Letter to the Editor

Year 2000 Status of MRI in Mexico

A. Rodrıguez,1 R. Rojas,2 and F.A. Barrios3*

The development of clinical magnetic resonance imaging inMexico has followed a different course from that in the U.S.and Europe. The first clinical unit was installed in Mexico inthe late 1980s at the very beginning of clinical applicationsworldwide. Since then, installations have proceeded at a se-date pace that now brings the installed total to 66 imagers.The largest fraction of these units (28, or 42%) is in MexicoCity, with a broad distribution across the remaining 23 Mex-ican states. There is a noticeable increase of the number ofunits (20, or 30%) in the states bordering the U.S., while thestates bordering nations to the south have no units. Morethan half the units (38, or 58%) are 0.5 T units, while afurther 35% are 1.0 T or higher. Slower addition of units inMexico relative to the U.S. is attributed to the higher fractionof public-funded hospitals and the inherent conservatism ofsuch institutions when considering new technologies.Present public planning for health care development sug-gests that the coming decade will see more rapid installationof units to meet growing demand in Mexico for the latestmedical technology. Experience over the past two decadesindicates the need for more systematic training of technicaland clinical personnel to implement these additions. TheNational University (Universidad Nacional Autonoma de Mex-ico (UNAM) and the Metropolitan University (Universidad Au-tonoma Metropolitana (UAM) are collaborating with diverseclinical facilities to create such a program. J. Magn. Reson.Imaging 2001;13:813–817. © 2001 Wiley-Liss, Inc.

Index terms: Mexico; MR imagers; National Health System;NAFTA; MRI

THE INTRODUCTION of magnetic resonance imaging(MRI) in the Mexican health care system has followed apath typical of Latin America but distinct from the U.S.and Europe. Mexico was among the first countries toinstall MRI in a hospital, but the extension of this pro-cess has been slower due to the unique demographicand organizational structures of the country. In thiswork we will first review the political and organizationalprovisions of health care systems in Mexico, and showhow this determines and at times limits the implemen-tation of a new technology such as MRI. We then reviewthe present status of MRI and distribution of unitsacross the country, and discuss some of the uniquelyMexican problems encountered with these installations

due both to physical and personnel factors. The presentplans of the Mexican federal government include a ma-jor commitment to improving access to the latest med-ical technology. In addition, private-sector support incooperation with the National University (UNAM) is im-proving the potential of MRI research and developmentgroups. These groups are now interacting with the bet-ter-established programs in the developed countriesrepresented at ISMRM meetings. The research groupsare also pooling efforts with UNAM and the Metropoli-tan University (UAM) to produce a cadre of studentswho will be the Mexican-trained technical and clinicalMRI experts of the future. These experts are crucial torealizing the benefit of the growing national investmentin MRI for clinical care.

The Mexican United States territory extends for1,967,183 km2. The country affiliates 31 free and sov-ereign states and the Federal District (Mexico City). Allthese states are united in a federation. The total popu-lation of the country, according to the 2000 census, is97.3 million, 26.5% living in rural areas and 73.5% inurban zones. According to the Human DevelopmentIndex (HDI), Mexico was ranked 50th, with an HDIequal to 0.853 in 1997 (1,2).

Planning and federal government activities areguided by a six-year National Development Plan (PND).The PND comprises the objectives, goals, and strategiesfor all sectors. The plan for 1995–2000 contains twocomprehensive goals in health: 1) to better quality byrestructuring health institutions, and 2) to extend ser-vice coverage, intensifying coordination and promotingthe federalization of the services. To address these ob-jectives, a Health Sector Reform Program was launchedin 1995. The North American Free Trade Agreement(NAFTA) between Canada, the United States, and Mex-ico (1994), opened new markets for exports and at-tracted foreign investment, particularly along the coun-try’s northern border, which became an area ofeconomic expansion. The treaty has implications forthe health sector through the relaxation of tariffs ontrade in medical and food products; changes in sanitaryand phytosanitary standards; regulations to protect theenvironment; and increases in the mobility of people,goods, and services.

MEXICO’S NATIONAL HEALTH SYSTEM

The health services system includes three primary sub-sectors: 1) social security institutions: the Mexican So-cial Security Institute (IMSS), the Social Institute forGovernment Employees (ISSSTE), and the medical ser-vices of Petroleos Mexicanos (PEMEX), medical services

1Departamento de Ingenierıa Electrica, UAM-Iztapalapa, Mexico City,Mexico.2Departamento de Imagenologıa, ABC Medical Center, Mexico City,Mexico.3Centro de Neurobiologıa, UNAM, Campus UNAM Juriquilla, Quere-taro, Mexico.*Address reprint requests to: F.A.B., Centro de Neurobiologıa, UNAM,Apdo. Postal 1-1141, Queretaro, QRO. 76001.E-mail: barrios@slytherin.cnb.unam.mxReceived August 1, 2000; Accepted November 10, 2000.

JOURNAL OF MAGNETIC RESONANCE IMAGING 13:813–817 (2001)

© 2001 Wiley-Liss, Inc. 813

for the military personnel, under the Secretariat of Na-tional Defense (SEDENA) and the Secretariat of theNavy (SEMAR); 2) public health services provided by theSecretariat of Health (SSA), the IMSS-Solidarity Pro-gram (IMSS-Sol), and the National Indigenous Institute(INI); and 3) the private sector. Health care is providedby segments, each of which covers different populationgroups: 1) public services for uninsured people (48% ofthe population), provided chiefly by the SSA, IMSS-Sol,and the INI; 2) several social security institutions, fromwhich workers in the formal economy can seek service(IMSS, ISSSTE, PEMEX health and social security ser-vices, and the armed forces); and 3) the private sector,with or without insurance plans (operating in an auton-omous context). All of these institutions operate indi-vidually, each institution developing its own strategiesof financing a service delivery. There is almost no coor-dination among providers, and each has its own net-work of primary care units and second- and third-levelhospitals.

Private health organizations operate independently ofone another and provide care at the primary and sec-ondary level. The majority of these facilities are corpo-rations. Their users come from every economic level,from the most affluent (some 3.6 million have privateinsurance) down to the middle class and the poor, whotend to pay for medical services out of pocket. Managedcare organizations are in their infancy, while NGOs donot play a significant role in the delivery of services. TheNational Institute of Statistical Information, Geographyand Informatics of Mexico (Instituto Nacional de Esta-dıstica Geografıa e Informatica, INEGI) only reports sta-tistical data on x-ray equipment located in both privateand public medical centers (3). This indicates the wide-spread use of this service. On the other hand, there isno record of the number of physicians involved in theclinical application of MRI, technicians operating thesystems, or patients examined with MRI scanners.

MR IMAGERS IN MEXICO

Since the very first MR imager, a FONAR prototypesystem, was installed and operated in Monterrey, Mex-ico, in 1987 (3,4), the number of MR units have consid-erably increased. This MRI system was one of the fourprototypes built by R. Damadian and consisted of apermanent magnet with a field intensity of 0.05 T (4,5).However, MRI was not approved by the U.S. Food andDrug Administration to carry out clinical studies at thattime. An MRI system of this type is depicted in Fig. 1.

The image characteristics produced by this systemdrew a great deal of attention from the Mexican medicalcommunity. Despite the high costs of this medicalequipment, costly maintenance service programs,training of radiologists and technicians, and expressly-built rooms to accommodate the magnets, hospitalsand clinics shortly followed this example and started toacquire MR systems. Consequently, qualified profes-sionals were urgently needed for a variety of importantareas, such as technical support in hardware and soft-ware, scanner operation, and interpretion of MR im-ages. In a relatively short period of time, MRI became animportant diagnostic tool in Mexico.

At the present time, radiology in Mexico is very wellestablished. Radiology students complete a residency offour years after attending medical school. The majorityof the radiologists and technicians involved in MRI havebeen trained on a day-to-day basis in the clinical envi-ronment. They usually follow the advice of senior radi-ologists with solid experience in x-ray imaging and anempirical knowledge of MRI. Radiologists require formalinstruction in the principles of MRI to be able to gener-ate an adequate interpretation of MR images. Medicalstudents, engineers, and medical physicists also needto be instructed in the basics of MRI, clinical MRI, andimage analysis. There is currently an advanced coursein MRI at the ABC Hospital with official validation byUNAM. These new, more specialized courses are ex-pected to generate a better interaction among the radi-ologists and MR researchers.

During the last 20 years, large sums of money wereinvested by groups of physicians and private hospitalsto purchase MR imagers. Attention has been given tothe fact that it is vital to initiate education programs inuniversities and colleges, to meet the needs of qualifiedpersonnel in this new, exciting interdisciplinary field.

RESULTS

Because there is no official record regarding the num-ber of MRI systems, radiologists, technicians, medicalphysicists, and biomedical engineers involved in thisimaging modality (5), we gathered information throughprivate conversations with the different radiologists andsalesmen of the manufacturing companies establishedin Mexico. In Table 1, we summarized the number ofMR imagers operating in Mexican clinics and hospitalsacross the country.

DISCUSSION

From Table 1 we can infer that 60.31% of the MR unitsare medium-intensity imagers. We learned from otherofficial sources that two more MR systems have beenbought but are not in service yet. Also, we can see fromTable 1 that only two companies dominate the Mexican

Figure 1. The first MR instrument installed in Mexico was aFONAR, one of the four prototypes built by R. Damadian,consisting of a permanent magnet with a field intensity of 0.05T. It is still in use today.

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market, with 68.25% of the total number of scanners:General Electric Medical Systems (50.79%) and Sie-mens (17.46%). Furthermore, as shown in Fig. 2,52.38% of the MR scanners are located in the capitalcity and nearby cities. This is a common characteristicof a centralized country: the majority of medical ser-vices are concentrated, and this type of modality is noexception. Also, along the Mexican-American border-

line the number of units represent 31.74% of the MRimagers installed in Mexico. This is mainly due to theenormous trade of services and products between thecountries. The assembly-factory industry is one themajor users of medical services in the region. Besides,competitive prices for medical care makes it attractivefor the inhabitants across the border. In addition, over75% of these systems operate in private hospitals and

Table 1Table Listing by Manufacturers of MRI Systems in Operation in Mexico

Manufacturer co. 0.05 T 0.2 T 0.5 T 1.0 T 1.5 T

General Electric — — 21 9 4a

Siemens — 4 1 3 3Phillips — — 7 — 1

Elscint (G.E.) — — 1 — 1Toshiba — — 7 — —

Picker (Marconi) — — — — 1FONAR 1 — — — —Shimadzu — — 1 — —

aAt the present time, there are two more G.E. 1.5T machines in the contracting process.

Figure 2. Distribution of MR imagers in use across the country.

Year 2000 Status of MRI in Mexico 815

clinics. It is also worth mentioning that there is only oneMRI scanner with a permanent magnet; the rest arecommercial scanners with superconducting magnets.

These clinical MR imagers have created a demand forqualified radiologists, technicians, engineers, andphysicists in different areas, such as scanner opera-tion, maintenance, and MR image interpretation. In thenear future, the need for qualified personnel will growdue to the increase in the number of MR scanners.However, higher-education institutions have not beenable to keep pace with these technological advances,and have not been able to meet the needs for technicalpersonnel in MRI in medical and engineering fields.

The imaging systems owners depend on the manu-facturers for training, maintenance, system upgrading,software, etc. The lack of experienced and trained peo-ple in MRI has originated a strong technological depen-dence on the manufacturing companies. Due to thehigh prices of these systems, imager owners are con-cerned about getting more patients in to generate aprofit so they can keep up with the payments. Underthese circumstances, there are very few opportunitiesto carry out research in private hospitals.

The federal government is going to invest around$865 million (U.S.) to equip public hospitals with thelatest medical technology (6). In particular, the NationalHealth System authorities have initiated a plan to pur-chase about 10 more clinical MRI systems.

MEXICO: RESEARCH AND DEVELOPMENT

As in many other developing nations, in addition toscience being treated as a curiosity by the general pub-lic, Mexican researchers have to face hard conditions incarrying out research in both basic and applied sci-ences. Scientists have to struggle with vested interests,oppressive bureaucratic administrative practices, andpolitical interference. Laboratory infrastructure at mostinstitutions is also a problem that requires adequatefunding and trained personnel. However, the NationalCouncil of Science and Technology (CONACYT) is asource of grants, and has supported some groups in thearea of medical imaging. Our group in particular countson this kind of support.

There is no MR imager operating outside the clinicalenvironment that is dedicated to research in MRI hard-ware and software. All the MR imagers are solely dedi-cated to diagnostic studies. However, in some institu-tions they are also used for teaching purposes, somedical students and technicians can be trained forclinical applications. During the last four years theAmerican British Cowdray Medical Center (ABC Hospi-tal) in Mexico City has granted continuous access to asmall group of MRI researchers to perform studies withMRI and spectroscopy. The ABC-UNAM-UAM MR re-search group is the only one currently active in basicand applied projects in MR, which are related to suchareas as volumetric high-resolution MRI for a brainbank, spectroscopy studies in Huntington’s diseaseand the heart, development of receiving coils, and func-tional MR studies in the primary sensorimotor cortex ofcontrol subjects and amputees (14–18).

CONCLUSIONS

Relevant information on MRI units is permanentlychanging, making it burdensome to report technicaldata about this imaging modality in Mexico. This wasmainly due to the fact that some imagers were underleasing agreements or were financed by internationalloans, and some underwent financial difficulties andended up being repossessed by the contracting or man-ufacturing companies. In addition, a couple of these MRimagers are on trailers and their location changed eas-ily. Considering that there is no official institution hold-ing records as to the number of MRI systems, radiolo-gists, technicians, and scientists working in this area,gathering trustworthy information on the number ofMRI instruments (location, technical characteristics,etc.) turned out to be a very difficult task. It is abso-lutely necessary to start assembling the appropriateinformation on these systems if we want to correctlyaddress all the problems involving the applications ofMRI. The number of MRI units seems to be increasingmoderately. However, federal officials announced thatthere will be an important investment in infrastructurein the health sector. We have been informed that anumber of quotations have been requested for purchas-ing MRI units this year. Since health and private sec-tors will be investing in this specific imaging modality,the demand for highly qualified and trained personnel,such as service engineers and technicians, will rise. Ifthe plan of the public sector to invest in infrastructuregoes ahead, the number of clinical MR imagers will growas much as 30% during the next two years.

Government and private institutions will need to copewith the requirements for technical support, education,and training. Substantial amounts of funding will berequired to meet the newly created demands of thismarket. Thus, the number of medical physicists, radi-ologists, technicians, and professionals involved withMRI and related technologies will experience an impor-tant growth. From experience we are convinced that astrategy for overcoming the demand problem (for qual-ified professionals in MRI) is creating interdisciplinaryresearch groups formed with MRI physicists, radiolo-gists, graduate students, and technicians from differentinstitutions. These groups will be able to train research-ers, radiologists, and technicians capable of facing theday-to-day problems encountered in medical and re-search centers. We believe that the creation of newresearch groups in various institutions is a very effec-tive way to meet these demands. These research andclinical groups must be able to interact with well-estab-lished research and clinical centers in the developedworld, participate in scientific meetings such as RSNAand ISMRM, and publish in their corresponding jour-nals to guarantee good quality of work.

In addition to this, the recently established graduateprograms in medical physics (UNAM) and biomedicalengineering (UAM) have to receive financial supportfrom the federal government to educate the mostneeded technical (nonmedical) professionals in this ex-citing imaging technique. At the same time, these pro-grams will need to interact in a more effective way withthe medical programs. This is just a starting point to

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create more graduate programs and interdisciplinarygroups across the country to meet the urgent necessi-ties of high-quality medical services and medical phys-ics research. With these highly specialized personnelwith practical “know-how,” smaller institutions will bein a better position to evaluate investment in more cost-effective elements, such as the Radiology InformationSystem (RIS) and Picture Archiving CommunicationsSystem (PACS). At the present time, with no or verylimited practical knowledge, all the institutions dependon external advisors and information from the commer-cial firms. Thus, state-of-the-art technological acquisi-tions have the potential risk of becoming low-profit,high-cost solutions in developing countries like Mexico.

Financial funding from public and private sectors willencourage the purchase of more MR imagers for thenext five years. This situation will increase the demandfor highly qualified professionals to meet the needs ofthis imaging modality. Furthermore, a market of goodsand services will be originated as well. This is a verychallenging situation that will require all of our effortand intelligence.

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