Peru is a consistently developing country located on the coast of South America and is home to many well-known landmarks such as parts of the Amazon rainforest and Machu Picchu, which is considered one of the new seven wonders of the world. Through this analysis of Peru’s past public health structure and its current structure, assumptions will be drawn on what health issues should be addressed in Peru’s future. This is done by analyzing the three main categories of disease, developing similarities and differences in a regional context, discussing quality of data, considering a subgroup, as well as examining a disease with growing concern in Peru.
Historical Context
In the early 1530’s, Francisco Pizarro began the colonization of the American continent, which led to the conquering of the indigenous Incas of Peru. The colonization of the Incas is thought to be one of the most successful military campaigns with evidence claiming that Pizarro poisoned Inca generals with arsenic laced wine as well as executed the Incan emperor (Zoppi et al., 2000). While under Spanish rule, the Crown constructed various hospitals spanning over Peru with the mind-set of establishing the idea of the King being a protector of the Indians, as well as a way to further monetarily compensate the Church. Care in these hospitals were dependent on the contributions of the Indian population in the area. This symbiotic relationship caused a need for ordinances to be set to safeguard resources of tribute in the chance that the Indians were unable to make their payments to the Church. Under Spanish rule, health care was not as important as the health of the soul. The indigenous people were motivated to “do good” to receive divine compensation in the form of having their soul saved. (Ramos, 2013). As the population grew and Peru became more civilized, there became a need for more modernized teachings and medical schools. Spanish doctors wanted to institute a colony wide medical reform movement. However, the movement became complicated by the interference of Peru’s creole physicians and other healers. Any traction that these two groups made in the medical reform realm was halted after Peru declared independence in July of 1821. High ranking medical officials abandoned their positions for the pursuit of high level government jobs that led to the decline in the movement for better health practices (Warren, 2010).
In more recent times, health care has once again become important in Peru, where they have begun focusing mainly on access to health coverage. Since implementing a health sector reform in 1998, 80% of Peru’s population have health services. Through legislation, which finances insurance as well as utilizes USAID’s health project, Peru has made steps in achieving universal health coverage. The most notable barrier has been is reaching the final 20% of the population which is located in rural areas (“Paving the Way for Universal Health Coverage in Peru,” 2015). More recent figures report that 5.5% of the GDP is spent on health expenditures. There are 1.12 physicians for every 1000 individuals and 1.6 beds for every 1000 patients (“The World Factbook — Central Intelligence Agency,” n.d.). Though lower then highly developed countries, these numbers show improvement and concentration on health reforms to better communities in Peru.
General Overview of Health
A good way of interpreting health impacts on a country is by evaluating the different aspects of the DALY. A large aspect of what calculates the DALY is the years of life lost. To know this calculation, the life expectancy of a country needs to be known. The observed life expectancies of men and women from 1990 to 2017 showed an upward trend until 2016 when 2017 statistics fell. From 1990 to 2016 there was an increase of about 10 years seen in both men and women with the respective numbers changing from 67.4 to 77.8 and 71.4 to 81.6 (“Peru,” 2015). 2017 reports showed that male life expectancies at birth fell to 71.9 years and female life expectancy down to 76.1 (“The World Factbook — Central Intelligence Agency,” n.d.). In 1990, the top five death categories (communicable, non-communicable and injuries) were at equal amounts of communicable to non-communicable diseases. Looking at the change in 2016, there is evidence of a decline in communicable diseases and an increase in non-communicable diseases are rising (“GBD Compare | IHME Viz Hub,” n.d.). One important non-communicable disease to note is the rise in neoplasms, which are abnormal mass growths that are associated with cancer (“NCI Dictionary of Cancer Terms,” 2011). In 2006, the Peruvian Ministry of Health set up mandatory cancer reporting systems to gather more information than they were receiving in the past from population based cancer registries. Yet due to “scarcity in public hospitals, high staff turnover, and the scarcity of supervision of data quality”, this system failed to yield complete and accurate data (“Cancer patterns, trends, and transitions in Peru: a regional perspective – ProQuest,” n.d.).
When looking directly at the differences between the DALYs from 1990 to 2016, the correlation of non-communicable diseases rising should also be a priority. One particular disease that is gaining traction around the world are mental, neurological, and substance (MNS) abuse disorders. Due to DALY calculations using years of life lost due to disability, MNS disorders have jumped from sixth place to third over the past thirty years (“GBD Compare | IHME Viz Hub,” n.d.). MNS has been seen to affect 1 in 5 people in Peru. Due to this influx of cases seen the need for a mental health care reform became apparent. Since 2013, the implementation of a community based model of education has been used within the population and health systems to strengthen and consolidate the necessary medical knowledge to treat patients. These systems are decentralizing the normal hospital-based care to community level treatment which has shown a general upward trend in the uptake of mental health services as well as securing the rights of the MNS patients of the community(Toyama et al., 2017). Though slow moving, it is apparent that mental health is important to Peru as shown by the interest in the mental health reform.
Injury and accidents, which have few appearances on the DALY makeup of 2017, still are necessary to consider in the general health of Peru overview. As of the 2017 Peru DALY, only unintentional injuries are in the top ten with a decline of 19.53% from 2010. The second highest attributed to the DALY are transport injuries (“GBD Compare | IHME Viz Hub,” n.d.). According to the latest WHO data published in 2017, road traffic accident deaths were 4,159, which is 2.84% of total deaths recorded (“Other Injuries in Peru,” n.d.). A large makeup of these traffic accidents are buss related. As of January of 2018, one stretch of a highway in Peru called “Devil’s Curve” is banned to be used by busses due to a major crash which killed dozens (January 4, 2018, & Am, n.d.). Transport injuries are a growing concern for Peru due to the dependency on tourism, which greatly utilizes busses on narrow roads to travel to destinations like Machu Picchu and the Mara Salt Mines.
Regional Context
As of July 2017, Peru’s estimated population is 31 million, which makes it the forty-third largest country in the world (“The World Factbook — Central Intelligence Agency,” n.d.). The world bank has deemed Peru to have an upper-middle-income economy, which by lending terms classifies them as a middle-income developing country supported by the International Bank for Reconstruction and Development (“World Bank Country and Lending Groups – World Bank Data Help Desk,” n.d.). Overall, Peru has a low headcount ratio of Multidimensional
Poverty Index (MPI) poor, destitute, and $1.90/day poor. There are more people who are MPI poor than in destitution or living off of $1.90/day. In terms of MPI values, Peru is a little over .04 at a national scale with higher MPI values coming from rural areas. When shown as a percentage, the national MPI can accredit 17.1% of its rating to child mortality which is the leading trend in rural and urban groups (Peru Country Briefings, 2017). These statistics demonstrate why Peru is considered to be upper-middle-income economy, as well as show how similar countries in similar situations and regions can be.
Nicaragua, which is also a part of the Latin American and Caribbean group has a lower-middle-income economy, has shown to have similar MPI trends according to the headcount ratios. It is interesting to note that even though they trend similarly, Nicaragua’s highest source of MPI value comes from years of schooling whereas child mortality is Peru’s (Nicaragua Country Briefings, 2017). Both of these countries are in the same region, but have very different areas that need focusing on. Peru, which is considered to have higher income, still has problems with child mortality whereas Nicaragua has problems with keeping education a priority. When it comes to comparing DALYs of the two countries, even more similarities and differences can be discussed. Overall, the two groups show a parallel trend of communicable to non-communicable disease. Both top ten DALYs have the same diseases just in different orders. Where neoplasms are number one for Peru, diabetes and kidney disease cause the most deaths in Nicaragua (“GBD Compare | IHME Viz Hub,” n.d.). These findings can show that there is a possibility that proximity of these two countries could be the reason for their similar DALY reports. Another analysis of these findings could just be that lower income economies have similar health concerns.
Quality of Available Health Data
Quality of data is also an important way of judging how health is being prioritized and how far the country has come in terms of progress of their health programs. In the Global Burdens of Disease Estimate, created by WHO, Peru was excluded due to low usability. This meant that WHO considered the cause-of-death data provided from 1998 to 2014 to be unreliable (Hufstader, 2018). To further demonstrate WHO’s point of untrustworthy data, birth registration in 2012 was at 96% whereas death registration was only at 69% (“WHO | Peru,” n.d.). These numbers seem generally high, but when compared to a developed country, they are low. The low national census given in Peru can also be attributed to why it was left off of the estimate. Peru’s National Institute of Statistics recently conducted a national census at the end of October of last year. This was the most recent census done in Peru regarding population size, the most recent census regarding health data was conducted in 2007. The Peru de facto census held face-to-face interviews which regarded housing, household demographics, education, migration, disability, employment for those 6 and older, and fertility for women 12 and older (“Peru Population and Housing Census 2007 | GHDx,” n.d.). This data included both urban and rural areas, which shows that Peru is improving their collection of population data. It is still challenging to use this data to form subsequent recommendations and treatments regarding how to deal with health in Peru.
Marginalized Subgroup
A general trend observed in health practices in Peru is the low availability and proximity of health centers for the part of the population living in rural areas. A particular group seen in these areas who have significantly worse health outcomes then the national averages are indigenous women. As previously indicated, cancer is a rising concern in Peru. For women in Peru, cervical cancer is the leading cause of cancer deaths. PAHO and WHO estimate that the incidence rate is 48.2 per evert 100,000 and the estimated mortality is 24.6 per 100,000 (“PAHO/WHO | Cervical Cancer Prevention in Peru: Lessons Learned from the TATI Demonstration Project,” n.d.). These figures should be higher but due to the lack of surveillance and hospitals in rural areas, the entirety of the population is not accounted for. Indigenous females are at a severe disadvantage when it comes to general health care, and are even worse off when cancer-care is involved.
For the indigenous Asháninka women, cervical cancer is a large threat, however, the only option of treatment are inadequate health outposts and expensive health care. These insufficient health outposts are not equipped with the correct medical instruments to be able to test samples for malignant cells, which makes the diagnosis period longer because samples need to be sent to urban labs. If ever diagnosed, these indigenous women would have to travel to an urban area like Lima for treatment. These women are considered to be a subgroup of the population with worse health outcomes because they do not have the same ability as an urban woman for treatment and prevention. Even if given a diagnoses, it does not mean a family is able to afford treatment (Hufstader, 2018). This is another example of why indigenous women have worse health outcomes then their urban counterparts.
Determinants Impacting Cardiovascular Diseases
Cardiovascular diseases (CVDs) are ranked as the number one cause of death globally. Of these deaths, over three quarters of fatalities are in low- and middle-income countries like Peru (“Cardiovascular diseases (CVDs),” 2017). As of 2017, cardiovascular diseases ranked second accrediting 8.14% of total DALYs which was a 3.01% increase from 2015 (“GBD Compare | IHME Viz Hub,” n.d.). The most recent CVD profile done by PAHO in 2010 showed that CVDs for males between 30-69 had 5,455 premature deaths where as women had 3,370 premature deaths (“PERU-CVD-PROFILE-2014.pdf,” n.d.). CVDs are all based on the effect of narrowing heart arteries, which leads to less blood and oxygen pumping into the heart. The World Heart Federation argues that physical inactivity, tobacco use, diets heavy in saturated fats, high alcohol usage and obesity are all modifiable risk factors (“Risk factors,” 2017). To better understand the risk factors associated with CVDs, social determinants of income, education, work, and physical boundaries should be discussed.
Sex is an important aspect to consider at when studying any type of disease. The male and female body can be effected in different ways due to altered circumstances. Although, in the case of CVDs, risk factors are very similar, the influence of social behaviors are where dissimilarities are detected by sex. A 2012 risk profile found that men overall had higher socioeconomic status’, completed secondary or higher levels of schooling and had more household assets then woman. Men were also reported as more likely to be current smokers and binge drinkers. Woman were found to have great rates of obesity inferred off of a BMI scale (Bernabe-Ortiz, Benziger, Gilman, Smeeth, & Miranda, 2012). The socioeconomic and education divide seen between the sexes is due to Peruvians society of prejudice and discrimination. Historically, the prevailing patriarchal systems as well as race and class keeps the woman of Peru is lower standing than the men (“Women in Peru,” n.d.). In educational terms, the divide of men completing higher levels of education lends to them having better jobs and lower rates of poverty. Being able to afford testing and treatment is one of the many areas where this sex divide can be seen, with lower income these treatments are out of reach to most. This gap seen between men and women shows that the determinates of health related to CVDs of how education and income effect Peruvians.
Diet is one the most important risk factors when it comes to CVDs. The buildup of plaque in the arteries comes from cholesterol which is broken down from food heavy in saturated fats. Thinking from a socioeconomic background, it is thought that to eat healthy, a higher income is necessary since fruits and vegetables are expensive. Diet and exercise are thought to worsen through the process of urbanization which leads to higher risk of CVD. In a recent study concerning the diet and activity rates across the urbanization divide in Peru, mixed results were found that lower obesity rates found in rural Peru could not be indicative of their diet. The study observed that on average urban dwellers ate more protein, refined grains, sugary items and fresh produce. Whereas rural areas showed a trend of consuming foods with more added salt and vegetable oils. The study’s conclusion reasoned that with the pedometer findings that rural residents walked a superior amount as well as their lack of highly processed foods, rural areas have less instance of chronic disease outcomes (McCloskey et al., 2017). In 2016, Peru was the 4th largest market for exports of processed foods out of the U.S. which has also produced a growth of supermarket outlets in big cities like Lima (“Peru Country Profile,” n.d.). This increased accessibility of processed food for Peruvians in urban areas can be a cause for higher risk of CVDs due to diet.
Mental health is considered a disease on the DALY for Peru by itself, but it also plays in to the high prevalence of cardiovascular risk factors due to the depressive symptoms associated with mental health issues. According to the Worldwide Mental Health Study, Peru was found to have a lifetime prevalence of depression to be 6.4%. Depression is a multi-factorial disease that shows similar trends with CVD risk factors. Extreme poverty, diet patterns, excessive drinking and exercise patterns are all common factors seen with depression and CVDs (Wolniczak, Cáceres-DelAguila, Maguiña, & Bernabe-Ortiz, 2017). As discussed previously, there is a rising concern for mental health care reform. This need for reform can be viewed in the high prevalence of risk factors in adolescents as well. From a cross-sectional report on the prevalence of CVD risk factors in adolescents as well as the common risk factors of obesity and high blood pressure, high rates of adolescent depression were also found. 66.4% of the 275 adolescents reported high rates of depression, 67.6% reported feelings of anhedonia which is the inability to feel pleasure and 37.9% reported self-harm behavior (Abbs, Viñoles, Alarcón, Johnson, & Zunt, 2017). Social factors like bully victimization in adolescents has shown outcomes of emotional and mental stress (Lister et al., 2015). Late on set mental disorders could be attributed to early adolescent stressors like bullying attribute, which lead to alcohol and drug abuse in the future. Excessive alcohol use is one of the four risk factors for major non-communicable diseases like CVD, which is why the connection to mental health is an important determinant to increase interventions for in the future (“PAHO/WHO | Experts discuss problem drinking in Peru,” n.d.).
As discussed, Peru has many concerning issues in the health field which need to be managed in order to continue developing. The three main categories of disease highlight areas that demand attention, especially non-communicable diseases. When compared with Nicaragua, a regionally similar country, their levels of poverty and DALY reports are comparable even though they have differing levels of income economies. Overall, the quality of data for Peru is low, and still has a way to go in order to better the health abilities of the country. As for the subgroup of indigenous women, through more access and better health care, better outcomes can be expected. This analysis communicates Peru’s need for a revitalized public health system which will bring their country into a new, healthier future.