It's 3:45 in the morning. Luz Elena Avanto Urvina, 76, puts on layers of thick wool as she she prepares for her journey to the hospital—one of the few reasons she has left to leave her house, where she lives alone in a poor district on the outskirts of Lima.
Slowly and carefully, Luz Elena navigates her frail body through the dark, unpaved back alleys. Her eyesight has deteriorated steadily over the years and now, with each step, the world seems to undulate about her.
The hospital is only a short bus ride away, but she lacks the means to pay the $0.30 fare. Her prolonged illness has rendered her incapable of work for over a year.
Upon arrival, she is greeted by lines of weary patients that wrap around the block—a sight not uncommon at hospitals around Lima. There, she will wait another four or five hours until the doors open and her turn in line arrives. By the time she is seen, it will be already past 9 am. If she's lucky, she might spend ten minutes with the doctor, but even that is no guarantee of treatment.
"Oh, my god! The pain. The doctors don't tell me what I have. They just tell me to get the drugs, but when I go to the dispensary, they don't have them. I don't even know what to do anymore," she says.
She sighs and stare off into the distance, as if lost in deep thought.
Demographic and Epidemiological Transitions
Luz Elena is one of the growing number of older adults in Peru who are facing increasing burdens of chronic conditions and disabilities, often with limited resources to cope.
In Peru, as in the rest of Latin America, older adults (defined as age 60 and above) are growing rapidly as a proportion of the population, with the fastest growth concentrating amongst older females and the "oldest old" (i.e. above the age of 80). While older adults represented only 6.1 percent of the population in 1990, today they represent 9.4 percent, with the United Nations predicting an increase to 14.5 percent by 2030.
The rapid aging of the population has compounded the effects of what experts refer to as "the epidemiological transition"—the gradual shifting of a country's burden of disease and disability from primarily infectious diseases and malnutrition to chronic, non-communicable diseases such as depression and heart disease.
According to the Peru Ministry of Health, in 2012 non-communicable diseases accounted for 60.5 percent of the national disease burden, versus 25.3 percent caused by communicable and maternal and child health-related conditions and 14.2 percent caused by accidents and injuries. Among the elderly population, the burden of non-communicable diseases increased to 79.8 percent—the highest among all age groups.
An Older Population Needs Different Health Care
Speaking at the Forum on Challenges of Public Policy for Healthy Aging in Lima, Peru, Dr. Miguel Mario Serrano, health promotion advisor at WHO/PAHO Peru, stressed the mismatch between existing health services and changing population needs.
"Right now we are still focusing on the 'classic patient', who has a single acute episode without long-term effects on functional status or patient autonomy," Serano explained. "We need to reorient ourselves to treat the 'contemporary patient', who experiences multiple chronic conditions, tends to be older and disabled, and affected by permanent functional limitations."
The challenge is figuring out how to individualize care and establish treatment guidelines, given the heterogeneity of health status of older adults.
"After a certain point, age alone is no longer the principal criterion for differentiating care," said Dr. José Francisco Parodi García, geriatrician and director of the Center on Aging Research at the University of San Martín de Porres. "You need to start looking at multiple variables, such as co-morbidities, life expectancy, disability and its reversibility, the ability to self manage, amongst others."
Unfortunately, evidence-based treatment guidelines for older adults have been limited due to the age group's under-representation in research trials. Older adults have historically been excluded from trials because they are more likely to have co-morbidities or higher risks of harm that prevent them from participating. As a result, older adults tend to receive care and drugs that are based on evidence and guidelines that were designed for a largely different age group, and with no consideration of other co-existing conditions.
Poor Treatment, Limited Access, and Discrimination
In addition to challenges in providing appropriate care for older adults, data on health systems performance to date in Peru suggests that existing services are still not universally accessible to older adults and insufficiently coordinated to address the needs of older adults.
Financial access remains one of the main barriers to health care for a large segment of the older population. Despite increases in health insurance coverage among older adults from 67.2 percent in 2011 to 76.6 percent in 2014, one in every four older adults in Peru is not covered by any insurance, according to the Peru National Institute of Statistics and Informatics (INEI).
Meanwhile, health worker discrimination and maltreatment of older adults remains a problem, with older adults reporting experiences of shunning and poor treatment from doctors and administrative staff. A recent survey of older adults by HelpAge Peru found that over a third of respondents had experienced some form of discrimination while seeking health services, with 30 percent of respondents having been denied or refused treatment.
"Health services have improved over the last few years, but sometimes what happens is an older adult goes to the hospital and is either treated poorly or given misinformation. The health workers might say, "You're paying out of pocket? Come up first. You're under the public insurance? You'll be seen later.' Or they might prioritize patients with personal connections to the staff," said Mario Vilcatoma Pillaca, president of the National Association of Organizations on Older Adults in Peru (Red-ANAMPER). "What we need is preferential treatment of the elderly."
An Inadequate Health Workforce
Experts are quick to point out that one of the continuing challenges for the health system is the lack of appropriate training and sensitization of the health workforce. According to the Ministry of Health, there are currently 165 geriatricians for a national population of nearly 300,000 older adults.
Fewer than six of the 34 medical schools in Peru offer an undergraduate geriatrics course, which generally ranges in duration from a few weeks to a month, with some consisting of only theory and no clinical practice.
"This means that the majority of Peruvian doctors in the last 30 years never received instruction how to treat an older person," said Parodi.
A multi-year WHO study in Peru found that older adults still received general medical care for adults rather than the specialized care that they need. The study went on further to highlight the lack of coordination for elderly care across all levels, as well as the general lack of awareness of concepts of continuity of care.
Addressing the Root Cause?
At the Peru Ministry of Health, Dr. Juan del Canto, Head of Older Adults Division, emphasized the need to take a life course perspective on healthy aging.
"Health in old age is directly linked to decisions and behavior that an individual takes throughout their lives. To improve the health of older people, we need to focus on education and prevention throughout childhood and adulthood, so that people reach the age of 60 in the best condition possible," said del Canto.
But for Luz Elena and the nearly three million older adults currently living in Peru, the window of opportunity has already long gone.
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