That looks like a cesspool,” says Leticia Páez, the director of an El Paso non-profit public health care organization, as she eases her car around a corner in the east El Paso County colonia known as Las Pompas. Sure enough, behind a mobile home is an expanse of standing water that seems to be leaking from a septic tank. As we drive by it, we see something else: a beautiful array of flowers on the porch of the trailer next door.

The colonias are like that. The pride of ownership is apparent and, if you can ignore the dust and the flies and the stray animals, there is something oddly romantic about these ramshackle settlements. For better or worse, this is how the nation was settled—by poor, humble people daring to build whatever they could afford on small slips of desolate land bought on credit.

The Mexican Americans who inhabit these odd little rural settlements along the border—which now number 1,500 and are home to 400,000 citizens (most of them, contrary to popular belief, legal)—are poor and uneducated and work in agricultural industries or in low-wage service- industry jobs. They wind up here because they want to own their own homes but can’t afford anything more than a plot of raw land in unzoned regions of border counties. Here, they can put a few dollars down and then pay on average $225 a month to a developer for the privilege of either building their homes with discarded or stolen construction materials or buying a used trailer. Their deal with the developer may or may not include water and sewage hookups.

What they also get for their money is one of the worst breeding grounds for disease in America. Around every corner, it seems, new health hazards pop up like cardboard monsters in a fun house. Many of the makeshift homes can be brutally cold in the winter. Unburied septic tanks sit worrisomely close to the large drums of purchased drinking water in yards landscaped only with varying shades and consistencies of dust, which may be laced with pesticides from nearby farms. A faint scent of pollution is in the air; some of it probably comes from the maquiladoras across the border in Juárez, but much of it is locally generated by people who burn their trash, which sometimes includes dead animals.

What you don’t see is as worrisome as what you do. The air and water here are thick with microbes. Tuberculosis, hepatitis A, and Helicobacter pylori (the bug responsible for many stomach ulcers) all travel freely across the border and are more prevalent here than in other parts of the state. Add to that the near plague of diabetes and hypertension among Hispanic adults and the substance abuse and depression that come with living in such oppressive poverty, and it’s no wonder that some of these colonias are among the sickest places in Texas—maybe even in the nation.

The conventional wisdom is that the colonias are sick because they lack safe drinking water and adequate sewage facilities. Twenty years ago that was probably true. But in the past few years, amazing progress has been made in solving those problems, the direct result of some $600 million in federal and state expenditures. And while some health problems still come from poor water and sewage, the Texas Department of Health now says that only an estimated 10 to 15 percent of colonia households are not hooked up to potable drinking water, and most of them are able to buy suitable water. And almost all residents are either connected to a public sewer system or have septic tanks (though the Department of Health would not swear by the viability of many of those tanks or their drain fields).

The real problem in the colonias these days is something you might not notice when you first drive through: the staggering lack of health care facilities. Many more colonia settlers have greater access to water and sewage facilities than they do to health insurance or hospitals; the sickest places in Texas are that way, in part, because they don’t have enough doctors and nurses. According to the Department of Health, 64 percent of colonia households have no private health coverage; another 20 percent have only partial coverage. And while about 30 percent of colonia residents get Medicaid, that still leaves a lot of people without any health coverage.

Since health care, perversely, tends to follow money rather than sickness, it should come as no surprise that all but 2 of 43 border counties have been judged “medically underserved” or that a study by the comptrollers office found that 22 community clinics along the border had to handle a staggering 700,000 medical and dental visits by 200,000 patients during a recent year. Public hospitals with emergency rooms or specialty services are often miles away; emergency medical service is a pipe dream. Páez, who is the director of Kellogg Community Partnership, an organization that runs four clinics that provide health care to several colonias, could name only seven clinics that serve the 72,000 people who live in El Paso County’s 214 colonias. “Schools can be tied in to economic development,” she explained. “That’s why you’ll see big, shiny schools around some of the colonias. But health care is just not part of that equation because it basically serves people with little economic influence: the elderly and the poor.” That’s true—no city ever sold a corporate relocation based on the health services provided to its poor neighborhoods.

But the colonias’ health care deficit also has to do with a certain assumption that has always been made about health and the poor: That, all things considered, the residents would just as soon live in squalor and ill health, and that even if you made facilities and information available, they wouldn’t avail themselves of them. This has always been especially presumed of the residents of colonias, given their insistence on an independent and somewhat isolated rural lifestyle. “I think there is an unfair presumption in that direction,” says Dr. Janet Gildea, a nun who runs the Clinica Guadalupana, which serves half a dozen colonias near the small town of Horizon City, in east El Paso County. “But until we opened six years ago, no one was coming to these people and saying, ‘We want you healthy.’ I’ve found that if you take the time, the patients will do what they need to do. The much bigger problem is whether they can pay for it.” Medicaid or the State Children’s Health Insurance Program (SCHIP) covers some of the children who come to the clinic. But most of the adults are classified as “self pay,” meaning they are uninsured and can pay only a nominal fee of $10 or so. The cruel irony is that many of them don’t qualify for public coverage (adult Medicaid) because they have jobs and some income—but not enough, of course, to afford private insurance.

But that fact doesn’t seem to be keeping them away from the doctor’s office. On a recent Wednesday morning, Gildea’s waiting room at the clinic—a rambling, freshly painted frame house—was swamped with remarkably cheerful people who seemed glad to have any clinic. Mothers were there to have their kids treated for skin, eye, and stomach infections that are common in the colonias, or to have their own diabetes or hypertension monitored. Patients were being counseled on critical public health issues such as antibiotic abuse, the tendency of Mexican immigrants to head back across the border for a cheap shot of the drugs whenever they feel ill—a habit that many doctors believe has contributed to the development of drug-resistant strains of infections such as tuberculosis.

Gloria Morales, who does clerical work for Gildea, is a dramatic example of what a difference the presence of health care facilities can make. Five years ago, before she began working for the clinic, Morales would cross the border to “get a shot of antibiotics anytime I felt sick with anything. Only it wouldn’t always work. So I finally came here, and Dr. Gildea found out I have diabetes. Now I try to find and educate people who are like I was.” Much as a police patrol car can help bring order and civility to a community by its mere presence, a clinic and a doctor can raise the level of public health just by being there. But it takes a certain critical mass to begin to make real progress. Gildea says that her clinic can handle checkups and screenings and education, but if she has to make a special referral, she often has trouble placing an uninsured patient. As the only clinic in an area with a potential patient base of 10,000, she worries that “at any time, something like cholera could break out, and then what would we do?”

How best to get a Clinica Guadalupana on every corner? One school of thought insists that it’s better to relocate these settlers closer to health services. “We are better served if we use the money we spend on water to give them housing vouchers to pay for regulated housing in the city,” says state senator Eliot Shapleigh, an El Paso Democrat whose territory includes a number of colonias. “The colonias are a symptom, not the problem. The problem is poverty.”

Fair enough. But if some of the colonias continue to be the sickest places in Texas, many of them have matured into reasonably safe and healthy places, and you’d hate to discourage these scrappy settlers just when they’ve begun to stand on their own. Besides, most of these settlements, feeble as they are, haven’t displayed the slightest willingness to die. So how does one get more health care to come to them, without just throwing more money at completely subsidized clinics or treatment? Something that could help immediately to encourage residents to take better care of themselves is some form of low-cost, partly subsidized health coverage. I’m thinking along the lines of one big HMO for the colonias. Residents would receive a voucher from the State of Texas, add to it what they could, and purchase their own health insurance—somewhat like the SCHIP for children. This plan has several virtues. First, and most obviously, it would improve treatment options. But it would also attract more medical services closer to the colonias because it would represent the money that such services always follow. Most important, it would play to the colonia residents’ greatest strength: their insistence on self-determination. Many of the patients at the Clinica Guadalupana may be able to afford only $10 a visit, but most of them pay it proudly, and I have no doubt they would pay a modest insurance premium as well.

Finally, this isn’t just a matter of improving the health care of a uniquely vulnerable population. It’s also a matter of regulating what could become a public health threat to any or all of us, which is why we should use state tax dollars to subsidize the insurance. Even though the colonias seem isolated, their health can affect yours. Microbes are built for long-distance travel, and all it takes is one carrier to pass along drug-resistant TB. As Páez says, “In public health, if you don’t pay now, you always pay later.”