Dear Editor:
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly
contagious infectious disease of international concern that spreads
mainly from person to person through respiratory
droplets.1,2 As of July 2020, outbreaks are being
reported in China, the country where the pandemic started and in which
it was thought initially to be controlled.3 In a
similar manner, in other countries like Peru, instead of being
controlled, the pandemic is increasing in severity and prevalence. Until
July 6, 2020, > 11 million cases had been confirmed across
the world, with > 300 000 cases and > 10 000
deaths in Peru.4
It is necessary to adopt intentional and thoughtful acts to control the
SARS-CoV-2 pandemic. Social distancing measures, minimization of
personal contacts, and hand sanitization are effective in limiting the
community spread of SARS-CoV-2.1 However, there are
social variables that cannot be controlled in Peru, such as lower level
education and poor socioeconomic status in a significant percentage of
the population5; these factors are related to the
morbidity and mortality attributable to COVID 19
infection.6
The Centers for Disease Control and Prevention (CDC) describes a list of
risk factors for SARS-CoV-2 infection that includes poverty and
crowding2. Likewise, a UK-based study investigated the
role of ethnicity and socioeconomic position in the development of
SARS-CoV-2 infection. They found that socioeconomic deprivation and lack
of qualifications were consistently associated with a higher risk of
confirmed infection6. Further, reports have shown
higher mortality from infectious diseases in patients with a low level
of education7. To our knowledge, no studies in Peru
have investigated the relationships among the level of education, the
socioeconomic status, SARS-CoV-2 infection, and the severity and
mortality of the infection, however, statistical findings show a higher
frequency of low educational level in people who have died as a result
of infection by the virus SARS-CoV-2(Figure 1)
Health outcomes are closely related to the educational level. Some types
of health behaviors, such as smoking, heavy alcohol drinking, physical
inactivity, and unhealthy diet, are expected to mediate the impact of
educational level on the incidence of non-communicable
diseases8. It is also remarkable that the total
prevalence of overweight and obesity in Peru is 60.2% in the total
population9. Moreover, lower levels of education are
related to higher incidence and prevalence of cardiovascular and
cerebrovascular disease, cancer, diabetes, hypertension, and chronic
respiratory disease8. Patients with these diseases are
at an increased risk of severe illness from COVID-19 because of lower
levels of immune cells and high cytokine levels in the body
fluids1,2.
Educational inequalities in these chronic diseases are mediated by the
patient’s socioeconomic status. As expected, low income level and
unstable job status that may be linked to low educational level are
reasonably predicted to raise the risk of these
diseases8. In Peru, >
1/3rd of the population lives in the urban capital,
Lima; however, a substantial population still lives in rural areas, with
limited access to medical care, chronic disease treatment, and
education. These rural residents are often poorer and less educated than
their urban counterparts10.
Another important factor that influences the characteristics of the
COVID-19 pandemic is population density;1 the
population density in Peru is 25 people per square kilometer, with a
substantial density in the rural population11. Some
studies have shown a significant positive linear relationship of
population density with number of cases, deaths, and case-fatality rate
of SARS-CoV-2. Moreover, there is a significant positive correlation
between the number of medical supplies and population density,
suggesting that this variable and the lack of medical equipment are key
factors that explain the morbidity and mortality of
COVID-1912.
By 2019, 87% of Peruvians had health insurance
coverage;13 however, the quality of health services in
the hospitals of the Ministry of Health, in regular situations, is
perceived to be low14. The pandemic hit Peru when the
country was in the process of improving health services and denoted
significant deficiencies across the health system, revealing the need
for urgent actions. The lack of equipment, supplies, and medications
translates into poor quality of care and plays an important role in the
health consequences of the COVID-19 pandemic.
In conclusion, we highlight the importance of eliminating the inequality
in the coverage of health services and continuing to improve the
education for the Peruvian population to control social factors and
enable optimal management of the COVID-19 pandemic.