Letter from Peru

Peru was the first country to achieve sufficient progress in tuberculosis (TB) control to exit the TB-80, the group of 22 countries with 80% of the global TB burden. The Peruvian TB control program became the best in the world. In the 1990s, the death rate of the Peruvian cholera epidemic was the smallest in the history of this terrible disease. As with TB and cholera, I thought Peru would beat COVID-19. Between 1987 and 1990, the Peruvian economy suffered the most severe economic crisis of its post-war republican history, recorded in a 25% cumulative drop in gross domestic product (GDP). This was the result of the prolonged attacks of the Shining Path, the most brutal terrorist group in Latin America, which caused an internal conflict with more than 70,000 deaths, poor macroeconomic management and social turmoil. The conditions were similar to an epidemic and spread easily. The cholera epidemic began in January 1991 in Chancay, 60 km to the north of Lima, and extended rapidly across the country. At that time, every primary Peruvian health centre and community centres had an oral rehydration unit. Peruvian health workers and community agents all over the country learned with the 1200 nurses and doctors trained in PROCAME (Programa de Capacitación de médicos y enfermeras; or Training program for doctors and nurses). It was a very successful project with hands-on training at Dr. Salazar's Cayetano Heredia Hospital Service, with theoretical and group classes at the Universidad Peruana Cayetano Heredia campus in Lima. Its program was based on training to manage diarrheal disease, with an emphasis on oral rehydration. The Peruvian Ministry of Health provided to this perfectly trained army the weapons to win the war against vibrio cholera: antibiotics, oral rehydration sachets, poly-hydroelectrolytic solutions and supplies to use them. Government and civil society constituted national, regional and local action committees. The media publicized measures to fight the epidemic. By the end of 1991, 322,562 Peruvians became ill, of whom 2909 died, a lethality (case fatality rate) of 0.9%, the smallest of all the cholera epidemics. The success of the fight against TB began in 1972 with the TB Control Pilot Program at the Hospital Cayetano Heredia (HCH). At the beginning of the 1980s, the TB cure rate was only 50%, because the Peruvian government bought treatments for only 41% of diagnosed patients. By July 1985 and for two consecutive years, there were sufficient resources for the diagnosis and treatment of the disease. Guidelines were updated, and training of primary care personnel under the Program was reinforced. Only in 1990, after several events widely publicized by the national media showing demonstrations by patients sick with TB, one of which was in the atrium of the Santo Domingo church in Lima, Peruvian society learned that a large number of patients with TB did not have access to a cure. Only those who had the financial resources to buy their medicines were cured. With the full cooperation of civil society, all the measures of the TB Program were optimized and others were implemented, such as outpatient retreatment in primary care centres for patients whose initial treatment had failed. Dropouts were reduced to 2%, with more than 95% of the patients cured. Therefore, the rate of TB was reduced each year, reaching 19% in 1996, the largest national decrease on record. Solidarity: An ancestral trait of Peruvian society. Every 4 years, the members of the nine communities of Marcapata, Cusco, located at 3100 meters above sea level, carry out the repaje (Wasichakuy). They change the deteriorated thatch from the roof of the church of San Francisco de Asís, built in the 17th century, in a 1 week task. This is a manifestation of the ancestral solidarity of the Peruvian communities that explains why in the 1990s when in a single day prices rose 7 times, but not income, no one died of hunger, because society was organized around soup kitchens. ©jesuitspe. Reproduced with permission. In 2020, Peru's GDP was 4.6 times higher than two decades ago (1.520.68 USD in 1991 and 6.955.81 USD in 2019). However, Peru continued to be considered as one of the most inequitable Latin-American societies, with 71% of workers in the informal sector. When the COVID-19 pandemic hit Peru, it was again in the midst of a chaotic socio-political situation, with inadequate availability of medical oxygen, only 773 UCI beds for 23 million habitants and the lowest availability of mechanical ventilators/population rate in the continent. The National Government ordered quarantine, but the most vulnerable population that need a daily income to feed their families continued working despite the lockdown. A return migration occurred from the most developed urban areas to the rural areas, from where most of these people came originally to work and have a better life. During the worst stages of the COVID-19 pandemic, it became impossible for them to pay for housing and food. A number of migrants opted to return by foot to the countryside, as a survival strategy. One could see on the main roads hundreds of people walking to return to their places of origin, unfortunately carrying and transmitting the SARS-CoV-2 virus. In the Peruvian health guidelines, hydroxychloroquine (HCQ) or chloroquine (CQ) plus azithromycin (AZT) was COVID-19 treatment and diagnosis could be based on symptoms, but many patients and physicians did not accept this approach and preferred waiting for a positive test, which was not easy to obtain. When a poor family had a COVID-19 case, they could not isolate the sick person, thus causing more infections among them. In addition, when they went to the hospital for attention they had to wait until there was a free bed or return to their houses, so they preferred to stay at home, increasing this vicious circle of infecting more patients. The Peruvian authorities answer to this incredible situation was to add more days of quarantine, leading to one of the most restrictive and prolonged lockdowns in the world. The second version of Peruvian COVID-19 guidelines introduced ivermectin. The General Directorate of Strategic Interventions in Public Health of the Peruvian Health Minister reported an operational result finding, that 35,392 people who followed Peruvian Guidelines had 63.4% lesser risk of lethality compared to 104,981 patients who only followed COVID-19 WHO recommendations.1 According to data reported from Social Health Insurance of Peru, in another study among 2854 patients who took ivermectin, lethality decreased by half compared with the value among 243,179 patients who followed only WHO recommendations.2 Considering these figures and the broader social and clinical context, further controlled studies are needed to fully assess this situation. As an additional measure, it was ruled that primary care centres were to close, as well as hospital outpatient care and that health personnel over 60 years old (with the most experience) would retire to their homes. There was a primary health centre in Lima, Tahuantinsuyo Bajo that remained open during the entire pandemic, giving their health workers treatment with hydroxychloroquine plus azithromycin under the leadership of senior physician Dr Juan Carlos Madrid. The reported lethality rate of 0.6% was 18 times less than the average for COVID-19 patients in Lima.3 The Peruvian COVID-19 case numbers were among the worst in the world. But could we obtain better results if we use the same community-focused strategies of the Tahuantinsuyo Bajo health centre? My answer is yes. None declared.