Toward the start of Mexico's swine flu outbreak on April 24, Ángel Flores Maldonado had so many patients at his office that when he finally escaped at 10:15 that night, the line still stretched into the street.
The doctor does not work at a hospital, or a clinic, or the government respiratory center, but on the evening shift at a pharmacy in the poor, crowded neighborhood of Iztapalapa, in eastern Mexico City. "The same but cheaper," reads the sign at this popular pharmacy chain, Similares, and that is the calculation many Mexicans seem to have made while the virus spread through the capital.
"In Mexico, we are very unaccustomed to going to the hospital. Here, if someone has a cold or anything else, they buy something in the pharmacy, or they leave it be," Flores said. "This is why Mexicans are dying. Because we are very indecisive about going to a hospital until it's too late."
Several theories have emerged as to why all but one of the confirmed deaths from swine flu have occurred in Mexico. Much of it is speculation — that Mexico City's 7,300-foot elevation exacerbates respiratory illnesses, that there may be a slight variation between the viral strain prevalent in Mexico and swine flu elsewhere, that Mexico is further along in disease transmission and other countries will eventually see severe cases.
'Precious time' lost
But a critical factor, according to specialists here, is that flu victims have delayed checking into hospitals until their condition has deteriorated so much they cannot be saved. While medicines are plentiful and cheap at Mexican pharmacies, swine flu antiviral medication was often not available or prohibitively expensive.
"Some patients arrive late at the hospitals, and to a certain degree this is a problem of education," José Sifuentes-Osorio, an infectious-disease specialist at the National Institute of Medical Sciences and Nutrition, said in a radio interview Monday. "Many of our people, independent of their socioeconomic situation, self-medicate for three or four days, and they lose precious time."
What is clear about the outbreak is that the epicenter is Mexico City, a megalopolis of more than 20 million people where about a third of the population lives in poverty. As of April 30, when there were 397 confirmed swine flu cases, 285 of those people lived in Mexico City, according to the most recent available statistics from the Health Ministry. Of the 26 people it said had died of the virus, 20 lived in the capital.
Mexican officials said Monday that the epidemic appears to have slowed here and that commerce and government work would restart Wednesday after a five-day shutdown. Restaurants will start serving sit-down meals again, and schools will begin to reopen Thursday. The Health Ministry, whose figures differ from those of the World Health Organization's, said there were 802 cases, including 26 deaths. "This is about going back to normalcy but with everyone taking better care," said President Felipe Calderón.
Among the largest concentrations of swine flu cases is in Iztapalapa, with nearly 2 million people the densest, most populous of Mexico City's 16 districts, and also one of the poorest, said Miguel Ángel Lezana, the government's top epidemiologist.
"It's an area with a huge demographic concentration. Since this is a disease that is transmitted and spread by personal contact, when you have this huge accumulation [of] people in a rather small area, you have a greater opportunity to spread the disease," Lezana said. "Besides, these are the people with not actual lack of access, but difficulty getting access to medical facilities, so they get there late to the doctor or the ERs in case they need it."
The reasons behind this delay have little to do with apathy, according to Mexican patients and doctors.
"Delaying medical care is a characteristic of poverty. For people living close to the edge, taking off a day to visit a doctor or staying home sick is literally taking food out of their mouths," said Paul J. Gertler, a professor of economics at the School of Public Health at the University of California at Berkeley, who has worked in Mexico.
The free public hospital down the street, Iztapalapa General Hospital, often requires patients to wait for hours with no guarantee that medicines will be in stock. A course of antiviral medication used to treat swine flu costs more than $100, pharmacists said, a price out of reach for many patients.
"People prefer to come here because it is cheaper," said Emelia Segura Vázquez, a homemaker who sought a consult with the on-site doctor at the Christ Medical Pharmacy in Iztapalapa for her 6-year-old son, Omar Israel, who had diarrhea. "This is the closest thing we have. And more than anything, I don't want to take him to a clinic because of all the contagion there from the flu."
Mexico has three parallel health-care systems. Workers who are employed by the government or private companies are part of the national social security system, as are their families. When they go to a hospital or doctor, the care is mostly free. The uninsured, about 50 percent of the population, include the unemployed and those who work in the informal economy. They also have access to health care, at public clinics and hospitals run by the Health Ministry. They are required to pay for services, but the amount is based on their income. It is often just a few dollars for a doctor's visit. A small fraction of people, about 3 percent, visit private hospitals using insurance or, if they are wealthy enough, by paying in cash.
"Mexico is a country with a lot of self-medication," said Homero Martinez, a researcher at the Rand Corporation in Los Angeles who specializes in the study of the Mexican health-care system. "You can go to the pharmacies, they are open 24 hours a day, they deliver, and you can buy all the medicine you want for yourself — and your neighbors."
Outside the Christ Medical Pharmacy waiting room, in a graffiti-scarred block of concrete buildings, 6-year-old Miguel Pérez threw up into the grass along the sidewalk. His mother, María, said her husband lost his job, along with his insurance, three months ago. Her government-assigned clinic, according to her address, is about 45 minutes away by bus. "They attend you well here, it's not a problem," she said.
During the outbreak, when masses of people became concerned about the possibility of infection, patients waited hours to see doctors. Some family members slept overnight on the sidewalks. The government deployed more than 100 ad hoc clinics — trucks and tents staffed with doctors and nurses — to quickly screen for prospective flu cases. At one mobile clinic in Iztapalapa, frustrated residents last week said they had waited for up to four hours to see the doctor. At one point, care was delayed even further because a crying boy had a high fever and the doctor wanted him rushed to a hospital, but there was no ambulance available.
'Very aware of the risk'
Health care has become more accessible during the outbreak. Calderón decreed last week that all public and private hospitals provide care for people with flu symptoms.
"Now everyone is very aware of the risk," Martinez said. "Nobody in his or her right mind would wait to rush to the hospital if they had a high fever."
But it is still not a simple process. When Araceli Durán took one of her four children, Noe Guillermo Ramos, 26, to Iztapalapa General Hospital last week, the doctor said he had laryngitis and sent them home with medicine, she said.
By Sunday, her son had a ragged cough, a fever and aching bones, so she went to a neighborhood public clinic, where a doctor said he had a common cold. She took him to another government clinic, but because of a shift change, she was told she would need to wait more than four hours for attention. She then went back to Iztapalapa General Hospital.
"He is worse now," she said. "It's obviously a serious infection that needs to get under control."
But Durán, like many people waiting at the hospital, did not even trust that swine flu was real. Some said it was an elaborate government lie. Others said they would be convinced only if they knew someone who had the virus.
"I don't believe any of this," Durán said. "This is all just psychological."
Staff photographer Melina Mara contributed to this report.