Doctors Cut Back Treatment : Hospital Suffers Ills of Tijuana’s Economy

TIJUANA — The General Hospital here was envisioned and built during an epoch when oil revenues made even the grandest projects seem obtainable in Mexico. The imposing, eight-story hospital was designed to revolutionize medical care here, replacing an antiquated, crowded facility and providing superior service for the mostly poor clients, who can afford no other hospital.

A group of enthusiastic, young specialists was recruited, largely from Mexico City, to staff the government-run facility. Proud officials promised a spacious, eight-story hospital with state-of-the-art equipment. Its 400-bed capacity would be sufficient to meet Tijuana’s needs for decades, authorities boasted.

Finally, it seemed, the politicians’ rhetoric would become reality and the boundless promises of the nation’s new-found wealth would filter down to the Tijuana residents who most needed relief.

Four years after opening its doors, though, the promises remain unfulfilled. At the hospital, shortages are so severe that doctors say they often don’t even have basic material such as scissors, sutures and surgical gowns, while more sophisticated items such as X-ray machines, heart monitors and respirators are often inoperative, outdated or non-existent. Patients are at daily risk of their lives, and some have probably already died needlessly, doctors say. The hospital is badly underutilized.

“The situation is critical, it’s grave,” said Dr. Alfonso Valenzuela, a pathologist who was among the enthusiastic young physicians who arrived from Mexico City four years ago. “We’re playing Russian roulette with patients’ lives. . . . This is a time bomb waiting to go off.”

Doctors have taken matters into their own hands, drastically reducing services and making their complaints public.

The hospital that was conceived with so much hope and optimism--too much, perhaps--now stands as a vivid, concrete-and-mortar symbol of the raised expectations of the Mexican oil boom and the dashed hopes of la crisis. It had the misfortune of opening its doors in 1982, when oil was no longer king and Mexico was already plunging into its most severe economic crisis in half a century.

“Had the boom continued for six more years, this hospital could have been one of the best in the country,” lamented Dr. Gabriel E. Garcia, the assistant administrator.

Doctors and other observers say the carencias, or shortages, at the General Hospital here are symptomatic of those throughout Mexico, where officials attempting to cope with a burgeoning foreign debt have cut back expenditures in areas such as health and education. Tijuana’s troubled hospital, in effect, represents the raw edge of the Mexican economic crisis.

“Health care has become a low priority” in Mexico, said Leo Chavez, a research associate at the Center for U.S.-Mexican Studies at UC San Diego who has studied border health issues.

During the oil boom, Chavez noted, there was a palpable optimism in Mexico that the new revenue would lead to vast improvements in health care, education and other areas, perhaps finally boosting Mexico into the developed world.

“The crisis eroded that optimism,” Chavez said, “and health care is just one victim of that.”

Adding to the frustration at Tijuana’s General Hospital is the fact that the facility is less than 25 miles from the gleaming medical institutions of San Diego. The juxtaposition vividly underscores the contradictions that characterize the U.S-Mexico border region, a place where the Third World meets one of the world’s most developed nations.

“We recognize that this is the Third World country; we’re not looking for ultramodern equipment, luxury equipment like they have in San Diego,” said Valenzuela, who heads the doctor’s association at the hospital. “All we are asking for is basic equipment so that this can function like a real hospital. Now, it’s not a hospital. It’s a joke.”

The joke, unfortunately, is on the patients--mostly Tijuana’s poor and emergency cases that are brought here from throughout the city. Besides being severely ill-equipped for its current role, physicians say the hospital is utterly unprepared for a major disaster, such as an earthquake, airplane crash or explosion. And Mexicans are not the only patients affected: After serious vehicle accidents and other medical emergencies, Americans and other foreign visitors are likely to be sent to the emergency room at General Hospital.

“It’s a pathetic situation. It’s very critical,” said Dr. Gerardo Sela, chief radiologist. “There are times when all we can do is look at the natural evolution of illnesses without doing anything to stop it, because we don’t have the equipment. As a medical doctor, it’s very frustrating.”

So frustrating, in fact, that the 58 staff doctors have taken the unusual steps of cutting back on treatment and going fully public with their demands for new equipment and better maintenance--even purchasing advertisements in Mexican newspapers to warn citizens and dramatize their complaints. Government health officials have responded slowly, at times chiding the doctors for exaggerating the situation and making “unrealistic” and “stratospheric” demands at a time of economic crisis.

“The doctors have to understand the situation in which we live,” Dr. Diego Fernandez de Castro, federal health chief in Baja California, pointedly told the Mexican newspaper ABC.

However, last month federal officials visiting the facility acknowledged shortages and vowed to provide up to $170,000 in equipment before the end of the year. Meeting the total need would cost more than $1 million. Hospital administrators say some material has already begun to come in.

“We’re optimistic about receiving new supplies and materials,” said Garcia, the assistant administrator, who acknowledged the validity of many of the complaints.

But staff doctors not connected to administration remain pessimistic.

“We’ll believe it when we see a change,” said Valenzuela, noting that the staff has been requesting help for years. “The crisis cannot be used as an excuse for inaction here.”

Since mid-June, the physicians have refused to accept all but emergency cases, contending that the hospital simply is not up to it. The move eliminated the crucial daily treatment of dozens of outpatients--non-emergency, walk-in patients who formerly could be examined by specialists and, if necessary, hospitalized. The practical result of eliminating outpatient treatment, doctors acknowledge, is to defer treatment of some ailments until the patients’ conditions deteriorate and they are brought in as emergency cases.

“It’s not good medicine,” Valenzuela said. “It’s a call of alarm. What should we do? Deceive people into thinking we have the resources to treat them safely? Is that ethical? Should we fill it up like a hotel? Would it be better to bring patients in so that we can watch them die and do nothing about it?”

The slowdown, combined with the fact that the hospital had been operating at less than half of its designed capacity anyway, results in a lack of patients that gives the modern facility an eerie, half-abandoned feel that is striking in this bustling city of more than 1 million people--a city where there is no shortage of health problems. Contributing to Tijuana’s health needs are a citywide lack of clean drinking water, an abundance of untreated sewage and a constant stream of migration from rural areas of Mexico where health care is scarce and many illnesses are endemic.

“The need is there,” said Dr. Guillermo Estolano, an internal medicine specialist. “We have the human resources, the physicians, to deal with the problem. We’re not looking for more money for ourselves. We simply need more equipment and maintenance of what we have.”

The patients at General Hospital are among the poorest of the poor in Tijuana. About 40% of the city’s estimated 1.2 million residents depend on the General Hospital, as do most emergency cases, according to hospital estimates.

Under the Mexican medical system, patients lacking medical insurance or substantial savings usually rely on the government- financed general hospitals for treatment of serious illnesses. Patients pay according to need; many pay nothing.

Patients with health insurance generally go to an array of Social Security and other hospitals that doctors say are usually better-financed and better-equipped than the general hospitals. Wealthy Mexicans can afford private hospitals, or, if necessary, can go to the United States for treatment--a common practice in border areas.

“People don’t come to this hospital unless they’re really in need of care,” said Dr. Alberto Ornelas, an internal medicine specialist. “They either get better at this hospital or they don’t get better at all.”

Most of the doctors at General Hospital are young physicians who attended medical school and completed their residency requirements in Mexico City before coming to Tijuana. Most came to the hospital in 1982, when the facility was opened to considerable fanfare after construction expenditures of about $17 million.

The beige, fortress-like structure, just east of downtown, now includes 127 permanent beds and 35 temporary ones, although it has an ultimate capacity of 400 beds. The additional capacity was designed to handle Tijuana’s future health needs, but it appears unlikely that the extra beds will be put to use anytime soon. Four of the facility’s eight floors remain largely unused.

The hospital staff includes specialists in more than a dozen fields, including internal medicine, neurosurgery, urology and pediatrics. For their hospital work, doctors earn less than $300 a month, although they say separate, private practices allow them to live comfortably.

In interviews, doctors spoke of the exciting challenge of coming to a modern facility four years ago. But disenchantment set in quickly.

“We all thought this was a great opportunity,” Valenzuela said. “It’s a new building, a beautiful building, really. But it takes more than a building to make a hospital. . . . When we arrived here we were shocked at the conditions, the shortages. We had never seen anything like it in Mexico City.”

For years, the doctors have sent authorities numerous written requests for needed equipment and material. Most went unanswered, they say. Finally, with the situation continuing to deteriorate, the doctors say they felt forced to go public in June and suspend treatment of outpatients. They describe it as a drastic step, but one that was unavoidable.

“It was a move of desperation,” Estolano said.

A kind of gallows humor now dominates discussions among doctors, with the latest horror stories quickly making the rounds. “If you come here with a broken bone,” one physician advised a visitor, “be sure to bring your own plaster. We’ve run out.”

On several recent visits to the hospital, the effects of the shortages were painfully obvious, starting with the chronically malfunctioning air conditioners and elevators. Noting the temperamental elevators, one doctor recounted having to take a patient suffering from a broken leg downstairs on a stretcher, risking additional injury. Numerous malfunctioning calendar digital clocks stood frozen to a time several months back, a constant visual reminder of the overall state of things.

In the intensive care ward one afternoon, a patient was recovering after an operation to remove a large tumor from his chest. What he didn’t know was that doctors had been forced to use inappropriate sutures and were still worried about it.

A few beds down, a 47-year-old former boxer was recuperating after an operation for a fractured skull. The back of his frail body was a series of raw red bedsores.

“The sores used to be much worse,” said Dr. Jorge Astorga, moving the patient to display the multicolored lesions. “He should be on a bed with a special mattress, but we don’t have any here, so all we can do is wash the sores and hope they don’t get worse, hope they don’t get infected.”

During a stroll through the ward, Astorga and a colleague pointed out the often-dramatic shortages.

“We don’t have heart monitors, we only have short-term respirators (a breathing apparatus), sometimes we don’t have proper clothing for surgery,” said Astorga. “What we do have is mostly vintage-World War II equipment, and none of it works. And no one pays for the repair. . . . It’s like a battlefield hospital.”

Throughout the hospital, the situation is the same:

- In the pediatrics ward, doctors are gravely concerned about the lack of working incubators--artificially heated containers in which premature babies are placed to assist their development. Inside one incubator, a 3-week-old, three-pound baby boy slept peacefully, unaware that a nurse was forced to adjust the temperature on the malfunctioning device every half hour.

- In the X-ray room, an ultrasonograph machine, used to detect tumors and other internal problems, has sat unused for eight months. The $1,500 needed to repair it has not been available. Two huge CAT-scans, sophisticated X-ray devices given the hospital last year by U.S. donors, have never been put into use because the cost of installation and maintenance is too high; they’re considered near-obsolete anyway.

- In the autopsy room, corpses have to be moved quickly for fear of decomposition because four of the refrigeration units are inoperative and two others are malfunctioning. “Even the dead have to wait in line,” the Tijuana weekly Zeta noted in a front-page headline above an article about the hospital’s problems.

- The hospital’s burn unit, opened to much public acclaim earlier this year, has yet to receive a patient because it lacks proper equipment, doctors said. Serious burn victims in Tijuana continue to attempt to gain entry into San Diego hospitals.

Everywhere, medical improvisation is in evidence. Patients are tied into their beds with rags to ensure that they don’t fall from beds not designed for extended stays. Radiologists taking skull X-rays have become adept at quickly manipulating X-ray plates to acquire a sequence of photographs that modern brain-scan machinery would provide automatically.

“We have to do it this way,” explained Sela, the radiologist. “We can’t just let people die.”

For the patients, there is simply no alternative.

“Where else can I go?” asked Yolanda Gonzalez, 29, a baker’s wife who had given birth to her fourth child, a boy, the night before, and was aware of the hospital’s problems. “We can’t afford to pay for another hospital.”