Doctors Without Borders/Médecins Sans Frontières (MSF) medical coordinator Emiliano Lucero recently returned from a year in Mexico. In this interview, he discusses the challenges MSF faces in the country and the populations the organization is assisting there: migrants traveling from Central America to the United States; people from Oaxaca State affected by Chagas disease; and people affected by urban violence in a neighborhood of Acapulco.
Why is MSF working in Mexico?
Regardless of the resources Mexico has as a country, parts of the population have to directly endure situations of extreme violence and find it difficult to access the health system.
Criminal organizations operating in large parts of the country use methods and strategies that have serious medical and humanitarian consequences for the population. MSF seeks to address these medical and humanitarian consequences as well as bring about changes and further engage institutions, bearing in mind that Mexico has a health system that theoretically has the capacity to respond to these needs.
What are these humanitarian consequences?
On the one hand, there are direct consequences of violence such as killings, injured people, sexual violence, forced displacement, kidnappings, disappearances, trauma, torture, and psychological problems. And on the other hand, access to health services is impaired and emergency services are overwhelmed, promotion and prevention programs have been suspended, and/or health facilities are no longer operational due to a lack of trained staff that often have to reduce their working hours, are exposed to being robbed, or are threatened in the areas affected by violence.
All of this affects the patients who see how their access to health services increasingly shrinks.
Who are the migrants passing through Mexico and why do they leave their countries?
Most of them are young Central American men traveling alone who are physically fit, as this is essential to embark on this journey. Yet there are also families, women, and even unaccompanied teenagers and children.
Most of them admit they are migrating to flee violence in their countries of origin. Marginalization, discrimination, and lack of opportunities are compounded by exposure to violence (threats and recruitment by street gangs) as determining factors triggering the decision to migrate. Their aim is always the United States, and they embark on this journey because what they are leaving behind is worse.
What do they tell you about the journey?
Their stories reveal suffering. Violence is ever-present throughout their journey, which may last up to two months. When they travel by train, which is the means of transportation they use in Mexico, sometimes they are attacked by criminal gangs. These gangs search them, remove their clothes, beat them up, and steal their belongings. They are tortured and ill-treated. There are also cases of rape, of both women and men. There is a lot of sexual violence but, as it is a taboo subject, finding these cases is not easy.
What pathologies do these migrants suffer?
We see pathologies derived from their journey such as blisters or fever, or injuries caused when they fall off trains such as fractures or amputations, or due to attacks or kidnapping. All this physical violence, whether they are victims or witnesses, has a psychological impact, too. And there are also diseases such as dengue or malaria when they cross endemic areas.
Do they have access to free care in Mexico?
In theory, care is free for people who have no insurance whatsoever, but most hospitals request co-payment of user fees. Because of this, many migrants, even if by law they have the right to receive care free of charge, cannot go to the existing health facilities because they are asked to pay fees they cannot afford.
How does MSF manage to provide care to such an itinerant population?
At first, we had two mobile clinics for migrants in shelters. But when we realized that this population is everywhere across the country we redefined our strategy to follow the railway track. We had to be more mobile. Now we have two bases. One is in the center, in Lechería, where we have a trailer clinic to enhance our mobility. Following the migration route, it stops by shelters, diners, the railway track . . . since migration routes keep changing, this enables us to move wherever we are needed the most. And then there is our base in the south, in Ixtepec, where there is an MSF clinic next to the railway track where we offer primary health care and mental health care.
In Mexico, MSF is also providing care to Chagas patients. The organization has recently opened a Chagas project in Oaxaca State. Tell us a bit more about it.
The idea is to hand over our 12-year experience with Chagas to the Mexican Health Secretariat. It is a pilot project where we provide technical support. MSF will not treat patients directly. We are going to train the staff and support the facilities by donating medicines during the first few months of the intervention. The idea is to develop a comprehensive project integrated into the health system in the San Pedro Pochutla municipality, in Oaxaca, to later replicate it in other municipalities.
Are the medicines needed available in the country?
The first batch of Benznidazole, the medicine used as a first-line treatment in most endemic countries, has already arrived in Mexico. Yet this medicine is not within the basic treatment scheme, which includes the essential medicines already found at the outpatient level. The next step is to include it, together with Nifurtimox (usually administered when Benznidazole fails, as it has more side effects), in the basic scheme making it available to everyone in need.
Is Chagas well-known in Mexico?
It is a neglected disease. Despite its recent recognition at the Health Secretariat level, health centers and health workers as well as the general population are relatively unaware of its diagnosis and treatment.
The first national Chagas diagnosis and treatment protocol led by CENAPRECE (National Center for Prevention and Disease Control Programs) and supported by MSF is about to be agreed.
Does Chagas affect the entire country?
There are chinches [the insect that transmits Chagas] across the country, in the jungle as well as inside and around houses. The ones inside the houses are the most contagious, as they feed on people’s blood. The infestation and prevalence rates are not known in the area where we are planning to work, but the prevalence among the population might be between 4 and 12 percent.
You were telling us that MSF is planning to provide care to the people affected by the violence in a neighborhood in Acapulco—can you describe the work that's being done there?
Colonia Jardín is a neighborhood in Acapulco highly affected by violence, where MSF will launch a mental health intervention, working inside primary health care facilities run by the country’s Health Secretariat. The challenge is to work with the community—their support is key to being able to do our work within a highly insecure environment.
We will start by sending a psychologist who will support patients through a mental health clinic set up inside the facilities provided by the church, as it is the church that has a good relationship with the community. Then we will scale up the project, providing psychologists that will work at the health facilities in place. We will also have a network of community health workers that will provide home-based psychosocial support to families needing direct care and promote mental health across the neighbourhood.