Jun32020

An insight into COVID in Mexico

Country profile

Mexico is a country located in the North American continent. It borders in the north with the United States of America and in the south with Guatemala and Belize. It has a federal democratic, representative government and it is divided into 32 federal sovereign states.  It has a population of 126.6 million people with a life expectancy of 78.5 years in females and 72.6 years in males, a GDP per capita of 16,829 USD, a mean fertility rate of 2.4, and mean educational attainment of 8.3 years 1. It is considered to be an upper-middle-income country 2, however, 43.6% of its inhabitants live in poverty and 7.6% of people live in extreme poverty 3. Regarding health care, it is estimated that 15.5% of the population lack access. In Mexico, only 6.2% (2013) of GDP is spent on health 4 and still, 44% of per capita expenditure on health is out-of-pocket 5. It is estimated that 60% of Mexican employment is in the informal sector 4, resulting in a high proportion of uninsured people.

The COVID-19 pandemic response

The COVID-19 response in the country has been led by the head of the Undersecretariat of Prevention and Health Promotion at the Mexican Ministry of Health, Dr. Hugo López-Gatell, and his team. The first confirmed cases in Mexico occurred at the end of February 2020 and all of them were said to have been imported from Italy.  On February 29th, shortly after the first four COVID-19 cases were confirmed in the country, a press conference was held by Dr. López-Gatell, at which point the situation was explained and a plan of action divided into three phases was presented 6:

Phase 1: Small isolated outbreaks; imported cases.

Phase 2: Virus dispersed in a localized area; community dispersion

Phase 3: Virus scattered throughout the country; epidemic

Each phase was paired to specific actions, for example, large events were only to be canceled until phase 2 was declared and only until phase 3, school and work activities were to be suspended in the case of confirmed outbreaks.

However, right after these declarations, the Mexican president Andrés Manuel López Obrador (AMLO) continued touring the country and invoking the masses to “keep hugging” despite the international concern of an uncontrolled spread if no measures of social distancing were implemented 7. This was seen by many groups as irresponsible and confusing and it even affected his very high approval ratings 8.

Approximately one month after the first announcement, on March 24th, López-Gatell declared phase 2, with 405 confirmed COVID-19 cases and 5 confirmed COVID-19 deaths, on March 30th a national emergency was declared and all non-essential economic activities were suspended and, since then, people are being urged to stay at home. However, the proportion of informal employment makes it virtually impossible to implement measures to restrict the economically active population. On April 21st the phase 3 epidemic was declared with 9,501 confirmed cases and 857 deaths and in less than three weeks later, on May 8th, the Ministry of Health reported 31,522 confirmed COVID-19 cases and 3,160 COVID-19 deaths (lethality 10.02%). According to the Health Ministry’s data, out of all confirmed COVID-19 patients, 40.26% have received in-hospital treatment and there are 20,571 unconfirmed suspicious cases 6.  

The Ministry of Health has reported 8,113 intensive care unit (ICU) beds and the hiring of 44,247 persons to help during the pandemic (around 3 thousand specialists, 7 thousand general practitioners, 500 specialized nurses and 18 thousand general nurses) 9

Other measures

One of the first formal agreements of public-private partnership structures in the country was signed between the Ministry of Health and several private medical institutions, stating that from April 23 to May 23, the population entitled to and benefiting from the National Public or Social Health System may be referred for care, if required, to one of the 146 private hospitals in 27 entities of the Republic to receive attention at the second level, with conditions or treatments other than COVID-19, such as childbirth, pregnancy and postpartum, cesarean sections, diseases of the appendix, hernias, complicated gastric and duodenal ulcers, endoscopies, and cholecystectomies 10.

A temporal hospital is currently being adapted for its use as a COVID-19 center with 234 hospital beds and 8 intermediate care beds 11.

Other more controversial measures have included recruitment of medical residents from hospitals that have not been adapted for treatment of COVID-19 patients to work at these centers in exchange for higher scores during their residency exams, more vacation days plus a salary bonus, and recognition as a “COVID Hero”. However, all the aforementioned only apply to certain residents, something which has been perceived as unfair by many 12.

Also, controversial, is that the government has invited about 500 Cuban doctors to work during the pandemic, this deal has been said to lack transparency as well as raised many questions about human rights’ issues since the UN has previously stated that previous deals between other Latin American governments with Cuba to get medical doctors out of the island to work abroad, have been in violation of their rights and could even be labeled as “slave labor” 13.

Current challenges

Violence against health care professionals

There have been numerous reports of attacks on healthcare workers, they range from reports of neighbors “inviting” or “asking” doctors and nurses to move from their homes to reduce the risk of contagion in the building, to health personnel being denied the usage of public transportation, to some more extreme cases where nurses have been thrown chlorine and hot coffee while on their way to or from work. Healthcare personnel has also been attacked inside the hospitals for not letting people inside to see their relatives and medical residents have experienced an increase in working hours and worsened working conditions.  

Another tensional factor corresponds with the fact that López Obrador has made various controversial allegations regarding the medical profession, the latest of which was that, according to the Mexican president, medical doctors “[…] were just looking to get rich, right, that the patient would arrive and the first thing they would do was ask them: What do you have? It hurts here, doctor. No, what do you have in goods?”. Various Mexican medical associations have condemned the president’s words stating that they have continued to work despite the lack of resources and with no intention of getting rich. AMLO apologized saying he didn’t mean to generalize, he only meant certain doctors and hospitals 14.

Discrepancies between perceptions and official government data

Medical burn-out might also be increasing among healthcare workers. I had the opportunity to gather opinions from attendings and residents in the front lines in Mexico City and they agree that they feel tired, confused, and undervalued. Many of them claim they have the required PPE, but not in sufficient amounts, and that the situation painted by the Ministry of Health differs greatly from their day-to-day perceptions. They comment that the hospitals where they are working (private and public) are at complete or near-complete capacity, with no ICU beds available and that “many patients have to visit many hospitals until they are received”, another one stated “I have known of patients that die on the sidewalk outside the hospitals” and that “even if we try to send some of them home with supplementary oxygen treatment, no one can find oxygen tanks or concentrators anymore”. Bureaucracy is also getting in the way of their daily medical practice: “at the new COVID-19 temporary hospital” they said, “they are only taking convalescent patients and they only receive them with a referral from a public institution”.

The discrepancy between front-line workers’ perceptions and the official reported numbers were depicted in an article published on May 8th on the New York Times. In this article, there is a concern about the Mexican government largely underestimating the number of infected persons, possibly because, according to them, less than 1 in 1000 people are being tested for the virus, while the OECD nations’ average is 23 tests per 1000 population, that the official data has a 2-week lag, and that in some scientists opinions, their modeling strategies are wrong 15. Dr. Hugo López Gatell responded to these allegations saying that people involved with this article, were only doing it to defend their own political and economic interests (including those of opposing political parties, people with political aspirations or involvement with the pharmaceutical industry) 16.

Gender-based violence and femicides

In the country, violence against women comes in many shapes and forms, from subtle sexism, to a limited amount of women in charge of the pandemic response, to the most extreme manifestations of gender-based-violence, which is murder. In Mexico regularly, there are approximately 10 femicides per day, which has lead to women’s protests and a government that refuses a change of strategy to tackle this violence epidemic 17. The COVID-19 pandemic has not improved the numbers, but it has reinforced the well-known fact, that women are killed by the people they know. Since the quarantine was dictated in the country, there have been over 200 femicides and according to the National Refuge Network, gender-based violence calls for help have increased by about 80% 18. The president’s response, (with no data to support this) was that the problem exists, however, that 90% of the 911 calls for gender-based violence are fake 19.

Organized crime

Organized crime, particularly due to drug cartels, is a large problem in the country and over 60% of the homicides can be linked with them 20. During the COVID-19 pandemic, these organizations have simulated charitable actions with no response from the authorities. They have openly distributed food to the poorest and vulnerable, and even masks and toys with an image of the “Chapo” 21. 

Conclusions

This pandemic has shaken Mexico as it has shaken the world. It has succeeded in unmasking the latent problems of a fragmented and disorganized health system, of the widespread mistrust in the government and public health institutions in the country, the immense inequities, the growing power of drug cartels, as well as of the growing generalized violence, including the horrific increase in gender-based violence and the indifference of the federal government to many of the populations’ complains.

It is clear that the resources in Mexico are limited, that our context as a country is very unique and we should also not try to copy strategies from countries like Germany, but that we should try to adapt or create a unique one that works in the complex Mexican system. Strategies that urge people to stay at home are needed but can only work if you can guarantee that people will not starve during a quarantine. In a country where more than half of the population works informally, such policies on their own, increase inequities. People from the middle and upper social classes have been able to stay at home and distance themselves socially and possibly work from there, but they represent a very low percentage of the population. Planning and implementing such strategies goes beyond the health sector’s response, it highlights the need for a multilateral approach to an epidemic and it also goes back to the need of considering health in every policy.

Questioning the government’s methods should be a drive towards its improvement and it shouldn’t be deemed as a personal attack on anyone.

This is only the beginning of the challenges that are about to come, and the consequences of this pandemic will affect everyone everywhere and for a longer period. We can also make this an opportunity to restructure the health system, to increase the budget and appreciate those who work on the frontlines. It is also the time to think globally, follow the advice from WHO, learn from each other, and beware of nationalism.

 

The author

Cristina MdC, MD, MScIH

Cristina MdC, Mexican, was born and grew up in Mexico City. She graduated as a medical doctor from the Medical Faculty of the National Autonomous University of Mexico (Facmed, U.N.A.M.) in 2014. She then completed her internal medicine residency in Mexico City, where she graduated in 2018. In February 2020 she received a postgraduate degree in International Health from Charité University in Berlin.

References

  1. IHME. Mexico – Global Burden of Disease Study. http://www.healthdata.org/mexico. Published 2017. Accessed December 1, 2018.
  2. World Bank. Mexico. https://data.worldbank.org/country/mexico. Published 2018. Accessed December 1, 2018.
  3. CONEVAL. Medicion de La Pobreza En Mexico y En Las Entidades Federativas 2016.; 2017. http://linkinghub.elsevier.com/retrieve/pii/S1889183713700126.
  4. OECD. OECD Reviews of Health Systems: Mexico. (OECD Publishing, ed.). Paris; 2016.
  5. WHO. WHO Global Health Expenditure Atlas.; 2014.
  6. Gobierno de México. COVID-19 México. https://coronavirus.gob.mx/datos/. Published 2020. Accessed May 15, 2020.
  7. González-Díaz M. Coronavirus en México: las críticas a AMLO por seguir besando y abrazando a sus seguidores pese a las advertencias sanitarias frente al covid-19. BBC News Mundo en México. https://www.bbc.com/mundo/noticias-america-latina-51921323. Published 2020. Accessed May 9, 2020.
  8. Graham D. Mexican president’s poll ratings hit record low in coronavirus crisis. Reuters.
  9. Romero R. Hay 8 mil 113 camas de terapia intensiva para atender COVID 19. Notimex. http://www.notimex.gob.mx/ntxnotaLibre/769444/hay-8-mil-113-camas-de-terapia-intensiva-para-atender-covid-19. Published 2020. Accessed May 17, 2020.
  10. Gobierno de México. Hospitales privados atenderán a pacientes del sector salud. https://www.gob.mx/salud/prensa/111-hospitales-privados-atenderan-a-pacientes-del-sector-salud. Published 2020. Accessed May 15, 2020.
  11. Milenio Digital. Así luce la unidad temporal contra covid-19 en Centro Citibanamex. Milenio. https://www.milenio.com/politica/asi-es-la-unidad-hospitalaria-contra-covid-19-en-centro-citibanamex. Published 2020. Accessed May 10, 2020.
  12. Cruz Martínez Á. En instantes, la virulencia del mal: médicos residentes. La Jornada. https://www.jornada.com.mx/ultimas/politica/2020/05/06/en-instantes-la-virulencia-del-mal-medicos-residentes-7648.html. Published 2020. Accessed May 17, 2020.
  13. Oppenheimer A. Cuban doctors in Mexico may be pawns in a shady giveaway and human-rights abuse. Miami Her. 2020.
  14. Redacción Animal Político. Médicos rechazan buscar solo ganar dinero con su profesión como dijo AMLO; él se disculpa. Animal Político. https://www.animalpolitico.com/2020/05/medicos-rechazan-buscar-ganar-dinero-pacientes-amlo-disculpas/. Published 2020.
  15. Ahmed A. Hidden Toll: Mexico Ignores Wave of Coronavirus Deaths in Capital. The New York Times.
  16. Milenio Digital. López-Gatell responde a prensa internacional sobre cifras de muertes por coronavirus. Milenio Noticias. https://www.youtube.com/watch?v=bMw1NfKeZxk. Published 2020. Accessed May 15, 2020.
  17. The Guardian. Mexico president’s response to historic femicide protests: more of the same. The Guardian. https://www.theguardian.com/world/2020/mar/10/mexico-femicide-amlo-protests-strategy. Published 2020. Accessed May 17, 2020.
  18. Telesurtv.net. Reportan 163 feminicidios en México durante cuarentena. Telesurtv.net. https://www.telesurtv.net/news/mexico-aumento-feminicidios-durante-cuarentena-coronavirus-20200424-0003.html. Published 2020.
  19. Forbes México. El 90% de las llamadas por violencia contra la mujer son falsas, asegura AML. Forbes. https://www.forbes.com.mx/politica-el-90-de-las-llamadas-violencia-contra-la-mujer-son-falsas-asegura-amlo/. Published 2020. Accessed May 15, 2020.
  20. Angel A. Diez grupos criminales lideran violencia y narcotráfico en sexenio de AMLO. Animal Político. https://www.animalpolitico.com/2020/05/diez-grupos-criminales-lideran-violencia-narcotrafico-sexenio-amlo/. Published 2020.
  21. Hernández A. Carteles de la droga simulan caridad por el coronavirus en México. DW. https://www.dw.com/es/carteles-de-la-droga-simulan-caridad-por-el-coronavirus-en-méxico/a-53200770. Published 2020. Accessed May 15, 2020.