| | |  Health & Beauty | May 2009 
In Flu Aftermath, New Tests
 Malcolm Beith & Nacha Cattan - The News
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 |  | In most health crises the information is of poor quality while the demand for information is very high. This happened in Mexico.
- Jorge Buendía |  | | |
Josefina Reyes wasn't taking any risks. The 37-year-old mother of four had come down with something - it seemed flu-like, but maybe she was being a hypochondriac, she said - and she wanted medical attention. Wearing a surgical mask, she waited with dozens of other prospective patients outside the IMSS hospital on Xola Avenue in the capital for the doors to open.
"I don't know what it is," she said. "But I'd rather know than not know."
As it happens, Reyes will not succumb to swine flu (she just had a common cold) - and neither, it appears, will Mexico. But two questions still linger: Did the government and health authorities handle the outbreak well, and will Mexico learn from this experience?
World health authorities and the foreign media have been heaping praise on the Calderón administration for its management of the situation. Information was shared with Canadian, U.S. and World Health Organization, or WHO, researchers almost immediately - standard procedure since the SARS outbreak in 2003. With outside help, the government quickly constructed special laboratories to test for the new strain. Containment measures were implemented that experts now say may have saved the world from mass infections. As the nation's chief epidemiologist, Miguel Angel Lezana, told The News: "The [international] effort was extraordinarily cooperative."
Questions remain over Mexico's own handling of the early stages of the outbreak, however, before the Centers for Disease Control, or CDC, and World Health Organization got involved on April 23. The way data was shared among health authorities and then disseminated to the public, conditions and resources at public health facilities, and political opportunism help make up the long list of criticisms.
Five years ago, according to health authorities, an information-sharing system - which meets international standards - was set up in Mexico. Designed to target the flu - a common killer worldwide - it also would end up being used "for lots of diseases" as it was further developed, said Lezana. The system allows private clinics and public and private hospitals to send any data to their local health authorities, who can then send that on to state and on to federal. According to Lezana, the central authority receives about 400 samples a week during a normal flu season.
Only time and thorough investigations will reveal whether those 400 samples are a result of hospitals using the system properly or whether there are more cases of this strain out there, as one model published this week in the journal Science projected. (Researchers from London say that as many as 23,000 Mexicans may be infected with the H1N1 influenza A virus, an estimate Lezana said will be "very useful" in studying what might have happened.)
Since the outbreak of flu last month, several doctors or medical staff at various Mexico City hospitals have told reporters that they didn't even gather information on flu cases - they just gave them anti-virals and sent them home.
Samples of any suspicious cases of flu are supposed to be collected, but Health Secretariat official Justino Regalado Pineda told The News that there can be glitches - there are less controls on private hospitals, which can prescribe medication more easily than public facilities, for instance.
There is also little information on how the virus first struck, he said, partly because blood samples from many of the first cases were either discarded or taken after patients had recovered.
As for the public hospitals, criticisms abounded throughout the outbreak over whether they were even capable of handling the influx of possible patients and cases. They were reportedly overcrowded and understaffed; hospital personnel have even staged protests over having to work in such conditions.
A backlog of more than 3,000 virus samples - which is now still being dealt with by the international team - has further muddied the situation.
"It's probable we've been missing some cases," said Gustavo Reyes, lab chief at the National Institute of Respiratory Diseases' Center for the Investigation of Infectious Diseases, in a recent interview with Bloomberg News.
One on-duty epidemiologist at a Mexico City IMSS hospital at the height of the crisis was even more blunt when asked about numbers of cases and the way data was being shared with federal health authorities.
"Information? What information? We treat the patients and they go home," she said, asking that her name not be used.
THE NUMBERS GAME
The numbers, since Day One, have appeared problematic. While Health Secretary José Angel Córdova has received international praise for his use of bar charts and apparent transparency, here in Mexico he has also come under fire. Many citizens have accused the government of manipulating information - in particular, when Córdova downgraded the number of deaths from 20 to 7 on April 28.
So have some opposition lawmakers, unsurprisingly.
"Detractors are trying to turn the pandemic into a PANdemic," said George W. Grayson, a Mexico expert and professor of government at the College of William & Mary in Virginia, adding that Washington's view of the crisis management has been favorable. "[President Felipe Calderón] took the action that he believed, based on information at hand, was in the best interests of the country. He didn't spend a week or two waiting for trends in public-opinion polls."
Polls released thus far actually show Mexicans, in spite of the skeptics, largely approve of the government's management of the crisis - a Mitofsky poll released last week revealed that 72 percent of those surveyed thought the health authorities had been "efficient."
But Jorge Buendía, a Mexico City-based pollster, said that even though preliminary results of his own national survey show similar opinion, it remains unclear whether the public thinks the dissemination of information was timely or well-managed.
The government slipped up, Buendía believes, by releasing numbers of "suspected" cases and deaths, which generated more panic. He said Mexico should have only released confirmed cases to the public, while suggesting that more cases were being investigated, like other nations have done.
"The challenge is to alert the population without generating panic," he said. "In most health crises the information is of poor quality while the demand for information is very high. This happened in Mexico. There was a need to know what was happening but the information was very, very vague and inexact."
ITAM epidemiology expert Tapen Sinha, on the other hand, praised the government for publicizing suspected or suspicious cases as a means to convince the public to take the situation seriously and abide by preventative measures.
Health authorities have been well aware of these risk since the beginning. Aside from the regular press conferences by Córdova, the Health Secretariat set up a call center for citizens to call with any questions - concerns about information, concerns about symptoms, concerns about the nature of the flu strain, "any doubts," according to Lezana. The center is staffed by 600 crisis-management operators, who are trained to refer specific calls to medical personnel. Since April 24, when the center was set up, they have received more than 4 million calls, Lezana said. "It's been a great tool."
Still, the numbers jumped almost daily, backlogs led to readjustments, new scientific projections have made headlines and distrust runs deep.
"They say they have 20 new deaths from the flu, and then they say, `Well, maybe it's not the flu after all,' " said Mexico City resident Tania Salinas last week. "It looks like they themselves don't know what's really happening, so it leaves us not knowing."
Mexicans are "incredulous" of their government, said UNAM sociologist Roberto Bermúdez Sánchez, adding that the lack of clear, timely information only contributed to the mistrust.
WHAT NOW?
Another criticism of health authorities has been follow-up since initial diagnoses, or alleged lack thereof. Some relatives of those who had been diagnosed and given the flu - even the new H1N1 strain - told reporters that they have not been visited by health officials since the sick relative returned. The government insists it is providing follow-up, and there is proof of that too.
Twenty-two year-old María Lui-sa Vázquez's mother Olga Cossío was diagnosed with swine flu and hospitalized on April 27. Her mother returned to her home in Chimalhuacán, State of Mexico, from the hospital on May 5. Two days later, nurses came to check up on the family and administer flu tests. They came again on May 10; the results were negative. Her mother is still weak but recovering, Luisa Vázquez said.
It's this kind of follow-up Mexicans are hoping for from their authorities. The nation's health system has suffered from budgetary deficiencies in recent years. And since joining the OECD in 1994, it has also come under more international scrutiny for its health budget and health system, while the media here consistently expresses outrage when Mexico ranks lowest in OECD rankings - regardless of whether the 32-nation membership is reserved for the world's wealthiest.
Lezana, for one, is optimistic that this experience will serve Mexico in the long run. The nation now has more than a handful of new labs to test for rare or unknown strains of flu, and going forward, intends to re-examine the way its hospitals share information in order to make the process even "more fluid."
"We have learned values that will help us perfect our own processes," he said. When the foreign experts leave, he said, "the issue will be in our hands."
Whether or not they believe the government's line with regard to the flu outbreak, ordinary Mexicans may learn something from it too. Health experts have included cultural habits - putting off going to the doctor, for instance - as one reason so many Mexicans may have died.
Citizens like Reyes, who went straight to the hospital at the first sign of trouble, could set an example. So could public institutions that carry through with newly imposed precautionary measures, said Bermúdez Sánchez, the sociologist. "If schools keep up prevention methods such as surgical masks, gels and sending students to doctors for more than just one or two weeks, people will begin to incorporate these habits into their everyday life."
Jonathan Clark contributed reporting |
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