Health system barriers to hypertension care in Peru: Rapid assessment to inform organizational-level change.

Traditional patient- and provider-level hypertension interventions have proven insufficient to halt hypertension as the leading cause of morbidity and mortality globally. Systems-level interventions are required to address factors challenging hypertension control across a social ecological framework, an under-studied topic particularly salient in low- and middle-income countries (LMICs) such as Peru. To inform such interventions, we sought to identify key health systems barriers to hypertension care in Puno, Peru. A participatory stakeholder workshop (October 2021) and 21 in-depth interviews (October 2021-March 2022) were conducted with 55 healthcare professionals (i.e., doctors, nurses, midwives, dentists, nutritionists), followed by a deductive qualitative analysis of transcripts and notes. Participating healthcare providers indicated that low prioritization and lack of national policies for hypertension care have resulted in limited funding and lack of societal-level prevention efforts. Additionally, limited cultural consideration, both in national guidelines as well as by some providers in Puno, results in inadequate care that may not align with local traditions. Providers highlighted that patient care is also hampered by inadequate distribution and occasional shortages of medications and equipment, as well as a lack of personnel and limited opportunities for training in hypertension. Multiple incompatible health information systems, complicated referral systems, and geographic barriers additionally hinder continuity of care and care seeking. Insights gained from health providers on the healthcare system in Puno provide essential contextual information to inform development of organizational-level strategies necessary to improve provider and patient behaviors to achieve better hypertension care outcomes.

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.

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.

The "Double Burden of Malnutrition" in the Amazon: dietary change and drastic increases in obesity and anemia over 40 years among the Awajún.

Undernutrition and overnutrition are interconnected. Yet few studies have examined the "double burden of malnutrition" (DBM) over time in indigenous communities. We investigated changes in the food systems and nutritional health of Awajún communities in the Peruvian Amazon in the 1970s and in 2013. Methods included ethnography, 24 hr food recalls, and biological measures. In 2013, the number of traditional foods consumed decreased to 10% of levels in the 1970s and the number of market foods consumed increased 40-fold. Rates of anemia and obesity were also substantially higher in 2013 compared to the 1970s (23% vs 6% for anemia and 30% vs. 0% for obesity) indicating a DBM has emerged. Examining the predictors of hemoglobin levels and body mass indices in the 2013 sample reveals that this DBM is differentially impacting women and that risk for obesity among the Awajún is associated with multiple proxies of market integration beyond just the consumption of market foods. These findings highlight the complex pathways by which rapid lifestyle changes are creating gendered health inequalities within indigenous communities over time.

Metabolic syndrome risk unexpectedly predicted by traditional food consumption: shifting food systems and health among the Awajún of the Peruvian Amazon.

BACKGROUND: Dietary changes, especially declines in traditional food diversity and increases in the consumption of processed foods, have previously been shown to increase the risk of developing cardiovascular diseases. AIM: We evaluated the prevalence and risk factors for metabolic syndrome in four Awajún communities in the Peruvian Amazon. SUBJECTS AND METHODS: A total of 222 participants answered a socioeconomic questionnaire, a 24-h food recall, and completed a physical examination for metabolic syndrome diagnosis. A Poisson regression with robust variance was used in the statistical analysis of risk factors for metabolic syndrome. RESULTS: We found an overall prevalence of 24% for metabolic syndrome. Being female, increased age and body mass index were significant risk factors for metabolic syndrome. Surprisingly, risk more than doubled with the ratio of traditional foods. However, this study revealed that there are fewer traditional foods being consumed in this study compared to prior studies among the Awajún. CONCLUSION: We suggest that the unexpected relationship between traditional food consumption and metabolic syndrome may be due to substantial reductions in the diversity of traditional foods. Currently available traditional foods are primarily high in carbohydrates and are supplemented with cheap, non-perishable, and carbohydrate heavy market food items.

A "Cookbook" for Vulnerability Research.

There is a growing need to facilitate the interdisciplinary study of the relationship between the environment and human health and well-being. It is increasingly recognized that vulnerability is a key construct allowing discipline-specific research questions on these topics to be meaningfully contextualized. However, there is little consensus regarding the meaning of the concept of vulnerability or how it can best be utilized in research studies. In this perspective article, we use the metaphor of a "cookbook" to review promising trends in vulnerability research and to make this body of research accessible to a multi-disciplinary audience. Specifically, we discuss a selection of "recipes" (theoretical frameworks), "ingredients" (vulnerability domains), "cooking tools" (qualitative and quantitative methods), and approaches to "meal presentation" (communication of results) drawn from vulnerability studies published in the past 15 years. Our aim is for this short "cookbook" to serve as a jumping-off point for scholars unfamiliar with the vulnerability literature and an inspiration for scholars more familiar with this topic to develop new ways to navigate the tension between locally-specific assessments of vulnerability and attempts at standardization. Our ultimate take-home message is that the specifics theories and methods used in vulnerability research are less important than attention to what we see as the 3 'T's of transparency, triangulation, and transferability, and to efforts to make vulnerability research both "place-based" and comparable.

Uncovering population structure in the Humboldt penguin (Spheniscus humboldti) along the Pacific coast at South America.

The upwelling hypothesis has been proposed to explain reduced or lack of population structure in seabird species specialized in food resources available at cold-water upwellings. However, population genetic structure may be challenging to detect in species with large population sizes, since variation in allele frequencies are more robust under genetic drift. High gene flow among populations, that can be constant or pulses of migration in a short period, may also decrease power of algorithms to detect genetic structure. Penguin species usually have large population sizes, high migratory ability but philopatric behavior, and recent investigations debate the existence of subtle population structure for some species not detected before. Previous study on Humboldt penguins found lack of population genetic structure for colonies of Punta San Juan and from South Chile. Here, we used mtDNA and nuclear markers (10 microsatellites and RAG1 intron) to evaluate population structure for 11 main breeding colonies of Humboldt penguins, covering the whole spatial distribution of this species. Although mtDNA failed to detect population structure, microsatellite loci and nuclear intron detected population structure along its latitudinal distribution. Microsatellite showed significant Rst values between most of pairwise locations (44 of 56 locations, Rst = 0.003 to 0.081) and 86% of individuals were assigned to their sampled colony, suggesting philopatry. STRUCTURE detected three main genetic clusters according to geographical locations: i) Peru; ii) North of Chile; and iii) Central-South of Chile. The Humboldt penguin shows signal population expansion after the Last Glacial Maximum (LGM), suggesting that the genetic structure of the species is a result of population dynamics and foraging colder water upwelling that favor gene flow and phylopatric rate. Our findings thus highlight that variable markers and wide sampling along the species distribution are crucial to better understand genetic population structure in animals with high dispersal ability.

Critical linkages between land use change and human health in the Amazon region: A scoping review.

Land use change (LUC) is a main cause of global environmental change, and is an important activity to be studied. Our research aims to examine the current state of evidence on the link between LUC and human health in the Amazon region. We conducted a scoping review of literature in two research databases, resulting in 14 papers for analysis. Our analysis demonstrated a lack of clear definitions for LUC, a wide variety of negative health effects from LUC, the lack of qualitative articles, a lack of studies exploring the potential positive health effects of LUC, and the predominance of studies coming from the Brazilian Amazon. Our study validated the prevailing idea that LUC can lead to negative health consequences, if not managed properly.

Contrasting patterns of selection between MHC I and II across populations of Humboldt and Magellanic penguins.

The evolutionary and adaptive potential of populations or species facing an emerging infectious disease depends on their genetic diversity in genes, such as the major histocompatibility complex (MHC). In birds, MHC class I deals predominantly with intracellular infections (e.g., viruses) and MHC class II with extracellular infections (e.g., bacteria). Therefore, patterns of MHC I and II diversity may differ between species and across populations of species depending on the relative effect of local and global environmental selective pressures, genetic drift, and gene flow. We hypothesize that high gene flow among populations of Humboldt and Magellanic penguins limits local adaptation in MHC I and MHC II, and signatures of selection differ between markers, locations, and species. We evaluated the MHC I and II diversity using 454 next-generation sequencing of 100 Humboldt and 75 Magellanic penguins from seven different breeding colonies. Higher genetic diversity was observed in MHC I than MHC II for both species, explained by more than one MHC I loci identified. Large population sizes, high gene flow, and/or similar selection pressures maintain diversity but limit local adaptation in MHC I. A pattern of isolation by distance was observed for MHC II for Humboldt penguin suggesting local adaptation, mainly on the northernmost studied locality. Furthermore, trans-species alleles were found due to a recent speciation for the genus or convergent evolution. High MHC I and MHC II gene diversity described is extremely advantageous for the long-term survival of the species.

Molecular Epidemiology of Avian Malaria in Wild Breeding Colonies of Humboldt and Magellanic Penguins in South America.

Avian malaria is a disease caused by species of the genera Haemoproteus, Leucocytozoon, and Plasmodium. It affects hundreds of bird species, causing varied clinical signs depending on the susceptibility of the host species. Although high mortality has been reported in captive penguins, limited epidemiological studies have been conducted in wild colonies, and isolated records of avian malaria have been reported mostly from individuals referred to rehabilitation centers. For this epidemiological study, we obtained blood samples from 501 adult Humboldt and 360 adult Magellanic penguins from 13 colonies throughout South America. To identify malaria parasitaemia, we amplified the mtDNA cytochrome b for all three parasite genera. Avian malaria was absent in most of the analyzed colonies, with exception of the Punta San Juan Humboldt penguin colony, in Peru, where we detected at least two new Haemoproteus lineages in three positive samples, resulting in a prevalence of 0.6% for the species. The low prevalence of avian malaria detected in wild penguins could be due to two possible causes: A low incidence, with high morbidity and mortality in wild penguins or alternatively, penguins sampled in the chronic stage of the disease (during which parasitaemia in peripheral blood samples is unlikely) would be detected as false negatives.