30 months after the arrival of covid19 in Mexico, President Andrés Manuel López Obrador insists that the national health system is heading to match that of Denmark, although workers in that sector denounce that they work under the same conditions as 20 years ago: with a lack of inputs, low wages and even precariousness.
Rufina Martínez Ortiz and María Eugenia Muñoz Pomares have been nurses for more than two decades; both work at the Regional Hospital of Coatepec, a small town located in the state of Veracruz, southeast of Mexico.
In their professional practice, they had to overcome the AH1N1 and covid-19 pandemics, although today they face a bigger problem: the lack of tools and infrastructure to carry out their work, such as not having an operating room for a year.
Despite the fact that the lesson that this disease teaches Mexico is precisely the need to invest in more equipment in hospitals, vaccines, medicines, and disease prevention, to date there has been no significant progress in strengthening its infrastructure. .
On the contrary, the Government recognizes the shortage of doctors in the most remote and violent regions of the country.
The current health system in Mexico
Jorge Alcocer Varela, Secretary of Health in Mexico, indicated during his appearance before senators that, during the current administration, 180 health centers and hospitals that previous administrations left abandoned have been launched.
Another 127 works are pending to conclude before 2024; In addition, since 2019, conservation and maintenance work has been carried out in more than 4,234 health centers and 160 hospitals.
Despite this scenario, next year, according to specialists, will be complex for health in Mexico due to budget cuts.
With the COVID19 pandemic, private pharmacies that offer low-cost consultations proliferated in Mexico. Photo: Yamiri Rodriguez.
The AH1N1 crisis
The first modern pandemic that the country faced was that of Influenza AH1N1 in 2009. The new viral variant was immediately associated with a series of severe cases of atypical pneumonia that had been present in Mexico since March of that year, which led to the declaration of a national emergency on April 23, 2009.
On April 25, the World Health Organization (WHO) declared the epidemic outbreak that was taking place in Mexico and the USA as a public health emergency of international concern, and recommended that countries intensify epidemiological surveillance in search of «type of» disease. ” Influenza and severe pneumonia.
Two days later, the pandemic alert level was raised, and on April 29, Margaret Chan, WHO Director-General, declared a new pandemic imminent, calling on all nations to activate preparedness and response plans.
On June 11, the WHO officially declared the existence of a pandemic.
Who were affected?
In Mexico, according to the Health authorities, influenza A H1N1 2009, unlike seasonal influenza, mainly affected the young population; most of the infected people recovered without consequences.
Until July 2010, the pandemic caused the deaths of 1,316 people, and 72,548 cases were confirmed by molecular tests.
These figures only represent cases in which a diagnostic test was carried out by the health systems, following sampling criteria.
However, the general proportion of the population that was infected by the virus is unknown, since most of those who presented some symptoms did not require medical attention (since they suffered mild or even asymptomatic infections) and in other cases, they simply were not registered.
Vaccination plans
Given the uncertainty of the moment when another influenza pandemic will appear, the place and particular characteristics of the new virus, and the constant attack of seasonal variations, the Mexican authorities prepared the National Plan for the Preparation and Response to the Intensification of the Seasonal Influenza or in the event of an Influenza Pandemic, based on and enriched by programs and guides from 2006, 2009, 2011 and 2015.
In addition to the above, this October 3 began, as every year, the massive vaccination campaign against influenza. The Ministry of Health reported that it will be in force until March 31, 2023, with the goal of vaccinating more than 30 million people.
The objective is to immunize people over 60 years of age, girls and boys from six to 59 months; health personnel, pregnant women and those between five and 59 years of age, and present risk factors such as immunosuppression, kidney failure, diabetes, hypertension and cancer.
“Vaccination is the most effective way to prevent and avoid serious cases of the disease; Therefore, a call is made to those who are in any of the population groups at risk to go to the health center or clinic of the Health sector to receive their vaccine, ”said the Ministry of Health.
IMSS Bienestar clinic in the coffee-growing municipality of Coatepec, in the mountainous area of Veracruz, Mexico. Photo: Ya mirin Rodriguez.
Nonconformities in the health sector
María Eugenia Muñoz has been working at the Coatepec Hospital for 22 years. There the population is vaccinated every year against influenza, in addition to treating the ills that afflict a dozen municipalities in the mountain area.
Within the framework of Doctor’s Day, which is celebrated in Mexico on October 23, the nurse took to the streets to protest, along with colleagues, for the conditions in which they have to work, very similar to those of 2009 and even before. Among their claims are changes in breaks, days, and schedules, without prior notice.
“Before we had ups and downs, but not like now; the hospital is stopped in many ways, ”, he narrated.
Stop the restrictions
The second great health crisis began on February 27, 2020, when the Ministry of Health detected the first case of covid-19 in Mexico; and on March 18, the first death as a result of this disease. Five days later, the National Day of Sana Distancia was established in the country; and from April 1 to 21 of that year an emergency was declared.
From that moment on, cases skyrocketed and extremely complex days came, especially for health sector personnel.
Nurse María Eugenia had to attend, without extra bonus or compensation, those long days and nights when the covid hit Mexico.
“We had to face the crisis. We had a lot of work and even so we managed everything; that is why we asked that all that work that was carried out in that time be considered, which was a lot. We requested support, but it was very little,» said the health professional. He also says that unlike other of his colleagues, he did not contract the virus, although he was afraid of it.
Unlike other Latin American countries, in Mexico just on October 7, almost 30 months after the arrival of Covid-19 in the national territory, the New Normality Committee, made up of the secretariats of Health, Economy, Labor and Social Welfare (STPS), and the Mexican Social Security Institute (IMSS), updated the health security guidelines for the healthy continuity of economic activities before Covid-19.
As part of the suggestions is the elimination of the use of sanitizing mats and the sanitary filter; and the guidelines for the use of face masks in open and closed spaces.
Some Mexican doctors insist that, contrary to what the government has said, the use of face masks must be maintained in the country as new strains could arrive. Photo: Yamiri Rodriguez.
The business sector was recommended to designate a committee or responsible person, who in their facilities implements, offers follow-up and supervises the measures that help to reduce risks within the workplace, which are valued in the National Strategy for Work Environments and Insurance from the Ministry of Health.
Air travel restrictions
A few days later, on October 11, the Ministry of Infrastructure, Communications and Transportation (SICT), through the Federal Civil Aviation Agency (AFAC), informed airport commanders, the Local Airport Security Committees, Local Operation and Schedule Committees and the Authorities Coordinating Commission, that the use of face masks for those who use airport facilities, as well as aircraft cabins, would no longer be mandatory, until the health authorities modify the health protocols inherent to its use.
The explanation given by the authorities was that both the outpatient clinics and the last-waiting rooms in the airport facilities are large and sufficiently ventilated spaces, while the aircraft use a high-efficiency filtration system (HEPA) that eliminates 99.9 percent of microparticles, bacteria and viruses.
The foregoing renders void the «Agreement establishing the Specific Technical Guidelines for the Reopening of Economic Activities», published in the Official Gazette of the Federation in May 2020.
However, the gap with other countries that had already lifted the restrictions was also due to the fact that Mexico was one of the last nations to apply the protocols against the disease.
The numbers
At press time, 7,107,009 total cases and 330,332 deaths from covid-19 were confirmed in the country. The incidence rate of accumulated cases is 5,462.0 per 100,000 inhabitants.
The distribution by sex in the confirmed cases shows a predominance in women (53.2%). The median age overall is 38 years.
Health challenges
Dr. Alejandro Macías, an epidemiologist who was part of the national team that responded to the wave of influenza in 2009 and a level 3 investigator in the National System of Investigators, explained that a potentially deadly H3N2 strain that circulates throughout the world is a threat to public health, plus Covid this winter.
«Let’s not doubt it: to the extent that covid-19 subsides, influenza will come under its jurisdiction,» he assured, and warned that the wave of cases in Western Europe is not yet due to the effects of variants, except perhaps in Austria. but to the seasonality, decreased immunity, and behavior, thus indicating that variants such as BQ.1.1 are expected to cause an additional wave starting in November.
At the same time, the specialist said that BA.2.75.2 proved to be the most evasive variant of immunity, «the one with the greatest escape», but now it is surpassed by XBB, which is predicted to challenge the protection of the new bivalent vaccine with BA.5 that is applied in the USA.
“Undoubtedly, there will be new variants, but in countries like Mexico, where there is a lot of immunity, a catastrophic entry is not expected, with hospital saturation or social collapse. Sure, no one can predict the future with certainty; nobody has a better crystal ball,”, added the specialist.
Mexicans returned this fall to the new normality after 30 months of Covid19. Photo: Yamiri Rodriguez.
The risk is not over
For his part, Dr. Francisco Moreno Sánchez, Internist and Infectologist, National Health Award 2020 in Mexico, indicated that the Covid-19 pandemic has not ended, although today there are fewer cases and little mortality, but it cannot be stopped carry out preventive measures, so use the mask in closed spaces, if you are vulnerable or if you live with someone low in defenses.
“Recently, outbreaks of Ebola, measles, cholera, syphilis and other infections have been documented around the world. The Covid-19 pandemic has taught us that only by working together can we get ahead. Challenges for science that require everyone’s cooperation”, Moreno commented.
And, in addition, he regretted that, although the health authorities vaccinated Mexicans against the so-called Smallpox of the Monkey, it was only at the Chicago consulate, in the United States.
«While in other countries there is a decrease in cases of this disease, in Mexico the number of new cases continues to increase,» he criticized.
He asserted that the covid-19 vaccines have been purchased with public taxes and ordered to demand that the monopoly of its application end, which he considered to have been a failure on the part of the health authority.
“It is evident that for our government, health is far from being a priority. The most unlikely thing is that people with economic possibilities will be vaccinated abroad; those who were promised better health coverage will be left with Soberana,» he explained after it was revealed that the bivalent vaccine that acts against covid-19 and its variants will not reach Mexico.
Lastly, the doctor stressed that the long-term consequences of Covid-19 are a challenge for future health programs.
Monkeypox, the new pandemic?
Since the registration of the first case and until October 24, the Ministry of Health has confirmed 2,654 infections of monkeypox in Mexico and no deaths from this disease.
In the referred period, 4,471 people who met the operational definition of a probable case were identified, of which 2,654 were confirmed, 377 under study, and 1,440 discarded by laboratory tests.
The Institute of Epidemiological Diagnosis and Reference (InDRE) reported that the positive cases are distributed in 32 states: Mexico City, 1,601 infections; Jalisco, 301; state of Mexico, 272; Yucatan, 93; Quintana Roo, 58; Tabasco, 39; Nuevo Leon, 30; Chiapas, 28; Puebla, 25; Veracruz, 20; Lower California, 19; Queretaro, 17; Morelos, 16; Guanajuato, 16; and Sinaloa, 13.
Also, Chihuahua, 13; Hidalgo, 12; Coahuila, 11; Nayarit, nine; Tamaulipas, nine; Oaxaca, eight; Aguascalientes, seven; Campeche, seven; Michoacán, six; Tlaxcala, five; Colima, four; Warrior, four; Sonora, four; Zacatecas, three; San Luis Potosi, two; Baja California Sur, one and Durango, one.
Of the total confirmed cases, 98 percent corresponded to men and two percent to women; 46.7 percent of people were between 30 and 39 years old; that is, 1,239 of the 2,654 confirmed.
Likewise, of those under 20 years of age, 13 are 19 years old; four, 18 years old; three are 17; two are 16; three are 15 years old; two are 14; one is 13; two are 12; one is 11; two are nine years old; one has four; and one is three years old.
As of October 21, 75,441 confirmed cases were reported worldwide in 109 countries, territories, and areas in the six regions of the World Health Organization (WHO), as well as 32 deaths.
Likewise, a website was developed that has information available to the population, as well as to health personnel who care for patients suspected of having the disease. But until the closing of this edition, in Mexico, there is a lack of massive campaigns of prevention that alert the population of this disease.
The Ministry of Health maintains on its site a talk that it gave on July 27 as a reference resource to clear up doubts from the population.
They ask for community orientation
The general director of Censida, Alethse de la Torre Rosas, stated that the comprehensive response to monkeypox must include community guidance that identifies the most urgent needs and allows joint action with community leaders to deal with this health emergency.
At Censida, de la Torre Rosas said, the objective is to bring health services closer to people and facilitate access. He reiterated that awareness will be strengthened for the epidemiological monitoring of cases and to avoid stigma and discrimination, as well as guarantee respect for confidentiality in monitoring chains of transmission of the virus.
During the panel of specialists «Everything you should know about monkeypox», organized by Cen sida, the general director of the agency explained that the center under her responsibility works in coordination with other health institutions and civil society organizations to prevent not only monkeypox, but human immunodeficiency virus (HIV) and other infections.
Diagnosis of the health sector
Beyond anticipating a new pandemic, it is necessary to review the state of the health infrastructure in Mexico. This is divided into social security institutions, made up of the Mexican Social Security Institute (IMSS), the Social Security Institute at the Service of State Workers (ISSSTE), the medical services of Petróleos Mexicanos (PEMEX), the Ministry of National Defense (SEDENA) and the Ministry of the Navy.
Then come health services for the uninsured population, provided by the Ministry of Health (SSA) and private services. There are 4,718 second and third level hospital units in Mexico.
ISSSTE Clinic in Coatepec, Veracruz, Mexico, dedicated to the exclusive care of government workers. Photo: Yamiri Rodriguez.
Prior to the covid-19 pandemic, the National Institute of Statistics, Geography and Informatics (INEGI) obtained national information from 2,855 private hospitals, in which 14,650,020 outpatient consultations were provided and 1,942,738 patients who required the service were discharged. Of hospitalization.
The entities that concentrated 52.2% of censusable beds required for the use of inpatients were Mexico City 4, 727 (14.1%); state of Mexico, 3,874, (11.5%); Jalisco, 3,071 (9.1%); Guanajuato, 2,058 (6.1%); Nuevo Leon, 2,042 (6.1%);, and Puebla, 1,791 (5.3%).
Another relevant fact was that of every 100 private establishments that provide health services, 90 are classified as general hospitals; 5 are specialized in obstetrics and gynecology; 3 are other specialties, and the rest correspond to pediatrics, psychiatry, and traumatology.
However, prior to the AH1N1 pandemic, there were 2,950 private medical units with hospitalization services, totaling 31,241 beds, of which 48% were in establishments with less than 15 beds; that is, more than there is now.
The president of Mexico, Andrés Manuel López Obrador, reiterated on October 25 that the country will have a health system comparable to that of Denmark.
IMSS Wellness clinics in Mexico look the same as before the arrival of the Covid19 pandemic. Photo: Yamiri Rodriguez.
“It is quite a challenge. There I have been reading our adversaries who bet that we will not be able to achieve it. Because about a year ago I talked about how we were going to have a public health system like in Denmark, like in the Nordic countries that have one of the best welfare states in the world, and we accepted the challenge, the challenge. We are going to offer, when we finish, we are going to have a first-rate health system in operation, with the support of health workers and many of us who are participating, municipal and state authorities,» he explained in his morning conference from the National Palace. .
a different landscape
But for nurses María Elena and Rufina things are very different. Rufina Martínez revealed that the only operating room in the small hospital where she works has not been working for a year, due to remodeling that began during the pandemic, so every woman who requires a cesarean section or a patient who needs an operation has to travel to the capital. Of the state, about 20 kilometers away.
Protests by health personnel in Mexico occurred in different parts of the country due to the poor conditions in which they work. Photo: Yamiri Rodriguez.
To this we must add that there are few ambulances, so if the situation is delicate, the family must pay even more.
“We had had ups and downs due to other situations, but never like in this situation. Furthermore, our Director told us: demonstrate, do what you want. I am going to send for the police and pick them up; that is already a threat,” he said, while holding protest banners outside the hospital.
For her part, the nurse María Elena commented that there is discomfort among the patients because there are deficiencies, they ask them to buy the supplies in a particular way in order to be able to complete the processes, although this generates scolding from their superiors.
“The surgical area, the operating rooms, were stopped a year ago due to remodeling and until now they have not started up. We already want to work fully, but it has been difficult for us due to the fact that it is necessary to care for patients who come from afar”, added nurse María Elena.
The Regional Hospital of Coatepec, in Mexico, has been without an operating room for a year; patients who have to be operated travel to the state capital, 15 kilometers from there. Photo: Yamiri Rodriguez.
Shortage of doctors
To this we add that the Government of Mexico recognized that there is a shortage of doctors, mainly specialists.
INEGI also reported that the number of doctors per thousand inhabitants in the country is 2.4, a higher number than the average of two doctors per 1,000 inhabitants in Latin American and Caribbean countries. but lower than the average value of the Organization for Economic Cooperation and Development (OECD) which is 3.5 doctors per 1000 inhabitants.
In its most recent National Occupation and Employment Survey (ENOE), Mexico had until last year 305,418 people employed as doctors, of which 54% were men and 46% women, and of every 100 people with this occupation, 67 are doctors. General and 33 specialists in some other branch of medicine.
Due to the above, Mexican authorities have resorted to hiring Cuban doctors.
The general director of the Mexican Social Security Institute (IMSS), Zoé Robledo, reported that 352 specialist doctors from Cuba have arrived in the country, who have been located in 79 municipalities of nine entities, in regions and health jurisdictions that have high or very high marginalization, or in hospitals with vacancies that had not been covered for years.
After the COVID19 pandemic, far from improving their working conditions, health personnel in Mexico denounce that they want to pay them overtime in kind, which is against the law. Photo: Yamiri Rodriguez.
The foregoing, he recalled, is part of the collaboration agreement with the Cuban Ministry of Health, which has made it possible to have specialist doctors in hospitals with difficult coverage.
«There was a real veil, they did not want to see that there were no doctors on different shifts, not only in hospitals in city centers, but especially in these more remote locations,» he emphasized.
The Mexican official explained that the distribution by states of specialist doctors is in Nayarit, 92; Colima, 55; Campeche, 54; Baja California Sur, 30; Zacatecas, 10; Sonora, 17; Oaxaca, 61; Veracruz, 7; and Tlaxcala, 26.
Therefore, from October 12 to 25, another call was launched for general practitioners, specialist nurses and nursing technicians to work in the IMSS Well-being program in the states of Nayarit, Tlaxcala, Sonora, Baja California Sur and Campeche, although It is not specified whether they are based positions or the monthly remuneration.
Nurse Rufina, who is the legal representative of the nonconformist health personnel movement at this point in the Veracruz entity, explained that today their economic remunerations have affected them because, despite the fact that the law establishes that overtime cannot be paid in kind, In that hospital they intend to do it with vouchers, pantries or days off in exchange.
“There are no Sunday premiums; there is nothing to support us. It is fair that the population demonstrates, gets angry with the workers, but they do not know all the deficiencies that we have here in here”, he added.
Contributions to health in Mexico
In order to contribute to the investigation of pandemics and other diseases in Mexico, the National Autonomous University of Mexico (UNAM) launched the «Microsite of the Social and Cultural History of Health and Disease in Mexico Seminar.»
Claudia Amalia Agostoni Urencio and Laura Rojas Hernández, academics from the highest house of studies in the country, explained that although it was created for those
People interested in these issues, it also seeks to strengthen the dissemination and disclosure of historical research.
“The epidemics and pandemics of before and now have been of great interest, among multiple historians, among other reasons, because they condense the ecological, biological, economic and social bases of collective diseases, due to the way in which they break out, and They disrupt all areas of social life. In times of health emergency, the heterogeneous dimensions of the political, economic, and social fabric are visible, and also when a multiplicity of perceptions, practices, norms, and fears are discernible with uncommon clarity,” said Agostoni Urencio.
The winner of the Sor Juana Inés de la Cruz 2016 recognition, granted by UNAM, explained that although uncertainty, instability and loss of life seem endless, what is fundamental in this work is to demonstrate the importance of avoiding biases, generalizations and simplifications to visualize these events in particular spatial, temporal, political, economic and social contexts, for which reason he considered that this microsite brings a renewal of the traditional history of medicine, which had been written by and for those who practiced this profession, also makes a rereading and reinterpretation of traditional stories that paved the way for the development of new scientific knowledge.
Less resources for Health in 2023
Beyond everything, by 2023, the Federal Government intends to allocate fewer resources to the Health sector. The civil organization México Evalua carried out an analysis in which it warns of the decrease in resources for this item.
Health spending focused on protecting people without formal social security, the report indicated, will have a setback. Not only the Insabi and the IMSS-Bienestar will suffer cuts; the de facto elimination of the Health Fund for Well-being (Fonsabi), which covers high-cost diseases such as cancer or HIV/AIDS, is also anticipated.
And he explained that next year the Insabi will have a budget of 107 billion pesos, 1.2% less than in 2022 or 6.8% less than the average from 2013 to 2018. The IMSS-Bienestar will have 17% less in 2022, although 38.4% more than in the past six-year period. Both institutions –Insabi and IMSS-Bienestar– will add 4% less than in 2022 and 1.5% less than in the previous six-year term.
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The count is more serious -he continued-, if only the subsidies for the provision of health services are counted, those destined to guarantee the gratuity of said services. From this point of view, the 2023 budget of both agencies will add 4% less than this year and 6.2% less than the average during the previous government.
“There is little hope of a successful transition and of addressing the lack of infrastructure and the downward trend in care at both institutions, as we explained in our special investigation on the subject. It must be noted that this budget cut is the least pessimistic scenario for both health systems, since the federal government has the habit of under-exercising In sabi resources during the year, and disguising it at the end of the year with transfers to trusts greater than those approved”, concluded Mexico Evaluates.
In other words, after the emergency, the health sector in Mexico, the nurses Rufina and María Elena, will continue to operate in the same minimum conditions, waiting for the next pandemic that they will have to face with the same supplies from years ago. Nothing like Denmark.
@YamiriRodriguez
