It’s day 38 since the first COVID-19 was diagnosed in México.

Amongst the 94 reported deaths, there are three physicians from the Mexican Social Security Institute (IMSS). Besides other healthcare professionals’ lives already lost during this pandemic in México, these three are particularly indignant since they share a common cause: lack of personal protection equipment (PPE).

At the same time, patients’ relatives complaint about not being properly informed, while people suspicious of being infected or with flu-like symptoms are politely invited to go home and lockdown themselves, after an on-site triage or SMS consultation with no diagnostic testing performed.

Just shy of 2,200 confirmed cases, México is rapidly developing a curve that resembles those from Italy, Spain or the USA; however, in such an early stage of the epidemic, the country is already starting to feel the catastrophic effects of a health system collapse. From big important hospitals and medical centers “reconverted” into COVID-only units, to brand-new or refurbished regional clinics, México could easily face the worst health-care crisis in the last 100 years.

México has 118 million people and is the 15th economy in the world. It is also the country once praised by the World Health Organization for its management of the 2009 H1N1 flu pandemic; today México is in the start point of an epidemiological nightmare.

How did we get here?

A weak and underfunded health system

As I have wrote before, the Mexican healthcare system has been historically underfunded (Health at a Glance 2019: OECD Indicators).

Before 2012, there was a positive tendency on the governmental allocation of resources which became a plateau during the next 6 years. The leftist campaign discourse of the current administration, gave the impression that a great funding and spending on health would be planned since early 2019. That didn’t happen. The last two federal budgets had no real increase in the figures; on the contrary, there has been underspending (~35-50% for the first trimester) and direct aggressive cuts to some important institutions like the National Institutes of Health.

Arguing a constant fight against corruption, the government's system for public health procurement suffered major changes. The traditional control of the Health Ministry (Secretaría de Salud) over the tenders was eliminated while the Finance Ministry (Secretaría de Hacienda) took over. All supplies, assets, drugs and equipment are now centrally acquired. The individual institutions (IMSS, ISSSTE and PEMEX) have little or no opinions on the terms nor the final outcome of the purchasing process.

As the normal scheduling and rules changed with no opinion taken from suppliers, distributors, institutions, physicians or patients, the supply process was derailed. About 62% of goods considered on the first “consolidated tender” received no offer, creating the biggest shortage in supplies ever registered.

The lack of drugs for children’s chemotherapy or AIDS patients, became a public relations nightmare. In the case of cancer treatments, there was animosity from government towards the mayor suppliers; this lead to emergency purchases overseas. Although these processes overpassed the regulatory agency COFEPRIS (who was ordered to bend the rules), the final financial impact was non-significant after considering transportation and logistics costs.

In January 1st, the national system that covered health expenses for uninsured people “Seguro Popular” was eliminated and the Health and Wellness Institute (INSABI) took over its funding. At the same time, the federal government asked the states to hand their healthcare infrastructure, assets and staff to the new INSABI. With no operational rules and no clear information for patients, the first two months of 2020 added more chaos to the lack of vaccines, cancer therapies or basic drugs, as well as broken diagnosis equipment and severely cut resources for scientific research.

Then, the first COVID-19 patient arrived.

Arriving late to the battle

There has been a lot of discussion over if the government general measures were set on the right time. Government officials have claimed they took the appropriate measures just when they were better to be decided, arguing very specialized epidemiological models and calculations.

In the mean time, as a big part of society took the leadership and started to keep social distance and self-quarantined themselves since late February, Mexican president (AMLO) defended his decisions on the argument that everything was under control and fully planned three months ago. It wasn’t.

Theses were the actual response dates, corroborated by internal memos and official news:

Before February 28th.- General information. No specific measures.

February 28th.- Ministry of Health officials announce the first patient in México.

March 9th.- The Coordinator of the National Health Institutes suggested the “hospital conversión” program to the INSABI and asked for resources.

March 18th.- A final ~ $143 million USD appraisal for the “conversion program" was made. Health authorities asked the Secretaría de Hacienda to start the acquisition process.

March 26th.- After the Secretaría de Hacienda proposed a calendar for tenders, pricing, registry, custom permits and logistics, the best estimations needed two more weeks for having a final decision on key suppliers. Obviously, México doesn’t have that time, so the process was taken out from Hacienda and handed to the Army. Under "emergency status", the Army has the power for look after and purchase whatever goods are needed, directly and with no immediate need for sanitary registry or pricing contests. Ventilators now are at the top of the list.

March 30th.- A modified version of the National Sanitary Emergency status was issued. Strong recommendations were given and partial quarantines were declared. The Army informed that “contracts have been signed” to get the ventilators supplied. However, it wasn’t until the last week of March, when México started to look for emergency supplies in the international market.

In a world where New York is begging for help, Turkey has confiscated the Spanish cargo, and governments are locking their national industries for their own supply, even refurbished ventilators will be a very difficult (if not luxury) asset to get.

A severe lack of testing

In the middle of the international discussion regarding testing, there are two main tendencies:

Those with aggressive testing programs, apparently showing more success on their epidemic curve as well as lower mortality rates. Those with initially conservative testing programs (like USA) who has switched into massive ones.

Whatever the criteria, there is current consensus on broader testing linked to a higher number of earlier detections, so at this point the main discussion has turned on the right test for massive use.

With little more than 130 tests made per million habitants, México has one of the lowest detection rates in the world. As I've mentioned, the government has defended its testing criteria; however, that has not helped against the broad perception of being under-diagnosing. With 2143 cases reported as of April 5th, this number is impressively lower than the USA. México has diagnosed only 12% of the number of cases in Canada, and 18% of Brazil, a country always used to be compared with, and 25% of Chile.

The actual figures on available test are not promising:

Initially, the undersecretary of Health stated that México had 9,100 total coronavirus test for all the 32 states. During more than 6 weeks, he claimed that those quantities were more than enough (for 118 million people) and fought over great criticism for not being testing more suspicious patients.

Just two weeks ago he announced that México received 30,000 mores tests.

Apparently, there are about 70,000 tests coming from overseas.

Even under this pressure, the official position of the Mexican government has been to avoid or even ban quick tests. As a result, the accurate number of actual patients in México is unknown.

Shortage of physicians, underpaid and with no body armor.

One of the main concerns exposed since the beginning of the epidemic in México, is the shortage of personal protective equipment (PPE). Mexican public health system has never had state-of-the-art gear or PPE, so the sudden change and upgrade on international standards has been difficult to handle.

ICU and ER physicians, as well as Pneumologists have formally complained about the lack of protective clothing, N95 masks, face-shields and even gloves.

As of today, there is an unknown number of infected health workers. In one single incident, more than 20 physicians and nurses tested positive after one colleague died from COVID-19 due to a work-related contagion in the northern state of Coahuila. The PPE was released to that medical unit several days after and only after big protests.

The lack of adequate PPE has become one of the most delicate subjects, besides the shortage of trained physicians. In a desperate move, the federal government is hiring General Practitioners, with the promise of extra points on the Mexican Residency Test (ENARM), and planning to re-hire retired specialists. With a standard mean salary of just $18, 500 USD a year, and no extra payment for high-risk duties, the enrollment programs intends to get 2,500 physicians on board.

The next weeks.

It is clear that registered cases are increasing in México, following the same trend of the high-incidence countries. As I wrote before, the pandemic couldn’t arrive to México in a worse moment.

With a weakened healthcare system, an economic crisis created months before and a government who runs most decisions based on ideology instead of facts and figures, the immediate scenarios are not promising.