Midnight_Family

How One Family Makes a Living Operating an Underground Ambulance Service in Mexico City

The harrowing documentary ‘Midnight Family’ examines the country’s broken healthcare system and corrupt law enforcement. The director talks to MEL about medical ethics, what it’s like to see people die and what America can learn from Mexico

Life and death frequently hang in the balance in Midnight Family, a documentary that tackles the gig economy from an unexpected angle. American filmmaker Luke Lorentzen introduces us to the Ochoa family — father Fer and his two children, teenage son Juan and kid brother Josué — as they go about their job, which is operating one of Mexico City’s many private ambulances. In an opening title card, the film informs us that a city of approximately nine million people has fewer than 45 government ambulances, which has opened the door for a booming black-market emergency-vehicle business. The Ochoas have been doing this high-stress work for 10 years, picking up patients and then hurtling through crowded city streets, their sirens blazing, to get the injured to a hospital. It’s harrowing, heroic work, but is it entirely ethical?

Lorentzen, who spent months with the family over the course of a few years, raises questions without offering easy answers. We see how the Ochoas work diligently night after night to save lives, but this is a for-profit enterprise, which requires them to make iffy moral choices. (Certain hospitals will pay the Ochoas to bring patients to them, even if another hospital might be closer.) But as Midnight Family explains, it’s not so easy to judge the Ochoas — after all, they’re only responding to a Mexican health-care system that’s seemingly irreparably broken. It’s not just that there are so few government ambulances — it’s that proper resources aren’t spent to assist the country’s imperiled, who often find themselves waiting endlessly in overcrowded hospitals. Add to that the fact that some cops exploit the private ambulances, wanting bribes or threatening to ticket them for made-up reasons, and you begin to understand that the Ochoas, though hardly saints, are performing an important service. 

During a call from the Netherlands, where Midnight Family was screening as part of the International Documentary Film Festival Amsterdam, Lorentzen (who’s in his mid-20s) discussed his desire to keep the movie open-ended, letting audiences decide for themselves how the feel about the Ochoas and their milieu. “Certain cuts of the film started to get overburdened with information,” says Lorentzen, who shot Midnight Family himself, riding in the back of the ambulance with the Ochoas and witnessing his fair share of death along the way. “I really wanted to pull back and have the film be an experience. Have it be a roller coaster. Then afterwards, you can talk to me and I’ll answer the questions.”   

So that’s exactly what we did. Below, he chats about the Ochoas’ unusual family dynamics — Fer may be the dad, but he doesn’t really run things — what it’s like to watch someone die and why Mexico’s dysfunctional medical services should serve as a warning for Americans.

One of the things I was struck by while watching Midnight Family was that this hardly seems like the easiest ways to make a living. It’s not like it’s a get-rich-quick scheme.
Mexico’s a country where 60 percent of the population makes a living in some sort of informal economy. More than half of the country is making work for themselves, whether it’s a pop-up taco stand or an ambulance.

The Ochoa family got into this work about 10 years ago. The father was working for the Mexican Red Cross, noticed this need and met other independent ambulances that had their own business. So he broke off and opened up his own shop.

It’s not get-rich at all — as I tried to show in the film, they’re barely scraping by. But it’s what they’ve decided to make their work — their alternatives are really slim. And while they’re just scraping by, they’re still putting food on their table. It’s work that they also take pride in. It’s more exciting than being a janitor or some other type of work. It is really engaging.

I wasn’t there when the business started, but from what they’ve told me, I have a hunch it wasn’t always this difficult. There were time periods in the history of health care in Mexico City where the government wasn’t cracking down on these businesses so much — they didn’t have to bribe police officers so much. They could work without that hassle. Honestly, year by year, from when I started through now, it’s getting more and more difficult for them. This family business is starting to get crushed.

There are all kinds of different family businesses. Running a private ambulance is among the most unique. You don’t provide much background on these three guys — you just show them on the job, with Juan piloting the ambulance during their mad dashes to the emergency room.
Fer’s son, Juan, who’s 17 in the film, grew up in the ambulance, like Josué [who’s nine in the film] — he obviously wasn’t driving the ambulance 10 years ago. Fer was a bouncer at a nightclub before he opened up this business. He got to know the Mexican Red Cross through being in that kind of nighttime economy.

What’s interesting about the ambulance is when it does go well, you make a good amount of money — 3,800 pesos for transport to a hospital is a lot of money for the Ochoas. There are jobs in Mexico where you’re [only] making a couple hundred pesos a day. While [the Ochoas] might seem poor and lower-class to an American, there are still three, five, maybe even more social classes below them. They sometimes will hire someone to clean their apartment, which seems crazy. But there are these social classes that exist far below them that don’t quite exist in the U.S., where the wealth gap is still enormous but smaller than it is in Mexico.

It’s not an easy life at all, however. Just this past month, they got kicked out of their apartment because they couldn’t pay rent. It’s very unpredictable. There’ll be weeks when they’re making more money than anyone in their neighborhood, because they got one or two accidents where people were willing to pay.

In the movie, we see the Ochoas tell people that they pick up, “We waited 30 minutes for a government ambulance to show up.” I got the impression that this is some rule they’re supposed to follow. But are they lying to patients when they said they waited?
I mean, they’re running a scheme. There are moments throughout the film where they say something that’s part of their pitch. The ethics get more and more gray as the film develops — your ability to trust them as heroes blurs. That was really what the story was, for me, from the beginning. The first night I was with them in the ambulance, there were moments when I was totally blown away by what they were doing for patients — sometimes saving people’s lives. Then we’d speed off to another accident, and I’d really fear for the people in their care. And that balance between “Are they saving lives or are they scamming people?” is really what the film is about. With each accident, I wanted to heighten those ethical stakes. It’s an open-ended film in a lot of ways — it puts a lot of questions and doubt on the viewer. That line, “We waited 30 minutes for a government [ambulance]” is one of the first moments in the film where you wonder about that.

Did you ever confront them?
I was definitely eager to get them to tie a nice bow around these questions that are ambiguous and complicated. But all of the times that I sat them down for an interview were really unfulfilling — in part, because there’s no easy answer to what is right and what is wrong in this context. I was really hesitant to take an American sense of what I’d do as an EMT and apply it to a system that was far less functional.

What was so harrowing and gut-wrenching in some of their ethical slips was that the alternative was so blurry, too. It was hard to nail down an obvious alternative, despite it still feeling wrong at times. I’d ask them about those things, and I don’t think that they liked to go there. They just don’t engage with this stuff on that level, because it’s just how the system works. They’ll be quick to say that it’s broken, and that there are things they’d want to improve about it. But I don’t think they’re going to put the burden of the ethics of it all on their shoulders.

It’s a much bigger [problem] than that. Patients are being victimized by the ambulances. The ambulances are being victimized by law enforcement. Law enforcement is being victimized by bigger government. There’s this whole food chain of corruption, where no one’s getting what they need to survive.

(Left to right) Police talking to Juan Ochoa by his family’s ambulance in
Midnight Family, directed by Luke Lorentzen. Courtesy of 1091 Media.

What’s the reputation of these private ambulances in Mexico City? Are people glad they exist? Or are they considered vultures?
Very few people know about them — if you need an ambulance once in your life, it’s a lot. But even in a country like Mexico, you still assume that the government will show up when there’s an accident. [Mexico City has a] small government presence when it comes to ambulances. [Private ambulances] aren’t something that people know about, and the ones who do tend to think of them more like vultures than heroes. They tend to only get press when it’s negative press with people who are extremely upset with how they were treated.

Part of what I wanted to do with the film was to try and tell a much more holistic story: “Look, as patients, what you experienced [with a private ambulance] is extremely valid and horrifying. The flip side is that there are families here just trying to make a living.” The film is about these two types of survival — the survival of the Ochoa family and the survival of patients.

You also show that some of their customers refuse to pay, saying they have no money. Were people lying to the Ochoas to get a free ambulance ride?
They’d definitely do everything they could to get out of it. The way the system is set up, because the Ochoas are on such legal thin ice, [the family] can’t force somebody to pay. The last thing they want is that person going to any sort of authorities complaining. So, they’re pretty quick to back off. What happens is less than a third — maybe a quarter — of the people that they transport actually end up paying them. And so you see [the Ochoas] coming up with these far more problematic but necessary means to make the business stay afloat. That’s where the hospital commissions come in.

That brings me to my next question: Midnight Family suggests that the Ochoas get paid by the hospitals to bring them patients. How does that system work?
Just looking big-picture, Mexico promises health care for all. But the government system doesn’t have the actual infrastructure to follow through on that promise. A government hospital is free, but you’ll wait days. It’s a country where a very, very small percentage — less than 10 percent — has private health insurance. [Editor’s note: According to one figure, it might actually be less than one percent.] But the vast majority of resources are private. Over 75 percent, at least in Mexico City, of all hospitals are private. You have people who thought they were covered, and then, at the last minute, they’re paying out-of-pocket for health care at a private institution.

What the Ochoas do is they have private hospitals that pay them a commission for every patient they bring in. The way that gets tricky is that those hospitals aren’t always the closest or the best for a given situation, but they’re incentivized heavily to work with those doctors.

And we see that in the film: The Ochoas will tell people, “Well, that hospital was closer, but it has a much longer line…”
Right, that’s Moment No. 2 where you hopefully question the truthfulness of what’s happening — and wonder what the alternatives are. There’s just so much ambiguity in terms of what the right thing to do is. But the ultimate feeling is that money is [a driving factor]. Yes, they go to a government hospital first. Is it overcrowded? Yes. Are the Ochoas really pushy when it comes to finding the next-best option? Yes.

The Ochoas have been doing this 10 years. Have they used the same van that whole time?
No, they’re constantly replacing bits and swapping engines from other old vehicles. They’re taking parts to put together one working vehicle. There’s a whole industry of American ambulances being sent down to Mexico and sold really cheaply, because once an ambulance reaches 200,000 miles it just can’t be certified as safe in the U.S. So they sell them to Mexico. The Ochoas’ actually came from a hospital in Oklahoma.

They’re now in a different ambulance, and part of that is sometimes one vehicle will get targeted by law enforcement. It’ll be either taken away or just become too notorious, so you have to switch to another vehicle. There’s this whole rotation process among all the private ambulances to keep themselves from being too notorious in a given area.

How many of these private ambulances are family affairs?
There are a few that are family businesses. But the Ochoas are pretty unique in that sense. The others are often run by friends or coworkers who pitched in together to buy an ambulance. Sometimes cousins or uncles work together. But in terms of having the children involved, the Ochoas’ is the only ambulance that I found like that.

It’s hard not to be judge-y while thinking about Fer’s two sons. This can’t be a good way to raise kids.
Josué was seven when I first met him. He’s maybe 11 now — he’s seen more suffering than most people see in a whole lifetime. You can’t imagine how that affects his general understanding of the world, but also his ability to connect with people and process emotions. Just what his understanding of death is — for such a young kid, that’s really too much.

I filmed over the course of three years, and spent maybe 80 to 100 nights in the ambulance, and in just that relatively small period of time it was emotionally so overwhelming. To have that be your everyday norm is heartbreaking. [Josué] is already not really doing school very much. His options, in terms of what he will be able to be when he gets older, are really limited. This is what he’ll do.

The press notes mention that not everybody in the family even has medical training. That seems like, just as a baseline, something you’d definitely need for such a job.
Fer got trained officially through the Mexican Red Cross when he was first getting into the business. He’s been very diligent about teaching his sons what they know. I think you see in the film that the big problems that arise aren’t because they’re misdiagnosing or mistreating people at a medical level. If anything, they come to patients with a level of compassion that you don’t see in the U.S., just in terms of giving a hug to a patient or just their way of being.

There are other ambulances in Mexico City, which are being operated by a few 16-year-olds, that truly don’t know how to put a neck brace on properly, or other very fundamental procedures. I don’t think the Ochoas are the most exceptional when it comes to certain diagnoses, but they try their best to be professional. Having to do it every night has taught them a lot.

This is a question I get a lot in Q&As. I mean, Juan is 17 in the film, so he can’t even legally drive in Mexico City. But it’s just the system where those sorts of rules are [ignored]. The U.S. has a very rigid system when it comes to licenses, and Mexico is far more lenient. The big problems that I wanted to explore with the film are more about the finances and the corruption, and less about the [family’s] fundamental lack of [medical] knowledge.

Juan Ochoa in his family’s ambulance in
Midnight Family, directed by Luke
Lorentzen. Courtesy of 1091 Media.

The Ochoas are an interesting family — the head of the household really seems to be Juan, not his dad. Juan drives the ambulance. Juan kinda calls the shots.
It’s this funny system where Juan, as a 17-year-old, has so much more ambition than his father that he’s stepped up to really run this business. Part of the reason why I anchored the film behind him is that I knew that if I could tell the story through the lens of this highly ambitious 17-year-old — who might be a little bit naïve or a little bit young, [although] he’s trying really hard — I knew that would be an easier entry point than a lazy 45-year-old, who’s emotionally burned out from years and years of having a really, really tough job.

Juan is the boss — he’s so street-smart and so energetic and young. And you see how that dynamic unfolds. They’re such an unusual family in so many ways. Just the way they interact is nothing like I’ve ever seen in an American family or even a Mexican family. It’s a traditional dynamic that you have between father, son, little brother, [but] all mixed up. I mean, Josué is the one paying for dinner because he doesn’t have any real expenses — so when they run out, he’s the one to have [money]. They’re a group of people who are pooling together all their resources.

Does Fer feel emasculated about being usurped?
I think he’s okay with it because it takes him off the hook a little bit. I mean, he still works hard and he’s still there. But, no, I don’t think he’s particularly embarrassed. I don’t think he’d admit it, but anyone who watches the film can tell that he’s trailing behind his son’s ambition and doesn’t do the work. They all have titles on their jackets — Fer’s title is technically the director of everything, but he’s not when it really comes down to it. There are certain situations where having Fer take control is really important. Like you see in the film, a lot of the more difficult police conversations, Fer is the one to be at the center of that. He’s more experienced, but he doesn’t want to do the work.

With the presidential election next year, there’s a lot of talk about our health-care system and why it’s not more like Canada’s or Europe’s. Midnight Family suggests some places do have it worse than us.
Oh yeah, [Mexico’s] is significantly worse than the U.S. But there are still certain parallels that are important. I had a doctor come up to me after a screening in New York. He was like, “People seem pretty shocked by how that system works. But in my hospital here in the city, we have to make financial decisions about people’s well-being on a daily basis. My hospital has a budget and we need to take that into consideration when we’re putting resources into people.”

In some ways, I feel like the Mexico system is a warning call, or an exaggerated version, of what it looks like when money and profit is infused into the well-being of people. It’s not a pretty picture — no one is getting what they need. I don’t know as much about L.A. or even the rest of the country, but even a public ambulance in New York, FDNY will charge you upwards of $1,500 for a transport. So it’s not free. A lot of people just won’t be able to pay, or they’ll be in debt. It’s still a system that asks you to pay.

Did you witness anyone die while making this movie?
Yeah. I mean, it’s hard to not see that in this line of work — multiple, multiple people. Not something I had experienced before. The first time it happened was a totally life-changing moment. Then your brain and body have this bizarre way of processing the next experiences. I tried to come up with mechanisms that I’d use to distance myself in some of those moments. Sometimes just having the camera as this mechanism that could separate me from what I was filming…

Are the Ochoas conditioned not to be affected anymore? Are they comfortable with death?
They’re so used to it. “Comfortable” is one word, but it’s a much darker sense of comfort, where they cope. I don’t think they fully know, or have come to terms with, how much it affects them emotionally. They’re just surrounded by this world and haven’t had the space or resources to step away and process a lot of it. But they’ll see multiple people dying in any given week. That’s just how they experience the world. It’s really, really tough.

The film shows how tenacious the cops can be. If they want to mess with the Ochoas, they can make the family’s lives hell — and yours.
You never know when you show up at one of these accidents [if] the police officers are someone the Ochoas know and will treat you like a close friend — or if they’ll want to take your camera away. It was something that took a long time to learn how to navigate. Despite having all the proper filming permits and going through all the right bureaucratic steps — which is a film in and of itself — it was unpredictable.

The Ochoas were great allies with that stuff. Sometimes if they knew a police officer was going to be aggressive, they’d just tell me to lay low. But another thing I’ll say is that, with the bigger accidents, there’s a whole industry of night-crawler journalists that would often be there before the ambulances were. Police were used to a lot of press. I was able to hide behind some of that — they’d often have far more pressing things to worry about than a camera guy.

Midnight Family hasn’t been released yet in Mexico. Are the Ochoas worried they’ll receive reprisals from cops or other people because of the movie?
There’s nobody out there that would put the Ochoas at risk that aren’t in some way also involved. We went scene by scene through the film with the Ochoas before we locked picture to see how they felt with what was being revealed — they were very cool and comfortable with it because it’s not news to really anybody other than some of the public. And from what we’ve seen, the public has been quick to embrace the Ochoas and criticize the system.