At the height of the coronavirus pandemic, Peruvian hospitals were on the verge of collapse, patients were lying in corridors for want of beds, and people were dying in the streets due to shortages of oxygen. Peru’s 32 million people are the worst hit per capita in the world, with almost 800,000 cases and more than 32,000 deaths since the pandemic started. The week of Sept. 23, the Ministry of Health reported more than 11,000 new cases and 185 deaths, and in the months of July and August, between 5,000 and 10,000 cases per day was common. Underpinning these losses were a deeply deficient health care system, coupled with financial mismanagement by the country’s leadership. Peru had initially hoped to avoid the scourge of the virus entirely.
On March 16, nine days after the first infection in the country was diagnosed and before anyone had died, Peru entered into a quarantine that, although intended to last only 15 days, is still in effect in some provinces and cities. Most businesses closed, and only essential establishments—such as hospitals, food stores, and banks—were able to remain open. These limitations did not prevent cases from reaching the thousands in a few days.
“These measures did not work well, because Peru is an informal country; these are structural social issues that have been around for many years,” said César Ugarte, an epidemiologist and researcher at the Lima-based Instituto de Medicina Tropical Alexander von Humboldt. In Peru, around three out of every four workers are working informally, and many families live in harsh and unhealthy conditions without access to basic services. In Indigenous populations, limited access to health care and continued government neglect have been responsible for the loss of countless lives.
The strong impact of the pandemic on the country was exacerbated by the near impossibility of obtaining medical oxygen—a shortage that continues. The sudden and disproportionate demand due to the large number of respiratory infections in such a short time caused the price of oxygen to rise tenfold, when it was available at all. It was a predictable problem: Most hospitals in Peru, unlike in other countries, do not have their own oxygen generators and instead have to source it from outside. This affects public hospitals, which depend on the government, and the problem is even more noticeable in rural areas, where most oxygen generators, already short in number, are out of operation due to a lack of repair services. The black market, which has been cornered by several powerful individuals, has concentrated what little oxygen there is in the hands of the rich.
The government has produced no real solution to the problem, which is instead being addressed by organizations with small funding campaigns, or churches, as is the case with “Respira Perú” (“Breathe Peru”), a program promoted by the Catholic Church that seeks to bring oxygen generators to the country’s most remote cities.
In the last month, the situation has eased a little: “Until a month and a half ago, doctors told me there were no beds, no oxygen. Five weeks later, I talk to my colleagues at the hospital and they tell me that yes, there is a bed, that I can bring a patient in,” said Ugarte, who currently works directly with COVID-19 patients. “It’s not that everything has been released, but the system has been hit so hard that now it is having a few minutes to breathe.”
That breathing room is waning, though, and the second wave of the pandemic is about to hit. “We are beginning to learn now that there are many infected people who are beginning to have chronic, long-term symptoms. There are a lot of these people, but they are invisible,” said Jaime Miranda, the director of the Center of Excellence in Chronic Diseases at Cayetano Heredia University. He explained that the Peruvian health system—focused on curing the disease and not on offering long-term treatment—is not adapting well to the situation, and it was not so adapted to the needs of the population before. “With a highly aging population and where the problems are more and more chronic, that have no cure, we need not just to solve the problems, but also guarantee a continuity of care, a chronic accompaniment,” he said.
“We are told that Peru is growing, that Peru is advancing, and that we have had years of stability, but the pandemic has come and has exposed, quickly and abruptly, how precarious and vulnerable and how weak the social fabric of the country is, including the health sector,” Miranda added.
“One of the things that is striking about Peru is that it is been marked as one of the success stories in terms of economic growth, increasing GDP, or reduction in poverty,” said Christopher Hewlett, an anthropologist who specializes in Indigenous studies in the region. “There are many international organizations and institutions that have held up Peru as a good model—but when you’re on the ground, it becomes clear that that growth and that increasing wealth was increasing inequality, because the access to actual good health services was not really improving during that time.”
Despite its sustained economic growth in recent decades, the country’s investment in health has been low, with public spending reaching only 3.2 percent of GDP, a figure far below the 4 percent average in the region and one of the lowest in South America. Added to this is endemic corruption that has plagued the region and siphoned away the funding needed to fight the pandemic. According to Transparency International’s Corruption Perceptions Index, Peru ranks 101st out of 198 countries analyzed, far behind some other Latin American countries such as Chile, Argentina, and Uruguay. Its corruption score, which Transparency International measures on a scale of 1 to 100, where 100 represents total transparency, is 36, placing Peru in a similar position to some other countries in the region, such as Panama and Brazil.
“As a result of the Odebrecht incident,” Ugarte said, referring to the global corruption scandal involving a Brazilian company that paid bribes to important political leaders around the world, including four former Peruvian presidents, “it was seen that in addition to the roads, the other inflated constructions were hospitals, and several hospitals in many regions were half-finished when the pandemic occurred, stopped by corruption.”
Miranda noted: “For many World Health Organization indicators, Peru is doing very well. It’s true, we could say it’s fine, but if you just look at the isolated parts without looking at the context, you lose the rest, and then you realize that the situation is not really as it seems.”
Rural areas were worst-hit by the lack of construction funds for new health centers. “It’s difficult to get people to build those hospitals in rural areas, but what’s sad is that they did invest, but it was so poorly done,” Hewlett said. “There was very little oversight, there was corruption, but when you build a hospital that costs you millions of dollars, and you go over budget, and you go over time, and then when finally it is done it was built on a flood plain. That’s disheartening.”
The fragmentation of the health system and its slowness were also critical factors. In addition to the public health system, which serves approximately 60 percent of the population, Peru has a contribution-based health system, accessed by those on fixed salaries; the private system, which is outside of state control; and an extensive military health care system. Before the pandemic, these were disconnected from each other—and when the pandemic came, burdensome bureaucracy and administrative problems made it difficult to interconnect them in the first few months, something that would have saved thousands of lives by making more equipment and care available.
Peru is also a highly centralized country, with the capital, Lima, accounting for over half of GDP. Most hospitals, intensive care beds, and sites with access to oxygen are in Lima, which meant that in the jungle towns—and in smaller cities that together hold millions of people—there was often no access to health care, inflating the number of dead. “Iquitos [the largest city in the Peruvian Amazon] was a disgrace the first few months, simply because no capacity had been built there,” Ugarte said. With educated Peruvians often heading abroad, many cities also suffered a lack of doctors. Lima has 12 doctors per 1,000 people; Peru as a whole has 1.3.
But even worse hit than the smaller cities were Indigenous populations. “When the pandemic arrived, the Peruvian state issued a state of emergency decree, but the public policies were made from a purely urban perspective, in Lima,” said Maria Pesantes, a medical anthropologist and researcher at the Cayetano Heredia University. “The Indigenous population lives in remote areas, they have a precarious health system, and certain prevalent diseases and health conditions like high rates of anemia and tuberculosis make them more vulnerable. When the containment policy was made, no thought was given to how something specific should be done to include all their territories.”
Health centers in these regions are not only sparse, but also suffer a serious lack of personnel and supplies. “Often what happens is the hospitals don’t have the right medicines or the right equipment, so the patients are told … that they get a prescription, but the hospital doesn’t have it, so they have to find private treatment instead,” Hewlett explained.
Health center staff, who are usually nurse technicians—who have only studied for three years—or recent graduates are also often not prepared to work with Indigenous populations, who not only speak their own languages but also often have traditional health practices.
“There is a lot of prejudice toward Indigenous practices, so the health personnel don’t know how to reach the population,” Pesantes said. “This lack of respect for Indigenous culture and knowledge means that, in addition to the geographical distance, there is a distance of empathy. The population does not feel welcome in a system that does not take into account their reality.”
The rapid action of Indigenous organizations in closing their territories and implementing various forms of protection was overshadowed by government actions that, although well intentioned, led to tragedy. “A voucher was issued for people in situations of poverty and extreme poverty, and this meant that people in the communities had to go to the nearest town or city to pick it up, at a bank, and these became the spaces where these people were infected, bringing the virus to the whole community,” Pesantes said. “For these populations, one could say that the state has been a vector of contagion.”
Despite this, the pandemic has also made the system stronger, exponentially increasing the number of beds in intensive care, which were few, and accelerating the development of many laboratories. Doctors who learned on the fly during the first wave are now more prepared for the future. What is needed now, experts say, is a plan—not only to deal with the second wave, but also to continue to improve in the future.
For Pesantes, it is investment in the health system—and in all those aspects that have been neglected in recent years, such as rural areas and training in intercultural health—that will allow Peru, once all this is over, to emerge stronger from the pandemic. Another lesson, she says, is that the government must listen to the Indigenous people, who have been ignored for decades but who are, in the end, the ones who know most about their own territories.
“Although we are a little behind, I think it is necessary to make a plan to prepare for the second wave that will come in a few months,” Ugarte said. “We already have experience, we already know how things should be handled, we already know what medications not to use, and we already know what things to do and what things not to do. We can’t make the same mistake that Madrid or Paris are making right now.”
