Collaborating to build inclusive health systems abroad

Colorful houses dot the hills of Cerro San Cristobal, Lima, Peru

Cerro San Cristóbal, Lima, Perú | Source

Author: Kaitlin Sullivan

In November 2021, Peru logged the highest COVID-19 death rate in the world. With nearly 6,000 deaths for every 1 million Peruvians, the rate was double that of neighboring Brazil. 

Maria Sofia Cuba Fuentes, MD, McS, PhD a professor and Director of the Center for Research in Primary Health care at the Universidad Peruana Cayetano Heredia in Lima, Peru, believes the actual rate was even higher. 

“COVID does not affect people differently because of their nationality, but mortality rates are different because of the resources countries have for people,” she said. 

Cuba-Fuentes led a team of researchers that investigated why Peruvians were hit so hard by COVID-19. The project was one of the inaugural recipients of the Center for Global Health and Social Responsibility’s (CGHSR) Global Engagement Grants program

Maria Sofia Cuba Fuentes and Carlos Zegarra smile toward the camera
Maria Sofia Cuba Fuentes, right, during a meeting with research team member and resident Carlos Zegarra

The program was created in 2021 in response to the ongoing pandemic. It funds collaborative work that blends research, education and capacity building, including Fuentes’ team’s project in Peru. The results of their research were published last month in the journal PLOS Global Public Health

“The University of Minnesota gave us freedom to choose the point of view we want to research. They were confident that we knew best what was happening in our country,” said Dr. Cuba-Fuentes, noting that this is a rare experience. “It’s not what usually happens in collaborations between low and high income countries. Usually there is an imposition of a point of view, but this project was very collaborative.”

Global Engagement Grants as a Unifier

Also on the research team is Pavel Contreras, MD, MSc, who was a 2021-2022 CGHSR Fogarty Global Health Fellow. Contreras worked in tandem with Dr. Cuba-Fuentes on this project during his fellowship year. 

This type of collaboration between members from the University of Minnesota and on-the-ground in Peru is part of the ethos of CGHSR. Particularly at the height of the COVID-19 pandemic in 2021, in a time when global travel was difficult, Global Engagement Grants were built to support international collaborations and continue global health work that do not necessarily involve travel.

"Traditional research and capacity building efforts in global health have been curtailed with COVID-19. This can add to the sense of further isolation,” said Shailey Prasad, MD, MPH, executive director for CGHSR. “As a center, we feel that ongoing engagement is key in global health and we wanted to encourage our faculty to look at newer forms of engagement in global health. While these are not exclusively in global health research, the goal is to continue to build bridges with our colleagues in other countries."

The success of Cuba-Fuentes’s team’s project set the stage for CGHSR to establish a formal, long-term Global Engagement Grants program. The program has gone on to award 12 grants to UMN and international teams since 2021.

Quantifying the impact of complex health disparities 

In Peru, the research team centered on mapping how social determinants of health––things like economic opportunity, disabilities and access to medical care––drove such dire COVID-19 outcomes in Peru.

For example, more than 70 percent of the country’s population does not have stable work. “They have to work every day for the money they earn. It’s not possible to do remote or online work,” said Dr. Cuba-Fuentes. 

These socioeconomic factors, paired with scarce access to personal protective equipment (PPE) and skilled medical professionals, stacked the odds against all Peruvians, but especially those living in mountain communities or in the dense Amazon rainforest. 

About one-third of Peru’s population lives in the capital city, Lima, and most Peruvians live somewhere along the coast. 

“Usually places outside of that, in the highlands in the jungle, have scarce resources, both economic and services like universities, schools and hospitals,” Dr. Cuba-Fuentes said. “There was more vulnerability in those areas.”

Skyline of Lima along the coast of the Pacific
Skyline of the city of Lima, Peru | Source

To determine which of these remote populations were most in need of the nation’s resources, the researchers evaluated the unique web of social determinants of health for each of Peru’s 196 provinces. They included 33 variables split into four categories––socioeconomic status, household composition and disability, whether people belonged to a minority group or spoke a minority language, and the type of housing and transportation people had access to.  

Unexpectedly, the highest mortality rates were not actually in the areas that scored highest on the Social Vulnerability Index (SVI). Dr. Cuba-Fuentes said that’s because there was one factor they weren’t able to account for: unrecorded deaths. 

If they are able, people living in remote areas of Peru often travel to bigger cities to seek care. If they died while seeking that care, their death would be counted in that province. For those who die in areas with scarce access to medical resources, a physician or official may not be available to register their death, leading to an under-count in these provinces. 

Half of the primary care facilities in Peru do not have a physician. The problem was more prominent in rural areas, which also usually do not have access to electronic record systems. “Often a nurse, and sometimes just a nurse tech, is the only provider of health in those areas,” said Dr. Cuba-Fuentes. 

A path forward

Peru has experienced a growing economy in the past 20 years, but the financial benefits are far from evenly distributed among its people, Dr. Cuba-Fuentes said. 

By scientifically documenting these disparities, she and Dr. Contreras, along with their team of four other Peruvian health experts, uncovered vital information about drivers of health disparities that the country can use to better plan for public health emergencies in the future. For example, creating culturally sensitive TV and radio public service announcements, and allocating more economic and medical resources to vulnerable areas before, during, and after a crisis.

“The problems still exist, but they were amplified by the pandemic,” said Dr. Cuba-Fuentes.