The 2023 Latin America report of the Lancet Countdown on health and climate change: the imperative for health-centred climate-resilient development.

In 2023, a series of climatological and political events unfolded, partly driving forward the global climate and health agenda while simultaneously exposing important disparities and vulnerabilities to climate-related events. On the policy front, a significant step forward was marked by the inaugural Health Day at COP28, acknowledging the profound impacts of climate change on health. However, the first-ever Global Stocktake showed an important gap between the current progress and the targets outlined in the Paris Agreement, underscoring the urgent need for further and decisive action. From a Latin American perspective, some questions arise: How do we achieve the change that is needed? How to address the vulnerabilities to climate change in a region with long-standing social inequities? How do we promote intersectoral collaboration to face a complex problem such as climate change? The debate is still ongoing, and in many instances, it is just starting. The renamed regional centre Lancet Countdown Latin America (previously named Lancet Countdown South America) expanded its geographical scope adding Mexico and five Central American countries: Costa Rica, El Salvador, Guatemala, Honduras, and Panama, as a response to the need for stronger collaboration in a region with significant social disparities, including research capacities and funding. The centre is an independent and multidisciplinary collaboration that tracks the links between health and climate change in Latin America, following the global Lancet Countdown's methodologies and five domains. The Lancet Countdown Latin America work hinges on the commitment of 23 regional academic institutions, United Nations agencies, and 34 researchers who generously contribute their time and expertise. Building from the first report, the 2023 report of the Lancet Countdown Latin America, presents 34 indicators that track the relationship between health and climate change up to 2022, aiming at providing evidence to public decision-making with the purpose of improving the health and wellbeing of Latin American populations and reducing social inequities through climate actions focusing on health. This report shows that Latin American populations continue to observe a growing exposure to changing climatic conditions. A warming trend has been observed across all countries in Latin America, with severe direct impacts. In 2022, people were exposed to ambient temperatures, on average, 0.38 °C higher than in 1986-2005, with Paraguay experiencing the highest anomaly (+1.9 °C), followed by Argentina (+1.2 °C) and Uruguay (+0.9 °C) (indicator 1.1.1). In 2013-2022, infants were exposed to 248% more heatwave days and people over 65 years old were exposed to 271% more heatwave days than in 1986-2005 (indicator 1.1.2). Also, compared to 1991-2000, in 2013-2022, there were 256 and 189 additional annual hours per person, during which ambient heat posed at least moderate and high risk of heat stress during light outdoor physical activity in Latin America, respectively (indicator 1.1.3). Finally, the region had a 140% increase in heat-related mortality from 2000-2009 to 2013-2022 (indicator 1.1.4). Changes in ecosystems have led to an increased risk of wildfires, exposing individuals to very or extremely high fire danger for more extended periods (indicator 1.2.1). Additionally, the transmission potential for dengue by Aedes aegypti mosquitoes has risen by 54% from 1951-1960 to 2013-2022 (indicator 1.3), which aligns with the recent outbreaks and increasing dengue cases observed across Latin America in recent months. Based on the 2023 report of the Lancet Countdown Latin America, there are three key messages that Latin America needs to further explore and advance for a health-centred climate-resilient development. Latin American countries require intersectoral public policies that simultaneously increase climate resilience, reduce social inequities, improve population health, and reduce greenhouse gas (GHG) emissions. The findings show that adaptation policies in Latin America remain weak, with a pressing need for robust vulnerability and adaptation (V&A) assessments to address climate risks effectively. Unfortunately, such assessments are scarce. Up to 2021, Brazil is the only country that has completed and officially reported a V&A to the 2021 Global Survey conducted by the World Health Organization (WHO). Argentina, Guatemala, and Panama have also conducted them, but they have not been reported (indicator 2.1.1). Similarly, efforts in developing and implementing Health National Adaptation Plans (HNAPs) are varied and limited in scope. Brazil, Chile, and Uruguay are the only countries that have an HNAP (indicator 2.1.2). Moreover, self-reported city-level climate change risk assessments are very limited in the region (indicator 2.1.3). The collaboration between meteorological and health sectors remains insufficient, with only Argentina, Brazil, Colombia, and Guatemala self-reporting some level of integration (indicator 2.2.1), hindering comprehensive responses to climate-related health risks in the region. Additionally, despite the urgent need for action, there has been minimal progress in increasing urban greenspaces across the region since 2015, with only Colombia, Nicaragua, and Venezuela showing slight improvements (indicator 2.2.2). Compounding these challenges is the decrease in funding for climate change adaptation projects in Latin America, as evidenced by the 16% drop in funds allocated by the Green Climate Fund (GCF) in 2022 compared to 2021. Alarmingly, none of the funds approved in 2022 were directed toward climate change and health projects, highlighting a critical gap in addressing health-related climate risks (indicator 2.2.3). From a vulnerability perspective, the Mosquito Risk Index (MoRI) indicates an overall decrease in severe mosquito-borne disease risk in the region due to improvements in water, sanitation, and hygiene (WASH) (indicator 2.3.1). Brazil and Paraguay were the only countries that showed an increase in this indicator. It is worth noting that significant temporal variation within and between countries still persists, suggesting inadequate preparedness for climate-related changes. Overall, population health is not solely determined by the health sector, nor are climate policies a sole responsibility of the environmental sector. More and stronger intersectoral collaboration is needed to pave development pathways that consider solid adaptation to climate change, greater reductions of GHG emissions, and that increase social equity and population health. These policies involve sectors such as finance, transport, energy, housing, health, and agriculture, requiring institutional structures and policy instruments that allow long-term intersectoral collaboration. Latin American countries need to accelerate an energy transition that prioritises people's health and wellbeing, reduces energy poverty and air pollution, and maximises health and economic gains. In Latin America, there is a notable disparity in energy transition, with electricity generation from coal increasing by an average of 2.6% from 1991-2000 to 2011-2020, posing a challenge to efforts aimed at phasing out coal (indicator 3.1.1). However, this percentage increase is conservative as it may not include all the fossil fuels for thermoelectric electricity generation, especially during climate-related events and when hydropower is affected (Panel 4). Yet, renewable energy sources have been growing, increasing by an average of 5.7% during the same period. Access to clean fuels for cooking remains a concern, with 46.3% of the rural population in Central America and 23.3% in South America lacking access to clean fuels in 2022 (indicator 3.1.2). It is crucial to highlight the concerning overreliance on fossil fuels, particularly liquefied petroleum gas (LPG), as a primary cooking fuel. A significant majority of Latin American populations, approximately 74.6%, rely on LPG for cooking. Transitioning to cleaner heating and cooking alternatives could also have a health benefit by reducing household air pollution-related mortality. Fossil fuels continue to dominate road transport energy in Latin America, accounting for 96%, although some South American countries are increasing the use of biofuels (indicator 3.1.3). Premature mortality attributable to fossil-fuel-derived PM2.5 has shown varied trends across countries, increasing by 3.9% from 2005 to 2020 across Latin America, which corresponds to 123.5 premature deaths per million people (indicator 3.2.1). The Latin American countries with the highest premature mortality rate attributable to PM2.5 in 2020 were Chile, Peru, Brazil, Colombia, Mexico, and Paraguay. Of the total premature deaths attributable to PM2.5 in 2020, 19.1% was from transport, 12.3% from households, 11.6% from industry, and 11% from agriculture. From emission and capture of GHG perspective, commodity-driven deforestation and expansion of agricultural land remain major contributors to tree cover loss in the region, accounting for around 80% of the total loss (indicator 3.3). Additionally, animal-based food production in Latin America contributes 85% to agricultural CO2 equivalent emissions, with Argentina, Brazil, Panama, Paraguay, and Uruguay ranking highest in per capita emissions (indicator 3.4.1). From a health perspective, in 2020, approximately 870,000 deaths were associated with imbalanced diets, of which 155,000 (18%) were linked to high intake of red and processed meat and dairy products (indicator 3.4.2). Energy transition in Latin America is still in its infancy, and as a result, millions of people are currently exposed to dangerous levels of air pollution and energy poverty (i.e., lack of access to essential energy sources or services). As shown in this report, the levels of air pollution, outdoors and indoors, are a significant problem in the wholeregion, with marked disparities between urban and rural areas. In 2022, Peru, Chile, Mexico, Guatemala, Colombia, El Salvador, Brazil, Uruguay, Honduras, Panama, and Nicaragua were in the top 100 most polluted countries globally. Transitioning to cleaner sources of energy, phasing out fossil fuels, and promoting better energy efficiency in the industrial and housing sectors are not only climate mitigation measures but also huge health and economic opportunities for more prosperous and healthy societies. Latin American countries need to increase climate finance through permanent fiscal commitments and multilateral development banks to pave climate-resilient development pathways. Climate change poses significant economic costs, with investments in mitigation and adaptation measures progressing slowly. In 2022, economic losses due to weather-related extreme events in Latin America were US$15.6 billion -an amount mainly driven by floods and landslides in Brazil-representing 0.28% of Latin America's Gross Domestic Product (GDP) (indicator 4.1.1). In contrast to high-income countries, most of these losses lack insurance coverage, imposing a substantial financial strain on affected families and governments. Heat-related mortality among individuals aged 65 and older in Latin America reached alarming levels, with losses exceeding the equivalent of the average income of 451,000 people annually (indicator 4.1.2). Moreover, the total potential income loss due to heat-related labour capacity reduction amounted to 1.34% of regional GDP, disproportionately affecting the agriculture and construction sectors (indicator 4.1.3). Additionally, the economic toll of premature mortality from air pollution was substantial, equivalent to a significant portion of regional GDP (0.61%) (indicator 4.1.4). On a positive note, clean energy investments in the region increased in 2022, surpassing fossil fuel investments. However, in 2020, all countries reviewed continued to offer net-negative carbon prices, revealing fossil fuel subsidies totalling US$23 billion. Venezuela had the highest net subsidies relative to current health expenditure (123%), followed by Argentina (10.5%), Bolivia (10.3%), Ecuador (8.3%), and Chile (5.6%) (indicator 4.2.1). Fossil fuel-based energy is today more expensive than renewable energy. Fossil fuel burning drives climate change and damages the environment on which people depend, and air pollution derived from the burning of fossil fuels causes seven million premature deaths each year worldwide, along with a substantial burden of disease. Transitioning to sustainable, zero-emission energy sources, fostering healthier food systems, and expediting adaptation efforts promise not only environmental benefits but also significant economic gains. However, to implement mitigation and adaptation policies that also improve social wellbeing and prosperity, stronger and solid financial systems are needed. Climate finance in Latin American countries is scarce and strongly depends on political cycles, which threatens adequate responses to the current and future challenges. Progress on the climate agenda is lagging behind the urgent pace required. While engagement with the intersection of health and climate change is increasing, government involvement remains inadequate. Newspaper coverage of health and climate change has been on the rise, peaking in 2022, yet the proportion of climate change articles discussing health has declined over time (indicator 5.1). Although there has been significant growth in the number of scientific papers focusing on Latin America, it still represents less than 4% of global publications on the subject (indicator 5.3). And, while health was mentioned by most Latin American countries at the UN General Debate in 2022, only a few addressed the intersection of health and climate change, indicating a lack of awareness at the governmental level (indicator 5.4). The 2023 Lancet Countdown Latin America report underscores the cascading and compounding health impacts of anthropogenic climate change, marked by increased exposure to heatwaves, wildfires, and vector-borne diseases. Specifically, for Latin America, the report emphasises three critical messages: the urgent action to implement intersectoral public policies that enhance climate resilience across the region; the pressing need to prioritise an energy transition that focuses on health co-benefits and wellbeing, and lastly, that need for increasing climate finance by committing to sustained fiscal efforts and engaging with multilateral development banks. By understanding the problems, addressing the gaps, and taking decisive action, Latin America can navigate the challenges of climate change, fostering a more sustainable and resilient future for its population. Spanish and Portuguese translated versions of this Summary can be found in Appendix B and C, respectively. The full translated report in Spanish is available in Appendix D.

Prevalence, awareness, treatment and control of high blood pressure in a cohort in Northern Andean Peru.

BACKGROUND: Gaps exist along the high blood pressure (HBP) diagnosis-treatment-control pathway in high, low and middle-income countries. OBJECTIVE: To determine the prevalence of HBP and to describe the levels of awareness, control and treatment of HBP in the rural Peruvian Andes. METHODS: This cross-sectional study is embedded into a multigenerational cohort. We analysed data of all adult participants aged ≥ 30 years (n = 2752) who answered a baseline health and lifestyle questionnaire and underwent a physical examination, which included three blood pressure readings. HBP was defined as measured systolic or diastolic blood pressure (BP) ≥140 and/or 90 mm Hg and/or self-reported physician-diagnosed hypertension and/or self-reported antihypertensive intake. The determinants of the prevalence of HBP, unawareness of HBP and uncontrolled HBP were assessed using mixed-effect logistic regressions. RESULTS: HBP was present in 18.9% of the participants. Of those with measured HBP, 72.2% were unaware of their HBP. Among those with a diagnosed or medically treated hypertension, 58.4% had uncontrolled HBP. The prevalence of HBP was higher in women (OR: 1.12, CI: 1.02-1.24), increased with age (OR: 1.01, CI: 1.01-1.01) and the presence of family history of hypertension (OR: 1.15, CI: 1.08-1.24), and decreased with healthier lifestyle score (OR: 0.93, CI: 0.91-0.95). Unawareness of HBP was lower among women (OR: 0.56, CI: 0.38-0.83), higher among participants living over 3000 m Above Sea Level (OR: 1.15, CI: 1.03-1.27) and decreased with age (OR: 0.99, CI: 0.98-0.99). CONCLUSIONS: Unawareness of HBP was high, few HTN patients received treatment and BP remained high in the presence of antihypertensive treatment.

A scoping review of the health co-benefits of climate mitigation strategies in South America.

The accelerated production of greenhouse gases (GHG) due to human activity has led to unprecedented global warming, making climate mitigation strategies crucial for minimizing its impacts. South America, a region highly vulnerable to climate change, stands to benefit from implementing such strategies to reduce future risks and generate health co-benefits. This scoping review, aimed to assess the existing evidence on the health benefits of climate mitigation strategies in South American countries. PubMed, Web of Science, and LILACS databases were searched until June 15, 2023. Nine studies published between 2001 and 2021 were analyzed, focusing on Brazil, Chile, and Bolivia. All the studies identified in this review used scenario modeling. They evaluated various GHG emission mitigation strategies, including land management, reducing livestock production, biofuel production, increased active transportation, renewable energy, and waste reduction. Only one study looked at GHG capture and sequestration through afforestation. Given the limited information available, there is a pressing need for more research on the region's potential health, environmental, and economic co-benefits. This review serves as a starting point and suggests that climate mitigation can offer a range of positive co-benefits, such as improved air quality and increased resilience to climate impacts, thereby advancing public health initiatives. Funding: MYG was supported by the Wellcome Trust (grant number 209734/Z/17/Z). The other authors did not receive financial support for their research or authorship. The publication of this article was financially supported by Universidad Peruana Cayetano Heredia.

Reflections on the impact and response to the Peruvian 2017 Coastal El Niño event: Looking to the past to prepare for the future.

Climate-related phenomena in Peru have been slowly but continuously changing in recent years beyond historical variability. These include sea surface temperature increases, irregular precipitation patterns and reduction of glacier-covered areas. In addition, climate scenarios show amplification in rainfall variability related to the warmer conditions associated with El Niño events. Extreme weather can affect human health, increase shocks and stresses to the health systems, and cause large economic losses. In this article, we study the characteristics of El Niño events in Peru, its health and economic impacts and we discuss government preparedness for this kind of event, identify gaps in response, and provide evidence to inform adequate planning for future events and mitigating impacts on highly vulnerable regions and populations. This is the first case study to review the impact of a Coastal El Niño event on Peru's economy, public health, and governance. The 2017 event was the third strongest El Niño event according to literature, in terms of precipitation and river flooding and caused important economic losses and health impacts. At a national level, these findings expose a need for careful consideration of the potential limitations of policies linked to disaster prevention and preparedness when dealing with El Niño events. El Niño-related policies should be based on local-level risk analysis and efficient preparedness measures in the face of emergencies.

Home-Based Respiratory Physiotherapy and Telephone-Based Psychological Support for COVID-19 Survivors in Peru: Protocol for a Randomized Controlled Trial.

BACKGROUND: Both pulmonary and mental health are affected following hospitalization for COVID-19 pneumonia. Pulmonary rehabilitation therapy has demonstrated benefits in improving mental health, but no validated combined programs that include mental health have been proposed. OBJECTIVE: This article presents the design of a trial that aimed to assess whether the participation in a combined rehabilitation program that includes home-based respiratory physiotherapy and telephone-based psychological support is associated with a greater improvement of pulmonary and mental health outcomes 7-12 weeks after COVID-19 hospitalization discharge compared with posthospital usual care provided by a public Peruvian hospital. METHODS: WAYRA (the word for air in the Quechua language) was an open-label, unblinded, two-arm randomized controlled trial. We recruited 108 participants aged 18-75 years who were discharged from the hospital after COVID-19 pneumonia that required >6 liters/minute of supplemental oxygen during treatment. Participants were randomly assigned at a 1:1 ratio to receive the combined rehabilitation program or usual posthospital care provided by a public Peruvian hospital. The intervention consisted of 12 at-home respiratory rehabilitation sessions and 6 telephone-based psychological sessions. The primary outcome was the 6-minute walk distance. Secondary outcomes included lung function, mental health status (depression, anxiety, and trauma), and quality of life. Outcomes were assessed at baseline (before randomization) and at 7 and 12 weeks after hospital discharge to assess the difference between arms. RESULTS: This study was funded by the Peruvian National Council of Science Technology and Technology Innovation in July 2020. Ethics approval was obtained on September 2, 2020. Recruitment and data collection occurred between October 2020 and June 2021. Results are expected to be published by the end of 2022. CONCLUSIONS: WAYRA was the first randomized controlled trial evaluating combined pulmonary-mental health rehabilitation for hospitalized COVID-19 survivors in resource-limited settings, potentially providing a foundation for the cost-effective scale-up of similar multidisciplinary rehabilitation programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04649736; https://clinicaltrials.gov/ct2/show/NCT04649736. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/36001.

Effectiveness of a home-environmental intervention package and an early child development intervention on child health and development in high-altitude rural communities in the Peruvian Andes: a cluster-randomised controlled trial.

BACKGROUND: Unsafe drinking water, poor sanitation and hygiene, exposure to household air pollution and low cognitive and socio-emotional stimulation are risk factors affecting children in low- and middle-income countries. We implemented an integrated home-environmental intervention package (IHIP), comprising a kitchen sink, hygiene education and a certified improved biomass cookstove, and an early child development (ECD) programme to improve children´s health and developmental outcomes in the rural high-altitude Andes of Peru. METHODS: We conducted a one-year cluster-randomised controlled trial among 317 children < 36 months divided into 4 arms (IHIP + ECD, IHIP, ECD, and Control) and 40 clusters (10 clusters per arm). ECD status (socio-emotional, fine and gross motor, communication, cognitive skills, and an overall performance) measured with the Peruvian Infant Development Scale and the occurrence of self-reported child diarrhoea from caretakers were primary outcomes. Secondary outcomes included the occurrence of acute respiratory infections and the presence of thermo-tolerant faecal bacteria in drinking water. The trial was powered to compare each intervention against its control arm but it did not allow pairwise comparisons among the four arms. Primary analysis followed the intention-to-treat principle. For the statistical analysis, we employed generalised estimating equation models with robust standard errors and an independent correlation structure. RESULTS: We obtained ECD information from 101 children who received the ECD intervention (individually and combined with IHIP) and 102 controls. Children who received the ECD intervention performed better in all the domains compared to controls. We found differences in the overall performance (64 vs. 39%, odd ratio (OR): 2.8; 95% confidence interval (CI): 1.6-4.9) and the cognitive domain (62 vs 46%, OR: 1.9; 95% CI: 1.1-3.5). Data analysis of child morbidity included 154 children who received the IHIP intervention (individually and combined with ECD) and 156 controls. We recorded 110,666 child-days of information on diarrhoea morbidity and observed 1.3 mean episodes per child-year in the children who received the IHIP intervention and 1.1 episodes in the controls. This corresponded to an incidence risk ratio of 1.2 (95% CI: 0.8-1.7). CONCLUSIONS: Child stimulation improved developmental status in children, but there was no health benefit associated with the home-environmental intervention. Limited year-round access to running water at home and the possible contamination of drinking water after boiling were two potential factors linked to the lack of effect of the home-environmental intervention. Potential interactions between ECD and home-environmental interventions need to be further investigated. TRIAL REGISTRATION: ISRCTN, ISRCTN-26548981. Registered 15 January 2018-Retrospectively registered, https://doi.org/10.1186/ISRCTN26548981 .

Whole-Genome Characterisation of ESBL-Producing E. coli Isolated from Drinking Water and Dog Faeces from Rural Andean Households in Peru.

E. coli that produce extended-spectrum ß-lactamases (ESBLs) are major multidrug-resistant bacteria. In Peru, only a few reports have characterised the whole genome of ESBL enterobacteria. We aimed to confirm the identity and antimicrobial resistance (AMR) profile of two ESBL isolates from dog faeces and drinking water of rural Andean households and determine serotype, phylogroup, sequence type (ST)/clonal complex (CC), pathogenicity, virulence genes, ESBL genes, and their plasmids. To confirm the identity and AMR profiles, we used the VITEK®2 system. Whole-genome sequencing (WGS) and bioinformatics analysis were performed subsequently. Both isolates were identified as E. coli, with serotypes -:H46 and O9:H10, phylogroups E and A, and ST/CC 5259/- and 227/10, respectively. The isolates were ESBL-producing, carbapenem-resistant, and not harbouring carbapenemase-encoding genes. Isolate 1143 ST5259 harboured the astA gene, encoding the EAST1 heat-stable toxin. Both genomes carried ESBL genes (blaEC-15, blaCTX-M-8, and blaCTX-M-55). Nine plasmids were detected, namely IncR, IncFIC(FII), IncI, IncFIB(AP001918), Col(pHAD28), IncFII, IncFII(pHN7A8), IncI1, and IncFIB(AP001918). Finding these potentially pathogenic bacteria is worrisome given their sources and highlights the importance of One-Health research efforts in remote Andean communities.

Living at High Altitude and COVID-19 Mortality in Peru.

Nicolaou, Laura, Anne Steinberg, Rodrigo M. Carrillo-Larco, Stella Hartinger, Andres G. Lescano, and William Checkley. Living at high altitude and COVID-19 mortality in Peru. High Alt Med Biol. 23:146-158, 2022. Background: Previous studies have reported a lower severity of COVID-19 infections at higher altitudes; however, this association may be confounded by various factors. We examined the association between living at altitude and COVID-19 mortality in Peru adjusting for population density, prevalence of comorbidities, indicators of socioeconomic status, and health care access. Methods: Utilizing administrative data across 196 provinces located at varying altitudes (sea level to 4,373 m), we conducted a two-stage analysis of COVID-19 deaths between March 19 and December 31, 2020, Peru's first wave. We first calculated cumulative daily mortality rate for each province and fit lognormal cumulative distribution functions to estimate total mortality rate, and start, peak, and duration of the first wave. We then regressed province-level total mortality rate, start, peak, and duration of the first wave as a function of altitude adjusted for confounders. Results: There were 93,528 recorded deaths from COVID-19 (mean age 66.5 years, 64.5% male) for a cumulative mortality of 272.5 per 100,000 population between March 19 and December 31, 2020. We did not find a consistent monotonic trend between living at higher altitudes and estimated total mortality rate for provinces at 500 - 1,000 m (-12.1 deaths per 100,000 population per 100 m, 95% familywise confidence interval -27.7 to 3.5) or > 1,000 m (-0.3, -2.7 to 2.0). We also did not find consistent monotonic trends for the start, peak, and duration of the first wave beyond the first 500 m. Conclusions: Our findings suggest that living at high altitude may not confer a lower risk of death from COVID-19.

Metabolic syndrome in rural Peruvian adults living at high altitudes using different cookstoves.

This study determined the prevalence of metabolic syndrome (MetS) in open fire stoves and improved cookstoves users (ICS) in the rural Peruvian Andes. Participants answered a socioeconomic questionnaire, one 24-hour food recall and underwent a physical examination. We analysed data from 385 participants, 190 (112 women and 78 men) were ICS users and 195 (123 women and 72 men) were open fire stove users. The prevalence of MetS was 21.3, 26.4% in women and 13.3% in men. We found no statistically significant association between the type of cookstove and MetS. Body mass index and altitude were important determinants of MetS. Research on cardiometabolic diseases and open fire stove use contributes to understanding the effect of household air pollution on health in high altitude populations.

Peru - Progress in health and sciences in 200 years of independence.

Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population. Resumen translated abstract: El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.

Ecosyndemics: The potential synergistic health impacts of highways and dams in the Amazon.

Ecosyndemics refer to disease interactions that result from environmental changes commonly caused by humans. In this paper, we push scholarship on ecosyndemics into new territory by using the ecosyndemic framework to compare two case studies-the Southern Interoceanic highway in Peru and the Belo Monte hydroelectric dam in Brazil-to assess the likelihood of socio-environmental factors interacting and leading to ill health in a syndemic fashion. Assessing these two case studies using an ecosyndemic perspective, we find that the construction of dams and highways in tropical forests create the conditions for increases in vector-borne illnesses, surges in sex work and sexually-transmitted infections, and increased psychological stress resulting from violence, delinquency, and the erosion of social cohesion. We suggest that these processes could interact synergistically to increase an individual's immune burden and a population's overall morbidity. However, we find differences in the impacts of the Interoceanic highway and the Belo Monte dam on food, water, and cultural systems, and observed that community and corporate-level actions may bolster health in the face of rapid socio-ecological change. Looking at the case studies together, a complex picture of vulnerability and resilience, risk and opportunity, complicates straight-forward predictions of ecosyndemic interactions resulting from these development projects but highlights the role that the ecosyndemic concept can play in informing health impact assessments and future research. We conclude by proposing a conceptual model of the potential interactions between psychological stress, vector-borne illnesses, and sexaully-transmitted infections and suggest that future investigations of synergistic interactions among these factors draw from the biological, social, and ecological sciences.

Cardiovascular Disease in the Peruvian Andes: Local Perceptions, Barriers, and Paths to Preventing Chronic Diseases in the Cajamarca Region.

Objectives: Public health interventions can be improved by understanding peoples' explanatory models of disease. We explore awareness and perceptions of cardiovascular diseases (CVD) and options for preventative actions in young adults living in rural Andean communities. Methods: We used convenience sampling to select 46 men and women from communities in Cajamarca (Peru). Subjects participated in eight focus groups where they discussed their understanding and perceived causes of CVD as well as barriers and pathways to healthy lifestyles. Results: Fresh foods, physical activity, unpleasant emotions, and healthcare access were cited as important determinants of healthy lifestyles. Barriers to healthy diets included lacking nutritional knowledge, fluctuating food prices, and limited access to foodstuffs. Women felt particularly vulnerable to CVD and identified gendered barriers to manage stress and engage in sports. Low health literacy, poor doctor-patient relationships, and long distances prevented participants from fully accessing healthcare. Conclusion: CVD prevention interventions should consider local knowledge of these diseases and of healthy lifestyles, and harness ongoing programmes that have successfully promoted good nutrition in children and pregnant women. In concert with public-private parterships, governments should include disease prevention interventions for the entire family.

Antimicrobial Resistance in Rural Settings in Latin America: A Scoping Review with a One Health Lens.

Antimicrobial resistance (AMR) in rural Latin America is not fully understood. The transmission pathways are partially known since research predominantly focuses on the urban hospital setting. The contribution to AMR from environmental factors is usually only mentioned in large-scale animal production. To understand the state of the literature on AMR in rural LA, we carried out a scoping review using the One Health (OH) perspective. OH recognises the concomitant contributions and interconnectedness of humans, animal, and the environment, thus, we used the OH perspective to select those articles adopting a holistic view of the problem. We searched original articles in English, Spanish, and Portuguese in four peer-reviewed databases and included 21 publications in the analysis. We charted data on bibliometrics, design, data collection sources, and instruments. We identified the human, animal, and environmental contributions to AMR in rural locations, and information gaps on AMR transmission routes and AMR drivers. Intensive and non-intensive animal production systems and agricultural practices were the most frequently found human contributions to AMR. Poultry, swine, cattle, and fish were the most frequent livestock mentioned as sources of AMR bacteria. Animal carriage and/or transfer of AMR determinants or bacteria was recognised as the primary contribution of livestock to the problem, while water, soil, and farming were predominant environmental contributions. We found that only 1 article out of 21 considered the OH approach as a framework for their sampling scheme, whereas 5 out 21 discussed all the three OH components. There were hardly any descriptions of humans or human waste as reservoirs for AMR in rural locations, and rural health centres or hospitals and wildlife were not represented. No studies identified mining as an anthropogenic activity driving AMR. More OH-oriented studies, with emphasis on molecular approaches-for identification and comparison of AMR genes-are sorely needed to understand better the existence of a network of interconnected transmission routes in rural Latin America and provide efficient strategies to prevent further AMR emergence.

Socio-cultural factors for breastfeeding cessation and their relationship with child diarrhoea in the rural high-altitude Peruvian Andes - a qualitative study.

BACKGROUND: In some areas of the world, breast milk is seen as a potential source of child diarrhoea. While this belief has been explored in African and Southeast Asian countries, it remains vastly understudied in Latin American contexts. We investigate socio-cultural factors contributing to breastfeeding cessation in rural high-altitude populations of the Peruvian Andes. The role of socio- cultural factors in the local explanatory model of child diarrhoea, and whether these perceptions were integrated in the local healthcare system were assessed. METHODS: Within the framework of a randomised controlled trial, we conducted semi-structured interviews with 40 mothers and 15 health personnel from local healthcare centres involved in the trial. RESULTS: Cultural beliefs on breastfeeding cessation included the perception that breast milk turned into "blood" after six months and that breastfeeding caused child diarrhoea. We identified eight local types of child diarrhoea, and women linked six of them with breastfeeding practices. "Infection" was the only diarrhoea mothers linked to hygiene and the germ disease concept and perceived as treatable through drug therapy. Women believed that other types of diarrhoea could not be treated within the formal healthcare sector. Interviews with health personnel revealed no protocol for, or consensus about, the integration of the local explanatory model of child diarrhoea in local healthcare and service provision. CONCLUSIONS: The local explanatory model in rural Andean Peru connected breastfeeding with child diarrhoeas. Cultural beliefs regarding diarrhoea management may increase home treatments, even in cases of severe diarrhoeal episodes. Future national breastfeeding support programmes should promote peer-counselling approaches to reduce negative attitudes towards breastfeeding and health practitioners. Local explanatory models should be incorporated into provincial and regional strategies for child diarrhoea management to promote equity in health and improve provider-patient relationships.

RESUMEN: ANTECEDENTES: En diferentes partes del mundo, la leche materna es percibida como una fuente potencial de diarreas infantiles. Mientras que estas creencias se han estudiado en África o el Sudeste Asiático, su análisis en el contexto latinoamericano es limitado. Esta investigación se centra en el estudio de los factores culturales que contribuyen al cese de la lactancia materna en poblaciones rurales de los Andes peruanos. Al mismo tiempo, también se analiza el papel de estos factores culturales en el modelo explicativo local de diarreas infantiles y la integración de las creencias en los servicios locales de salud. MéTODOS: Dentro de un ensayo clínico aleatorizado, se llevaron a cabo entrevistas semi-estructuradas con 40 mujeres y 15 trabajadores de salud de centros participantes en el ensayo. RESULTADOS: Las creencias culturales en torno a la lactancia maternal incluían la percepción de que la leche materna se convierten en "sangre" a los seis meses del parto y que la leche materna causaba diarreas en los niños lactantes. Identificamos ocho tipos de diarreas locales, seis de las cuales fueron asociadas con la lactancia por las madres participantes. "Infección" resultó ser el único tipo de diarrea que las madres asociaron con los principios de la higiene y la teoría microbiana de la enfermedad y percibían como curable por medio de medicamentos. Las mujeres creían que el resto de diarreas locales no podían ser tratadas dentro del sistema de salud. Las entrevistas con el personal sanitario indicaron una falta de protocolos y consenso sobre cómo integrar el sistema de creencias locales en torno a las diarreas infantiles en los servicios de salud. CONCLUSIONES: El modelo explicativo local en zonas rurales de los Andes peruanos asocia la lactancia con las diarreas infantiles. Estas creencias culturales dan lugar a prácticas de manejo de diarreas infantiles que pueden incrementar los tratamientos domiciliarios, incluso en episodios de diarrea severos. Futuros programas nacionales de apoyo a la lactancia materna deben promover la consejería y apoyo de pares y profesionales de salud con la finalidad de reducir las actitudes negativas hacia la lactancia materna y el personal de salud. Los modelos explicativos locales de las diarreas infantiles deberían incorporarse a las estrategias provinciales y regionales con la finalidad de promover la equidad en salud y mejorar las relaciones médico-paciente.

Antimicrobial Resistance in Humans, Animals, Water and Household Environs in Rural Andean Peru: Exploring Dissemination Pathways through the One Health Lens.

Antimicrobial resistance (AMR) is a global public health threat, especially for low and middle-income countries (LMIC) where the threat has not been fully identified. Our study aims to describe E. coli AMR in rural communities to expand our knowledge on AMR bacterial contamination. Specifically, we aim to identify and describe potential dissemination routes of AMR-carrying bacteria in humans (children's stools), community water sources (reservoirs and household sources), household environments (yard soil) and domestic animals of subsistence farmers in rural Andean areas. Our cross-sectional study was conducted in rural households in the region of Cajamarca, Peru. A total of 266 samples were collected. Thirty-four point six percent of reservoir water and 45% of household water source samples were positive for thermotolerant coliforms. Of the reservoir water samples, 92.8% were positive for E. coli, and 30.8% displayed resistance to at least one antibiotic, with the highest resistance to tetracycline. E. coli was found in 57.1% of the household water sources, 18.6% of these isolates were multidrug-resistant, and displayed the highest resistance to tetracycline (31.3%). Among samples from the children's drinking water source, 32.5% were positive for thermotolerant coliforms, and 57.1% of them were E. coli. One third of E. coli isolates were multidrug-resistant and displayed the highest AMR to tetracycline (41.6%) and ampicillin (25%). Thermotolerant coliforms were found in all the soil samples, 43.3% of the isolates were positive for E. coli, 34.3% of the E. coli isolates displayed AMR to at least one antibiotic, and displayed the highest AMR to tetracycline (25.7%). We determined thermotolerant coliforms in 97.5% of the child feces samples; 45.3% of them were E. coli, 15.9% displayed multidrug resistance, and displayed the highest resistance to ampicillin (34.1%). We identified thermotolerant coliforms in 67.5% of the animal feces samples. Of those, 38.7% were E. coli, and 37.7% were resistant to at least one antibiotic. For all the samples, the prevalence of resistance to at least one antibiotic in the E. coli and Klebsiella spp. isolates was almost 43% and the prevalence of MDR in the same isolates was nearly 9%, yet the latter nearly doubled (15.9%) in children's stools. Our results provide preliminary evidence for critical pathways and the interconnectedness of animal, human and environmental transmission but molecular analysis is needed to track dissemination routes properly.

A factorial cluster-randomised controlled trial combining home-environmental and early child development interventions to improve child health and development: rationale, trial design and baseline findings.

BACKGROUND: Exposure to unhealthy environments and inadequate child stimulation are main risk factors that affect children's health and wellbeing in low- and middle-income countries. Interventions that simultaneously address several risk factors at the household level have great potential to reduce these negative effects. We present the design and baseline findings of a cluster-randomised controlled trial to evaluate the impact of an integrated home-environmental intervention package and an early child development programme to improve diarrhoea, acute respiratory infections and childhood developmental outcomes in children under 36 months of age living in resource-limited rural Andean Peru. METHODS: We collected baseline data on children's developmental performance, health status and demography as well as microbial contamination in drinking water. In a sub-sample of households, we measured indoor kitchen 24-h air concentration levels of carbon monoxide (CO) and fine particulate matter (PM2.5) and CO for personal exposure. RESULTS: We recruited and randomised 317 children from 40 community-clusters to four study arms. At baseline, all arms had similar health and demographic characteristics, and the developmental status of children was comparable between arms. The analysis revealed that more than 25% of mothers completed primary education, a large proportion of children were stunted and diarrhoea prevalence was above 18%. Fifty-two percent of drinking water samples tested positive for thermo-tolerant coliforms and the occurrence of E.coli was evenly distributed between arms. The mean levels of kitchen PM2.5 and CO concentrations were 213 µg/m3 and 4.8 ppm, respectively. CONCLUSIONS: The trial arms are balanced with respect to most baseline characteristics, such as household air and water pollution, and child development. These results ensure the possible estimation of the trial effectiveness. This trial will yield valuable information for assessing synergic, rational and cost-effective benefits of the combination of home-based interventions. TRIAL REGISTRY: ISRCTN-26548981.