Understanding Mexico's management of the A(H1N1) outbreak

When the hitherto undetected A(H1N1) influenza attacked Mexico explosively in late April 2009, the world watched with critical attention as that country's leaders scrambled to manage the emerging public health crisis.

President Felipe Calderon invoked emergency health powers on April 24, setting into motion a broad range of community mitigation strategies, or non-pharmaceutical interventions (NPIs) including school closures, public gathering bans, isolation, quarantine and social distancing. Today, Mexico remains under scrutiny as the global community examines myriad data to identify the most successful and reproducible NPI tactics should another epidemic emerge in the coming months and years.

"Understanding how Mexico managed its preparedness strategies speaks volumes to those interested in assessing the implementation and response to NPIs during a major infectious outbreak," says Alexandra Minna Stern, Ph.D., the Zina Pitcher Collegiate Professor in the History of Medicine, associate director of the U-M Center for the History of Medicine and director of its Program in Contemporary History and Health Policy.

In a commentary published in the Sept. 16, 2009 edition of the Journal of the American Medical Association, Stern and co-author Howard Markel, M.D., Ph.D., director of the U-M Center for the History of Medicine, provide a historical snapshot of Mexico's emergency A(H1N1) public health strategies that is based on dozens of interviews they and their researchers conducted in Mexico in July 2009 with citizens and public officials.

The commentary is framed by their conversation with Dr. Ignacio Villasenor Ruiz of Mexico City's health department, who said officials "had to recognize that influenza transmission could not be stopped, but we could do two things: first, slow the transmission rate and lower mortality."

The authors say Mexico demonstrated that rapid, transparent communications provided real-time help for other countries grappling with their own emerging influenza crises. Officials also carried out generally effective communications within Mexico's borders. Of special note was Health Secretary Jose Angel Cordova's role as an able and trusted communicator who worked to align sources and unify messages in order to avoid public confusion.

Simple printed public health messages and cooperative media helped to positively influence social behavior, even when dealing with a heterogeneous population and uneven literacy rates. Interviewees noted widespread compliance throughout the country with little pushback, and a temporary suspension of partisan politics. And finally, health officials reacted nimbly to support and encourage the population's spontaneous use of face masks.

Still, the authors say, authorities had problems, especially in terms of technical and scientific infrastructure. For example, there were difficulties with accurate, timely surveillance and reporting because some areas still rely on pen and paper, or do not generate any public health data at all. And without its own viral library, Mexican scientists were unable to conduct rapid genomic identification of patient specimens. And one problem was beyond the realm of control: the pandemic's impact on Mexico's economy.

Even with these difficulties, Mexico's authorities and its people have set a high bar for establishing and executing effective community mitigation strategies.

"If anything can be called fortunate about the spring 2009 outbreak of A(H1N1), it is that the global community is eager to extract lessons from Mexico's experience with influenza in order to replicate its successes and avoid similar problems during future public health emergencies," said Markel, who is the George E. Wantz Distinguished Professor of the History of Medicine.