The Intersections of Global Health Security - 2nd Final Version - USAID Official.pdf

The Intersections of Global Health Security with:

Inclusive Development, Migration, Private Sector, and

Climate Change

Pablo Fabian Aguilar Alcala, doing business as Resilient Development LLC was contracted by International Business & Technical Consultants, Inc. (IBTCI) through the USAID funded-Global Health Technical Assistance and Mission Support (GH-TAMS) Project.

SUBMITTED BY

Pablo Aguilar Alcala, MD, MSc.

Resilient Development, LLC|CEO-Technical Lead

SUBMITTED TO

Danielle Spinard

USAID | Peru| Director | Regional Migration & Health Office

Marvin Crespin-Gamez, MPH

USAID | Peru| Deputy Director | Regional Migration & Health Office

Mariana Ramos MD, MSc, MSc

USAID | Peru|Global Health Security Advisor| Regional Migration & Health Office

Jaime Chang N. MD, MSc, MPH

USAID | Peru|Advisor|Regional Migration & Health Office

FOR MORE INFORMATION

Resilient Development, LLC

13007 Town Commons Drive, Germantown, MD, 20874

ACKNOWLEDGEMENTS

The Intersections of Global Health Security with: Inclusive Development, Migration, Private Sector, and Climate Change is an analysis conducted by Resilient Development LLC with financial and technical assistance from the United States Agency for International Development Mission to Peru (USAID/Peru). We extend our heartfelt gratitude to USAID/Peru for its unwavering support from the inception of the IDA.

Our deepest appreciation goes to Ms. Danielle Spinard and Mr. Marvin Cresping for their pivotal roles, along with Dr. Mariana Ramos (Health Security Advisor) and Dr. Jaime Chang (Technical Advisor), for their invaluable insights, guidance, and contributions to the analysis and compilation of this report. The IDA would not have been possible without the support of our colleagues at Resilient Development, Alexandria Lenk, and J. Ignacio Aguilar.

We also extend our special appreciation to our in-country partners for providing us with documents and perspectives, as well as for their time, cooperation, and valuable insights. Lastly, we would like to express our gratitude to the IBTCI management team and administrative staff, particularly Madeline Orange, for their indispensable logistical support throughout the study.

Once again, we sincerely thank USAID/Peru for its steadfast support throughout this endeavor.

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TABLE OF CONTENTS

EXECUTIVE SUMMARY

Part 1 Chapter 1: INTRODUCTION

1.1. PURPOSE AND SCOPE

1.2. METHODOLOGY

1.3. THE REGIONAL CONTEXT

1.4. THE PERUVIAN CONTEXT

1.5. USAID PERSPECTIVE ON GLOBAL HEALTH SECURITY

Part 2: THE INTERSECTIONS WITH GLOBAL HEALTH SECURITY

Chapter 2: INCLUSIVE DEVELOPMENT

2.1. CONSIDERATIONS

2.2.KEY FINDINGS

2.3. PROGRAMMATIC RECOMMENDATIONS

Chapter 3: MIGRATION

3.1. CONSIDERATIONS

3.2. KEY FINDINGS

3.3. PROGRAMMATIC RECOMMENDATIONS

Chapter 4: THE PRIVATE SECTOR

4.1. CONSIDERATIONS

4.2. KEY FINDINGS

4.3. PROGRAMMATIC RECOMMENDATIONS

Chapter 5: CLIMATE CHANGE

5.1. CONSIDERATIONS

5.2. KEY FINDINGS

5.3. PROGRAMMATIC RECOMMENDATIONS

INTRODUCTION

1.1. PURPOSE AND SCOPE

USAID/Peru's Global Health Security Portfolio conducted an analysis about Global Health Security and the intersections with Inclusive Development, Migration, Private Sector, and Climate Change. The purpose of this analysis is to provide a perspective on how these cross-cutting themes relate with Global Health Security and serve as a basis for USAID/Peru’s new activity designs.

1.2. METHODOLOGY

The methodology employed in this analysis consists of a literature review of secondary data complemented by empirical evidence, with the application of the intersectionality concept.

The aim of this analysis is to delineate the intersections between Global Health Security and four variables: Inclusive Development (1), Migration (2), Private Sector (3), and Climate Change (4.)

The guiding questions are as follows:

● Why are "Variables 1, 2, 3, and 4" pertinent to Global Health Security?

● What considerations should be taken into account when examining the relationship between "Variables 1, 2, 3, and 4" and Global Health Security?

● How these variables impact prevention, detection and response.

● How can the findings of this analysis inform recommendations for Global Health

Security programming?

It's important to note that this literature review is not exhaustive. Sources utilized encompass academic articles, working papers, discussion papers, book chapters, and publications from various international development assistance organizations, as well as those from the Government of Peru.

The search engines employed include the National Library of Medicine (NLM), Google Scholar, PLOS, and The Lancet Global Health and Climate Change.

1.3. THE REGIONAL CONTEXT

Latin America has experienced significant social and economic changes both before and after the COVID-19 pandemic. Pre-pandemic, the region showed steady economic growth and declining poverty rates. However, persistent inequalities remained, with many countries facing high levels of informal employment, political instability, and inadequate healthcare infrastructure.

The COVID-19 pandemic stopped the development of the region and reversed much of this progress. Lockdowns and economic downturns severely impacted sectors like tourism, manufacturing, and agriculture. The informal labor force was particularly affected, pushing millions back into poverty. The World Bank estimates that the region experienced a contraction of 7% in 2020 (The World Bank 2020). Healthcare systems were overwhelmed, exposing gaps in access and preparedness.

Post-pandemic recovery has been uneven. While some countries like Brazil and Mexico have seen some economic rebound due to commodity exports and vaccination campaigns, challenges persist. High inflation rates, rising debt, and the ongoing social impact of prolonged school closures continue to hinder progress. Additionally, climate change, migration, and political instability remain significant concerns.

The region is now focused on equitable growth, improved healthcare infrastructure, and social protection to rebuild and enhance resilience for future challenges.

The relations between Global health security and inclusive development, immigration, the private sector, and climate change in Latin America exist and are relevant. Addressing these interconnected factors through comprehensive policies and regional cooperation is essential for enhancing global health security and ensuring sustainable development. Here’s an overview on how these factors impact the region.

● Inclusive Development aims to ensure equitable access to resources and opportunities, which is crucial for building resilient economic and social systems. Health service coverage in the Americas improved gradually over the 20 years before the COVID-19 pandemic. By 2019, 77% of the population had health coverage, up from 65% in 2000.

The number of health workers increased, and government health investment rose by 1.1 percentage points. Average life expectancy at birth also increased from 73.7 years in 2000 to 77 years in 2019. However, these gains were not universal, as a third of the population continues to face barriers in access and coverage, the health workforce remains understaffed, and access to medicines and technologies remains difficult despite improvements in state regulation and surveillance (Pan American Health Organization 2022). Countries have challenges to enforce constitutional rights by expanding access to healthcare for its poor, geographically distanced and marginalized citizens, failing to prevent, detect, and respond to outbreaks, particularly in remote areas.

● Migration across the Americas is multifaceted and shaped by socio-economic and political crises, natural disasters, violence and war. The Venezuelan crisis alone has expelled over 7 million migrants and refugees through 2024, comparable to the Syrian crisis becoming the main driver of migration in the region.

Moreover, the region is serving as a transit corridor for migrants who follow treacherous routes, including the Gap of El Darien in Panama, on their way to the United States. In 2023 over 500,000 migrants from more than 50 countries coming from Latin America and regions as far away as Africa and Asia crossed El Darien, one of the most dangerous jungles in the world. Studies on the prevalence of communicable diseases in refugees and asylum seekers, and migrants identified the highest reported prevalence of malaria, active TB, HIV, Hep B and C infections among African refugees and asylum seekers, meanwhile the highest reported prevalence of latent TB, HBV and HCV was among Asian and Eastern Mediterranean refugees and asylum seekers ((Taha 2023); (Monge-Maillo 2015)). On the other hand latino migrants showed higher prevalence of Chagas disease, and malaria, particularly in Venezuelans (Abdallah 2022).

The deadly Gap of El Darien, is a 130 kilometers of dense vegetation, with high humidity, suffocating heat, rivers and swamps, where the Pan American Highway cuts-off.

Migrants are exposed to dehydration, starvation, traumatic injuries, drowning, and psychological traumas, compounded by incidents of loss, violence and sexual assault ((Pappier 2023); (Núñez 2022)). Common diseases that are visible include open injuries, skin infections, gastrointestinal infections, fractures, and “trench foot”. Various deadly venomous reptiles, scorpions, spiders and toxic lepidoptera butterflies inhabit the area, causing accidents that range from local burning and necrosis to death. Mosquitoes are abundant, transmitting vector-borne illnesses like dengue, P. vivax and P. falciparum malaria, yellow fever, and Venezuelan equine encephalitis, eastern equine encephalitis,leishmaniasis, and avian schistosomiasis. Bat transmitted rabies is also present in El Darien ((Suarez 2022); (Escobar 2015)).

High volumes of migrants strain host countries' health systems, as evidenced in Brazil, Colombia, and Peru, where the influx of Venezuelan migrants has heightened demands on already under-resourced and understaffed healthcare services. Moreover, reports and studies indicate that migrants often carry and spread infectious diseases, complicating surveillance and response efforts. Additionally, migrants' poor living conditions, limited access to income and services, and avoidance of authorities if lacking documents increase their vulnerability to acquiring and spreading diseases. All these together make them a challenge for global health security.

● The private sector has played a notable role in poverty reduction, infrastructure development, and the extension of social protection. During the COVID-19 pandemic, it addressed supply demands (e.g., medicinal oxygen, medicines) and supported vaccine acquisition and distribution. Additionally, it has driven economic recovery in the post-pandemic period. The private sector's impact can be either beneficial or detrimental, depending on its activities. While sectors like tourism and agriculture have shown the benefits of collaborating with the health sector, potentially serving as valuable allies for global health security and One Health, sectors involved in infrastructure development, transportation, natural resource exploitation, and farming may lead to deforestation, pollution, and migration into wild forests. These activities can increase the risk of emerging and re-emerging diseases and antimicrobial resistance.

● Climate change is affecting Latin America, with direct and indirect implications for global health security and one health. The region’s ecosystems are being affected by extreme weather and climate shifts. Deforestation and increased droughts in the Amazon decrease its carbon sequestration ability, contributing to global warming while increasing wildfire risks. Livestock farming and land use changes increase deforestation and encroach on wildlife habitats, raising the risk of zoonotic diseases spilling over to humans. Glacial melting in the Andes jeopardizes water supply for millions, threatening agriculture and human health and increasing the risk of water borne diseases.

Agriculture, crucial to regional economies, faces growing threats due to erratic weather, droughts, and flooding, which undermine food security. Coastal communities are more vulnerable to rising sea levels and hurricanes, which can disrupt healthcare infrastructure and cause displacement, further straining health systems. The rise in infectious diseases like dengue and Zika is also linked to shifting climate patterns that create favorable conditions for disease-carrying vectors. Meteorological events such as “El Nino Costero” 2023-2024 has led to severe weather events in Latin America and the Caribbean, including droughts, flooding, heavy rainfall causing the rise of vector transmitted diseases.

1.4. THE PERUVIAN CONTEXT

Located in Western South America, Peru borders the South Pacific Ocean, and five countries, Bolivia, Brazil, Chile, Colombia, and Ecuador. Its terrain presents a western coastal plain, the Andes mountains (sierra), and the eastern lowland jungle of the Amazon Basin (selva).

Between 2000 and 2010, Peru experienced rapid economic growth fueled by mining, trade liberalization, and prudent fiscal policies. This growth made possible by the support of a strong private sector led to considerable poverty reduction and social inclusion, with the national poverty rate falling from about 58.7% in 2004 to 20.5% by 2019 (World Bank, 2021).

The government's investments in social programs, infrastructure, education, and healthcare also contributed to this decline. (World Bank, 2021).

Despite these improvements, the COVID-19 pandemic in 2020 caused a setback. Lockdowns and economic contractions disproportionately affected those in the informal sector, pushing millions back into poverty. The poverty rate climbed to 30.1% in 2020, undoing years of progress in poverty alleviation (INEI, 2021). Government initiatives, such as cash transfers and stimulus measures, aimed to cushion the impact of the pandemic and promote recovery.

Trade liberalization boosted exports, but pandemic-related disruptions highlighted Peru's dependence on commodity exports and global supply chains.

By 2021, after a significant economic downturn due to the COVID-19 pandemic, the economy bounced back quickly but has since slowed down sharply amid lower global growth related to Russia’s war of aggression against Ukraine, increased political uncertainty, high inflation, tight financial conditions and more recently widespread social unrest and extreme weather conditions. The impact of these shocks has manifested in inflationary pressures, with rising prices hitting many vulnerable families.

As a path for further recovery Peru is diversifying its economy by expanding mining, agriculture, and services. The mining sector remains crucial, high metal prices have supported the economy contributing to exports and foreign exchange (Peruvian Ministry of Energy and Mines, 2023).

In 2023, Peru's population totaled 33.726 million, reflecting a 28.9% increase since 2000 (INEI.2017). Gender distribution showed 102 women per 100 men, and the ratio of individuals over 65 years to those under 15 was 33.4 per 100. Life expectancy at birth was 77.0 years, slightly below the regional average but 6.5 years higher than in 2000.1 Most Peruvians are Mestizo 60.2%, Quechua 22.3%, white 5.9%, afro-peruvian or black 3.6%, Aymara 2.4%, Native or Amazon Indigenous 0.9%, Asian 1.2%, and 3.5% others (INEI.2017). The major languages are Spanish 82.9%, Quechua 13.6%, Aymara 1.6%, Ashaninka 0.3%, and other Amazonian languages 0.8% (2017 est.)

Peru's urban and coastal communities have benefited more from recent economic growth than rural and indigenous populations of the Amazon and mountain regions. As of 2020, 82.6% of Peru’s population is concentrated in urban areas (Situation of the Peruvian Population. INEI. 2023). Development of cities in Peru followed a pattern of inequality with the population, wealth, and services concentrated in Lima, the capital with 11 million inhabitants, followed by the second largest city in Peru, Arequipa that has less than 1 million inhabitants. Of the 10 million Peruvians identified at risk of falling below the poverty line in 2021, 72.6 % lived in urban areas, 17.5% in rural areas, and the 9.8 % in semi urban areas.(8)

Peru is a participatory democracy. The President is elected every five years through voting.

The country is divided into 24 departments, 196 provinces, and 1890 districts. The government has three branches at the national level, which are the Executive, Legislative, and Judicial branches. The Constitution is the highest law of the land. At the regional level, the departments and regions are in charge of governance. On the local level, provinces, districts, and populated centers exercise their authority. Local governments are the foundation of the country's territorial organization, and they operate with autonomy.(“Organización del Estado Peruano” 2024) Over the past decade, evidence of public-sector corruption in Peru has increased dramatically. This has eroded citizens’ confidence in democracy, and affected the country’s political stability.

1 Plataforma del Estado Peruano. Instituto Nacional de Estadística. 2023

1.4.1. Inclusive development

Approximately 60 percent of the Peruvian population lacks coverage for the four basic social protection guarantees outlined in the International Labour Organization's Recommendation No. 202. Nearly four million children (38 percent) live in poverty, lacking the minimum level of support necessary for food, education, care, and essential goods and services. Additionally, ten million adults (56 percent) lack full coverage under labor legislation, leaving them without basic protections for unemployment, disability, illness, or maternity. Moreover, ten million people (35 percent) lack access to essential healthcare, either due to a lack of health insurance or systemic barriers such as living in hard to reach areas, including geographical isolation. Furthermore, one and a half million older people (53%) lack basic income security due to insufficient coverage provided by pension systems. (Infante and Chalcana 2014)

The gap in inclusive development affects global health security in Peru by weakening the country's prevention, detection, and response capacities. Insufficient access to healthcare, education, and social services leaves marginalized populations, such as those in rural and remote areas, vulnerable to infectious diseases and health crises. This vulnerability results in delayed disease detection and impedes the implementation of preventive measures.

In terms of prevention, the lack of equitable healthcare infrastructure means many communities are excluded from vaccination programs, health education, and sanitation improvements. Consequently, these groups are more susceptible to disease outbreaks that can spread quickly across borders, threatening global health security.

Detection capacities are also impacted due to limited surveillance systems and diagnostic facilities in underserved regions. A lack of training and resources prevents healthcare workers from accurately identifying emerging health threats, which delays containment efforts and increases the risk of widespread transmission.

When it comes to response capacities, marginalized groups often receive inadequate care due to strained resources and logistical challenges. They face shortages of medical supplies and personnel, leading to delays in treatment and ineffective outbreak containment.

According to the United Nations Office On Drugs and Crime, following COVID-19 gender-related killings of women and girls increased in Central America by 3 percent and in South America by 5 per cent from 2019 to 2020 (UNDOC 2022). (for further detail on inclusive development see Chapter 2)

1.4.2. Migration

Venezuelan migration significantly impacts Peru's global health security capacities in prevention, detection, and response. Peru hosts over 1.5 million Venezuelan migrants, and this influx strains the country's healthcare system.

The sudden increase in demand for healthcare services has overwhelmed local health infrastructure, limiting the ability to deliver vaccines and preventive care. Migrants, often lacking formal health insurance, struggle to access regular immunization programs and health education. This situation can increase the vulnerability of both migrant and host populations to vaccine-preventable diseases.

The influx of migrants has complicated disease surveillance systems. Many migrants live in informal settlements with limited sanitation, which are prone to outbreaks of diseases like tuberculosis and dengue. The lack of robust healthcare data collection for this population makes it challenging to detect early signs of outbreaks, undermining prompt response.

The high demand for healthcare from migrant populations stretches Peru's healthcare workforce, resources, and facilities. This leads to treatment delays, shortages of essential medications, and inadequate care, limiting effective outbreak containment. Furthermore, the language barrier and varying healthcare practices hinder communication and coordination between healthcare workers and migrants. (for further detail on migration see Chapter 3)

1.4.3. Private sector

The private sector in Peru has both positive and negative impacts on global health security, affecting the country's prevention, detection, and response capacities.

The private sector can provide crucial support in healthcare delivery, innovation, and resource mobilization. Private hospitals and clinics increase access to essential health services, complementing the public system. During the COVID-19 pandemic, private companies assisted with mass testing, vaccine distribution, and the production of essential medical supplies like oxygen. Their resources and logistics expertise can strengthen emergency response efforts, allowing for more rapid and effective containment of outbreaks.

However, certain activities of the private sector can also undermine global health security. In mining, agriculture, and infrastructure development, environmental degradation and deforestation increase the risk of zoonotic disease transmission. For example, land-use changes and pollution can push wildlife closer to human populations, raising the likelihood of new outbreaks. Furthermore, private healthcare often prioritizes profit over equity, leading to disparities in access to care and preventive services. This creates pockets of vulnerable populations susceptible to infectious disease spread. (for further detail on the private sector see Chapter 4)

1.4.4. Climate change

Climate change directly impacts global health security by affecting Peru’s prevention, detection, and response capacities. Rising temperatures, changing rainfall patterns, and extreme weather events like floods and droughts are already exacerbating the spread of infectious diseases and straining healthcare systems.

Increasing temperatures and shifting rainfall patterns provide ideal breeding conditions for disease vectors, such as mosquitoes. This leads to higher transmission rates of diseases like dengue, Zika, and malaria, especially in regions that lack adequate vector control measures.

Additionally, agricultural disruption from droughts and floods threatens food security, leading to malnutrition, which weakens immune responses to infections.

Climate change disrupts disease surveillance efforts by creating new areas of vulnerability.

Populations migrating due to climate impacts often settle in informal areas with poor sanitation and limited healthcare, making it difficult to monitor disease trends effectively. This increases the likelihood of delayed detection of outbreaks, hindering containment efforts.

Extreme weather events damage healthcare infrastructure, disrupt supply chains, and create logistical challenges that delay emergency responses. This makes it harder to deliver timely treatment and vaccinations during outbreaks. In addition, resources are often diverted to disaster relief efforts, limiting the healthcare system’s ability to address other emerging health threats. (for further detail on climate change see Chapter 5)

1.5. USAID PERSPECTIVE ON GLOBAL HEALTH SECURITY

Since the start of the 21st century, infectious disease outbreaks and epidemics have increased both in severity and frequency. The vast majority - 75% - of emerging infectious disease threats originate from animals, at a time when an increasing number of people around the world, including those in conditions of vulnerability, are living in closer proximity to animals due to deforestation, land use change driven by private and state actors, climate change, and a variety of other factors including human mobility. Around the world, millions of people have lost their lives and livelihood because the world lacks the capacity to prevent, detect, and respond to COVID-19 and other emerging infectious disease threats.

There are an estimated one billion cases of zoonotic diseases in people annually, and numerous other species are threatened or on the brink of collapse from a combination of anthropogenic pressures, including human-driven infectious disease transmission. Epidemics due to emerging viral diseases, in particular those caused by viruses with origins in wildlife hosts, are increasing in both frequency and severity. Spillover of these viruses from wildlife can be directly attributed to human activities. John Locke. PREDICT: Advancing Global Health Security at the Frontiers of Disease Emergence. USAID. 2021

USAID Global Health Security (GHS) Program seeks to prevent and mitigate the increasing occurrence and severity of epidemics, pandemics and other emerging infectious disease threats. USAID does this by partnering with countries, as well as global, regional, and local public and private sector organizations. These partnerships build and strengthen measurable, sustainable capacity while helping to develop and adopt evidence-based and innovative solutions to prevent, rapidly detect, effectively respond to, and ultimately recover from emerging infectious disease threats – whether naturally occurring, accidental, or deliberate.

Recognizing the connection between the health of the environment, animals and people, USAID implements the One Health Approach. The GHS Program uses an integrated approach that is inclusive of four main efforts: strengthening capacity; responding to outbreaks and other health emergencies; bolstering the GHS architecture; and building resilience in concert with USAID’s broader global health programs. This program works with USAID’s health emergency response effort, which seeks to rapidly contain outbreaks and mitigate pandemics. It also seeks to support linkages among USAID GHS-funded efforts and other USAID programs, such as: COVID-19; PEPFAR; PMI; tuberculosis and antimicrobial resistance (AMR); Maternal and Child Health and Nutrition; and food security. USAID’s GHS Program works with countries to identify and address their highest priority gaps, with to strengthen their national International Health Regulation (IHR) core capacities, required to detect, assess, notify and report events, and respond to public health risks and emergencies of national and international concern. (World Health Organization 2005)

Chapter 2: INCLUSIVE DEVELOPMENT

2.1. CONSIDERATIONS

This chapter delves into the factors influencing the inclusion or exclusion of individuals, or groups thereof, and their ramifications from the perspective of Health Security, with a One Health approach.

When we think about inclusive development and GHS, we should consider:

● Lack of enforcement of Laws protecting those vulnerable

● Gender violence driven by stressors as epidemic increased (check gender section below)

● Poverty

● Hard to reach

○ Geographic distance-Isolation

○ Marginality in the slums of LIma and MDR

● Lack of social cohesion-community participation

● Lack of coordination and communication between community and health system

● Poor - under equipped healthcare facilities - weak countereference

● Services not culturally adapted

● Health providers challenges

● Insufficient prevention, challenging surveillance and response

● Poor health outcomes

● Gender aspects as per ADS 205.3.1

○ Law, policies, regulations, and enforcement

○ Cultural norms and beliefs

○ Gender roles, responsibilities, and time use

○ Access to and control over assets and resources

○ Patterns of power and decision-making

○ Personal safety and security

Below is an analysis of the factors influencing inclusion or exclusion in health, along with their consequences and recommendations. We also provide a set of examples based on the review of the literature and what was observed in recent health events in Peru, some examples are:

● Polio case in Datem del Marañon (poverty and geographic distance)

● TB in the marginal populations living in the slums of Lima (hard to reach)

● The health sector providers protection being systematically neglected during the

COVID-19 Pandemic; and

● The Awajun- Wampis suffer high HIV/AIDS and Hep B rates, and are affected by contamination generated by illegal mining (lack of coordination, poor health care facilities, services not culturally adapted, health providers challenges, insufficient prevention, challenging surveillance and response, and poor health outcomes).

2.2. KEY FINDINGS

Despite major advances in the fight against poverty, healthcare access remains a challenge for vulnerable populations in Peru. In order to access healthcare vulnerable individuals require healthcare facilities are available-accessible within a reasonable distance, that they are able to afford the cost of transportation and care, that the services are provided and are adequate to patients culture, and that care being offered is acceptable to users' dignity, culture and expectations.

2.2.1. LAWS- LEGAL FRAMEWORKS AND ENFORCEMENT

i) Lack of enforcement of Laws protecting those vulnerable Laws establish frameworks for systematic and consistent implementation and enforcement. In Peru, the Constitution is the highest law, safeguarding human rights and ensuring access to services like education, health, work, and housing. Laws prioritize resource allocation for health, education, infrastructure, and emergency preparedness, enhancing the country’s capacity to meet objectives and respond to emergencies, including pandemics.

Health and life are fundamental rights guaranteed by society and assumed by the State. Civil rights significantly influence health as social determinants. The General Health Law (Law No.

26842) regulates actions to ensure the right to health, including disease surveillance and control (MINSA 2012). The National Multi-Sector Health Policy 2030 prioritizes health infrastructure and crisis response. The Law of the National Coordinated and Decentralized Health System (Law No.

27813) decentralizes health services, and the Law for Strengthening the Ministry of Health's Epidemiological Surveillance (Law No. 31961) outlines responsibilities for disease notification (MINSA 2023), and coordination with the Data Protection Law (Law No. 29733).

Peru has entered various international agreements to protect vulnerable populations, including indigenous peoples, recognizing their collective rights and territories. The State is responsible for providing fair and efficient responses, anticipating and mitigating future health risks, and ensuring the protection of women, children, young people, and medical personnel. The pandemic revealed that vulnerability among populations evolves, with health personnel being among the most vulnerable and unprotected.

The International Health Regulations (2005)-is one of those treaties- a legally binding agreement among WHO's 196 Member States, requires countries to conduct surveillance for potential international health threats and report them to WHO promptly. This aims to prevent, control, and respond to the international spread of disease while minimizing interference with international trade and travel (WHO, 2005).

Laws alone are insufficient without comprehensive regulation, funds, human resources, equipment, and effective enforcement. Vulnerable populations, particularly in isolated regions, often face discrimination and neglect, leading to inadequate enforcement of existing laws.

There is a lack of serious planning, insufficient funds, inadequate emergency responses, and poor-quality healthcare services. Information management is irregular and inadequate, and healthcare issues rarely feature on the political agenda unless societal pressure escalates.

Transmission in public places and at the workplace are important because these are where people get the disease. The state has to regulate these that the health sector is often unaware

of. For example, during the COVID-19 pandemic, the GOP issued fines for non-compliance with preventive measures to contain the disease's spread at various instances-unauthorized walking in the streets, not using masks, public disobedience, not respecting social distancing, and attending to work unvaccinated (Gobierno del Perú 2021). Large companies often chose to pay fines rather than comply with implementing protection measures for their workers, leading to increased transmission and death of their personnel (OSHA/Oficina California 2020).

a) Indigenous populations: Laws provide the framework to protect indigenous populations' health security by guaranteeing enrollment in public health insurance (SIS) and preventing exploitation of indigenous lands. However, inadequate enforcement, insufficient political will, and removal of legal protections undermines these efforts. The cessation of mobile services to geographically distant areas where indigenous Amazon communities live during the COVID-19 pandemic have impeded access to SIS and other governmental social programs, restricting healthcare and education rights. (Ombudsman Office Peru.2021).

The recent enactment of Law No. 31973 on January 11, 2024(Congreso de la República del Perú. 2024), amending Articles 29 and 33 of the Forestry and Wildlife Law (Law No.

29763), has removed long-standing legal protections for indigenous lands, forests, and resources. This change is expected to negatively impact indigenous Amazon communities by accelerating deforestation, illegal mining, illegal logging, and narcotics trafficking. These activities pose escalating threats to the lives and livelihoods of indigenous peoples.

Environmental defenders and their families have faced threats, with the SERVIR-Amazonia Program revealing troubling patterns in Madre de Dios, such as deforestation, mercury contamination, and exploitation of indigenous women (Calle 2023). As a signatory of the Minamata Convention, Peru is responsible for reducing and eliminating mercury use to prevent severe health effects, similar to Minamata Disease documented in Japan (Gibb and O'Leary 2014).

b) Disabled people: Laws protecting disabled people are relevant for health security in Peru as they ensure equal access to healthcare, reduce health disparities, and enhance the overall well-being of this vulnerable population. According to the INEI, 3.2 million people in Peru have disabilities, many of whom rely on others for care and mobility (INEI Perú and Rivera-Araujo 2019).

Health coverage for disabled individuals through SIS has increased to 92%, compared to 86% for those without disabilities. However, coverage is still lower in rural and hard-to-reach areas (INEI-ENAHO. 2014-2022; Observatorio Nacional de la Discapacidad 2022). Inclusion in health security measures helps prevent disease spread, reduces healthcare costs, and promotes societal well-being. Effective implementation of the General Law on Persons with Disabilities (Law No. 29973) can improve access to healthcare and social services, thus strengthening Peru's health security (Ministerio del Trabajo y Promoción del Empleo-Discapacidad. 2024).

Challenges include gaps in enforcement, limited resources, and lack of accessibility in public infrastructure (Hashemi. 2022; Flores-Flores. 2018). About 63.5% of healthcare facilities have access barriers, and only 0.7% of schools are accessible to disabled people. Additionally, 88% of children with disabilities do not attend school (CONADIS- Grupo de Trabajo Multisectorial - PNA 2018; Defensoría del Pueblo del Perú 2019).

Employment rates are also low, with 43% of disabled individuals employed compared to 72% of non-disabled individuals; 55% of the unemployed cite health reasons (Observatorio Nacional de la Discapacidad 2022).

2.2.2. POVERTY AND HARD TO REACH

i) Poverty, ethnicity and access to health care

In 2022, extreme poverty affected 5.0% of the population, increasing by 0.9 percentage points from 2021 and 2.1 percentage points from 2019. Extreme poverty was higher in rural areas (14.6%) than in urban areas (2.6%), with respective increases of 2.5 and 0.5 percentage points from 2021, and 4.8 and 1.6 percentage points from 2019 (INEI Peru 2022).

While almost the entire Peruvian population is covered by some type of health insurance, split between the state-subsidized Comprehensive Health Insurance (SIS) and the Social Health Insurance (EsSalud), there is still a high degree of fragmentation, barriers to access, and large differences in coverage among different groups (Casal-ILO 2020).

During the COVID-19 pandemic, indigenous people were disproportionately affected due to limited access to healthcare, water, sanitation, health personnel, equipment, medicines, tests, and vaccines. Regional governments lacked the budget to attend to Indigenous populations in remote areas, prioritizing large cities instead. Over 379,000 Indigenous people live in the Peruvian Amazon, with approximately 150,000 in urban areas and over 220,000 in rural areas.

Their access to programs depends on identification documents issued by the National Registry of Identification and Civil Status (RENIEC) through limited campaigns in hard-to-reach areas. In Lima, stay-at-home orders and social distancing measures led to the unemployment of 2.3 million people, increasing the risk of food insecurity, especially for low-income families relying on daily wages (Cañari-Casaño 2021).

Systemic discrimination in healthcare manifests in the denial of care and mistreatment, eroding trust among users. This reflects societal discrimination and undermines efforts towards universal coverage and the Sustainable Development Goals, jeopardizing health security in Peru.

The GOP has the challenge to seek alternatives to include those excluded and provide to them a social protection floor as a set of social security guarantees that should ensure, as a minimum, that, over the life cycle, all in need have access to essential health care and to basic income security which together secure effective access to goods and services defined as necessary at the national level (International Labor Organization 2020).

ii) Geographic distance-Isolation Our analysis reveals that geographic distance affects most those residing in the Peruvian Amazon, who are highly vulnerable and suffer disparities in health service access and coverage (Informe defensorial No 169. 2010; Informe defensorial No 001.2023). Geographic barriers include distance, limited means of communication such as roads and transportation (long trips by land or river), lack of economic means to cover the cost of transportation and stay.

Transportation could take between seven hours to five days and cost between $40 to over $70.

All of these are out of reach for a family living in poverty. Even if they would be able to get the funds, transportation is highly dependent on seasons and weather conditions.

Populations in voluntary isolation and those with initial contact deserve separate consideration, as they are highly vulnerable to respiratory-transmitted infectious diseases, particularly those that haven't been circulating in their communities, often referred to as external diseases.

Historical records indicate that the spread of illnesses like influenza or malaria caused the death of one-third of the population in the 1990s due to contact with missionary priests. During the COVID-19 pandemic, illegal loggers entering from Brazil introduced the virus, resulting in significant impact.

The consequences of geographic isolation, specifically the lack of accessibility, are manifold.

Firstly, there is reduced and unequal access to preventive information and a reduced offer/access to preventive methods, resulting in e.g., immunization coverages falling below the protective threshold, a reduction in Sexually Transmitted Infection (STI) preventive methods, and the lack of use of water treatment. Moreover, the likelihood of providing timely diagnosis and appropriate care is reduced because primary healthcare facilities available in remote places often lack the means and have to refer the cases to facilities with a higher capacity, delaying diagnosis and treatment. Adequate treatment and outbreak control measures could be compromised due to the distance, time between the population and healthcare facilities, and bureaucracy. Treatment could be delayed because of limited information regarding the capacity of services and operating hours, potentially causing additional delays due to gaps in service availability. There are systemic failures that are present often when facilities are distant, these include the lack of personnel and funds to implement vaccination campaigns, and weakness in the disease notification and surveillance systems.

These circumstances not only escalate the direct and indirect costs associated with diseases but also heighten the risk of disease exacerbation, transmission to others, and mortality. Even if all necessary criteria are met, the utilization of services ultimately hinges on user demand and acceptance, further complicating the provision of care (Garbus et al., 2012; Giovanella and Fleury, 1995).

Based on the review of the literature and what was observed in recent health events in Peru, an example is:

a) Polio case in Datem del Maranon: A case of acute flaccid paralysis was detected in a one-year-old indigenous male infant in Manseriche, Datem del Marañón Province, Loreto, a remote area in the northeastern Peruvian jungle (Subgrupo de Inmunizaciones de la Mesa de Concertación de la Lucha contra la Pobreza (MCLCP)). Such low levels of coverage could allow the virus to circulate and mutate to a variant capable of causing paralysis.

The child was initially taken to the district health center. Due to the center's lack of resolving capacity, he was referred to the regional hospital two days later. There, the syndrome was diagnosed, and a sample was taken for confirmation of vaccine-derived polio 22 days after the onset of illness. The sample was sent to the Oswaldo Cruz Institute in Brazil (FIOCRUZ) because Peru lacks PCR and genomic tests for polio. This led to a delayed outbreak control response. The child was taken to Lima for further assessment.

The results from the Reference Laboratory were received three months later, on March 21, 2023, triggering notification to the National Liaison Center (CNE) of the IHR International Health Regulation and the launch of epidemiological control measures.

Unfortunately, these measures were too late, resulting in an epidemiological alert, risk communication, and the deployment of a response team to search for cases and implement vaccination containment measures (Al-Kassab-Córdova et al.).

The child was discharged after assessment at the Children's Health National Institute (INN), but continuing care in Loreto is difficult due to poor access to services, a lack of specialists, and the need for dedicated care. Long distances, which can take between seven hours to four days, have an extremely high and unaffordable cost of $40 to over $70, which is unreachable for a family living in poverty.

Since the elimination of polio in Peru 32 years ago, six cases of vaccine-derived poliovirus (VDPV) were reported between 2003 and 2011 in urban and semi-urban areas. This was the seventh confirmed case of VDPV infection, attributed to low polio vaccine coverage at the community level. Polio vaccine coverage was below 59% in 2020 and 75% in 2022 (Subgrupo Inmunizaciones de la MCLCP 2023).

iii) Marginality in the Slums of Lima-Multidrug resistant Tuberculosis

Individuals in vulnerable social classes, races, lower socioeconomic statuses, and other minority groups bear the highest burden of both, chronic diseases (Havranek 2015), and emerging and re-emerging infectious diseases (Teitelman, Riegel, and Oseei Baah 2018).

Disease outcomes are not solely determined by the healthcare received during illness; societal factors such as access to social services, employment, education, and basic needs also significantly impact health. These social determinants of health (SDH) are unevenly distributed across gender, class, race, sexual orientation, socioeconomic status, and minority groups, contributing to the disproportionate burden of chronic diseases in vulnerable populations (Heidenreich 2011).”Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups” (Osei Baah 2018). Marginalization, as defined by Hall et al. in 1994, is "the process through which persons are peripheralized based on their identities, associations, experiences, and environment" (Meleis 1994).

Tuberculosis (TB) remains the world's leading infectious disease killer in low- and middle-income countries, also being the overall leading cause of death among people living with HIV (PLHIV), accounting for around 30 percent of AIDS-related deaths. Nearly 95 percent of TB deaths occur in the developing world. HIV and multidrug-resistant TB (MDR-TB) present a particularly deadly combination (USAID, TB/HIV-Global Health). The risk of developing TB among PLHIV is 18 times higher than in the rest of the global population, posing a significant concern for global health security.

b) TB in the marginal populations living in the slums of Lima: Peru is one of the most affected countries by tuberculosis, with increasing disease rates. TB rates have risen from 200 per 100,000 inhabitants in 1990 to 75.3 per 100,000 inhabitants in 2020, with a further increase to 96.9 per 100,000 inhabitants in 2023. The slums of Lima, Peru, particularly Carabayllo, are the epicenter of TB and MDR-TB transmission . Over 55.7 percent of all TB cases in Peru are reported in Lima and Callao, with 77.8 percent of these cases being MDR-TB (MINSA-Sala de Situación TB 2023).

Carabayllo, a sprawling slum in the north of Lima, is a tuberculosis hotspot characterized by overcrowded, poorly ventilated, and humid housing conducive to disease transmission. Individuals marginalized in Carabayllo, including drug addicts and those living with HIV and tuberculosis coinfection, are particularly vulnerable (Collyns 2017).

HIV/AIDS and tuberculosis coinfection have been reported in PLHIV in Peru since 2000, comprising 5 percent of all TB cases (1,418 cases), with 65 percent concentrated in Lima and Callao.

From a health security perspective, multi-drug-resistant tuberculosis (MDR-TB) is a significant concern. With support from USAID/Peru, Partners in Health worked with thousands of patients to reduce treatment abandonment rates from 7 to 8 percent to less than 1 percent by empowering local community members as health promoters.

These community members were essential to this effort because they knew which members of their community were coughing or had lost weight, as well as those who were hiding or were otherwise not reachable by other health services (Rueckert 2017).

Since 2012, Partners in Health has implemented a strategy in Carabayllo, supported by a state-of-the-art tuberculosis detection laboratory housed in an old shipping container.

This laboratory, the only one of its kind in Latin America, can make 25 diagnoses a day, significantly enhancing Peru's healthcare services. Diagnostics are crucial for detecting tuberculosis, emphasizing the importance of timely diagnosis in disease control.

However, the challenge of tuberculosis extends beyond medical issues to encompass social factors.

iv) Lack of social cohesion-social participation and equity on health

According to the U.S. Department of Health and Human Services, social cohesion refers to "the extent of connectedness and solidarity among groups in society" (“Social Cohesion - Healthy People 2030 | health.gov” 2023). Social networks not only foster social capital but can also influence health behaviors and outcomes, a phenomenon known as "social contagion."

Social cohesion plays a crucial role in understanding social inclusion and the dynamics among different social actors towards a comprehensive conception of health as "a complete state of physical, mental, and social well-being" (WHO, 1946). This approach integrates biomedical aspects of diseases, such as curative strategies, with the social context, considering social determinants of health and disease. These determinants are influenced by various mechanisms, including macroeconomic policies, public policies (such as education and health), and social policies, leading to disparities in income, ethnicity, social class, and education. These factors act as modulators, exacerbating health inequities rather than serving as primary causes (Solar 2007).

Addressing health inequities requires strategies targeting the structural and intermediate determinants of health, focusing on socio-economic and political contexts through intersectoral actions, social participation, and citizen empowerment. However, these efforts are hindered by dysfunctions in the governance system, including:

● Limited representation of social actors, particularly Amazonian indigenous people.

● Insufficient involvement of health specialists and marginalized…