A CHAT WITH MEXICO’S CORONAVIRUS CZAR
By Richard Ensor, The Economist’s Mexico City bureau chief
For political junkies in Mexico used to a president hogging the spotlight, the rise to household-name status of Hugo López-Gatell, a once-obscure health undersecretary, has been breathtaking.
Each evening Mr López-Gatell holds a press conference in which he reveals Mexico’s daily covid-19 figures and exhorts Mexicans to stay in their homes. Andrés Manuel López Obrador, the populist president, has at times resembled Donald Trump in playing down the pandemic. So Mr López-Gatell has earned a reputation similar to that of Anthony Fauci in America: a by-the-book health bureaucrat who must contend with an unhelpful boss.
Yet Mr López-Gatell himself is controversial. His critics fret that too little is being done. The total number of coronavirus test results that Mexico has processed until now, 11,357 as of April 4th, is roughly what the United States goes through every two hours. Like many countries, Mexico uses a sentinel model for tracking the disease, using only a few high-quality testing centres, with narrow criteria for testing eligibility. This is a reliable way to track overall trends, but it almost certainly leads to a drastic undercount of the pandemic’s true spread. Unlike in most countries, Mexico’s quarantine measures have been lax and unenforced. I interviewed Mr López-Gatell on April 3rd. Below is the transcript, lightly edited for brevity and clarity.
Photo by Richard Ensor – Hugo López Gatell (left), Richard Ensor Right, Susana Distancia (centre)
Richard Ensor: How do you balance the need to tell the public the full truth about the crisis — and perhaps catastrophe — that is coming, up against a desire to reduce panic and maintain public morale?
Hugo López-Gatell: This is possibly one of the most challenging or complex elements of managing an epidemic. I mention as a starting point, that in Mexico governmental public health has a tradition of, I would say, rudimentary and politicised risk-communication policy. This is something that I personally have dealt with in the last 10 or 11 years, including when I worked in the government during the 2009 [swine flu] pandemic.
When I was in academia at the Institute of Public Health, I would give a course on health safety. And I always emphasised a lot that the idea that information must be hidden from the population is completely wrong. Not only in ethical terms, individual ethics, government ethics, but technical ones. There are manuals and textbooks which can be summarised with the notion that the faster you make the population participate in a problem, explaining it to them frankly, absolutely transparently and candidly, adding them to be part of the solution, setting out the alternatives and what they can do, this is the most effective way for government and society to work together towards a solution.
In Mexico we began preparing for this epidemic of covid-19 from January 3rd. And very early, on January 22nd, we gave a press conference. And I remember that one of the journalists asked us: “Why are you giving us this news?” I made reference to what occurred 10 years ago, with the influenza pandemic, where the very first [government] communication was a very formal decision, by the health secretary, to decree the immediate closure of activities in metropolitan areas. So, this journalist’s question is: you’re presenting us with a catastrophic situation at this moment? And he was surprised to see that we were telling him about something that hadn’t even arrived yet.
We had the first case in Mexico more than a month later, on February 27th. And my response, we are telling you now because we want you to know it from the beginning, so that society works with us from the preparation [phase]. Of course, each day carries a new challenge, and one has to have clarity in that regard. But the fundamental principle is that transparency helps.
RE: But is it possible to be fully transparent with the population when you are using the sentinel model of epidemiological surveillance? You acknowledge that this number [of cases] you are publishing every night is not the true number of cases that are in Mexico today. When this government publishes crime statistics, it acknowledges the numbers it collects are not accurate; to compensate for that, it tries to estimate the cifra negra (“black number”) that the system is missing.
RE: Why is your government not making more of an effort to provide a cifra negra for covid-19 cases, which would improve transparency?
HLG: We are doing it and we will continue to do it. Today we are publishing a new indicator of sentinel surveillance: the percentage of confirmation [positive test results as a share of all results]. It does not matter if a country has 20 cases, 400 cases or 1,000 cases. The proportion of confirmation itself reveals what the pattern is. A rising rate of confirmation of covid-19 cases, among suspected cases, is an indicator that things are progressing in the epidemic. On several occasions, in our press conferences, we have said: we use the sentinel model, and in this sentinel model not everything is visible.
The sentinel model formally started operating when we moved to Phase Two last Monday [March 23rd]. And we are just now doing the whole package of estimations to present it publicly. It is not that we wish to restrict it, but rather that the model’s numbers are not yet available because it has only just begun operating.
RE: So you cannot put a number on the true number of cases that are in Mexico? You report 1,700 cases today in total. What is the real number in your estimation?
HLG: In Mexico, we don’t have that yet. That is a technical issue. In the world, there have been two or three publications, some more technical than others, that have suggested a factor of 10, a correction factor of 20, a correction factor of 40. These estimates are not universal. Because for each country, the expansion factor, or the correction factor, depends on various elements. Above all it has to do with risk behaviour. There are segments of the population that, with the smallest encouragement, will seek medical attention. Then there are segments of the population that never go, or take a long time. So, the patterns of demand are one factor.
In the sentinel model of influenza surveillance, there is an indicator that is very useful, and it is the one that the CDC formally proposed with the PAHO in 2005. That is: the proportion of health consultations due to an influenza-like illness. And from this attribution the number increases, when the number of consultations is known. Right now, we are calibrating this. And this has to do with the fact that we still have influenza, it is still active in Mexico. We have about 30% of acute respiratory infections — symptoms compatible with covid-19 — which are clinically indistinguishable from influenza, but which are still due to the influenza virus. So, it is not, I insist, incorporating the sentinel model for covid-19, this is an issue that was recently activated. We had it planned this way, because by changing the phase of response [from eliminating the spread of the virus to mitigating it], the surveillance model required also changed.
RE: in the absence of a proper numerical estimate, there are other pieces of statistical information that the General Directorate of Epidemiology could be providing to the public in the coming weeks, which has been useful in other countries. I will give two examples.
The first is from Brazil: the total number of hospitalisations for respiratory illnesses. In the last 3 weeks, Brazil has seen about 16,000 more hospitalisations than during the same period in 2019. Just 1,000 of these cases, as of March 28th, have positive diagnoses for covid-19. So there are 15,000 unexplained hospitalisations on a date by which the country had diagnosed just 3,784 people (see chart below). Now, in Mexico you have similar data that you could be releasing each week in the absence of your own cifra negra number. And a second example: The health secretary could begin publishing its internal database of new death certificates, broken down by sanitary district, on a weekly basis.
HLG: This is an excellent idea that we have considered for 10 years. These figures are very useful. It is good that you know the quality of the information system that exists in Mexico. It has great virtues, but also, great limitations. This system to document deaths has existed since the 1990s. The processing of information is so primitive that it takes a year, if we are lucky, to have the information. It is not a real-time system where death certificates can be automated and converted into electronic records. I wish that were the case. And the other, that of hospital admissions, has big limitations and its information is not in real time either. If you tell me that you have seen yesterday’s admissions, please give them to me.
RE: Sometimes in your daily press conferences you show statistics from the health secretary’s modelling about how many beds or ventilators Mexico will need, what share of people will end up in intensive care and so on. When you show these figures, you do not tell us whether this is the model’s worst-case scenario or the best-case scenario. Could you be clearer in explaining what these figures mean?
HLG: We have said that the key parameter is the cumulative incidence rate. That is the crucial point and the base parameter for what can happen in the distribution of cases in general, out of 127m Mexicans. Of those who receive attention, it is [a breakdown of] 80%, 15%, and 5% for mild, serious and very serious cases or deaths. We took as a reference, first, Wuhan and Hubei. And there, the incidence rate was 0.1%. So we overestimated it, and we considered 0.2%. We recently took an additional scenario of 0.5% and adjusted this to be our average scenario. And we are still considering the scenario of 1% up to 2%.
And my emphasis, not only in public but inside the government, on staying home, is desperately looking to bring down the curve, to make it flatter. I have not yet wanted to present it formally, but I am optimistic that the qualitative data suggests that we are achieving it. For two reasons. One, communication. I want to gather more social commitment to the [quarantine] measures. If I announce now: “We are achieving it”, that emphasis deflates. And the other reason is technical. We do not yet have a sufficiently robust dataset to infer within the confidence band that we are achieving the suppression of transmission.
RE: One of the most consequential covid-19 questions for Latin America is what happens if you have a population that is not ageing like Europe’s, but where young adults are much more ill. Is that just as dangerous as having an ageing population? How does a young diabetic compare in your modelling with someone who is over 65?
Yes, we consider it. We have a median age that is 10 years younger than most European countries and 7 years younger than that of the United States. And that is an advantage. We have several models. There is a basic model, which we made with ordinary differential equations, a model to follow, compartmentalised and not stochastic. We have a model with the same characteristics, a little more complex, that considers some chances of recovery and other possibilities. We have models that have been brought to us by academic communities such as the UNAM Institute of Mathematics, the Centre of Complex Sciences; other colleagues, including a French colleague from Marseilles, Benjamin Roche, who is working at the faculty of veterinary science. And consistently, they have very similar signals, obviously with small differences.
And we have other, simpler models, like the one we use to estimate our needs: ventilators, beds, and so on. And then we made a refinement to this, which considered the difference in the risk of complication and death, with special emphasis on the age of 65 and over. One does not consider co-morbidity and another considers the huge prevalence of diabetes, hypertension and obesity in Mexico. Obviously, there is no previous experience of what the specific mortality rate of covid-19 is in these populations. They are known only to be higher-risk populations. But there are no comparative studies yet. Those will come out at some point, but they don’t exist yet. So, what we did was, assume that they have similar risks, with different scenarios for the adult population. But we were doing several scenarios and in the end we were left with an idea that is not very encouraging, that the advantage of age in Mexico is negated by the disadvantage of illness.
RE: So, there is no big difference between the demographics of Italy and the demographics of Mexico?
HLG: Yes. I do not trust too much in wishful thinking. I would like to think that these 10 years of average youth would help us, but with the monstrous burden of diabetes, 14% of the population, 25% hypertension and 75% of the population overweight and obese, it is difficult to think that 10 extra years of youth are going to help us.
RE: The fragmentation of Mexico’s public-health system is a great source of inequality in this country. So are the regional discrepancies that we see between urban and rural places and between states. A pandemic will exacerbate these inequalities. This government cares a lot about inequalities. What is its plan to minimise the inequalities that we are going to see in the next months?
HLG: Yes. I see this in two stages, starting with the acute stage. We have to be realists. There is an inequality in Mexico that was built over decades, 50 years. We cannot resolve it in two weeks before covid-19 comes. It is structural. What we can do is mitigate the impact. On health, we are doing it using the infrastructure and the organisation of government social programmes, [which] cover 20–25m people. And this also has a network of citizen participation, but they are mechanisms for linking citizens so that they have early access to certain resources: money, but also information, it is also internal linkage within communities. On that network we must mount the logistics of the distribution of supplies.
Now that we have the participation of the armed forces, offering civilian support — not militarised. We are defining access routes to certain critical foods. So, at any given moment, if the immobilisation caused by the pandemic or by government restrictions results in a shortage, we have mechanisms in place. They are not yet in the field, because they are not needed yet. But it is planned to have a supply of basic grains, milk, and so on. They are already planned, so that if they happen in the field according to what is happening with the epidemic.
Another side that should not be overlooked — we are still working on some details: what if we need to remove patients from a community where there is not enough access to services, for example? And here it has also been very useful to be able to trust that we have the support of the Armed Forces. Through the military we have at our disposal the possibility of air transfers and so on. But even on the civil side, we are making an inventory of the ambulances that depend on state and municipal governments, and private ambulances. What we want is to have an organising mechanism to optimise the use of ambulances.
RE: In January you were telling some very confused journalists that there was going to be a global health catastrophe. Now today, those journalists might ask you why you are still yet to buy medical equipment like gloves, masks and ventilators.
HLG: Because the global market became distorted immediately. Let’s not lose sight of the fact that the two biggest suppliers of PPEs [personal protective equipment] are Mexico and China…
RE: Mexico sold a large portion of its masks to China in February. You are now buying those same masks back on the Chinese market at 30 times the price. Should you have stopped those sales?
HLG: Maybe we should have done it in retrospect. We didn’t do it. There was no consideration of “we have to do it” and indeed China had the need, China had the power, that is, to locate the supplies. And it is not 30 times, it’s less. Stopping that would have involved making decisions in February that would have been extremely disruptive. For example, we would have needed the government to declare a state of emergency back in February in anticipation of what was to come, completely affecting the social, economic and political dynamic. So, in every moment, thinking about the counterfactuals based on how it turned out always has its consequences.
RE: It is considered a good thing to be the last in line for a pandemic. You have time to watch the responses elsewhere, to learn the lessons and for your population to have awareness of what’s going on. Is there also a disadvantage to coming after Europe? I am sure that none of the ventilator manufacturers have said to themselves: “We need to save 5% of these to send them to Latin America”. And so you have to join the end of the queue in this global free-for-all for supplies.
HLG: It has definitely been quite a challenge to get the different supplies and each one has its own specificity. There are those which are low-tech but for mass consumption, like PPEs, and those that are high-tech but not for such mass use. We have suffered many difficulties to find them, to the degree that we have had to obtain them in small proportions. This company has 50, that one has 120, that one has 10, that one has 2, that one has 1,000! Well, 1,000 in no case — the most that we have had from a single source has been 200. Tomorrow (April 4th), two planes are leaving for China to bring them supplies, mostly PPEs. A couple of days later they will return with ventilators. Today the Mexican president had a teleconference with the Chinese president. The foreign minister, Marcelo Ebrard, is doing an exhaustive search all over the world [for ventilators]. We have been working for 10 days now on utilising here the technological prototypes not just at MIT, but also others that were in Mexico. We discovered that there are seven [ventilator] prototypes in Mexico in an advanced state of development, thinking of the possibility that during the different phases we may be able to obtain more ventilators.
RE: Mexico is one of the few countries in Latin America with the kind of manufacturing base that could be repurposed for the making of these machines. Lots of Americans are expressing optimism that these Mexican factories are going to be making ventilators for the United States. Should the Mexican government have a problem with this prospect of factories in Mexico churning out ventilators for other countries when this country doesn’t have enough?
HLG: Once we meet our needs, I don’t see a problem. But obviously we are going to prioritise our internal consumption. We still do not have a massive response from the industrial sector, but we have had some positives. The automakers, Volkswagen, Audi, they are offering help. Others on a smaller scale, like maquiladores in the north, are offering help. There is a company in Tamaulipas that was already making ventilators, a French company.
RE: Ventilator parts?
HLG: Assembling it. Assembling it from the prototype. My understanding is that the technological part of the microcomponents is not the great challenge, but to assemble it later is. At this moment, as I say, we have seven prototypes under study. One of them is that of MIT. We have involved public universities, private universities. Our own health institutions, the nutrition institute and the Mexican social-security institute are running simulations, they are experiments on animals, in the last 72 hours they are already experiments on pigs, already the fine-tuning is the last issue.
RE: Where are the extra doctors and nurses that Mexico requires going to come from?
HLG: We opened a call, which is named “doctors for well-being” but also includes [a call for] nurses, it includes psychology personnel and chemists. And that recruitment process has begun. We assume that we will have an influx of two classes: the youngster who has just graduated and to whom we will give rapid progress, not to graduation but to specialisation, and the retiree who wants to return to help the country. We made this call before covid-19 began, we already had about 3,500 recruits, the goal is 45,000. And now we accelerated it with covid-19. I was asked today what would happen to these older doctors, being the population most at risk of complications from covid-19. The vision is that they come but obviously they cannot be in the front line for covid-19 but they can replace someone younger and free that someone to attend covid-19 patients.
RE: And Cuban doctors?
HLG: I would not rule it out. There is no specific plan at the moment but I would not rule it out. It will surely lend itself to political controversy if we implement it, but I would not rule out the assistance of Cuba or any other part of the world that could attend. Doctors of the world, Doctors without Borders, I don’t rule it out.
RE: Many countries go down a similar path towards total quarantine. They begin by asking citizens to do the right thing and stay home, and they end with forcing citizens to do the right thing. Mexico is in the stage of very nicely asking its citizens to “quédate en casa”. What happens next? Surely you have some other plans if this is not enough.
HLG: We formulated our recommendation so that it was not directed at citizens, but at the economic sector. And that makes a big difference. Our order by the Secretary of Health is to temporarily suspend work activity. That has two or three elements behind it. One: if one is to direct orders towards citizens, one must assume that there is a previous history of adherence to the law. And we know that Mexico is a country that in the last 30 years has been greatly affected by criminality that arises from socioeconomic inequality, the fatal war against drug-trafficking decreed by a president two terms ago. That has totally distorted the meaning of law enforcement. Nor should we lose sight of corruption, a historical phenomenon that has undermined the government’s ability to apply the law. A difference from — , I don’t know if I’m too optimistic — most of the countries in western Europe.
That is one factor, the other is the huge economic inequality in the country. So if one does direct the measure at citizens, if one is equally stringent with the street vendor, the taquero on the corner and the lady with her corn, as with the owner of a multinational company, then the one that suffers the worst consequences is the first group, not the second. So we designed the intervention so that it was destined for the productive sectors, because the productive sectors, by suspending activities, would set in place a mass demobilisation. Strictly speaking we must remember that the goal is mitigation, not containment. And so the intervention erodes, because if the taquero on the corner and his family are not to starve, there is going to be a certain number of people who will need to remain mobile, in addition to those workers deemed essential. But the sum of suspending the schools, suspending formal work, and suspending government work is a very large population volume. We had originally estimated it at 65m of immobility. That has a positive effect.
RE: Will that be enough? Many countries are concluding that you cannot reach a sufficient level of “demobilisation” without having a sufficient level of financial compensation to keep everyone indoors.
HLG: It is an excellent approach, I believe that in the near future we will start to see economic actions to support mitigation. Yesterday the president met with Carlos Salazar Lomelín, the president of the business coordination council. I do not know the specifics of what is agreed but I am aware that the Ministry of Finance, Ministry of Economy already have plans for compensation in the productive sector.
RE: Lots of countries in the developing world are also worried that this demobilisation will lead to an exodus from cities of migrants who will then go back to the villages, possibly with covid-19. Are you worried that this kind of population movement could spread the virus beyond urban centres?
HLG: Yes, we thought about it. According to demographic statistics, in the 1970s and 1980s, the poor peasant society that sent its people to live in the cities was a relatively recent phenomenon with a very large rate of return. From the late 1980s to today, it has become a more stable migration to the cities, either in Mexico or abroad. Internally it is unlikely that [we will see], in large numbers or in a small proportion, those people returning to their rural origins from those Mexican cities, including Mexico City. What may happen is the return of our migrant countrymen in the United States who, due to a fear of the epidemic there, a lack of services they need, and a desire to come home could make the trip back to Mexico.
RE: With the fullest respect to the Mexican cabinet, why is it the cabinet and not the president announcing some of the most consequential measures that Mexico has seen in many years? Is that a reflection of the level of interest that the president of this country has in this issue?
HLG: From the beginning the president wanted to make very clear a perspective that, it seems to us, has been very unfortunately blurred in other countries. Undoubtedly, the United Kingdom, the United States, Canada, France, Germany, and Denmark have very robust scientific and technical communities health, both outside government and their public-health agencies within government: CDC, the Public Health of Canada, Public Health England, etc. As a public-health specialist I find it regrettable to see that such robust scientific and technical communities have been displaced from the decision-making spectrum, to make way for political decisions that have governed, not in all but in many of these countries, the timing of decisions and even the technical content of these decisions.
And in Mexico I feel very encouraged due to the fact that we have a president who from the beginning said: these decisions are scientific, they are technical and the experts will take them. We had the G20 meeting a week ago, I had the privilege of accompanying the president in the videoconference. He opened his speech by saying “I share with you that in Mexico these decisions are those of the specialists”. I do not doubt that in other countries the experts have been taken into account, but if one sees the final result both of the implementation of the measures or their design, and of the governments’ positioning, what has prevailed is the political dynamic. So that is the main reason why the president said “I want to make it very clear that this is a technical decision and not a political one”. In turn we believe that this approach to new measures has positive consequences regarding the economic and social dynamics. I will close with the following example.
The measure, as you know, says that essential activities will remain open. The whole world assumes that they are essential: and so the steel sector comes, the construction sector comes, the beer sector comes! In the last 72 hours the beermakers were defending themselves. The best defence against these pressures has been to keep ourselves in the technical realm. It is not a political decision to marginalise or discriminate one sector from the other. It is a technical decision and what we want is for there to be fewer people in the public space. So for whichever sector that can promise to keep their operations to a minimum, it would be feasible to keep it running. But if a sector just because it has economic power, comes to say, “I want to remain open even if I do not remove superfluous administrative activities, marketing, and so on…” well, no. What has protected us is the technical.
About the author:
Richard Ensor is The Economist‘s Mexico City bureau chief and covers Mexico, Central America and the Spanish-speaking Caribbean. Prior to this, he was deputy news editor, based in London, where he helped oversee The Economist‘s news and online operations. He joined the newspaper as a social-media intern in 2015 and has appeared on several news channels on its behalf, including CNN and Al Jazeera. Before joining The Economist, he studied history and international relations in Australia, and then journalism in Russia and Germany.
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