Peru has a population of around 32 million of whom over a third live in its capital Lima.1 Like the rest of the world, it has been hit by the covid-19 pandemic. On 15 March 2020 a state of emergency was declared and its borders closed. The country’s vulnerability to the impact of the pandemic is evident. Peru’s health system is fragmented and segmented, which makes coordinated implementation of policies difficult. The sector is also very poorly resourced. Its health budget is one of the lowest in South America; the average investment in health is only 4% of the Gross Domestic Product (GDP) by contrast to an average of 8% in countries belonging to the Organization for Economic Cooperation and Development (OECD). For 2020, Peru’s allocation of GDP for health was only 2.2%, and health spending in previous years similarly low.2
Peru’s human resources for health are also low. The WHO recommends 44.5 health workers per 10,000 inhabitants. Peru has 32 for every 10,000 inhabitants and most are in urban areas. We have only 2 intensive care unit beds for every 100,000 inhabitants, and 700 intensive care physicians. This is at a time when the President of the Society of Intensive Medicine in Peru has said that 1,400 doctors are required and we need five times the number of ITU beds. Recent data show that the 808 ICU beds set aside for covid-19 were soon taken up and this has likely resulted in many seriously ill patients being denied the best care, and perhaps losing their lives as a result.
The implementation of lockdown policies has seen the cessation of all trade with the exception of banks, pharmacies and activities related to food supply. This, as in other countries, has had a big impact on independent self employed workers. According to the National Statistics Institute, these make up over 41% of the total number of people in employment. Of these, over half work in the commerce and transport sectors, and together with a further quarter of those in other services, the average wage is only $300 per month.3 This information is of utmost importance; the sudden imposition of quarantine and lockdown policies to prevent the spread of covid-19 has resulted in the sudden loss of livelihoods which is having a devastating impact.
Migrant workers have fled from the big cities
The 1 May 2020 marked day 56 since the diagnosis of the first covid-19 patient, and day 47 since the imposed quarantine. Covid-19 began in middle-class areas of Lima due to people returning from Europe, and since then it has moved throughout the country. Within Lima, it is the poorest and most vulnerable who have been most affected, producing a phenomenon never seen before; the exodus from the capital of thousands of out of work migrants who are returning to their towns and villages from which they originally came. They have been fleeing from hunger, moving on foot, sleeping on the streets, or waiting for the State to provide transport to get them to their desired destination.
On 16 March, the State granted a bonus of $110 to be distributed to 2,700,000 vulnerable families, then a second bonus as the quarantine was extended to 800,000 more families. This generated queues at the banks since dawn, without any respect for physical distancing. In addition, baskets with basic necessities have been distributed but have not reached all poor families. Civil society groups have also organised and tried to help by bringing food to those most in need.
Despite a clear policy mandating physical distancing, wearing of face masks, and hand washing and use of alcohol gels people in the food markets are taking little notice and do not respect these measures. They thus become, or risk becoming, sources of contagion. Many have little option but to shop on a daily basis for they don’t have refrigerators and don’t have the money to buy in bulk. The Ministry of Health recently did coronavirus testing on 842 food merchants in the Caqueta market in Lima and found that 153 tested positive. Some markets have now been closed and entry into others restricted.
The country is paying a high price for low investment in the health sector
The highest number of covid-19 infections and deaths are in Lima, and other large cities including Callao, Lambayeque, Piura and Loreto. As of 1 May, the country has recorded 40,459 positive cases of coronavirus, 1,124 deaths, 5,287 hospitalized and 658 on mechanical ventilation.4
Peru’s statistics are the second worst in South America after Brazil. Health personnel are making strenuous efforts to care for patients. New treatment protocols have just been introduced for selected patients with covid-19 infection. These include the use of methylprednisolone, enoxaparin, and tocilizumab. But every day the number of cases increases and there is a shortage of ventilators, oxygen, and personal protective equipment. We are seeing patients being turned away from hospitals and being left to try and find another which might be able to offer them a bed. And we have still not reached the expected peak of new infections.
The health system has cancelled all elective procedures and concentrated its resources on providing care for covid-19 patients, but it has begun to collapse. The country is paying a high price for its failure over many years to invest sufficiently in the health sector. We are also witnessing the inequitable impact of the pandemic. The coronavirus is said not to distinguish between people in different social classes, but undoubtedly here in Peru, the most severely affected are the poorest.
Nora Espiritu is a pediatrician at the Dos de Mayo National Hospital, with a master’s degree and a doctorate in public health. She is the former director general of the General Office of Research and Technology Transfer of the National Institute of Health and former head of the research subunit of the National Institute of Children’s Health San Borja, Peru.
Competing interests: None declared