Covid-19: How denialism led Mexico’s disastrous pandemic control effortBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4952 (Published 30 December 2020) Cite this as: BMJ 2020;371:m4952
As the streets in Mexico City filled with cars, crowds, and Christmas excitement this December, the traffic light system indicating the status of its covid-19 hospitals began to turn red.
“Our hospitals are full and the health system is collapsing,” says Mercedes Aranda, a resident in infectious diseases at one of Mexico City’s principal public hospitals. “It didn’t have the infrastructure to sustain itself before; now the situation is even worse as people have lost fear of the pandemic and the government has never taken responsible action.”
Mexico, under President Andrés Manuel López Obrador, is one of the world’s worst hit countries by the pandemic. In mid-November it became the fourth country to record more than 100 000 covid-19 related deaths. Since then, another 19 000 people have lost their lives to the illness.
Public hospitals are overstretched. Many are turning away patients because of a lack of beds and are running out of supplies for polymerase chain reaction tests. All are propped up by overworked and undertrained staff. Over 2000 healthcare workers have died from covid-19, more than anywhere else in the world.
Doctors who spoke to The BMJ expressed their disdain and grief over their suffering and that of their loved ones. “We have watched our coworkers die, we have put tubes into our coworkers, and we have cared for the parents of our coworkers,” Aranda says. “I know this happens all over the world, I’m not the only one. But it’s not all over the world that the president goes to events without a face mask saying, ‘There is no problem, it’s fine, the pandemic is under control.’”
Mexico is in “bad shape,” the director general of the World Health Organization, Tedros Adhanom Ghebreyesus, said at a press conference on 30 November.1 “We would like to ask Mexico to be very serious,” Ghebreyesus told reporters.
Mexico’s government responded to the plea as it has to all previous WHO recommendations: with little concern and an abundance of hubris. “If Tedros wanted to give that message to me, or the health secretary, or to the president, he would have maybe sent us a diplomatic cable,” Mexico’s health minister, Hugo López-Gatell Ramírez, said.
The government has consistently played down the threat of covid-19. In May, when questioned on the risk of non-essential travel, López Obrador boasted that “honesty” was a “protective shield.” He proudly displayed items given to him “by the people”—among them an amulet and a $2 bill—he said would protect him. He has thus far avoided the illness since it spread through Mexico, even without wearing a mask. At least 1.3 million others have not been so fortunate.
Mexico’s vast inequality, underfunded health system, large informal economy, and belts of cramped, multigenerational housing made it particularly vulnerable to the spread of the virus, say epidemiologists. But a lack of strategy, combined with mixed messages from the president, has exacerbated the situation in a country that is poorly equipped for a pandemic. Government figures have asked the public to practise social distancing and have recommended the use of facemasks, but López Obrador has refused to wear a mask himself and played down their effectiveness. He has declined to make them compulsory or declare a national lockdown, which he sees as authoritarian and economically damaging.2
Such a “soft” approach, relying on public compliance rather than law enforcement, has proved successful in some countries. Uruguay, Latin America’s least affected nation, has seen widespread compliance without ordering people to stay at home. But such successes have been in relatively equitable societies where there is high trust in authorities and institutions. Neither can be said of Mexico.
“There are still people in the street who say ‘the pandemic is not real,’ and some people are not wearing a mask because the president is not wearing a mask,” says Samuel Ponce de Leon, coordinator of the university health research programme at Mexico’s National Autonomous University. “Messages should be very clear and coherent, not saying one thing and then [doing another].”
Although the number of weekly cases and deaths in Mexico has doubled during November to December, Mexico is testing fewer people per number of cases now than at the beginning of the pandemic. The country currently has one of the lowest testing rates in the world.
The testing system has been hampered in part by a lack of infrastructure, but the low rates are also a choice. Mexico looks for cases only in the most seriously ill people. Wider testing would be a “waste of time, effort, and money,” López-Gatell has said. This is in direct contrast to most Latin American countries, which have ramped up testing capacity, and despite it being a primary recommendation of WHO as one of the few proved and least economically damaging methods of reducing virus transmission.
“We are estimating around 30% of [Mexico’s] population has been infected, but the government doesn’t know how many infected people there are, so that’s another big issue,” says Rafael Lozano, at the University of Washington’s Institute for Health Metrics and Evaluation.
Wider testing would provide a better understanding of how the pandemic is affecting different areas and how to manage them accordingly. Tougher measures can be imposed on the worst hit regions and laxer ones on those that are faring better. Without such data it is difficult to avoid the blanket national lockdowns López Obrador is so set against.
Moreover, Michael Touchton, at the University of Miami’s Covid-19 Policy Observatory for Latin America, says, “Pure testing, even alone, will cut some of the lines of transmission.” Every positive test result could lead to someone seeking medical attention before it is too late, potentially saving a life. Self-isolation could also stop them spreading the illness to others.
Mexico has followed one recommendation with zeal: ramping up hospital capacity.
Since March, 45 000 extra hospital staff have been recruited, and the number of intensive care beds has quadrupled from 2446 to 11 634.3 On 4 December López Obrador ordered another 500 hospital beds to be equipped in the capital. “Knowing that our health system is extremely weak and underfunded, this was a really good approach,” says Ponce de Leon.
While admissions at Mexico City’s hospitals are far higher now than when they were overwhelmed in May and June, care has improved. Some hospitals report mortality rates dropping by as much as three quarters. Nightmarish scenes, with patients being treated in hallways and relatives of the dead not being permitted into hospitals to identify bodies, are fewer than in the summer.
Yet beds and ventilators are not a silver bullet. Equipment can be supplied quickly; the specialists needed to use it cannot. “[Healthcare workers] are doing their best, but you cannot train for this in a couple of months,” Ponce de Leon says. “Mortality is going to be high.”
Inexperienced and non-specialist staff have worked hard to plug the gap, but their resilience has limits. “At the beginning, everyone, irrespective of their specialty, was helping treat patients,” says Ernesto Juárez, a lung specialist at Mexico City’s Centro Médico Nacional Siglo XXI, one of the country’s biggest public hospitals. “But obviously they get exhausted, they don’t have the experience, and the number of people helping these patients has dropped.”
Healthcare workers are unsure how much longer they can ride out the current wave of covid-19 cases understaffed, underequipped, and exhausted. In early December, doctors and nurses at one of Mexico City’s largest state hospitals signed an open letter threatening to cease treating covid-19 patients unless the city declared a partial lockdown, as it did in the spring.4
The call was heeded on Friday 18 December when the government announced that non-essential businesses in Mexico City would be closed until 10 January. Claudia Sheinbaum, the city’s mayor, had also taken her own action, announcing in late November that the number of daily coronavirus tests would be doubled to 10 000, with rapid testing at pop-up sites. “The goal . . . is to break the chain of contagion by identifying and isolating positive cases early,” Mexico City’s health department told reporters.5
The moves were welcomed by healthcare workers and experts but may have come too late. “With the current scenario, we’re projecting 161 000 deaths [for the whole of Mexico] by April,” says Lozano, who is modelling various outcomes of the pandemic. Mexico City alone is projected to have 22 242 deaths.
Early arrival of any of the current covid-19 vaccines would help, but administering repeat doses to 150 million people will be a challenge given the infrastructure and resource difficulties. “This is not the end of the tunnel, but it’s a little light out in front,” Lozano says.
Until then, healthcare workers must tend to the constant flow of patients and their own emotions. “It’s not just upsetting, treating covid in a country where there is not even minimal control, it’s infuriating,” Aranda says. “I live with my parents, who are 65 years old and have diabetes. If they get sick, they’ll die.”
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
Commissioning and peer review: Commissioned; not externally peer reviewed.