La Semana: Sunday, Mar 20
The week in public health and holiday pyrotechnics
Welcome to the Sunday edition of The Mexpatriate.
In today’s newsletter you will find the second part of my series on the public health crisis known as the “desabasto” as well as a re-published post from the 2013 archive:
Deciphering the “desabasto”: Part II
The irresistible urge to “make a joyful noise” (from 2013 archive)
Please send me your comments, feedback and questions, and feel free to forward this to anyone who may be interested. You can always find all sources (with links) at the bottom of the email.
Deciphering the “desabasto”: Part II
“If the pandemic doesn’t kill them, the medicine shortages will.”
This was written on a sign held by a parent protesting the lack of chemotherapy in May 2020, a few months into the COVID-19 lockdowns in Mexico. The protests have continued ever since.
“What is the magnitude of the shortages? In truth, this is a difficult question to answer,” according to Xavier Tello in his book La Tragedia del Desabasto. “The complexity of the response is caused by the inconsistency in how supplies have been procured in the last three years.” Sifting through the morass of data, “much like archaeologists excavating”, is how analysts have tried to gather precise numbers.
“We cannot forget that…there is a story of pain, desperation and systematic lack of access to healthcare behind every report, every figure and every unfilled prescription”
“The number of different agencies, methods and data make it difficult to establish tracking mechanisms that would help in the timely identification of issues affecting access to drugs and other medical supplies,” note researchers in the report “Radiografía del Desabasto” by Colectivo Cero Desabasto and Nosotrxs. Based on their extensive research, they conclude that 9.7% of prescriptions issued by public health institutions (24 million total) were unfilled because of the shortages in 2021.
As a reference, only 1.4% of prescriptions were recorded as unfilled in 2017, and the biggest annual increase happened between 2019-20 (2.7% to 7.7% unfilled). While 9.7% may seem an insignificant number, its effects on the population have been deeply felt. Every medicine unavailable at a public pharmacy has either had to be purchased at a private one out of pocket, not obtained or administered at all, or even purchased on the black market. Reported sales of fake or stolen drugs have gone up by 137% since 2017 according to COFEPRIS (the Mexican FDA equivalent).
In addition to the unfilled prescriptions, doctors at public hospitals have been frustrated in their efforts to treat patients by not having access to essential drugs, devices or supplies. Some find themselves in a grotesque bureaucratic labyrinth: according to the administration’s most recent legislation, all public healthcare must be provided free of charge and the law prohibits obtaining certain prescription medicines or other medical supplies via private pharmacies or vendors. This used to be a last resort available to patients and healthcare providers if the public institution could not provide for their needs.
Who has been most affected by these public health failures? Lower and middle-class Mexicans who rely on the public healthcare system and particularly those with chronic illnesses. The most dramatic proportional increase in out-of-pocket medication expenses was experienced by the poorest segment of the population (92.8% increase from 2018-20 according to the Center for Economic and Budgetary Research, CIEP).
The patients most impacted in 2021 by drug shortages were those with cancer, diabetes, organ transplants, hypertension and neurological/mental illness. Residents of Mexico City, Estado de México, Jalisco and Michoacán have registered the highest number of reports of shortages on the Cero Desabasto platform, but institutional complaints have been logged all over the country, in both urban centers and rural areas.
While shortages have also been reported in the private sector, they have been more occasional than chronic. Private pharmacies may at times have been out of stock of certain medications that patients suddenly couldn’t get at public pharmacies, and of course, they have not been immune to the supply chain disruptions caused by the COVID-19 pandemic.
In the face of the obfuscation and disinterest on the part of the administration regarding the “desabasto”—after all, AMLO notoriously has claimed to have “otros datos” (other data) when confronted with unflattering statistics—the challenge of documenting, researching and addressing the needs of those affected has been taken up by NGOs.
Colectivo Cero Desabasto is made up of 81 organizations “all committed to the idea that together we can achieve more and are concerned by the situation faced by the most vulnerable patients,” notes an article in Nexos about the efforts of civil society. “We cannot forget that…there is a story of pain, desperation and systematic lack of access to healthcare behind every report, every figure and every unfilled prescription: interrupted treatment, lack of medical supplies and the problems to which anyone who has had to go to a public health institution in Mexico can attest.”
For the 2019-20 reports compiled by Cero Desabasto, the organization filed 360 requests for information from over 200 public health and human rights institutions. Their efforts have provided a map, showing the patterns of the landscape many doctors, patients and families have been navigating without any guidance. While this organization focuses on collecting citizen reports on shortages and analyzing data, others are focused on providing legal counsel for those filing injunctions against the government, and there are those that have been supporting certain vulnerable populations for years—such as Nariz Roja, A.C., which provides resources for cancer patients—which now raise funds to purchase medicines.
The government narrative has been tweaked to address some of the public indignation over the past two years, particularly after Deputy Secretary Hugo López-Gatell’s cringe-worthy remarks in an interview in June 2021: blaming a “golpista” (coup-seeking) movement for hoodwinking Mexicans into believing the parents of children with cancer who have denounced the shortages, and alluding to a “right-wing” conspiracy behind it.
In November 2021, AMLO did acknowledge that the “desabasto” is real, and insisted that the problem be solved: “I don’t want to hear any more about lack of medicines…there are no more excuses.” There is no question that the “4T” still places the blame squarely on pharmaceutical companies and their corrupt practices, and theirs is a compelling narrative. In a survey conducted in 2019, 40% of citizens who responded thought that the shortages were caused by corruption in the pharmaceutical industry.
This leaves us to wonder: has all of this institutional upset brought more transparency? Have the corrupt been prosecuted? The COFECE (Federal Economic Competition Commission) has fined five companies since 2018 and sanctioned 21 individuals for colluding to set a limit on discounts offered to pharmacies and fixing prices of some items, but no criminal charges have been brought. The administration insisted that it was these middlemen in the pharmaceutical supply chain who were unethical in their practices, charging excessively for the distribution of medicines and supplies to pharmacies all over the country. While it is true that a handful of domestic companies have dominated this market, Mexico is certainly no exception in this: the largest U.S. distributor, McKesson Corporation, distributes to 50% of the country’s hospitals and 20% of all medications in the country.
Irene Tello of Impunidad Cero has pointed out that while the industry certainly suffers from corruption and needs more oversight, the practices that would improve transparency have only decreased during this administration: “there has been an abysmal regression in terms of transparency.” In fact, the abrupt changes in processes of procurement and distribution have only led to more ambiguity and opacity.
According to the report Operación Desabasto: “In 2020, the Compranet database registered the largest quantity of public procurement categorized under the new label ‘other contracts’—in other words, it is not clear whether these were conducted via public bidding or direct award. This category appeared in 2018 and registered 4 billion pesos that year, then 6 billion pesos in 2019 and 36 billion pesos by 2020.” While the direct awarding of contracts has been a significant part of public procurement of medications and supplies since before the AMLO administration, it has continued to gain ground over the more transparent and competitive public bidding process.
As explained by the think tank IMCO (Mexican Institute for Competition): “…In the direct award and/or restricted access to bids it is a discretionary process since suppliers are chosen to submit bids or be allowed to participate. In contrast, in a public bidding process, any company has the opportunity to participate and the best proposal that meets the quality and budgetary criteria is chosen.”
The public health system continues to be in flux. On Mar. 15 it was announced that INSABI (Institute for Health and Well-Being) will no longer provide services to the uninsured population and will only be responsible for procurement and other administrative tasks. The 28% of the Mexican population without access to public healthcare will now be the responsibility of the IMSS-Bienestar program. “It is a good alternative because at least they have the administrative infrastructure…but as of right now, what has been presented leaves us more questions than answers,” says Andrés Castañeda, coordinator of Cero Desabasto.
One of these questions is how the government plans to fund this dramatic increase in the IMSS-Bienestar coverage. As Jorge Andrés Castañeda writes in El Heraldo de México: “Once again we see that the road to hell is paved with good intentions. With all the budgetary problems faced by the government this year—a budget short of up to 250 billion pesos—it seems dubious that the government could assign the necessary resources.”
The irresistible urge to “make a joyful noise”
Originally published on The Mexpatriate blog in March 2013
Small talk in the United States might begin with the weather and traffic, perhaps venture further with a soundbyte from the morning news broadcast. If you're a foreigner living in a small colonial Mexican town, you skip right over the weather (lovely day...again!) and the traffic (unless you got stuck behind a parade) and go right to “did you hear those fireworks at the crack of dawn? My dogs were going crazy...Do you know what holiday it is?”
Loud celebrations are such a constant part of the town's life that the topic has become trite; one gringo will complain about another gringo who bothers to complain about the noise. Most of the explosions of cohetes (rockets) are tied to religious holidays - from the brightest stars in the Catholic galaxy of observances, like Semana Santa (Holy week) to the dimmest, in honor of a local patron saint. But secular holidays aren't safe from pyrotechnic madness either. Independence, the Revolution, the Battle of Puebla, Benito Juárez's birthday, your neighbor's 15th birthday party, are all honored with - you guessed it - fireworks!
Why are pyrotechnical displays such an integral - at times dangerous - part of religious life in Mexico?
On Mar. 15, a truck full of cohetes that was part of a religious procession in Jesús Tepectepec, Tlaxcala exploded, killing 17 and injuring 154 people. “The explosion occurred when one of the fireworks went astray and hit a truck where the parishioners were keeping a significant quantity of rockets,” according to a report in Animal Político. The head of the Tlaxcala public safety department, Mateo Morales Báez, stated that ecclesiastical authorities should better regulate and reduce the amount of explosives used in religious celebrations.
Why are pyrotechnical displays such an integral - at times dangerous - part of religious life in Mexico? Some say they ward off evil spirits or wake up the saints (and sinners too), but it seems that the origin of noise-making on the cusp of dawn can be traced back to pre-Hispanic rituals; the priests used drums, conches and flutes as a sort of alarm clock for the sun god, Huitzilopochtli, assuring that he would rise every morning and make his journey across the sky. After the Spaniards arrived, gunpowder was added to the traditional solar wake up call.
The boisterous, festive, almost feverish Mexican celebrations honoring Jesus or the Virgin or the saints may confound more Protestant perceptions of solemn worship and self-denial. But Martin Luther himself described quite a droll technique for outsmarting the Devil: “Whenever the devil harasses you thus, seek the company of men, or drink more, or joke and talk nonsense, or do some other merry thing. Sometimes we must drink more, sport, recreate ourselves, aye, and even sin a little to spite the devil, so that we leave him no place for troubling our consciences with trifles.” The devil doesn't want you to party, so you should really party harder!
Jolly old Martin would have found plenty of kindred spirits in Mexico. In the words of Octavio Paz, “Our fiestas are explosions. There is nothing so joyous as a Mexican fiesta, but there is also nothing so sorrowful. Life and death, joy and sorrow, music and mere noise are united.”
This catharsis has been viewed as a temporary relief and release from the burdens of Christian guilt; the guilt stems from both original sin and from Christ's death. As Paz's phrase implies, there is a seed of sorrow in the joyful inhibition of the fiesta, the foreshadowing of more guilt and regret to be experienced the morning after. In Mexico, you can have a physical hangover (“la cruda”) but you are particularly pitied if you suffer from “la cruda moral”, a moral hangover of repentance for sins committed the night before.
We are approaching some of the most cacophonous days in the Mexican calendar, the two weeks of festivities surrounding Easter; rockets will herald the dawn and the townspeople will gather to watch exploding effigies of Judas hanging above the streets. The cycle continues.
El desabasto existe y reconocerlo es el primer paso para solucionarlo (Nexos)
Pese a cuarentena, padres de niños con cáncer protestan en la CDMX por desabasto (Expansión MX)
López Obrador admite el desabasto de medicamentos y exige al secretario de Salud una solución: “ya no hay excusas” (El País México)
COFECE multa a empresas y personas físicas por coludirse en el mercado de distribución de medicamentos (COFECE)
Operación Desabasto (El Universal)
El mercado de medicamentos en México: retos y oportunidades (IMCO)
El INSABI se queda para compras y burocracia; IMSS absorbe atención (Animal Político)
¿Salud universal? (El Heraldo de México)
Aumenta a 16 los muertos tras explosión en Tlaxcala (Animal Político)
La fiesta: del alcohol al éxtasis (Revista Replicante)