COVID-19 and the Peruvian Amazon: Update
Update by devon graham, Project Amazonas
18 May – As of this date, the situation with Covid-19 in Peru, and particularly in Iquitos, is very grave. It is hard to imagine a worse scenario. I have been checking news reports on-line from Peru and elsewhere and have also been receiving first-hand accounts from Iquitos from friends and colleagues there, including e-mails and calls from Fernando Rios, Guillermo Guerra, Cesar Peña and others over recent days.
The official number of confirmed cases in Peru is growing rapidly, and as of earlier today was 92,272 persons infected, and 2,648 deaths. In Loreto state, where Iquitos is located, the official numbers are 2,696 cases, with no official death count until recently. On 14 May, an official government of Loreto reports stated 2,315 cases, and 1084 deaths. These numbers are certainly a gross undercount for several reasons enumerated below. The actual numbers are probably at least 10-20 times higher, if not considerably more.
Testing is extremely limited – to get a test in Iquitos you have to go to the Regional Hospital and the test costs s/200 (~3 days salary for a mid-level worker). With non-essential workers confined to home quarantine except for specific activities since 16 March, only the wealthy will be getting tests. The out-of-work average citizen will never be tested.
The official count only includes individuals recorded by the official health system. Many victims are dying at home, so they are never recorded. A recent e-mail from a partner organization – Amazon Promise - doing food distribution in the very poor areas of the Belen district of Iquitos commented that one of their volunteers had observed 8 bodies in homes (in one day!), and that people were taking them across the river to be interred. In a tropical climate with no AC, bodies are buried as fast as possible, so the 8 bodies were definitely not the accumulation of deaths over several days, but most likely a reflection of who had died in the past 24 hours (in a small part of Belen).
Hospitals are overwhelmed, and quite apart from the issue of testing, it is certain that many victims are simply not recorded.
There is little or no reporting from rural areas – all movement is highly restricted, and infrastructure is breaking down rapidly. Numerous victims will die and be interred in both rural and urban areas without ever being entered into medical databases.
Those data from 14 May? If those numbers are correct, that would indicate a staggering 44% mortality rate unprecedented anywhere else in the world to date. So it is certain that the true numbers of infections are much much higher than the official data would indicate. The 14 May mortality data also included a nearly 10-fold jump in deaths over what had been previously reported.
It gets worse. Multiple reports note that the two main hospitals in Iquitos have “collapsed”. Patients are lying on blankets in hallways, and bodies wrapped in plastic are stored in side-rooms (video still capture at right) until family members can recover them, or they are being put in mass graves located near the municipal landfill.
It’s not just the general populace that is being affected. One very recent report stated that 189 of 350 medical doctors in the public health system in Iquitos have been infected with coronavirus. Another report stated that 80% of health workers (MD’s, nurses, techs, other hospital staff, etc.) have been infected. At least 14 doctors (as of 14 May) as well as other health workers have died, and the best-equipped private clinic in Iquitos – the Clínica Ana Stahl – has shut down completely since the majority of their staff were infected and several have died. The Clínica Ana Stahl is the only place in Iquitos where I would ask to be taken if I was in a critical situation – it has a modern ICU, Cat-Scan and everything that a modest-sized hospital in the US might have. That it is completely closed down speaks volumes about the severity of the crisis. There are reports of doctors abandoning clinics in various towns out of fear for their own lives.
The health care system in Peru has never received the infrastructure and funding that it needed to meet the needs of the populace. A new hospital being built to replace the city’s first hospital (built by the Americans during WWII and in use without substantial modification for the past 65 years) was supposed to be finished in November 2019 – it is still far from being ready for use. Despite the best efforts of valiant health workers, the system was never going to be able to handle a pandemic like this one.
It gets still worse. Pharmacies are completely out of stock of necessary medications. Whereas in February I was able to purchase a box of 100 paracetamol (= Tylenol) for s/6 (less than $2), currently a blister of 10 tablets of paracetamol is selling for s/5 – (~$1.50), if it is available at all. This is almost 10 times the previous price. Corruption, greed and profiteering has set in despite the state of emergency. Although the national government has been sending medications and PPE from Lima, there is little indication that it is getting to where it needs to be. Another NGO was recently quoted a price of s/45 (~$15) per basic face mask (not even a N-95 mask) on the local black-market (in the past we have purchased these for about s/30 [~$9] per box of 100 masks. And black-market vendors have popped up at the gates of the Regional Hospital selling essential medications at vastly inflated prices. When the government announced that gloves would be required to enter stores, vendors were immediately selling gloves outside the stores, even while hospital staff were struggling to find enough for their own use. It seems clear that many of the medications and supplies being sent to Iquitos hospitals are being either stolen somewhere along the way, or being sold to middlemen or street vendors by persons or officials in the supply chain, and then being resold to the public at vastly inflated prices. Once this is all over, I wouldn’t be surprised to see a massive public “revolution” over how things have been handled.
Given that no ventilators are available, doctors in the health system are saying that most patients require oxygen to recover. But there is little oxygen to be had in the lungs of the world. The only commercial oxygen production plant in Iquitos can produce perhaps 60 bottles per day at maximum production – running 24 hours a day. The Regional Hospital’s own oxygen plant hasn’t been operational for years due to underfunding and neglect. The current need is 600-800 bottles per day. Prices for oxygen have soared to over US $1000 per bottle. This is an impossible price for the average family. The non-profit Amazon Promise was able to purchase an oxygen tank in Lima and have it flown to Iquitos – they took it straight to the bottling plant and a staff member stayed with it outside all night in the hopes that it could be filled first thing in the morning, but they had to leave it there and return another 24 hours later to get their oxygen. As you can see in the following photo, they weren’t the only ones waiting.
On one bright note, the Catholic Diocese of Iquitos initiated a fund-raising campaign to purchase oxygen bottling equipment to fill the void. They raised much more than they anticipated, and new equipment was purchased and has arrived in Iquitos and will be in use shortly, if it isn’t already in use, with capacity to produce several hundred bottles daily. This will give a great deal of hope to many patients and their families.
There is desperation in Iquitos. There is a void in civic leadership (apart from the Catholic church) and only the military and police are managing to hold things together. The question is how much longer they can manage that. Currently it is the threat of hefty fines that are keeping people at home. Those fines range from s/250 (~$75) for being out without your pass that designates you as an essential worker, to s/430 (~$128) for violating curfew. The official minimal monthly salary in Peru is s/930 (~US $275), so the fines are substantial. Many people are part of the informal economy, however and have no guaranteed income of any kind. Seniors without a pension (which would be the majority of seniors in Iquitos) receive s/125 monthly from the government – a bare pittance.
Only one family member at a time is allowed out to purchase essentials, and curfew in Iquitos is from 4 PM to 4 AM. But when there is nothing to eat and no money to purchase food, people may start to riot, and the few stores that are open will be ransacked
Our own personnel are being affected. Our general manager, Fernando Rios and his family snuck out of Iquitos on his boat at 3 AM on 16 March and have been at his farm at Santa Cruz (outside of Mazan – about 25 km from Iquitos) since then. Fernando reports that two people in Mazan had died from Covid-19 (14 May), and the town was under absolute lockdown from Monday 11 May to Monday 18 May – nobody allowed out for any reason, not even to take the dog to a patch of grass. The virus arrived on the heels of a dengue epidemic (another virus, but one that is spread by mosquitos) in the region, and for the past month Fernando and his family have been suffering with dengue symptoms – severe headaches, aching bodies and high fevers. They are fortunate to have a supply of paracetamol (Tylenol) on hand, and I never imagined that I would ever say “Thank God it’s only dengue”. When I talked with Fernando on 16 May the family was thankfully feeling much better.
Our logistics person, Guillermo Guerra, told me that his oldest brother (in his 70’s) now has the virus. His odds of survival are not great, but he has managed to get oxygen. Various other contacts in Iquitos have contacted me asking if we have medications for sick relatives, and the nurse-practitioner at our Orosa Clinic has stopped attending patients as he has completely run out of medications, and we have no way of getting any more to him, and there are none available for purchase anyway. One of our founding members and long-time friend to Project Amazonas, Dr. Ernesto Salazar Sanchez, who has served in virtually every medical capacity in Iquitos contracted Covid-19 on a dream vacation that he and his wife were taking to Italy at the start of the outbreak. He spent weeks in hospital and quarantine in Brazil as they tried to get home to Peru.
A couple of fellow non-profits in Peru are valiantly doing what they can. I have known Amazon Promise founder Patty Webster for many years. She is currently in the US but is coordinating with her staff and volunteers in Iquitos to distribute what food and face masks and medications they can acquire to some of the most vulnerable families in the shantytowns of the Belen district of Iquitos. The residents there are among the poorest of the poor and many are ineligible for government stimulus funds due to lack of documentation. Amazon Promise is working to provide families with a 10-14 day supply of food, along with soap and bleach. This will allow those families to better shelter in place and to avoid exposure to carriers of the virus. It is also hugely meaningful to families who have been largely ignored and marginalized by local, regional and national governments.
Likewise, Diana Bowie of DB Peru (based in Lima) and her organization have worked for many years with communities in the Iquitos region to address various serious health issues. They are collecting donations of PPE and medications to send on flights to Iquitos, and Grupo Romero, the owner of a prominent Peruvian bank is generously providing free shipping. PPE is being prioritized, as it is absolutely essential to first protect the health workers. After that, medications, oxygen tanks and various supplies will be sent. DB Peru is working closely with Dr. Valerie Paz Soldán, an infectious disease specialist in Lima who does research in Iquitos, and with Dr. Graciela Meza of the National University of the Peruvian Amazon and Dr. Martin Casapia at the Regional Hospital of Iquitos. These are dedicated professionals and caring public servants. Shipments will be met at the airport by trusted personnel and delivered directly to the Regional Hospital for inventory and use to eliminate the potential of theft and diversion of critical materials.
Both of these organizations do good work and, along with the Catholic diocese, are trustworthy channels for funneling desperately needed assistance to Iquitos.
If you would like to help, you can make donations to these two worthy organizations via their websites:
DB Peru: www.dbperu.org
Amazon Promise: www.amazonpromise.org
You can also donate directly to Project Amazonas if you prefer and we will direct part of those funds to the above organizations, and work at acquiring PPE and essential medications here in the USA to take to Peru as soon as it is possible to do so.
Donations can be made via PayPal to donate@projectamazonas.org If you have a PayPal account, just put in the email address above. If you don’t have PayPal, you can set it up in a few minutes at www.paypal.com – it is easy to do.
Checks can be sent to 701 East Commercial Blvd, #200; Ft. Lauderdale, FL 33334.
Venmo users can donate via the GiveButter platform by texting “PA” (just the letters, not the quotation marks) to 202-858-1233, a transaction screen will pop up immediately.
The GiveButter platform can also accept donations from all major credit cards and debit cards.
How did it get so bad so quickly? Scroll down to the end of the timeline for my perspective on that topic.
While we have heard over and over again that “we are all in this together”, the people of Iquitos and surrounding districts are more “in” than we can imagine. If there was ever a time to make a difference, that time is now. Thank you for reading this, and please stay safe and healthy. Don’t deceive yourself into thinking that we can go back to “normal” now.
Sincerely,
Devon Graham
Project Amazonas
Patients on cots in a hallway of the Regional Hospital, Iquitos
The reality of the aged Hospital de Apoyo
Hospital de Apoyo sometime in the future…
A hallway crowded with patients at the Regional Hospital – the city’s largest hospital
Attending to a patient at the Regional Hospital with social distancing virtually impossible to maintain
Waiting for oxygen bottles to be filled at the oxygen plant (I have no idea what the water jugs are there for!)
A re-purposed dining hall in the Regional Hospital
Timeline:
18 May – Covid-19 cases in Peru: 92,272 confirmed; 2648 deaths (officially); in Loreto state 2,696 confirmed cases (no report on deaths as yet).
17 May – Covid-19 cases in Peru: 88,541 confirmed; 2,523 deaths (officially); in Loreto state 2,444 confirmed cases and 1,084 official deaths. One municipality in Loreto (Amazon region) is injecting residents with the veterinary anti-parasite drug ivermectin to try and stop the spread. Ivermectin has been shown to reduce replication of the virus some 5000-fold.
15 May – Covid-19 cases in Peru: 80,604 confirmed; 2,267 deaths (officially). Several days later, it was reported that as of 15 May, 840 doctors in Peru had been infected and 20 had died, including a 33-yr old doctor with no underlying health conditions. It was also reported that 4,098 police had been infected and 82 police had died.
14 May – Covid-19 cases in Peru: 76,306 confirmed; 2,169 deaths (officially)
8 May – Peru announces that quarantine will be extended from 10 May to 24 May (4th extension of the quarantine)
23 April – Peru announces that quarantine will be extended from 28 April to 10 May (3rd extension of the quarantine)
11 April – Peru announces that quarantine will be extended from 14 April to 28 April (2nd extension of the quarantine)
28 March 2020 – Peru announces that quarantine measures will be extended from 1 April to 14 April (1st extension of the quarantine)
24 March 2020 - 50,000 cases in the USA, 600+ deaths, proposals being made to lift restrictions to “not hurt the economy”.
23 March 2020 – 396 confirmed cases and 5 deaths in Peru, country still on lockdown.
16 March 2020 – 11:59 PM – All land, sea and air borders in Peru sealed off. Country enters quarantine.
15 March 2020 – Peru announces that the country will go into quarantine at midnight on the 16th of March.
6 March 2020 – First confirmed case of coronavirus in a 25-yr old male in Lima, Peru.
How did it get so bad so fast?
If you read the background section that follows this, you will note that Peru took early and far-ranging action to try and stop the spread of coronavirus. I fully expected that the country would be able to control the spread beyond the metropolitan area of Lima with its population of 10+ million people. So how did Iquitos, with a metro population of ~600,000 become the epicenter of coronavirus in Peru? The first two confirmed infections in Iquitos were both tour guides for local lodges – they had been in contact with asymptomatic tourists.
After that, the rapid spread of the virus can pretty much be explained in two words: crowding & poverty.
Iquitos is on a narrow peninsula of high ground sandwiched between three rivers. With an annual rise and fall of water levels of up to 45 (not a typo!) feet, the city cannot spread out very far. For the most part, houses are small and crammed together, usually sharing common walls, and usually with multiple generations living in the same house. Social isolation within a household is impossible, and if one family member is exposed and infected, then every family member is going to be exposed. Population density is high.
In the poorest areas of town, houses are very small, and in areas of the Belen district (and other districts), shantytowns have been built on the only remaining open areas – the floodplain. Some houses are on large logs and float up and down with the rise and fall of the rivers, while others are built on stilts. Water levels are highest in April and May, and makeshift catwalks – often only 2 or 3 boards wide – provide the only pedestrian access. Again, social distancing is impossible. You can’t stay 6-feet away from someone when passing someone on a “sidewalk” that is only 3-feet wide.
A majority of residents in the poorer areas of town also lack any kind of refrigeration. They don’t have the option of storing perishables in the refrigerator or freezer, so most people shop for their food on a daily basis, buying only what perishables they need for that day. People can’t shop once every 10-14 days and then stay home. They also do their shopping in crowded, unsanitary, informal markets where the prices are cheapest. That means a lot of person to person contact, ideal for the spread of the virus.
Background from 20 March:
Peru has taken a very aggressive approach to containing the spread of the virus. On 15 March, a state of emergency was declared nationwide, and at midnight on 16 March, all land, air and sea borders were closed until 31 March. I and the academic group I was with were fortunate to be on one of the last flights permitted to depart for the US, but 1000's of foreigners (including hundreds of Americans) are currently trapped in Peru [most have since been able to leave on various repatriation flights]. There are severe restrictions on travel within Peru, with no domestic or international passenger flights, no bus, no train, no boat and no taxi services, a total ban on public events and gatherings, parks and beaches closed, all restaurants and bars closed, and police and military patrolling the streets to ensure that people stay in place at home and observe mandatory curfew. Only a few people at a time are being allowed out to purchase essentials. The nurse-technician at our Orosa River clinic texted me the day I departed asking for additional medicines and supplies. The local population that the clinic serves were all convinced that they had coronavirus (even if it was only the common cold), but getting anything to the clinic with the travel restrictions is extremely difficult. Our general manager, Fernando Rios, was going to see if he could take some of the medications and supplies we have stocked on our medical boat and send them to the Orosa Clinic by one means or another. [we have not been able to do so]
Although the emergency decree lasts until 31 March, it is quite likely that it may be extended beyond that if the strict controls on movement are not sufficient to control the spread of the virus. The first documented case in Peru was detected on 6 March, and by 16 March, there were 86 confirmed cases, mostly in Lima and Cusco. Yesterday I heard that there were two presumed cases in Iquitos, but I haven't been able to get an updated official count on the current number of cases. If the virus isn't contained, then the Peruvian medical system is certainly going to be overwhelmed, and significant mortality can be expected. I'm hopeful that the aggressive approach will work though.
Even if the state of emergency is lifted on 1 April, it is unlikely that normal flights will resume anytime soon after. Given the explosion of cases that we are seeing in the US (and yes, it is going to get much worse), I don't believe that Peru will be allowing flights to/from the US through the end of April at the least, and possibly into May. The earliest that normal travel will resume is likely going to be June or July at the earliest. I hope (but don't expect) that I will be proved wrong.
Our medical service trips are being severely impacted by the pandemic. This might be the time when our boat-based services are most needed in remote river communities, but trip participants won't be able to travel to Peru or Iquitos, and we also have to consider the risk of accidentally introducing the virus to isolated communities (for once, isolation is a very good thing) where there won't be any access to care once the medical boat leaves. Many medical students, who form the greatest block of participants on our trips, are also being prohibited by their universities from participating in any international placements. As such, our 22 April-2 May trip has been cancelled. Three participants from the US were forced to cancel due to university policy, and another 7 from Hong Kong would be forced to endure two weeks of quarantine on arrival in Peru (if they are even allowed to fly to Peru). Another 15 medical students scheduled for trips in July have also been told by their universities that they cannot participate. I am in the process of returning deposits and payments to students who have had to cancel, and expect that there will be additional cancellations in the immediate future. I hope to be able to salvage a couple of the July medical trips, but it is likely that all the trips prior to July will need to be cancelled. [all trips through the end of August have now been cancelled – 14 May]
The pandemic is also seriously impacting our finances. A large academic group that was going to spend most of the month of May with us was forced to cancel, and other users of our boats and field stations will be doing the same. This represents a significant loss of revenue for the organization. Likewise, payments from medical trip participants not only cover the actual operating costs of those trips, but also contribute to overhead - monthly payroll and maintenance of boats and facilities. I realize that the pandemic is going to hurt all of us financially, but if you have access to some additional reserves, making a contribution or increasing your normal contributions at this time will make a huge difference in our ability to bounce back and to continue serving the people and the natural environment of the Amazon as soon as we are physically capable of doing so.
I am confident that we can weather this global crisis, but it will require the efforts of each and every one of us to contain the pandemic - the virus doesn't recognize any borders. So please, closely follow the advice of the health experts, and take care of yourselves, your loved ones, friends and colleagues. I don't want to have to edit my contact list because of COVID-19!