Why is Mexico's Death Toll So High for 2009 H1N1 ("Swine Flu")?

First Flu Death Provides Clues to Mexico Toll

Adriana Zehbrauskas for The New York Times

By MARC LACEY and ELISABETH MALKIN
Published: April 30, 2009

OAXACA, Mexico — Adela María Gutiérrez fell ill in the beginning of April with what she thought was a bad cold. She tried aspirin and antibiotics, bed rest and moist towels, but nothing brought down her soaring fever, reduced her aches and pains, or boosted her energy level.

It would be more than a week before Mrs. Gutiérrez went to Oaxaca’s General Hospital, where she arrived listless and barely able to breathe, her extremities blue from a lack of oxygen.

That delay in getting expert help may explain why Mrs. Gutiérrez, 39, a mother of daughters ages 10, 17 and 20, became Mexico’s first death from a new, virulent strain of influenza A(H1N1). It may also suggest why this country’s death toll from the virus is higher than any other’s.

Epidemiologists are still puzzled by the virus, its origins and its modes of transmission. But they agree that prompt medical attention is crucial to treating it.

That has been where Mexico, which the Health Ministry said Thursday had 312 confirmed cases and 12 deaths, lags far behind.

“People wait too long to go to doctors,” said Dr. Marcelo Noguera, undersecretary of health for the state of Oaxaca.

“That’s a problem here in Mexico,” he continued. “If we can treat a disease like this early, we can stay ahead.”

There may well be other factors to explain why patients like Mrs. Gutiérrez, whose medical records show a desperate, belated scramble by doctors to keep her alive, are dying in Mexico at a higher rate than flu patients elsewhere. Mexicans may have been hit by a different, deadlier strain, or the flu may have infected more people who had other health problems, researchers speculate.

But one important factor may be the eclectic approach to health care in Mexico, where large numbers of people self-prescribe antibiotics, take only homeopathic medicine, or seek out mysterious vitamin injections. For many, only when all else fails do they go to a doctor, who may or may not be well prepared.

“I think it has to do with the culture, the idiosyncrasies of Mexicans,” said Dr. Nicolas Padilla, an epidemiologist at the University of Guanajuato. “The idea is that I don’t go to the doctor until I feel very bad.”

There also are logistical reasons that compel Mexicans to steer clear of hospitals. At overcrowded public facilities, they complain, they are often turned away, treated by indifferent doctors or made to wait endlessly.

Mrs. Gutiérrez’s husband, Luis, said Thursday in an interview in his home that when she arrived at the hospital, no bed was available, and no respirator. They give preference to people who are bleeding, who are near death, he said.

Making matters worse, because it was Holy Week, the hospital had lower staffing levels than normal, and she had to wait several hours before being seen.

The government is pushing to expand its public health network through a new insurance program that attempts to reach poorer people and those in remote areas.

But experts say the country has had a harder time improving quality.

Mexico’s public health budget is about 3 percent of gross domestic product — within the range of spending by other major Latin American economies, but well below the rate in developed countries, according to the World Bank; and Mexico has only about half as many hospital beds per capita than the United States.

To help Mexico meet the extra costs of the flu epidemic, the World Bank issued a loan of $205 million.

“The two key things that they need to work on now,” said Keith Hansen, a World Bank health official for Latin America and the Caribbean, “is surveillance, to pick up patterns of infection, and to make sure that everybody who needs care has access to it.”

In an acknowledgment that Mexicans frequently act as their own doctors, the government’s announcements, played repeatedly on the radio, advise people not to self-medicate and instead to seek out medical attention.

Mrs. Gutiérrez, in contrast, continued working as a field worker for the national tax agency after first showing symptoms. It took her three days to go to a doctor at a small clinic a few blocks from her home. She was told she had a throat infection and should take antibiotics. As her condition worsened, she sought other opinions but still avoided the hospital. On her third consultation, a doctor told her she had pneumonia and sent her to the hospital.

Once she was admitted, health officials appear to have acted relatively quickly. A laboratory test found an unusual virus. State and federal health authorities were notified. “She wasn’t responding,” said Dr. Yuri Roldán Aragón, one of her doctors. Her condition worsened by the day, and she died on the afternoon of April 13.

Her medical file, nearly an inch thick, sits on the desk of Dr. Jesús M. Salcedo, the hospital administrator, with the word “Defunción,” meaning she died, scrawled across the cover sheet in red marker. Her various diagnoses over the course of her treatment — pneumonia, coronavirus, SARS, among others — indicate the initial uncertainty about her condition.

Three days after she died, Mexican officials declared an epidemiological alert based on her case and others. That set in motion surveillance at 520 hospitals nationwide, and notification of an expanded flu season to the United States Centers for Disease Control in Atlanta.

The next chapter occurred on April 20, when the C.D.C. notified Mexican officials that two cases had been found in Southern California that showed components of human and swine flu, said Dr. Miguel Ángel Lezana, Mexico’s chief government epidemiologist.

On April 22, Mexican authorities sent samples, including ones from Mrs. Gutiérrez and a young boy in La Gloria, a small town in Veracruz, to the National Microbiology Laboratory in Winnipeg, Canada. The results came back the next day. Both Mrs. Gutiérrez and the boy, Édgar Hernandez, who survived, tested positive for the mysterious flu.

Epidemiologists in Oaxaca swung into action. They isolated Mrs. Gutiérrez’s family, disinfected her home and began more than 500 interviews with neighbors, co-workers and hospital workers.

Any who had flulike symptoms were tested, but none have been found to have the same virus that killed Mrs. Gutiérrez, said Dr. Rubén Coronado, a state epidemiologist.

Oaxaca, one of Mexico’s poorest states, has reported about 60 suspected cases. Mrs. Gutiérrez is the only confirmed death.

“We’re in a quandary,” Dr. Noguera said of how Mrs. Gutiérrez might have contracted the virus while others around her apparently did not. “I don’t have a theory. I just don’t know.”

Marc Lacey reported from Oaxaca, Mexico, and Elisabeth Malkin from Mexico City.

For more information:
http://www.nytimes.com/2009/05/01/health/01oaxaca.html?em