Venomous snakes bite up to 5.4 million people each year, resulting in 2.7 million cases of envenomation and up to 138,000 deaths, according to 2018 data. The grim statistics led the World Health Organization to class snake bites as a neglected tropical disease.

At the same time WHO decided to focus efforts on both prevention and increasing access to effective treatments, there are critical shortages in the global supplies of anti-venom.

Several companies, including a U.S. manufacturer of coral snake anti-venom, stopped making the medications because it was no longer cost effective, explains Leslie Boyer M.D., founding director of the Venom Immunochemistry, Pharmacology and Emergency Response (VIPER) Institute at the University of Arizona. The U.S. Food and Drug Administration, concerned about lack of access to the lifesaving medications, put out a call for help.

The UArizona received a $1.6 million FDA grant to work with a Mexico-based drug manufacturer to research new coral snake anti-venom. It was not the first time the VIPER Institute, in conjunction with researchers in Mexico and around the world, came together to develop innovative biologics. A collaborative that included researchers from the Institute of Biotechnology at the National Autonomous University of Mexico (UNAM) developed scorpion anti-venom, also in response to a critical shortage.

“Even though the U.S. pharmaceutical industry took off, we abandoned biologics, and, when that happened, Mexican biotech surpassed us,” Boyer says. “[With the anti-venom work] we did something together that neither of us could have done on our own: We took Mexican biotechnology and proved that it worked.”

The team imported anti-venom from Mexico and launched clinical trials in Arizona. Their 12-year collaboration led to an FDA approved anti-venom to treat scorpion envenomation and their research was published in the New England Journal of Medicine. Trials for the coral snake anti-venom are complete and the product is now an investigational new drug, according to FDA standards. A private entity holds the Investigational New Drug Application and will make the decision about pursuing further FDA approvals needed to commercialize the anti-venom.

Focus on the Future

After completing her doctoral degree at UNAM, Dayanira Paniagua received a Fulbright scholarship and joined the UArizona-based research team to assist with the clinical trials for coral snake anti-venom. Paniagua notes that the research has been translated into the market in Mexico and has spearheaded additional research projects to address an ever-increasing need for novel anti-venom.

“The importation of exotic snakes [into the U.S.] is a big problem…Before the internet boom, envenomation was from local snakes but now people are arriving at the hospital with envenomation from snakes from Australia or Africa … and there is no anti-venom available [to treat] snake bites from around the world,” she explains. “We need to work with the FDA to find ways of managing this new issue.”

The research has the potential to have a ripple effect across the globe.

Researchers at VIPER Institute and around the world are also engaged in exploring new treatments. The process used to make anti-venom is ancient: Small amounts of snake venom are injected into horses or ruminant animals like sheep that build up antibodies and their blood serum, when collected and processed, works like a drug. Anti-venom is species-specific, which means multiple products must be kept on hand to treat all manner of domestic and exotic snake bites.

“There are many international forces trying to combine different anti-venoms to make an anti-venom for a wide spectrum but, until that happens, the [formulations] are quite specific,” Paniagua says.

Paniagua attended a symposium in Kenya with Anne Wertheimer, Ph.D., the director of the VIPER Institute, to learn about efforts to renew the technology with new recombinant technology that could be both superior and more cost competitive than current therapies. Her next project, funded through a fellowship from the Mexican Council of Science and Technology, will focus on applying complex system science to envenomation, using databases of information about toxins to better understand its biochemical processes.

These kinds of cross-border collaborations, Boyer says, are going to facilitate discoveries that will lead to the next generation of anti-venom.

“We have come a long way and the next step is focusing on ways to improve our understanding of how the biotechnology works and using the science for the unique anti-venoms of the future,” she explains. “We must also take what we have learned from the science and applying it to policy so the mechanisms [to treat envenomation] are not so expensive and time consuming to put into effect.”

Many immigrants and temporary citizens live in the state of Arizona and, currently, 15 percent of the state’s population is without access to proper healthcare. While basic healthcare services are available to all state residents, in critical cases there are additional resources available—many provided in conjunction with academic institutions or official government services.

Together for Health

Groups like No More Deaths aim to support migrants and prevent fatalities in the Sonoran Desert by providing basics like food and water while, in Tucson and Phoenix, the University of Arizona has deployed a mobile health clinic to bring medical care to Mexican nationals living in underserved communities in Maricopa County. For two years, the UArizona van, dubbed "Juntos por la Salud," or "Together for Health," traveled to high-volume areas like churches, serving roughly 50 patients a day, depending on the weather.

The $199,000 van was built and initially operated through a $304,200 grant from the Binational Border Health Commission in collaboration with UArizona’s Mel & Enid Zuckerman College of Public Health. Its services including screenings, flu vaccines and preventative health-care tips, and primarily serves to aid residents of low-income communities who may otherwise be afraid to seek help in a more formal medical setting. Overseeing the program is Cecilia Rosales, the school’s Assistant Dean, who has enlisted students as volunteer medical workers, enabling them to gain professional experience working hands-on with patients.

The mobile care unit is an extension of—and inspired by—the Mexican government's Ventanillas de Salud program, which is in various consulate offices and provides health-care services to Mexicans living in the U.S. in 50 locations across the country. The mobile units, however, reach underserved patients where they live, and without stigma. When patients arrive at the clinic, they sign in, complete a basic pre-screening interview and discuss their medical histories. This information is then entered into an online database that enables the school to keep track of how many patients they treat, and to retrieve the information for future reference. After the prescreening, patients are brought in to the mobile unit for a physical exam, where trained students provide free screenings for hypertension, diabetes and obesity. The clinic also provides flu shots during flu season.

A Much-Needed Lifeline

The “real job” of these mobile units, says Jill Guernsey De Zapien, director of border, transborder and binational public health collaborative research at UArizona, is to “get the individual to come out of the woodwork" and connect to health services available to all uninsured individuals. She explains that UArizona also collaborates closely with federally qualified community health centers throughout Nogales, Douglass, Yuma and elsewhere.

“It’s the mainstay of care in the border region,” she says, “so we try to be supportive of those centers through a variety of both technical assistance and through our Arizona prevention research center, which programs with community health workers and collaborates for grants."

All of this allows health workers to target and help vulnerable populations gain access to healthcare "no matter who they are,” De Zapien says. She also endorses Patch, a local news source, which, like the mobile vans, provides services to individuals who lack health insurance, and LUCHA—Learning, Understanding and Cultivating Health Advocacy—which seeks to ensure that the UArizona College of Public Health is able to provide current and complete information and direct service relating to immigration reform and the U.S. border.

In 2018, UArizona also collaborated with local community health agencies to design, pilot and assess the feasibility of a worker-delivered diabetes education program for families. The program addresses family food choices, physical activity, behavior change, communication and support behaviors, and at its inception had 72 participating families. The 12-week program was facilitated by Promotoras de Salud in two counties along the Arizona-Sonora/Mexico border, with sessions including physical activity, and the creation of walking clubs through an initiative called Pasos Adelante, or “Steps Forward.”

While Arizona, and the U.S. as a whole, is far from providing accessible, affordable healthcare to its entire population, these services to this vulnerable group provide a much-needed lifeline.

Uncertainty and danger are familiar conditions for asylum seekers, and COVID-19 has only exacerbated a dangerous situation for an already vulnerable population, according to experts at the University of Arizona.

On March 20, 2020, nine days after the World Health Organization declared COVID-19 a global pandemic, the Centers for Disease Control and Prevention issued an Order citing the obscure 1944 Public Health Service Act that “suspends the introduction of certain persons from countries where an outbreak of a communicable disease exists.”

Lynn Marcus, Clinical Law Professor and Director of Community Immigration Law Placement Clinic, says there is “no question” that the previous administration used COVID-19 to restrict migration, not to contain the spread of virus.

“It’s a distorted reading of the [CDC order] to imply that you could legally send people back to their deaths when there are others ways of screening for disease,” says Marcus. “There’s nothing in the law that says some CDC law trumps the obligations under domestic and international law toward asylum seekers and torture survivors.”

The CDC Order provides no opportunity for asylum seekers–those who are fleeing their home country and seeking protection from persecution or death–to make their asylum claim, which is a human right protected by the domestic Refugee Act of 1980 and the procedures laid out at the international Refugee Convention in 1952.

Three days after the CDC Order was issued, the U.S. Department of Homeland Security and the Executive Office for Immigration Review released a joint statement­—which has since been reissued—suspending immigration court hearings for all asylum seekers waiting in Mexico.

Those asylum seekers are forced to wait in Mexico while their cases are being adjudicated because of the Trump Administration’s Migrant Protection Protocols (MPP), or “Remain in Mexico” policy. The program, implemented on January 25, 2019, allows for U.S. border officers to return non-Mexican asylum seekers to Mexico to remain there while the U.S. immigration courts review their cases. The suspension of those hearings creates even more danger and uncertainty for asylum seekers.

Daniel Martínez, Associate Professor of Sociology and the co-director of the Binational Migration Research Institute says, “This policy is clearly intended to make the process that much more difficult so people will become discouraged and opt to return to their communities of origin.”

At the same time, “Most asylum seekers are fleeing insecurity, violence, extortion, corruption, and threats of death, rape, and kidnapping. Abandoning their asylum cases and returning home places them at even greater risk,” says Martínez.

Dr. Anna Ochoa O’Leary, Professor and Head of the Mexican American Studies Department, says that the risks and challenges faced by women asylum seekers, including abandonment, injury, separation or losing family members, abuse from authorities, assaults from border bandits, and death are “only aggravated if [they] need to remain in Mexico, where discrimination and mistreatment of Central Americans is well-documented.”

“[Leadership] hasn’t responded in any way that is protective of asylum seekers or the public,” Lynn Marcus says.

Instead, this already vulnerable population is at risk of contracting COVID-19 because they are being held in unhygienic detention centers on both sides of the U.S.-Mexico border.

Shefali Milczarek-Desai, Assistant Clinical Professor and Director of The Workers' Rights Clinic says that a detention center “feels, looks, tastes, and smells like a maximum-security prison.”

Martínez says we do not know the extent to which COVID-19 is affecting those forced to Remain in Mexico, but he says we have a public health crisis in our detention facilities in the U.S. “‘Confirmed positive’ rates, among those who have been tested in detention facilities, are shockingly high relative to the general population. We should really be concerned about the conditions within which immigrants are being detained and the inadequate healthcare they're receiving in those facilities.”

“They’ve allowed the disease to spread and really fought tooth and nail in the courts to keep vulnerable detainees locked up in dangerous conditions,” Marcus says. “They are making everything very dangerous and very difficult, with the aim of people giving up.”

COVID-19 has worsened uncertain and dangerous conditions for asylum seekers at the U.S.-Mexico border, but the Biden administration is looking to slowly start reopening border crossing for asylum-seekers. 

According to the AP, the administration announced plans for tens of thousands of people who are seeking asylum and have been forced to wait in Mexico under a Trump-era policy to be allowed into the U.S. while their cases wind through immigration courts.

The first wave of an estimated 25,000 asylum-seekers with active cases in the “Remain in Mexico” program will be allowed into the United States on Feb. 19, authorities said. They plan to start slowly, with two border crossings each processing up to 300 people a day and a third crossing taking fewer numbers.

Narro gave a virtual seminar for Mexico Initiatives, co-sponsored by the Mel and Enid Zuckerman College of Public Health, Arizona International, and UNAM-Tucson Center for Mexican Studies. The event was simultaneously interpreted from Spanish to English to provide the most access possible to the community.

Mexico has seen enormous advances in its overall quality of public health in the last 50 years. The infant mortality rate decreased by nearly 85 percent. Life expectancy at birth rose 15 years. Most of Mexico’s health infrastructure was developed in these years. In 1980, there 7,938 medical units; in 2018, that number increased to 23,848.

However, Mexico still has a long way to go toward a healthy public infrastructure, according to Narro.

In the last 40 years, the state of Mexico’s urgent health crises shifted dramatically from infections and parasitic diseases to non-communicable diseases. According to the Institute of Global Health Sciences, the top three causes of death in Mexico are non-communicable diseases: coronary heart disease, diabetes, and cancer. Between 1980 and 2019, Mexico experienced a 34 percent increase in mortality from cardiovascular diseases; a 71 percent increase in the rate of malignant tumors; and a 296 percent increase in the death rate from diabetes.

This nationwide shift from overall cases of infectious illness to non-communicable disease has increased the cost of health care tremendously, reallocating the medical need to treat short, sudden, and fast-resolving illness to treating long-term illness, in which prevention and control is the optimal response.

Unfortunately, Mexico’s public health institutions lack preventative health programs for non-communicable diseases. Instead, institutions focus on emergency services and curative care: fixing health issues that have already become a medical problem.

The transition away from Seguro Popular–a public health insurance that covered a wide range of medical services without co-pays–weakened existing preventative programs even further.

Seguro Popular, which was adopted in 2004, ran until Mexican President Andrés Manuel López Obrador’s (AMLO) administration replaced it with the Instituto de Salud para el Bienestar (INSABI) on January 1, 2020.

AMLO has been known to say that Seguro Popular was “ni es seguro, ni es popular” (“neither safe, nor popular”). AMLO’s vision of a new Mexican health system, was founded on universality of coverage. After 15 years of Seguro Popular, 16.2 million Mexicans still lacked coverage under the program.

INSABI was meant to curtail some of the problems plaguing Mexico’s public institutions of health; however, Narro pointed out that there was no clear transition in place to go from Seguro Popular to INSABI. Worse yet, the introduction of INSABI happened just ahead of Mexico’s first case of COVID-19 on February 27, 2020.

The COVID-19 pandemic exacerbated many of the structural problems that plagued Mexican public health institutions, like excessive personnel in some units with understaffing in others, shortage of trained medical personnel, high costs, bureaucratic procedures, and inequality in the provision of services.

According to the Institute for Global Health Sciences, in February 2021, Mexico was number one in deaths of COVID-19 health workers and third in overall number of deaths worldwide.

The proportion of deaths increases with the level of marginalization of the municipality where the patient lives.

The outcomes of COVID-19 are reproductions of the outcomes of the structural inequality that already exists in the fractured Mexican health care system, which is divided into public and private institutions.

Only 7.2% of Mexicans hold private insurance, yet health outcomes are far better for those treated at a private institution. An average of 20% of the patients served at private hospitals die from COVID-19, compared to the public programs, where depending on the public program, averages range from 37% to 50% or higher.

Narro remains hopeful for the future of public health in Mexico. He says that preventative and primary care must be favored over hospitalizations and curative medicine. Mexico must also increase public investment for health and provide truly universal coverage.

As Narro said, “Health is not everything, but without it there is almost nothing.”