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or Canada<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a>&#59; nearly 30&#44;000 medical residents were registered to be trained in that country<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> and more than 50&#37; of the positions of residents in internal medicine were occupied by an international resident&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given that around half of the growth of the entire U&#46;S&#46; economy can be explained by the motor represented by the constant innovation in science and engineering&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> the sustained increase in the scientific and technological knowledge of the U&#46;S&#46;&#44; for more than half a century&#44; has counted on the valuable participation of millions of immigrants&#46; The recent toughening of the U&#46;S&#46; immigration policy<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> has the potential of provoking a disruption in this global trend&#44; that has permitted that 5&#37; of all of the current students in the U&#46;S&#46; are foreigners&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There is&#44; for example&#44; the latent proposal concerning the possibility of a massive deportation of undocumented immigrants contemplated in the program Deferred Action for Childhood Arrivals &#40;DACA&#41;&#46; Under this initiative&#44; it is estimated that 5400 physicians would no longer be eligible for introduction into the U&#46;S&#46; health care system over the next few decades&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The current immigration policy has also risked the health of certain seriously ill patients&#44; since the temporary prohibition of accepting refugees could mean denying hospital admission for 800 persons who urgently need medical care and treatment&#46; It has been calculated that&#44; prior to the prohibitions&#44; an average of around 200 refugees with different medical conditions&#44; were being resettled in the U&#46;S&#46; every month&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The fear of being deported can likewise provoke an increase in the costs of health care services by means of extra out-of-pocket expenses&#46; Since there is no universal health coverage in the U&#46;S&#46;&#44; payments of this type can&#44; on occasion&#44; represent a catastrophic volume of expenses associated with the impoverishment of both families and individuals&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The lack of alternatives for vulnerable groups also signifies that a growing number of immigrant patients are turning to the services offered by certain chains of pharmacies and retailers in the U&#46;S&#46; that run medical clinics attended to by nursing professionals and certified medical assistants&#44; referred to as retail clinics&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is expected that establishments of this type will undergo an annual growth of 14&#37; in 2017&#44; numbering more than 2800 clinics&#44; and will represent more than the levels registered in 2014&#44; when there were approximately 1914 retail clinics&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Concomitantly&#44; the U&#46;S&#46; government has announced stricter requirements for applying for a visa&#44; as well as additional security controls in airports&#44; international flights and customs&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the hypothetical case of massive deportation of undocumented immigrants&#44; it should be considered that the population returned to Mexico may need some supplementary type of medical care over the short term&#46; An excess in the demand could saturate the capacity to respond of the Mexican health care system&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Likewise&#44; the incidence of different common mental disorders&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> as well as infectious diseases found in certain immigrant groups&#44; could require the implementation of additional health services to reduce the burden of diseases of this type along the border and prevent a possible health crisis&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">All these changes and threats&#44; in combination with deportations and restrictions for the entry of refugees&#44; are actions that can affect supply and demand of U&#46;S&#46; and Mexican medical care&#44; as is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; For these reasons&#44; a stricter immigration policy could lead to a series of negative effects&#44; that commences with the criminalization of immigrants&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Mexico has the third largest immigrant community in the world&#44; after only China and India&#46; Ninety-five percent of Mexican immigrants are concentrated in the U&#46;S&#46;&#59; of the more than 32 million Mexicans residing there&#44; more than 1 million have technical and higher education&#44; including college and postgraduate levels&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">After India&#44; Philippines and China&#44; Mexico is ranked fourth as the origin of highly skilled immigrants living in the U&#46;S&#46;&#44; and is the first from the entire American continent as a whole&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">It is considered that the Mexican economy would have saved the U&#46;S&#46; 81&#44;000 million dollars&#44; over a period of 14 years&#44; corresponding to the costs of the education of immigrants &#40;skilled and unskilled&#41;&#46; This amount represents an average of nearly &#36;6 billion a year&#44; equivalent to nearly half a percentage point of the U&#46;S&#46; gross domestic product&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Even omitting this important fact&#44; if we add all the direct and indirect taxes paid by Mexican immigrants during that period of time&#44; it is calculated that the U&#46;S&#46; economy received around 2&#46;5 times what Mexico obtained in terms of transfer of funds&#46; Thus&#44; the net economic balance of this type of immigration is favorable for the U&#46;S&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In the case of Mexico&#44; the recent shifts in immigration policy are even more aggravating because of &#40;1&#41; the insistence of the U&#46;S&#46; in constructing a border wall&#44; &#40;2&#41; the possible cancelation &#40;or renegotiation&#41; of the North American Free Trade Agreement&#44; &#40;3&#41; the presence of 7 million undocumented immigrants in the U&#46;S&#46; and &#40;4&#41; the threat to impose tariffs to protect the heavy industry and manufacturers of the so-called &#8220;Rust Belt&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> The results of this whole adverse setting has provoked the depreciation of the Mexican peso against the dollar&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">There is an inverse relationship between the type of change and the funding of science in Mexico since&#44; 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of U&#46;S&#46; medical schools and of centers for training specialists&#44; many of which depend on funds of this type&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition&#44; the effects on public spending&#44; together with the generated uncertainty&#44; could provoke an increase in uncovered health care&#44; as well as a reduction in the number of insured patients in hospitals&#46; An example of this would be the recent legislative failure to replace the Patient Protection and Affordable Care Act by the so-called American Health Care Act&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the case of Mexico&#44; the announced budget cuts cast doubts on a large part of the funds for scientific collaboration with Mexico&#46; The National Science Foundation&#44; to mention a case&#44; is currently backing approximately 200 projects with Mexican collaborators&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> which could be affected by the announced adjustments&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Another impact for Mexico would be provided by the proposal to eliminated Fogarty International Center&#44; an institution that invests 69 million dollars every year to encourage joint work on the part of health research centers in different countries with the NIH&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Although the scenarios for Mexico are in general pessimist and are influenced by uncertainty&#44; the depreciation in the exchange rate could have an unforeseen collateral effect&#58; an increase in medical tourism&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In agreement with the CDC&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> Mexico is now the second destiny in the world for this activity&#44; with an expanding market for plastic surgery&#44; odontology&#44; cardiology&#44; orthopedic surgery&#44; bariatric surgery&#44; fertility&#44; transplantation and eye surgery&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The offer of health care services is attractive because of considerable comparative advantages&#44; such as the enormous differences in the cost of certain procedures and the emphasis on rehabilitation after surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> a common border&#44; skilled specialists&#44; a wide range of available procedures&#44; avant-gardism in infrastructures&#44; as well as high-quality services with international accreditation&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The Mexican Secretariat of Economy estimates that medical tourism reached 3300 million dollars in 2015 and that it increased by 7&#37; in 2016&#46; On average&#44; the savings in dollars for an individual from the U&#46;S&#46; ranges between 40&#37; and 65&#37; for a variety of specialties and procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In the case of rheumatic and musculoskeletal diseases&#44; the growing cost of medications prescribed in the U&#46;S&#46; has become an additional cause for concern&#46; Given that biological agents are now part of the arsenal of therapies for several rheumatic conditions&#44; such as rheumatoid arthritis&#44; lupus erythematosus&#44; spondyloarthritis and certain systemic vasculitides&#44; the cost of treatment has increased&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25&#44;26</span></a> This situation could lead to the search for new options in countries like Mexico&#44; in order that patients with chronic conditions not incur in catastrophic expenses&#46; In short&#44; it is highly probable that the impact of immigration restrictions and the proposed budget cuts be differentiated&#46; In their case&#44; Mexican rheumatologists devoted to research should expect&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">changes in the international funding of clinical&#44; biomedical and technological research projects&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">a lesser capacity to carry out projects because of the depreciation of the Mexican peso&#59; and</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0170" class="elsevierStylePara elsevierViewall">a decrease in the opportunities to do postgraduate studies and send students as fellows to other countries&#46;</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">All of these situations could make it even more difficult to train young scientists since&#44; rheumatology is an integrating activity within the basic research setting&#44; as well as multidisciplinary in the clinical field&#44; with a constant interaction with other health professionals&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">However&#44; the depreciation of the Mexican peso and uncertainty resulting from the reform of the U&#46;S&#46; health system could open a window of opportunity toward the future for the clinical exercise of the profession&#44; stimulated by a growing demand provided by a search for high-quality specialized care&#44; through medical tourism&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The scenarios mentioned here are not definitive&#44; but they offer an analytical basis for impending discussion on the probable impacts that the shifts may have on the present and future of rheumatology in Mexico&#44; as well as on the type of strategies and public policies to be implemented to prevent that these effects become more severe&#44; given that the immigration policy underway is contrary to the deontological and behavioral concepts and to the professional performance of rheumatologists&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p></span>"
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Feasible type of impact&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8595;</span>Costs of fellows<br><span class="elsevierStyleBold">&#8595;</span>Costs to access databases&#44; catalogs and journals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8593;</span>Public spending for emergency care for immigrants and deported individuals&nbsp;\t\t\t\t\t\t\n
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Editorial
Probable Impacts of United States Immigration Reform: Some Scenarios for Mexican Rheumatology
Impactos probables de la reforma migratoria estadounidense: algunos escenarios para la reumatología mexicana
Carlos Pinedaa,
Corresponding author
carpineda@yahoo.com

Corresponding author.
, Hugo Sandovalb
a Dirección de Investigación, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
b Unidad de Vigilancia Epidemiológica Hospitalaria-Investigación Sociomédica, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">For more than 50 years&#44; hospitals and specialized medical centers&#44; organizations for basic and clinical research&#44; the drug industry&#44; high-tech health-related firms and institutions for higher education that&#44; together&#44; constitute the biomedical research sector of the United States &#40;U&#46;S&#46;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> have benefited from the immigration of skilled students&#44; scientists and academics from the entire world&#46; Making use of this source of immigrant talent is unquestionable&#46; In 2016 alone&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> of a total of 897&#44;783 registered practicing physicians in the U&#46;S&#46;&#44; 206&#44;030 &#40;22&#46;95&#37;&#41; graduated from a medical school from outside the territory of the U&#46;S&#46; or Canada<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a>&#59; nearly 30&#44;000 medical residents were registered to be trained in that country<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> and more than 50&#37; of the positions of residents in internal medicine were occupied by an international resident&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given that around half of the growth of the entire U&#46;S&#46; economy can be explained by the motor represented by the constant innovation in science and engineering&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> the sustained increase in the scientific and technological knowledge of the U&#46;S&#46;&#44; for more than half a century&#44; has counted on the valuable participation of millions of immigrants&#46; The recent toughening of the U&#46;S&#46; immigration policy<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> has the potential of provoking a disruption in this global trend&#44; that has permitted that 5&#37; of all of the current students in the U&#46;S&#46; are foreigners&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There is&#44; for example&#44; the latent proposal concerning the possibility of a massive deportation of undocumented immigrants contemplated in the program Deferred Action for Childhood Arrivals &#40;DACA&#41;&#46; Under this initiative&#44; it is estimated that 5400 physicians would no longer be eligible for introduction into the U&#46;S&#46; health care system over the next few decades&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The current immigration policy has also risked the health of certain seriously ill patients&#44; since the temporary prohibition of accepting refugees could mean denying hospital admission for 800 persons who urgently need medical care and treatment&#46; It has been calculated that&#44; prior to the prohibitions&#44; an average of around 200 refugees with different medical conditions&#44; were being resettled in the U&#46;S&#46; every month&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The fear of being deported can likewise provoke an increase in the costs of health care services by means of extra out-of-pocket expenses&#46; Since there is no universal health coverage in the U&#46;S&#46;&#44; payments of this type can&#44; on occasion&#44; represent a catastrophic volume of expenses associated with the impoverishment of both families and individuals&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The lack of alternatives for vulnerable groups also signifies that a growing number of immigrant patients are turning to the services offered by certain chains of pharmacies and retailers in the U&#46;S&#46; that run medical clinics attended to by nursing professionals and certified medical assistants&#44; referred to as retail clinics&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is expected that establishments of this type will undergo an annual growth of 14&#37; in 2017&#44; numbering more than 2800 clinics&#44; and will represent more than the levels registered in 2014&#44; when there were approximately 1914 retail clinics&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Concomitantly&#44; the U&#46;S&#46; government has announced stricter requirements for applying for a visa&#44; as well as additional security controls in airports&#44; international flights and customs&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the hypothetical case of massive deportation of undocumented immigrants&#44; it should be considered that the population returned to Mexico may need some supplementary type of medical care over the short term&#46; An excess in the demand could saturate the capacity to respond of the Mexican health care system&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Likewise&#44; the incidence of different common mental disorders&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> as well as infectious diseases found in certain immigrant groups&#44; could require the implementation of additional health services to reduce the burden of diseases of this type along the border and prevent a possible health crisis&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">All these changes and threats&#44; in combination with deportations and restrictions for the entry of refugees&#44; are actions that can affect supply and demand of U&#46;S&#46; and Mexican medical care&#44; as is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; For these reasons&#44; a stricter immigration policy could lead to a series of negative effects&#44; that commences with the criminalization of immigrants&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Mexico has the third largest immigrant community in the world&#44; after only China and India&#46; Ninety-five percent of Mexican immigrants are concentrated in the U&#46;S&#46;&#59; of the more than 32 million Mexicans residing there&#44; more than 1 million have technical and higher education&#44; including college and postgraduate levels&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">After India&#44; Philippines and China&#44; Mexico is ranked fourth as the origin of highly skilled immigrants living in the U&#46;S&#46;&#44; and is the first from the entire American continent as a whole&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">It is considered that the Mexican economy would have saved the U&#46;S&#46; 81&#44;000 million dollars&#44; over a period of 14 years&#44; corresponding to the costs of the education of immigrants &#40;skilled and unskilled&#41;&#46; This amount represents an average of nearly &#36;6 billion a year&#44; equivalent to nearly half a percentage point of the U&#46;S&#46; gross domestic product&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Even omitting this important fact&#44; if we add all the direct and indirect taxes paid by Mexican immigrants during that period of time&#44; it is calculated that the U&#46;S&#46; economy received around 2&#46;5 times what Mexico obtained in terms of transfer of funds&#46; Thus&#44; the net economic balance of this type of immigration is favorable for the U&#46;S&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In the case of Mexico&#44; the recent shifts in immigration policy are even more aggravating because of &#40;1&#41; the insistence of the U&#46;S&#46; in constructing a border wall&#44; &#40;2&#41; the possible cancelation &#40;or renegotiation&#41; of the North American Free Trade Agreement&#44; &#40;3&#41; the presence of 7 million undocumented immigrants in the U&#46;S&#46; and &#40;4&#41; the threat to impose tariffs to protect the heavy industry and manufacturers of the so-called &#8220;Rust Belt&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> The results of this whole adverse setting has provoked the depreciation of the Mexican peso against the dollar&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">There is an inverse relationship between the type of change and the funding of science in Mexico since&#44; as the peso continues to depreciate&#44; it also reduces the purchasing power of Mexican scientists&#44; who need to import a large part of their supplies&#44; reagents&#44; materials and equipment from the U&#46;S&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The depreciation also limits or cancels attendance at international meetings&#44; makes it difficult to subscribe to scientific journals&#44; catalogs or specialized repositories&#44; and reduces options for publication in peer-reviewed international journals&#44; many of which require the payment of a fee in dollars&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Making the immigration policy tougher can likewise change the destination and numbers of Mexican fellows&#46; Although&#44; in 2016&#44; the Mexican Council of Science and Technology awarded 1550 grants to postgraduate students and researchers to study in the U&#46;S&#46; &#40;which is still the primary place for human resource training outside of Mexico&#41;&#44; a cooling of the relationships between the two countries can reduce and&#44; at some time&#44; channel the flow of researchers toward options like the European Union&#44; China and Japan&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The economic integration between Mexico and the U&#46;S&#46; is intense and increasingly involves the scientific setting&#46; From 1940 to now&#44; for example&#44; Mexican researchers have published a total of 104&#44;057 articles in collaboration with international colleagues&#59; of these&#44; nearly a third &#40;equivalent to 36&#44;057 articles&#41; have been published with U&#46;S&#46; scientists as coauthors&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The new immigration rules can have a larger or smaller impact on U&#46;S&#46; government budgetary allocations&#46; For the time being&#44; multiple cuts in public spending have been proposed for the purpose of freeing resources to finance the wall along the Mexico-U&#46;S&#46; border and to increment militarism&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the initial proposal&#44; which will be spelled out in May&#44; the U&#46;S&#46; government asks to reduce the budget of the National Institutes of Health &#40;NIH&#41; by &#36;5&#46;8 million<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> and cut that of the Prevention and Public Health Fund of the Centers for Disease Control and Prevention &#40;CDC&#41; by nearly 1000 million dollars&#44; in addition to eliminating 403 millions of dollars destined to health professions and programs for nurse training&#44; among others&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">These adjustments would have a direct impact on the biomedical research sector&#44; given that funding from the NIH is distributed among more than 2600 institutions around the U&#46;S&#46; and is responsible for the creation of more than 313&#44;000 full- and partial-time jobs&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">19&#44;20</span></a> The cuts could undermine the economic stability of the universities&#44; of U&#46;S&#46; medical schools and of centers for training specialists&#44; many of which depend on funds of this type&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition&#44; the effects on public spending&#44; together with the generated uncertainty&#44; could provoke an increase in uncovered health care&#44; as well as a reduction in the number of insured patients in hospitals&#46; An example of this would be the recent legislative failure to replace the Patient Protection and Affordable Care Act by the so-called American Health Care Act&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the case of Mexico&#44; the announced budget cuts cast doubts on a large part of the funds for scientific collaboration with Mexico&#46; The National Science Foundation&#44; to mention a case&#44; is currently backing approximately 200 projects with Mexican collaborators&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> which could be affected by the announced adjustments&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Another impact for Mexico would be provided by the proposal to eliminated Fogarty International Center&#44; an institution that invests 69 million dollars every year to encourage joint work on the part of health research centers in different countries with the NIH&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Although the scenarios for Mexico are in general pessimist and are influenced by uncertainty&#44; the depreciation in the exchange rate could have an unforeseen collateral effect&#58; an increase in medical tourism&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In agreement with the CDC&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> Mexico is now the second destiny in the world for this activity&#44; with an expanding market for plastic surgery&#44; odontology&#44; cardiology&#44; orthopedic surgery&#44; bariatric surgery&#44; fertility&#44; transplantation and eye surgery&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The offer of health care services is attractive because of considerable comparative advantages&#44; such as the enormous differences in the cost of certain procedures and the emphasis on rehabilitation after surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> a common border&#44; skilled specialists&#44; a wide range of available procedures&#44; avant-gardism in infrastructures&#44; as well as high-quality services with international accreditation&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The Mexican Secretariat of Economy estimates that medical tourism reached 3300 million dollars in 2015 and that it increased by 7&#37; in 2016&#46; On average&#44; the savings in dollars for an individual from the U&#46;S&#46; ranges between 40&#37; and 65&#37; for a variety of specialties and procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In the case of rheumatic and musculoskeletal diseases&#44; the growing cost of medications prescribed in the U&#46;S&#46; has become an additional cause for concern&#46; Given that biological agents are now part of the arsenal of therapies for several rheumatic conditions&#44; such as rheumatoid arthritis&#44; lupus erythematosus&#44; spondyloarthritis and certain systemic vasculitides&#44; the cost of treatment has increased&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25&#44;26</span></a> This situation could lead to the search for new options in countries like Mexico&#44; in order that patients with chronic conditions not incur in catastrophic expenses&#46; In short&#44; it is highly probable that the impact of immigration restrictions and the proposed budget cuts be differentiated&#46; In their case&#44; Mexican rheumatologists devoted to research should expect&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">changes in the international funding of clinical&#44; biomedical and technological research projects&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">a lesser capacity to carry out projects because of the depreciation of the Mexican peso&#59; and</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0170" class="elsevierStylePara elsevierViewall">a decrease in the opportunities to do postgraduate studies and send students as fellows to other countries&#46;</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">All of these situations could make it even more difficult to train young scientists since&#44; rheumatology is an integrating activity within the basic research setting&#44; as well as multidisciplinary in the clinical field&#44; with a constant interaction with other health professionals&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">However&#44; the depreciation of the Mexican peso and uncertainty resulting from the reform of the U&#46;S&#46; health system could open a window of opportunity toward the future for the clinical exercise of the profession&#44; stimulated by a growing demand provided by a search for high-quality specialized care&#44; through medical tourism&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The scenarios mentioned here are not definitive&#44; but they offer an analytical basis for impending discussion on the probable impacts that the shifts may have on the present and future of rheumatology in Mexico&#44; as well as on the type of strategies and public policies to be implemented to prevent that these effects become more severe&#44; given that the immigration policy underway is contrary to the deontological and behavioral concepts and to the professional performance of rheumatologists&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Demand&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8595;</span>Budget allocation for NIH<br><span class="elsevierStyleBold">&#8595;</span>Scientific innovation<br><span class="elsevierStyleBold">&#8595;</span>Frontiers of knowledge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8593;</span>Out-of-pocket expense<br><span class="elsevierStyleBold">&#8593;</span>Catastrophic expenses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8595;</span>Costs of fellows<br><span class="elsevierStyleBold">&#8595;</span>Costs to access databases&#44; catalogs and journals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8593;</span>Public spending for emergency care for immigrants and deported individuals&nbsp;\t\t\t\t\t\t\n
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ISSN: 21735743
Original language: English
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Idiomas
Reumatología Clínica (English Edition)
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