Kiran Mitha: Covid-19 is testing the limits of the fragile healthcare system in Peru’s Amazon region

In the remote Peruvian state of Loreto, physicians are a rare human resource and are risking their lives to care for patients with covid-19. How many more doctors must die before governments learn their value, asks Kiran Mitha

Peru has reached the grim milestones of having more than 240 000 confirmed cases of covid-19 and more than 7000 deaths. Leadership in this country acted swiftly to close its international borders on 16 March, 10 days after its first confirmed case. However, covid-19 has continued to spread within communities and to remote areas, where indigenous populations, and the healthcare workers who care for them, are ill equipped to cope.

The northeastern state of Loreto, which includes the Peruvian Amazon, has long been a challenging place to live and practice medicine. It’s isolated from the remainder of the country by rivers and jungle. For the people who live in these rural communities in the Amazon, access to a physician can mean travelling for days to weeks by boat to reach the region’s capital city of Iquitos. More than 30% of the population in Loreto live in poverty, many in overcrowded areas, and this magnifies the risk of infectious disease.

Loreto has dealt with more than its fair share of outbreaks. Dengue and malaria have been rampant in the region for many years. The Zika virus also found its way from Brazil to this remote region, as have outbreaks of rabies. The poor living conditions there help outbreaks to thrive.  

The few doctors who practice in this secluded region of Loreto, however, have a distinct level of resilience in the face of these challenges. As an experienced global health physician, I recognize the inspiring work of my colleagues in Iquitos. They have eschewed the attraction of a more cosmopolitan lifestyle and higher pay that working in Lima, Peru’s capital city, offers. At times, they even work without pay when hospital funds are depleted. 

Loreto’s doctors have adapted to serving their communities when there are not enough within their ranks. Loreto has about one third of the physician workforce per capita compared with the more appealing coastal areas of the country. They care for vulnerable patients with limited resources in a strained health system. Some work well into their retirement years because they provide such a vital service for this population. For reasons of personal connection to the region or dedication to the underserved people who live there, these healthcare workers have found ways to thrive in a taxing environment.

Covid-19, however, has tested the limits of their altruistic capabilities. Since the pandemic hit, the inequities that existed in Loreto have been amplified. To curb the spread of covid-19, the country stopped all commercial and cargo flights in and out of Iquitos. Since the city is inaccessible by road, the communities of Loreto are now dependent on infrequent military flights to bring everything from food to medical supplies. The geographic isolation of this region has allowed a black market to emerge for those who can source critical supplies for covid-19, such as oxygen for sick patients and personal protective equipment (PPE) for medical personnel. Social distancing is not feasible for impoverished communities where overcrowding is the norm and access to clean water scarce. Lack of health information about coronavirus has caused mass panic.

The healthcare providers who have been at the frontlines of multiple outbreaks in the Amazon are now at the forefront of yet another epidemic, but woefully underprepared. The surge of patients to the Hospital Regional de Loreto, the main hospital treating patients with covid-19 in Iquitos, has increased the already heavy demands on healthcare workers. 

Physicians have been spending days and weeks caring for patients without returning home, in order to prevent infecting their families. The lack of adequate and affordable PPE has exposed hundreds of physicians in Iquitos to covid-19. I have worked with colleagues to help provide PPE to frontline staff, but the needs are overwhelming and supply chains are broken. 

Recent estimates suggest that more than 200 doctors in Loreto have contracted covid-19, almost half of the physician workforce, and dozens are struggling to survive on a ventilator. Nineteen physicians have died unnecessarily, including specialists direly needed in Iquitos. Organizations are raising money to evacuate severely ill physicians to Lima to try to save this critical human resource.

Highly skilled physicians are fundamental to an effective health system, especially a fragile one. Covid-19 is unmasking the existing inequities for remote communities in Peru and the healthcare workers who are sacrificing their lives to care for them. Even one physician lost in this under-resourced region is one too many. 

As the epicenter of the covid-19 pandemic shifts from the US to South America, we cannot forget about frontline workers around the world who are still at risk. They deserve the same protections to care for their communities. We must stand together as a medical community and advocate for governments to treat frontline workers as essential and not expendable. They are the key to strengthening health systems in the most vulnerable places, both during this pandemic and beyond.

Kiran Mitha is a pediatrician and assistant clinical professor at the David Geffen School of Medicine at UCLA in Los Angeles. She has spent her professional career focusing on the health of vulnerable populations, particularly in under-resourced areas in South America and sub-Saharan Africa. She leads an academic partnership with the Hospital Regional de Loreto in Peru and supports pediatric educational programs in Uganda and Malawi.

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Competing interests: I am the Peru partner lead for UCLA’s Global Health Program.