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TB control is just the start, officials say
Late last month, when American and Mexican top-level officials signed their names to a document that will commit USAID to providing a $10 million funding package earmarked for cross-border TB control, Bill Archer, MD, the Texas Commissioner of Health, wasn’t there.
That’s surprising, considering it was Archer’s arm-twisting that convinced USAID to cough up 10 times the amount the agency originally had budgeted for TB control on the border. Instead, Archer, son of the powerful chairman of the House Appropriations Committee who shares his name, was doing what his staff say he likes doing best: hanging out at a three-day state health department conference in San Antonio, talking to people.
"Oh, man, does he love talking to people. In fact, he talks too much," says R.J. Dutton, PhD, director of the Texas Health Department’s Office of Border Health and one of Archer’s most fiercely loyal employees. "What he likes is to get out there and engage people one-on-one," Dutton adds. "It’s one of his biggest strengths."
Archer, who is fluent in Spanish and served as a medical missionary in South America before he was appointed to his current post, has been talking to Mexican health officials for the last three years, trying to win the trust he says had to be there before anything else could happen.
"It’s easy to think you can build a bridge across a cultural divide, but it’s not a simple thing," Archer says. "Because of that kind of trust and commitment, Congress finally was willing to justify the kind of investment USAID is about to make in Mexico to improve TB control there."
In true Texas spirit, Archer sees no reason to stop with just a big package for cross-border TB control. Across the same cultural bridge, he envisions a whole gang of fellow travelers, including cross-border programs for rabies, neural-tube defects, diabetes, dengue fever, and environmental issues, along with beefed-up programs for surveillance and epidemiology and more binational sharing of data.
In this, Archer has the support of another son of a well-connected guy, Texas Gov. George W. Bush, says Archer’s chief of staff, Jacquie Shillis. "Gov. Bush very much wants projects for TB and diabetes on the border," she says. "As he sees it, we’re connected to Mexico historically and economically; the part of our population that’s Mexican-American is large and growing. So it’s imperative that the two countries have a good relationship."
The only hitch is how to make sure the money stays where Archer is determined it will: on the border, and not go into TB control in other parts of Mexico such as the Baja peninsula, for example, or along Mexico’s southern border with Guatemala.
Strictly from a programmatic point of view, confining the money to the U.S./Mexican border makes the most sense, Archer contends. "For one thing, $10 million isn’t enough to make a difference in an entire country," he says. Plus, he adds, the border is unique — a Tex-Mex hybrid that’s neither one nor the other and has special problems that deserve customized solutions.
From a political perspective, things aren’t that simple. "If Congress perceives that [US]AID is unable to accomplish this significant investment on the border, they’ll be frustrated," Archer says. "If Mexico perceives that all the money is going to the border, which is their richest region, well, then they’ll have political problems."
It’s a difference that still has to be worked out, but Archer thinks it can be. "Both sides are committed to working out the differences," he says. "I’ve got some ideas."
Archer’s ideas about TB control have their origin in what he experienced as a volunteer for Project Hope, a nongovernmental organization that recruits physicians willing to volun -teer their time helping train health providers and build sound health policies in developing countries.
During a stint in Kazakstan, where he was working as an obstetrician/gynecologist, Archer says he was struck by the enormity of the country’s TB burden and the scarcity of resources available for fighting the disease. At one point, moved by TB patients’ plights, Archer took over the care of 50 or so of the nation’s most intransigent cases. For some patients, four drugs and direct observation did the trick; but for about a dozen patients, it would take expensive second- and third-line drugs, which Archer purchased with money he wrangled from USAID. Altogether, he achieved a 90% cure rate, "battling physicians there all the way," he says. The headiness of his accomplishment is still audible in his voice when he talks about the experience.
Next came a stint for Project Hope in South America. At about the same time, Archer also began serving as a representative for Project Hope at Ten Against TB (TATB), a binational coalition founded three years ago to address cross-border issues in 10 counties and Mexican departments that line the southern U.S. border.
Though chronically underfunded and top-heavy with officialdom and bureaucrats from both countries, TATB nevertheless created a place where Archer and others could begin to reach across the cultural divide. "TATB absolutely laid the foundation for everything that’s happened since," says Shillis.
The upshot of all this was a man with a self-confessed "passion for TB." As soon as he was appointed health commissioner in 1996, Archer formed an internal working group at the health department and told the group to get to work on Washington policy-makers. At the same time they were convincing Congress that the border deserved more attention, they were charged with finding some governmental or nongovernmental agency that would provide the necessary funding, Shillis says.
Hearkening back to Kazakstan, Archer’s inner radar steered him toward USAID. But there, a former head of the development agency strongly disliked the notion of spending taxpayer dollars on TB projects on the border. By the time the House Appropriations Committee was finished, the situation looked bleak. Language approved for appropriations allotted a measly $1 million for a TB project, plus a report on the work.
"When I read that, I figured we’d lost," says Dutton. Undeterred, Archer went to work. The state’s newspapers continued to trumpet news of a $10 million aid package whose arrival suddenly looked unlikely. Archer caught a plane to Washington; once on the ground in the nation’s capitol, he started talking.
"My dad has never talked to [US]AID — he’s not that heavy-handed," Archer says. "But there’s no question he’s helped open doors for me. He’d say, Sure, you can go talk to Sonny Callahan, the Alabama Republican who chairs the Appropriation Committee’s Foreign Operations Subcommittee. But he’d never go to Callahan himself and tell him what to do."
Then, one day, as R.J. Dutton recalls, a staffer in the health commissioner’s office picked up a phone and found himself talking to Paul White, head of USAID in Mexico. The tide had turned.
By the time Archer was schmoozing the audience at the three-day health conference, White had come up to south Texas, talked to docs and administrators there who knew the border and its issues, formed a binational task force with the Mexican government, toured Mexico, and cobbled together a memorandum of understanding between high-level officials in both countries. Dutton says he remembers with crystal clarity the day he was sitting in a meeting with White and others, listening to speakers drone on, when, almost as an afterthought, White asked Archer how he would like the $10 million delivered.
My God, R.J. Dutton remembers thinking, they’re cutting the deal right here in front of me.
To Archer, though, the defining moment arrived on another day. Archer, White, and Annette Riggio, a former head of TATB, were in Mexico City with a copy of the language that was to go into the appropriations bill. They needed to know for certain whether Mexico could pledge its willingness to accept the aid package and work with the United States to fight TB but on what had to be, at bottom, essentially American terms?
The answer was yes. So far, says Archer, the bridge of trust between the countries is still holding.