordinate cross-border communication and collaboration was essential. By creating an effective infrastructure and deepening cross-border relationships, it will be possible to reestablish this sector in the event of any future public health emergency or natural disaster and it will be feasible to carry out the same successful and impactful operations.