Affordable clinic–pharmacies have vastly expanded health-care access for Mexicans. They’ve also bred a dangerous attitude towards prescription drugs.
Hard afternoon winds and rain graze the inside of Dr. Javier Gomez Castrejon’s open-air waiting room on a late September afternoon at Farmacias Similares in Mexico City. The shop sits parallel to the sidewalk and faces a series of stands selling belts, clothes, and juice; inside wait several parents, mostly long-haired mothers and their toddlers, who are managing their boredom by rolling around on the black plastic chairs.
Next door is the pharmacy, where cashiers in white lab coats talk with customers about the latest medicines and promotions. Sex workers stand around the entrance chatting; one says that sometimes thousands of people come here in the course of one day.
Most pharmacies in Mexico look something like this: a medical clinic–pharmacy combination, better known as a consultorio. Thirty pesos ($1.50 USD) gets patients a consultation with a doctor, and then they can easily fill their prescription with the expansive inventory of discounted medications next door.
In the last 20 years, the proliferation of consultorios has made health care exceedingly more accessible and affordable for Mexicans. But what’s come as a result of the increased convenience and cheaper drugs is a culture of prescription error, self-medicating, and prescription-drug abuse across the country. What’s more, it’s contributing to the problem of antibiotic resistance, which has complex effects on public health. As viruses such as H1N1 spread and are misdiagnosed, the way they are treated in Mexico ends up affecting their proliferation not just locally but around the world.
Pharmacies are everywhere in Mexico. There are 6,444 pharmacies in Mexico City’s 16 delegations, and throughout the country, there are around 15,000 pharmacies with consultorios. During the day, their speakers blast catchy Reggaeton remixes and announcements for discounts; late at night, they remain virtually the only retail shops open, their bright fluorescents illuminating the otherwise dim sidewalks.
To put their numbers into perspective, consider New York City, which has roughly the same population as Mexico City—8.6 million to Mexico City’s 8.9 million—but only 2,888 pharmacies throughout the five boroughs.
Because they are convenient and cheap, consultorios have become a popular alternative to public and private health-care facilities. But the quality of care varies dramatically. In perfectly ironed clothes, 64-year-old Francisco Avila Hernandez traveled an hour and a half from his home in Ecatepec to Dr. Gomez Castrejo’s consultorio because the ones where he lives are “just drug sellers and don’t really care about talking with you.” He had tried going to the city’s National Rehabilitation Institute for his back pain but was rejected for not being able to provide pay stubs because he works informal odd jobs.
Consultorios promote the cheapest medications: interchangeable generics (GI), which is how Mexico labels their generic drugs. Some patients believe that GIs are not exactly the same as their name-brand counterparts; others figure that, because of their low cost, the drugs are weaker, so they should take more of the medication. Regulations now require the generics to be as safe and potent as brand-name drugs, but that was not always the case, so out of skepticism and inertia, doctors and patients have hung on to a casual, self-directed approach to treatment.
“Self-medicating is very common. Everyone one takes what they believe they should take,” says Dr. Laura Yañez, who works at Farmacia Similares in Ciudad Nezahualcóyotl, one of Mexico’s largest municipalities. “Sometimes you fix them what they want. There are patients who say, ‘I remember that this is for fever,’ so I give it to them.”
“Culturally, we’re made to self-medicate, it’s not really frowned upon in our society,” says Dr. Marisol, a physician at Farmacias del Ahorro, who asked me to not use her last name.
Of course, self-medication has consequences; experts at Mexico’s National Cancer Institute speculate that late detection of colorectal cancer is in part due to patients’ avidly self-medicating. Even Dagoberto Cortés Cervantes, president of the National Association of Drug Manufacturers, is critical of pharmacies’ prescription practices, which he contends are swayed not by the best treatment options but by what they have in stock. “We’ve done some surveys to see what’s in the prescription, and 95 percent of the products are the same products that are available in the [adjacent] pharmacy. So this appears to us as a conflict of interest, because the doctor should have the availability to prescribe what they want, and in fact, they aren’t able to,” he says.
This conflict of interest is artfully camouflaged by the consultorios’ marketing strategies. Of the handful of consultorio franchises in Mexico, the most successful one is Farmacias Similares, better known as “Dr. Simi.” With 6,000 shops across Mexico, the brand is recognized by its iconic mascot, a bald, bushy-mustached doctor dancing in front of the store’s open-air entrance, beckoning customers.
In the last decade or so, Dr. Simi has become the dominant health-care service for Mexico’s low-income population. It claims to serve up to 7 million patients every month and enjoys 26.6 percent of the generic market share. Its swift and impressive rise to success was built on the exploitation of generic medications, along with some unsavory regulatory moves.
The man behind Dr. Simi is Victor Gonzalez Torres. He opened up the first Farmacia Similar in 1997, with the slogan “lo mismo pero más barato” (the same but cheaper), and claimed to sell generic medicines for 75 percent less than other pharmacies. Heavy set, light-skinned, with gray hair, González Torres comes from a family of pharma magnates. In 1875, his great-grandfather opened up the first pharmacy in Mexico. His father went on to start Laboratorios Best, a major generic-drug manufacturing company, of which González Torres became CEO in 1976. His brother Javier runs two pharmacy chains, El Fénix, and Dr. Ahorro.
González Torres became involved in politics, largely for the benefit of his company. He ran for president as a write-in candidate in 2006, promising to “run the country like a business.” In 2009, the Green Ecologist Party of Mexico, a right-leaning group founded by González Torres’s brother, proposed the “Simi law,” an initiative to let people on public health-care plans get medication from private pharmacies. That same year, President Felipe Calderón Hinojosa implemented a version of the plan for state employees. It proved to be enormously lucrative for private pharmacies like Dr. Simi: Their profits increased nearly eight times as much as the state pharmacies.
Dr. Simi’s relationship with the government wasn’t always so friendly. In 2005, then–Secretary of Health Julio Frenk required all generic drugs to go through bioequivalence testing to show they were as effective as their brand-name counterparts. Successful testing would earn those drugs the “GI” label, and by around 2010, all generics should have been certified in this manner.
This scared González Torres. Generics were Dr. Simi’s bread and butter, and although they were approved by the Ministry of Health, they were never classified as being equivalent to the brand-name medication. The government, on its part, was struggling to determine the quality of Dr. Simi’s drugs. “González Torres is a brilliant man who knows to not step outside the law, but is always on the edge of it,” Dr. Fermin Valenzuela, a consultant to the Ministry of Health and former pharmacology professor at the Universidad Nacional Autónoma de México (UNAM), told me over coffee.
Wearing a gold chain necklace and chain-smoking, Valenzuela recalled his time developing a program to evaluate generics for the health secretary during the 1990s. He notes that the Simi generics were, at the time, found to be subpar. “González Torres was able to find a series of gaps in Mexico’s legislation. He says, ‘The same but cheaper,’ so in the given moment, we did the work to do see if it was the same. We did a series of tests, and no, it wasn’t. There was a lot left to do to close up those gaps in the legislation.”
Laboratorios Best and Dr. Simi protested at first but ultimately gave in to demands to sell medications that have undergone and passed testing. Now, his shelves are supposed to be stocked with effective and tested drugs, and González Torres has mostly retreated from public life, shape-shifting his public persona into his business’s mascot: Dr. Simi. Like Santa Clause or Mickey Mouse, the plush, imposing doctor character spreads pharmaceutical-themed cheer throughout Mexico. He gives Christmas gifts to low-income children in hospitals, talks in an adult-sounding Elmo voice, and invites customers to dance-offs.
Dr. Cori Hayden, an anthropologist at the University of California–Berkeley, who has extensively researched the politics of generic medications, notes that for years Mexicans were unsure about the effectiveness of the bioequivalence-testing regulation. “During the early years of the Peña Nieto administration, regulators and researchers involved in bioequivalence testing were fairly disenchanted with the efficacy of the regulatory state,” she says. “They felt that the state had abdicated its regulatory responsibility and that bioequivalent wasn’t really doing the work it was meant to do,” she says. “Now,” she adds, “people in power say they are confident in its efficacy”—but consultorios show that this confidence does not always make its way into the pharmacy, or indeed the clinic.
Even—and in some cases, especially—if the similares are up to standard, a potentially even bigger question is the effectiveness of the care in consultorios: Patients are never sure if what they’re going to be prescribed is, in fact, the right drug.
Melina Rivera, a 31-year-old art teacher with a reserved smile, says she was suffering from a sore throat and figured the immediate solution was to go to a consultorio. She was prescribed three injectable medications, one of which was an antibiotic commonly prescribed for gonorrhea. After no improvement, she went to an otolaryngologist, who diagnosed her with a dust allergy. “It was such a horrible experience. After that, I never went back to a consultorio,” she says.
Dr. V (who requested that her name be redacted for confidentiality reasons) is worried that these kinds of stories have damaged consultorio doctors’ reputations. The physician—whose wavy shoulder-length dark hair and somber black pantsuit belie her effervescent energy—has been working at a Farmacias Similares consultorio in Benito Juárez, a largely working-class borough, for the past seven years.
In high school, Dr. V loved dissecting cow hearts in science class and watching ER. After graduating from UNAM, she wanted to specialize in gynecology. She took the entrance exam four times, but never managed to get a passing score—as of 2016, the overall acceptance rate for medical residency was 22 percent—so she was left with the option of practicing medicine in a consultorio.
“I’m the first contact for people. There are patients who come to the consultorio for a respiratory infection or a gastrointestinal issue. They have some kind of pain, and they think it’s something infectious,” Dr. V told me, in the exasperated voice of someone who is frustrated with their job but isn’t quite ready to throw in the towel (she has plenty of patience: On top of this job, she’s also a physician at a youth shelter for survivors of domestic abuse).
“It’s incredibly challenging to convince patients that they don’t need an antibiotic for their condition. I’ve had altercations with patients when I won’t prescribe them what they want. They get very rude and demanding. I’ve seen other doctors here give infinite prescriptions for Ceftriaxone”—a very strong, broad-spectrum injected antibiotic used to treat meningitis, urinary tract infections, and other bacterial conditions. “For colds, cough, mucus, it’s always Ceftriaxone.”
National Institute of Public Health (INSP) researcher Dr. Sandra Díaz-Portillo says that Ceftriaxone “is prescribed like chewing gum in hospitals.” According to research from her colleague Dr. Anahí Cristina Dreser Mansilla, Ceftriaxone has been given to approximately 12 percent of consultorio patients who are seeking help for a sore throat.
During the 1980s and 1990s, between 60 to 80 percent of patients with respiratory and diarrheal infections were prescribed antibiotics, when the healthy prescribing rates should be around 10 to 15 percent. A 2008 study found that around 43 percent of children who primarily went to consultorios were prescribed as many as three medications, with at least one being an antibiotic.
The overprescribing of antibiotics was supposed to change after 2009 when H1N1—commonly known as swine flu—broke out in Mexico, prompting the government to crack down on over-the-counter sales of antibiotics in 2010. But the state didn’t bother with campaigns to teach citizens healthy and practical use of antibiotics, so it remained easy for pharmacy-company owners to figure out a way to skirt the regulation. They did so by opening up more consultorios: According to Dreser Mansilla, the law resulted in the number of consultorios to triple.
Nor did the state do anything to ensure quality control at these clinics. In some consultorio chains, doctors earn a commission for prescription sales; Dr. Simi does not, but its physicians take home only the $30 pesos per patient they charge. Dr. V says her monthly take-home pay varies widely, making it difficult for her to move out of her parents’ house and into her own place.
“They ask us to provide friendly, quality service, which is great, but then why are we forced to charge such a miserable amount for our consultations?” says Dr. V. A lot of what she’s asked to do by Farmacias Similares goes against what she was taught in medical school. “They demand that you work fast and efficiently, and it’s totally illogical because it’s impossible to give your patient a sufficient amount of attention if you’re pressured to go so fast.”
In addition to Dr. V’s complaints are many other problems with working conditions in consultorios: An INSP study found that in some cases, major-franchise consultorios like Dr. Simi are missing clinic essentials such as chairs, sinks, and light. Regulators are aware of these issues, and in their most recent report found that 25 percent of consultorios failed to their meet health and safety guidelines. They only suspended 347, or 4 percent, for noncompliance.
Mexico’s incoming president, Andrés Manuel López Obrador, has proposed health care for all citizens. But it’s difficult to tell if his administration will do anything to reinforce or increase health and safety standards in consultorios. However, Argentina could possibly serve as a model for what could happen to consultorios with López Obrador in power. In 2004, Dr. Simi opened started opening consultorios in Argentina as a part of his plan to expand throughout Latin America. They thrived during time periods of high unemployment rates and low GDP growth, but when the economy came to during the mid-2000s, people found no need for Dr. Simi, and he shut down all of his consultorios.
In Mexico, citizens have long lived in a state of economic precariousness. Latest figures show that the average Mexican worker makes $357.4 pesos a day, or around $19 USD. López Obrador wants to double pensions for the elderly, slash the salaries of senior government officials, and provide substantial financial assistance for the disabled and students. If he follows through on his plans, then a new era of economic prosperity could mean a disruption to the dependency on cheap, private health-care services.
The United States is seeing an emergence of consultorio-like health-care operations. In 2006, Walmart launched a $4 generic program for a 30-day supply of commonly prescribed medications. It’s an initiative that has benefited some Medicare subscribers; a 2018 Yale School of Medicine study found that approximately 20 percent of beneficiary cases’ out-of-pocket costs were lower with the Walmart program.
CVS, Walgreens, and Target are also competing with the public sector by rapidly opening up health stations staffed with a nurse practitioner or physician assistant. According to health-care consulting firm Merchant Medicine, the number of retail clinics has jumped from 258 in 2007 to 1,866 in 2015, with an estimated 2,800 open today. The retail-clinic boom has been enormously profitable, and sales have increased 20.3 percent every year since 2010. But although consultation rates are cheaper than out-of-pocket rates at standard clinics or hospitals, they’re not inexpensive: Walgreen clinic consultations go for $149 and CVS MinuteClinics visits can range from $99 to $149.
“Even for insured US residents, many of them would still choose to go to Mexico for health services because of the lower cost there,” says Dr. Dejun Su, director of the Center for Reducing Health Disparities at the University of Nebraska Medical Center. Dr. Su’s survey of South Texas residents found that 49.3 percent had purchased their medications in Mexico. Dissatisfaction with US health-care systems and lack of health insurance are strong factors that push people to seek health-care services in Mexico, with 47 percent of the study respondents reportedly having no health insurance, and about 22 percent making less than $10,000 a year. The researchers also found that people who considered themselves to be in poor health were more likely to go to a Mexican clinic.
“If you think about the high concentration of poverty in border areas, many people can simply not afford medications on the US side of the border, that’s the reality,” says Dr. Su. “So this medical tourism in Mexico is a very crucial source of supply for border residents, who simply cannot afford US prices, regardless of their health status.”
Dr. Su suggests that US and Mexico health officials should work together to create a binational approach to health care, one that would include measures to support underserved border residents in the United States. Until then, Mexican consultorios will remain a lifeline for both US and Mexican citizens alike who can’t afford anything else.
In Mexico, the thousands of consultorios have won people over with their fairground-level enthusiasm for medications. “Medicine is very expensive. We would die without the consultorios,” says Avila Hernandez. With a flattop of gray hair, the former windshield maker is confident his health-care needs are fully met here. And when the doctor appears around the corner, he rushes up to shake his hand.
“As Dr. Simi says, ‘Help those who have the least,’” he says. “And I think that’s true because the analyses are not expensive and the consultations are cheap.”
By Julie Morse, Julie Morse is a journalist in Mexico City.
Source: The Nation
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