Impact of the COVID-19 Pandemic on Health and the Environment in Rural Peru

Infectious diseases such as COVID-19 are indicators of the complex interaction between the human species and the environment.¹ Peru has among the most extensive levels of biodiversity in the world², concentrated in the eastern Andean-Amazon region. In the last two decades, Peru has developed biodiversity conservation policies in conjunction with policies for adapting to climate change at sub-national levels of government.^3,4 At the same time, there has been a boom in mining, oil, and gas in areas with high biodiversity,^5,6 which has not only put the balance between conservation and the use of nonrenewable resources in question but also led to an increase in the loss of biodiversity and dietary, occupational, sociocultural, and socioeconomic changes. Access to local medicines has become precarious, which has had a negative impact on public health⁷. There has also been an increase in chronic diseases among the rural population living close to mining activities, and to legal and illegal timber industry^8,9. All of this has resulted in marked insecurity and a greater need for income, food, education, and healthcare services.

Peru’s experience of the COVID-19 pandemic has been shaped by all of these factors, as well as by recent societal developments, such as socioeconomic and socio-cultural, in the identity of the Peruvian people. The migratory waves from the rural interior to Lima, the revaluation of the products of the popular layers of society, and an exponential growth of the middle class are the main features of the new sense of Peruvian identity or “peruanidad.” The pandemic hit Peru the year before the Republican Bicentennial,¹⁰ at a time when the resignification of this sense of Peruvian identity converged with many other sociopolitical and socioeconomic developments in Peruvian society: the diversification of economic production¹¹; the widening of the middle class;¹² the emergence of new actors within the framework of an acute crisis and instability of the political system;¹³ old and new inequalities;¹⁴ active illegal economies;¹⁵ judicialization of political corruption;¹⁶ and a sophisticated revaluation of aspects of popular culture,¹⁷ such as Peruvian cuisine. In particular, the crisis and instability of the political regime led to the closure of the Peruvian Congress at the end of September 2019¹⁸ and the subsequent election of new members of congress in January 2020. This was followed by a presidential vacancy that has been resolved with a president appointed by Congress,¹⁹ all in the context of a series of protests and demonstrations led by student and youth groups, which have been called the “Bicentennial Generation”²⁰ alluding to the Bicentennial of the Republic that will be celebrated in July 2021.²¹

On March 15, the state declared a National State of Emergency²² in response to the presence of COVID-19 in Peru, providing the government with considerable discretion to address the urgency and complexity of the pandemic. As of November 30, 2020, COVID-19 has caused more than 35,932 deaths in Peru²³ with an excess mortality rate of 156 percent during the pandemic, according to data analyzed by the Financial Times.²⁴

This essay considers the pandemic’s impact on the rural-indigenous environment in Peru, within a historical, environmental, and health system setting as the country moves toward the bicentennial. We argue that the socio-environmental, socioeconomic and socio-political dynamics of the last decades have created a socio-ecological dysbiosis in Peru. This is the context in which the COVID-19 pandemic has been experienced and confronted, individually and collectively.

Shifting Demographics, Rising Tensions

In 1971, the military dictatorship of Velasco²⁵ brought about educational and agrarian reform,²⁶ the latter designed to establish the equitable distribution of land and territorial rights and providing land titles to indigenous people for their ancestral land. However, since the return of democracy in 1980, and under the neoliberal influence of the 1993 Constitution, there has been a return to unequal distribution and a reconcentration of land ownership,[note]Burneo, Zulema. El proceso de concentración de la tierra en el Perú. Coalición Internacional para el Acceso a la Tierra, 2011. Roma: Coalición Internacional para el Acceso a la Tierra Cirad
CEPES. http://biblioteca.clacso.edu.ar/Peru/cepes/20170323043255/pdf_591.pdf.[/note] along with a shift in land use toward export crops for use in global production chains.

In 2002, Peru introduced a process of political, financial, and economic decentralization. Regional governments took over the provision of healthcare. As a result, from Kent Eaton's²⁷ perspective, there is now a tension between the regional administration, which uses this new power to oppose the neoliberal strategy of extractivism, and the state, which promotes the privatization of essential services, such as health and infrastructure.

The Land and “Peruanidad” Reconnected

Most of the rural areas in Peru are home to indigenous peoples and native communities. Over the last fifty years, indigenous peoples have increased their agency through the establishment of indigenous organizations linked to the management of national and international platforms and initiatives.²⁸ Their dialogue and presence are increasingly visible through engagement at the national level organized by the Peruvian Ministry of Culture, and internationally with specialized agencies of the United Nations and other entities for the defense and promotion of the rights of indigenous peoples. Alongside this, during the last decade, there has been a change in rural-urban relations. Urban Amazonian indigenous groups, such as the peoples along the Ucayali River, have long engaged in seasonal migration between rural and urban areas for subsistence purposes. New connectivities with rural areas²⁹ through transportation, digital communications, and electrification, have allowed people across Peru to remain in rural areas or move to rural areas while continuing to participate­ in the economy and in public affairs. At the same time, the increasing use of digital technology has to some extent served to disconnect the indigenous from traditional forms of learning and has created a tension in their interrelationship with the environment. We can also expect that climate change and biodiversity loss will likewise have a profound impact on these people’s experiences and relations with their environment and Peruvian society over the next decades.

Although over the last decade connectivity between rural and urban areas has driven the return to rural areas, the COVID-19 pandemic has generated a greater displacement of Peruvians from urban to rural areas³⁰ and from the capital to their places of birth due to job loss, lack of social security, and extreme poverty. Peruvians traveled hundreds of kilometers through the interior of the country, with unreliable and insufficient support and coordination from the government, while support and coordination was provided for Peruvians overseas to return home.³¹

As a result of this return to rural living we have also seen a return to a Peruvian identity that values ​​and connects with the land, with its ancestral origins and with nature. This reconnection has also emerged as a way of managing the current health crisis.

The relationship between land, environment, ecosystem, and the people of Peru is closely linked to food and food security and, therefore, to the conservation of biodiversity. The damage done by the pandemic has been more severe as a result of growing food insecurity in the country. Peruvian cuisine has been affected by global franchises and restaurants.³² As a result, there have been significant nutritional changes in rural as well as urban areas. These changes include a loss of access to wild food due to deforestation and the fragmentation of forests. In addition, the loss of biodiversity has resulted in increased dependence on processed food and a loss of self-sufficiency. This in turn has brought about health problems, including high rates of anemia, diabetes, and other chronic diseases related to malnutrition. Recently there has also been an increase in malnutrition of children in urban indigenous families. The chronic diseases that are linked to food insecurity and dependence on processed food have emerged as an even more severe problem for rural areas in times of confinement from the pandemic. Not only, do people with chronic diseases have a higher risk for severe COVID complications. Food insecurity in times of confinement has become severe showing a higher dependency on external food supplies. In response, there has been a new dynamic, most recently, on the occasion of the International Day of Indigenous Peoples, Amazonian leaders issued a call to ensure food sovereignty.³³

The Turn to Traditional Healthcare

The damage done by the COVID-19 pandemic in Peru is partly a result of thirty years of neoliberal policies that have actively transformed the Peruvian health system³⁴ into a model that focuses on urbanity and profit, resulting in marginalization of rural and indigenous peoples. In 2009, Peru passed the Law for Universal Health Insurance,³⁵ which engineered a profound change in its health system that was aimed at strengthening the financing mechanism through insurance partnerships involving public and private actors, within a neoliberal framework of health care financing. At the beginning of the year, 2020 was officially designated the "Year of Universalization of Health"³⁶to better respond to the challenge of comprehensive and timely health care for all Peruvians in any part of the country. However, instead, there continues to be a lack of public health infrastructure as well as exploitation by the private sector, all of which predates the pandemic.³⁷

Healthcare in rural Peru has been precarious during the pandemic, continuing a long-term trend. Communities lack clinics and face inadequate human resources, equipment, and medicines.³⁸ This is due in part to a failure of the state and private sector to develop and provide a comprehensive intercultural health system, particularly in rural areas, where it would be possible to harness local expertise in biodiversity for food security and herbal treatments, among other local practices.

Indigenous organizations, although they have gained agency in recent decades, are still subject to the policies of the Ministry of Culture, which oversees Peru’s multicultural representation. Indigenous organizations have engaged with the Ministry of Health to advocate for the development of intercultural health care practices, in an effort to shift away from the current healthcare system, which continues to exclude and discriminate against indigenous peoples. In the context of the pandemic, indigenous organizations have not been included in the development of an initial response to the needs and realities of the indigenous populations, including in regard to the uncontrolled spread of COVID-19 in the Loreto and Ucayali regions. Many indigenous people were infected, dying, and at risk of contracting the coronavirus before national and regional indigenous preparedness and response plans were formed. These plans were developed directly by indigenous organizations, such as Regional Organization of the Interethnic Association of Development of the Peruvian Rainforest in Ucayali (ORAU),³⁹ and through the participation of indigenous representatives in the COVID-19 Regional Commands.⁴⁰ Unfortunately, however, they have limited capacity to address the situation effectively. Indigenous organizations are not fully included in local, regional, and national governments as independent political actors, and therefore do not directly receive a budget to implement their programs. Addressing the health needs of the indigenous groups is difficult for other reasons as well. In the regional health system, urbanity is synonymous with modernity, and traditional forms of health care are dismissed. While urban healthcare is precarious, in rural areas it is even worse. In addition, the provision of healthcare operates under a neoliberal market mechanism, where medicines and access to supplemental oxygen is controlled by the market and therefore are unaffordable for many people.⁴¹ In the Amazonian context, this dynamic is even more stark.⁴²

For these reasons, indigenous organizations have found it necessary to organize their communities, activate social capital, look abroad for international financial support, and draw on traditional remedies. For example, with no biomedical treatment or vaccine available, and no access to supplemental oxygen for severe cases of COVID-19, a Shipibo-Konibo indigenous initiative, Comando Matico⁴³, was developed in May to use local plant remedies and treatment practices and to organize access to oxygen and social support at home.

Conclusion

The impact of the COVID-19 pandemic in Peru has presented an enormous challenge for a health system organized on the basis of public and private insurance and the inequitable distribution of public and private social benefits. While there have been institutional improvements to the healthcare system in the last decade, there have also been changes to economic production and profound sociodemographic changes. We now face a socio-ecological dysbiosis, a rising political crisis, and new and persistent inequalities between city and country. The fight against the pandemic has the potential to serve as a turning point to generate better dialogue regarding the conceptions and practices of healthcare, and the interrelationship between health and the environment. It also, however, has the potential to reinscribe existing inequalities, deepening the disconnect between the needs of marginalized communities and the policies put forward by the Peruvian government. Meeting this challenge will require redistributive policies, innovation and technology developments, and renewed links with the land and the environment that are more just, creative, and healthy. On the cusp of Peru’s bicentennial, nothing could be more urgent.

—Doreen Montag and Marco Barboza

Doreen Montag is a senior lecturer in Global Public Health at the Centre for Global Public Health, Institute of Population Health Sciences, Queen Mary University of London, UK.

Marco Barboza is a research affiliate at the Centro de Investigaciones Tecnológicas, Biomédicas y Medioambientales – CITBM Universidad Nacional Mayor de San Marcos, Lima, Peru.

Funding

DM was supported through Medical Research Council – MRC grant number MR/S024654/1.

NOTES