They broke into the clinic during the early hours of the morning, slamming shut the door of the room, gun in hand. The young intern regretted choosing that vacancy. He had heard the stories of fellow students in the mountain ranges of Oaxaca or in other states of the country but he never thought he would become a victim of insecurity while he did his social service .
The criminals broke into the medical clinic of Santa Rita Tlahuapan, in Puebla. They hit him. They tied his hands and feet. One of them said: “Don't you dare move, you son of a bitch or we're gonna kill you. I've killed many already, don't think I won't kill you.” He thought he was going to die. He thought about his girlfriend and his family. He recalled fragments of his childhood and of the moment he was accepted at the National Polytechnic Institute (IPN) to study Medicine.
That June 7, 2017, staring down the barrel of a gun, Alfredo Carbajal thought he was dead. Had that been his fate, he would've become one more of the many medical interns killed, threatened, beaten, raped, mugged, harassed or kidnapped in the last two administrations while doing their social service. The criminals? Inhabitants of the communities, patients, authorities, medical staff, and the organized crime .
Despite the danger, each year close to 18,000 interns are sent to communities throughout Mexico to do their social service. Federal, state, and local authorities believe all the cases are isolated incidents but they aren't. They are the result of an outdated model that no longer works and that has no regard for the security and integrity of the interns.
Students, legislators, and civil society organizations consulted by EL UNIVERSAL agree that the current model needs to be updated – whether by decreasing the duration of the social service from one year to six months (as required in most majors) or by offering vacancies within the same state of the education center. Likewise, the model should also offer better security and economic support to the students who are sent to distant communities or be otherwise canceled.
In February 2016, this newspaper published 84 official complaints had been filed by interns due to threats and assaults, in 21 Mexican states from 2007 to 2015. To date, they are still a target of crime. Violence doesn't relent. According to the response to an informal inquiry through the Transparency system, the Ministry of Health denied having information on this matter, despite having recorded it in recent years. The IPN reported 12 cases (among them the rape of an intern in Guanajuato in July 2017) from January 2016 to August 2017. The National Autonomous University of Mexico (UNAM) pointed out that its role wasn't to keep track and refused to provide information to our inquiries, made through the Transparency system.
To this, we have to add the number of unreported cases since many victims choose not to come forward, in part due to the fear of retaliation. Although the Ministry of Health states there are no data available, another document exposes a pattern in the growing number of interns who resign to their social service each year. In 2011 there were seven resignations and by 2016 the number had already reached 91, without specifying the reasons, according to documents issued by the Ministry in charge of José Narro.
Without specifying the causes, another document records 20 deaths of interns who did their social service from 2010 to August 2017. This journal learned of other four cases through the information requests made to the IPN and other news outlets. Thus, we have a total of 24 deaths (nine women and 15 men). Through an Internet search, it was found out that five were murdered, one died after being mugged, and another allegedly committed suicide.
During an interview with EL UNIVERSAL, Sebastián García Saisó, General Director of Quality and Education in Health of the Ministry of Health said there is no evidence linking the incidents to the status of the victims as medical interns.
“It's not that we don't have records. It's that there is no analysis that proves interns are being targeted due to their activities. Yes, there are muggings, incidents in which interns have been killed. There have even been rapes and we made that list two years ago. So there have been incidents but these aren't related to their work as doctors or interns,” he claims.
To protect the intern's safety Mexico has the Official Mexican Standard (NOM) 009, which sets forth the minimum security requirements. Although this “isn't the responsibility of health care providers,” given it falls within the jurisdiction of law enforcement agents, of local, state, or federal authorities.
A section of NOM 009 states that “there shall be an area solely for the rest, quarters, and meals, with privacy and security conditions at the medical area; and an external means of communications such as a telephone, radio transmitter, or Internet system, whenever the infrastructure of the community allows it.”
García claims that when an act of violence is recorded in a community and the integrity of the interns is threatened, social service vacancies in the community are immediately canceled.
The Mexican Association of Faculties and Schools of Medicine (AMFEM) was contacted yet as this edition went to press we got no reply.
Rethinking the model
Doctor Julio Bueno, a member of the movement #YoSoy17, says there is a great concern in the community regarding the incidents. “Interns are still being sent to dangerous areas and the government has done nothing in the last years. It's enraging to see the kids are being exposed to perilous situations.”
“Nothing has been done to improve the Health Deparment. Narro Robles came and only campaigned for a year and a half. He never sat down to address the issue,” he complains.
If violence were to continue, Bueno claims social service should be cancelled. “What happens is that interns are able to get the job done at a very low price – if they are paid at all. Then, they cover the need for doctors […]. I do agree the social service model should either be modified, updated, or canceled,” states Bueno.
Martha Palafox Gutiérrez, Senator of the far-left Labor Party (PT) and member of the commissions of Health and Education, confirms interns in recent years have indeed been killed and been victims of rape, blackmail, and kidnappings in the most dangerous states of the country: Nayarit, Tamaulipas, Sonora, Chihuahua, Guanajuato, Michoacán, and Guerrero.
She considers the model needs to be updated to ensure safety, transportation, meals, and lodgings to interns doing their service: “We have to update the model or devise a new one so they can provide their services.”
Palafox is amiable to seeking an agreement and claims a proposal is necessary to find the most adequate model: “We have to talk with academics, representatives, UNAM researchers, and interns in order to define the criteria and then make them a law.”
Carbajal says he doesn't see why the social service cannot be scrapped completely or reduced to six months and allow interns to do it while they are still studying. “I don't see why it couldn't apply to Medicine. They justify it by saying this is where we learn and become responsible for patients but the truth is that when we finish our major, after four or five years, we do an extra year of internship. You get the knowledge of a general practitioner.”
In January, the Minister of Health announced the launch of a new model for the 32 states, focused on family medicine to prevent diseases. There are 3,500 interns from 115 institutions enrolled in the project that will alternate between first-level clinics and community hospitals, yet the matters of security were neither mentioned nor included.
A threatened or beaten intern, or one that has been a victim of a violent aggression, may suffer anxiety, insomnia, irritability, low performance, inability to focus, rapid heartbeat, lack of appetite, and low sexual drive, according to Francisco Shimasaki, a psychiatrist at the Fray Bernardino Álvarez Hospital.
Others may experience depressive episodes. They start with PTSD then they suffer from a major depressive disorder. Likewise, there is a lack of enthusiasm for Medicine and it leads interns to quit, at times, the service, which was the case of Paola, who lost her enthusiasm for her major and the empathy for patients after a year.
During her first incident – one week into her social service – she had a patient yell at her for refusing to give him two months worth of diabetes medication. She seldom left the clinic in Colima where she was sent for fear of ending up “missing.” One time, a man under the influence of illegal substances demanded that she gave him a controlled drug. The stray dog she sometimes fed defended her and the man ran away. Yet the one she remembers the most is the drug dealer who harassed her until the day he ended up dead.
Social service resignations continue growing, with seven in 2011; 38 is 2012; 42 in 2013; 37 in 2014; 64 in 2015; 91 in 2016 and 21 until August 2017. Out of the 300 resignations, 190 were female interns, according to data obtained through Infomex. Out of the 39 institutions listed here, the UNAM is in the first place with 103; the IPN has 47 and the Autonomous University of Guadalajara, with 25.
am