November 30, 2022

Natur family

Health Care

Systemic gaps in health care system affect migrants in

TAPACHULA, Mexico – On a cool Monday morning in early March, dozens
of people – migrants and citizens alike – line up outside a public
health clinic as rush hour traffic hums by.

One man’s knee is wrapped. Another has a large growth on his face. A
teenager is pregnant. Mothers and fathers hold coughing babies, some
parents cough themselves. A child vomits onto a pink cloth on a woman’s
shoulder.

As she waits, Karla Matute, 35, holds the right hand of her son,
Joryí, 7, whose left hand is wrapped in thin gauze at the wrist. They
are migrants from Honduras.

When Matute gets to the front of the line, she shows the nurse a
letter from the Mexican government’s refugee agency, known as COMAR,
giving her permission to seek free treatment for her son. She says
someone from the Red Cross told her that he may have a fractured arm.

They came to the clinic, Matute said, after a public Tapachula
hospital told her they could not treat Joryí for free because she hadn’t
started the asylum application process and they aren’t Mexican
citizens.

Public directories list more than a dozen hospitals in Tapachula –
but depending on interpretation of law and policy by hospital staff –
some turn migrants away if they can’t pay, others only treat them after a
referral from a primary care clinic, and others only after they have
paperwork proving they are in the asylum system. The situation is
confusing for migrants seeking care.

The nurse asks, “Where do you live? I need your proof of address so that you can pass through to consultation.”

“Parque Bicentenario,” Matute replies, referring to a park in the city center where she and her son sleep in a tent.

The nurse looks up, confused.

“In the park?”

After further discussion, Matute and Joryí are allowed inside.

Health care in Tapachula was not built for this moment. It is a city
of 350,000 in one of Mexico’s poorest, most under-resourced states. Tens
of thousands of migrants heading north are stuck here as they await
asylum meetings, humanitarian visas and other documents that will allow
them to gain residency or legally continue their journeys to Mexico’s
border with the United States.

And as policies enacted by Mexico and the U.S. have trapped migrants
in Tapachula for months at a time, the city’s health care system has
been entirely overwhelmed. The crush comes in addition to the ongoing
effects of the pandemic, limited amounts of medication, the high costs
of medical testing, paperwork inefficiencies and reports of
discrimination based on race and nationality.

But experts say the situation in Tapachula would be far more dire
without the involvement and dedication of nonprofits, nongovernmental
organizations, and local health officials.

Under Mexico’s complex health care system, the law guarantees that
all people, citizens or not, have access to basic care. That care is
provided by a complex web of coverage that includes private insurers
(for those who can afford it), employee-provided coverage, and various
public coverage programs. But migrants can’t always access care, say
experts and advocates. Communication between policymakers and providers
on how to cover migrants and under which programs has been slow and
unclear.

Underlying these challenges is the inability of Tapachula’s health
care system to meet the needs of its own citizens. Medical providers
face resource shortages and structural challenges brought on by limited
government funding. Chiapas state has a poverty rate that far exceeds
that of other Mexican states; almost 70% of the state’s population qualified for free public health care in 2020, according to Mexico’s Government Institute of Statistics and Geography.

Migrants, particularly women, children and those with chronic
conditions, are among the most vulnerable to these gaps and disparities.

‘They threw them in the trash’

When Erliwe Germain went into labor in September, she had been
sleeping in Tapachula’s Central Park for five days. Hungry and tired,
and unable to find housing, she made her way to the public hospital, an
experience she described as difficult and scary.

Germain gave birth in a room with seven other mothers. They didn’t
even clean the baby, she said, only giving one unidentified injection
and no followup care.

Germain had arrived in Tapachula with her husband, Dimitry Docile,
just a few weeks before that. The couple, who are from Haiti, had been
living in Chile, but she said they were subjected to racism there and
wanted better for their unborn daughter. They migrated north and
eventually made their way to Tapachula.

Having a baby in Tapachula has allowed Germain to get permanent
residency status in Mexico, which affords her access to more services.
Germain’s cousin, Christela Saint-Louis, and her cousin’s husband,
Dieulifoute Dorme, are not so lucky.

Saint-Louis said her year-old son was born in Chile before the family
started the journey to Tapachula with Germain. She suffers from ongoing
medical issues that have gotten worse on the trek north.

Although UNHCR, the U.N. agency for refugees, claims they should be
able to seek care and gave them the paperwork to do so, Saint-Louis
said, they haven’t gotten the help they need.

In Haiti, Saint-Louis said, doctors operated to remove fluid in her
lungs, and she had ongoing medical care after migrating to Chile.
However, after walking through the Darién jungle from Colombia to Panama
for five days, her breathing problems started again. She said she has
lost weight and the pills she was given at a clinic in Tapachula, an
antibiotic and anti-inflammatories, don’t work for her.

Dorme, who developed a rash on the journey, said the antifungal
ointment he was given didn’t work either. Their children are
well-prioritized by local organizations, he and Saint-Louis said, but in
their experience, care for the adults is minimal.

Leila Castro came to Tapachula in March with her 7-month-old girl and
4-year-old son. They were dropped off at the shelter Jesús El Buen
Pastor by immigration officials. Castro left behind two more children in
Honduras.

One recent night, Castro’s daughter developed diarrhea, and then a
rash on one shoulder. Castro said the doctor and nurse on staff at the
shelter gave her electrolytes for the diarrhea but had no medication to
treat the rash.

As the baby coughed, Castro held her tightly. The girl has a lung
condition, and her health already is complicated, Castro said, but she
intends to keep trying to find treatment for her daughter.

Roberto Báez Castillo was detained by immigration authorities just a
day after arriving in Tapachula in late February. He was taken to Siglo
XXI, the city’s immigration detention center, where he remained for 11
days.

When he got there, he said, he showed officials the prescriptions for
his three-month supply of antiretroviral medication, which he’d
received for free in Panama to treat HIV. But the paperwork didn’t
matter, said Báez, who has been living with HIV for 12 years.

“These are all the documents I gave them so they would know I have my
condition. And yet my medications were thrown away at Siglo XXI,” he
said. “They threw them in the trash.”

As he waited outside the COMAR office, he recalled his long struggle
with getting the medication he needs to manage his condition.

Báez, who is gay, said he fled Cuba to escape ongoing, violent
discrimination from authorities. He spent a year in Peru without
medication. Eventually, he made his way north to Panama City, where he
finally started getting medical care in mid-2019.

On this day, he spoke with someone at the UNHCR office in Tapachula
who told Báez the agency would connect him with a local nonprofit that
serves HIV patients. It’s progress, but he remained distressed that it
could be another week before he would get antiretrovirals, putting him
at further risk for complications from the virus.

‘Not as bad as it was’

To understand how so many gaps in access exist for Tapachula’s
migrant population, it’s necessary to look at the complex network of
available care.

The vast majority of primary health care for migrants is provided by
NGOs – nonprofit, nongovernmental organizations – including shelters,
many of which are still reeling from the huge increase in migration over
the past few years and the effects of the pandemic.

“Nothing here is enough,” said Laura Benitez, the project manager for
Global Response Management’s site in Tapachula. Among other things, the
international NGO provides free medical services in Tapachula on a
walk-up basis. No paperwork is necessary.

Benitez, who also has experience working with migrants in Tijuana,
said things have been especially difficult in Tapachula since 2019, when
U.S. demands that Mexico slow northward migration led Mexico City to
institute a containment policy for migrants who entered the country from
Guatemala. The previously transient population became a static one,
overwhelming health and aid workers.

“The health system collapsed, basically,” Benitez said, “and there’s
not many NGOs. If we compare this with Tijuana, it’s like, we don’t have
enough.”

Global Response Management addresses a need among migrants for good
primary care they can easily access. The agency recently moved its
office from a public clinic to a park complex called Tapachula Station,
where other services, including dentistry, are available. Workers treat
such issues as dehydration, foot injuries, fevers and skin conditions.

The team of fewer than 10 serves 20 to 50 people a day, and Benitez
predicts those numbers will increase as word of their new location
spreads.

“I’m sure in a few weeks, we’ll have more patients,” she said.

Paperwork has been a major barrier for migrants seeking medical care,
Benitez said. When migrants apply for asylum in Tapachula, their first
point of contact is with the COMAR office to get an appointment date and
time. At that appointment, they receive official documents that allow
them to more easily access services, including health care at public
clinics and hospitals.

However, Benitez said, at the end of 2021, asylum seekers were
receiving appointments as far as six months out, causing delays for
those with urgent health needs.

“In six months, they cannot work, they cannot leave, they don’t have
money, they don’t have food to eat, and they don’t have access to
medical health services because they don’t have the document,” she said.
“So it was desperate times. It was chaos.”

Although wait times have improved, COMAR staff members still are
overwhelmed as the flow of asylum seekers into the city continues.

“People were coming to us crying. They didn’t know what to do,”
Benitez said, “but now it’s better. It’s not OK, but it’s not as bad as
it was.”

Paperwork, however, is just one hurdle. Haitian and African migrants
in particular face shortages of interpreters in medical settings, as
well as widespread reports of systemic racism and anti-immigrant bias.

“It’s not just about them being migrants,” Benitez said. “It’s about them being dark-skinned.”

Research by Amnesty International and the Haitian Bridge Alliance
released in October contained accounts from Black migrants in Tapachula
of “intersecting forms of discrimination in accessing health care,
based on language, race and nationality.”

And one 2020 study
from the Population Council in Mexico about migrant women’s access to
reproductive health care in Tapachula found that discrimination and
racism has a measurable effect and “acts to the detriment of these
women’s health.”

Female migrants of multiple ethnicities have reported physical
reactions to this discrimination, the study said, including “high blood
pressure, tachycardias and stress and anxiety symptoms.”

Although the report highlighted efforts to hire Haitian migrants as
interpreters and translators, the researchers made it clear these
resources aren’t sufficient.

‘There’s a magic word’

Dr. David Jimenez, coordinator of attention to the migrant population
in Sanitary District VII of the Ministry of Health of Chiapas, is a big
believer in order.

Every day, he reviews data sent to him by COMAR and other agencies.
Jiménez is responsible for 108 health units – clinics, hospitals and
ambulances – in Tapachula and the vicinity. There are services in each
of the shelters, too. As he spoke, he answered multiple calls requesting
ambulances and medical services from around the city. In essence,
everyone in Tapachula answers to him when it comes to the government
response to migrant health care.

“There’s a magic word,” Jiménez said. “It’s called teamwork.”

Although the health system as a whole faces challenges, Jiménez cited
many ways in which the state health ministry has been successful in
working with such NGOs as UNHCR and UNICEF to facilitate medical care
for migrants in Tapachula.

UNHCR has donated ambulances, masks, gloves and auxiliary ventilators
to medical settings in Tapachula and throughout the region. It also has
provided access to prenatal ultrasounds and support for newborns.

Additionally, UNHCR works with the local university to make more
interpreters for Haitian migrants available and makes pamphlets and
banners in Spanish and Creole that provide instructions on preventive
health care and how to seek services.

“And these materials also benefit the entire population, because it
is material that everyone needs, not only refugees and migrants,” said
Pierre-Marc René, a public information associate for UNHCR Mexico.

UNICEF also is filling gaps in maternal health care by hiring a
gynecologist and providing resources to support children, adolescents
and pregnant women. It serves about 150 patients a week, according to a UNICEF report from mid-March.

Lastly, with assistance from the federal programs IMSS-Bienestar and
Grupo Beta, Jiménez and his team have assured that most every shelter in
Tapachula has some level of medical staffing and transport to hospitals
when necessary.

Despite these steps, some gaps remain.

Herbert Bermudez, a worker at Albergue Jesús El Buen Pastor, said he
sometimes uses his own money to buy medicine for migrants who can’t find
what they need in the shelter’s supply of donated medications.

In addition, COVID-19 continues to be a challenge in many shelters,
creating staffing shortages and safety concerns because of overcrowding,
which forced some to shut down, UNICEF reported in late March.

Jiménez acknowledged that it was difficult at the beginning to treat
so many people from so many cultures, but said they’ve come a long way.

“I do not think I know perfection, but I think that we are already
getting to know each person: the migrants from different countries,” he
said.

But he also expressed long standing frustrations.

In his experience, Jiménez said, Haitians in particular are
constantly in conflict with those who’re trying to help them, always
pushing to the front of the line. He wants everyone to follow the system
laid out for them and go through proper channels.

Jiménez also said migrants prioritize their health after everything
else, especially immigration appointments and their attempts to leave
Tapachula.

“More than anything, you need to know how the migrant puts other
things first,” he said. “The least important of those things is their
health.”

Benitez at Global Response Management also spoke to this phenomenon, although with a differing perspective.

“There’s a lot of people who need medical attention or psychological
help, but they have other priorities,” she said. “Even if they know they
need it (medical care), they prefer to go look for a job or make money
to feed their family.”

More support needed

President Andrés Manuel López Obrador (referred to as AMLO) addressed
the inefficiencies in this web of health care in a large-scale reform
of Mexico’s health care system in early 2020. Healthcare reform was a
major talking point of his campaign in 2018.

Although the strengths and weaknesses of the old system, known as
Seguro Popular, were nuanced, it did guarantee asylum seekers three
months of free health care access once they had their asylum
appointments.

AMLO’s government created a fully public option, known as INSABI, to
make health care more accessible for all, including migrants. Public
funding was expanded by 35% in 2020 to meet these goals. That ended the
three month limit for asylum seekers and expanded access, on paper
anyway.

But communications about policy and expectation remain poor,
according to some medical researchers, and there are widespread accounts
of medication shortages and access issues for migrants and Mexican
citizens alike. In addition, there have been reports of corruption
within hospitals, which, when supplies are low, may charge patients for
resources that should be free.

Experts also have criticized López Obrador for severely underfunding health care. An independent analysis
in 2020 indicated health care in Mexico is under-resourced by as much
as 658.5 billion pesos. And despite some funding increases, that gap
hasn’t been closed.

Although the Chiapas health ministry contributes resources for
migrants, the majority of the funding Jiménez distributes comes from
NGOs. Jiménez is proud of the strides his team has made, but more
support is needed, he said.

Jiménez said the NGOs he works closely with would soon be petitioning
AMLO, who visited Tapachula on March 11, asking that “more resources be
allocated to the health system.”

Benitez agreed that resources from the Mexican government have been lacking.

“The government doesn’t do enough,” she said. “That’s why it’s important that we NGOs are here.”

Government reforms have also been affected by the ongoing pandemic.
Mexican public hospitals, which serve people who need more than basic
care, often have found themselves overwhelmed, and wait times in
emergency rooms remain high.

Furthermore, private and specialized treatment is beyond the financial reach of many migrants.

Caught in these currents are migrants like Karla Matute, the Honduran mother who sought help for her son’s injured arm.

At the clinic, a doctor put a more durable wrap on Joryí’s arm and
referred him for an X-ray at the local hospital. Matute said the arm
likely isn’t broken – Joryí would be in more pain if it were – but it’s
worth checking to be sure.

They left the clinic with painkillers, but instead of heading to the
hospital, Matute went to the National Immigration Office (INM). The
night before, she had heard the agency might be giving humanitarian
visas to the single mothers with children who’ve been sleeping in the
park.

For the moment, anyway, Joryí’s arm will have to wait.

She’s hoping to leave soon and make her way north to Monterrey, where she heard there is work.

Additional reporting was contributed by Jennifer Sawhney,
Julliette Rihl and Salma Reyes. Translations were done by Jennifer
Sawhney and Salma Reyes.

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