People in Iquitos, Peru, refer to their city as "una isla," an island, even though it's not an island. Iquitos is a port city of roughly 400,000 people on the Amazon River in northeastern Peru. Residents proudly note that it's the largest city in the world that's unreachable by road. You can only get there by boat or by plane.
In the early days of the COVID pandemic being isolated seemed like an advantage. It might delay the arrival of the virus. It might make it easier to contain. But that didn't turn out to be the case for Iquitos.
The first COVID cases appeared in Iquitos in March of 2020 at a time when cases were starting to pop up in many parts of the world.
"We were hearing news about the pandemic in other countries," says Catholic priest Raymond Portelli, who is also a physician. "But sincerely, we thought it wasn't going to be that disastrous and it wasn't going to come to Iquitos."
The disaster unfolding in Iquitos would quickly play out across the South American nation. Peru's death toll from COVID is now the worst in the world, far higher than any of its neighbors and twice the rate of the United States. In Peru COVID officially caused nearly 6,000 deaths for every 1 million Peruvians. In neighboring Ecuador the mortality rate is just over 1,800 per million. In the U.S. the COVID death rate is roughly 2,400 per million.
Mariana Leguia, an infectious disease expert in Lima, says a combination of factors made COVID so deadly in Peru. "It was sort of a perfect storm," says Leguia, who directs the genomics laboratory at the Pontificia Universidad Católica del Perú.
Padre Raymundo, as he's known, runs a medical clinic in Iquitos on the ground floor of his church 6 days a week.
"In the morning, I'm a doctor. And in the evening I'm a priest," he says with a laugh.
Portelli, who's originally from Malta, has been in Iquitos for the last 25 years.
He says that in those early days of the pandemic, he wasn't too worried about this new coronavirus that was causing such a ruckus elsewhere in the world.
But that early optimism would quickly evaporate. On March 15, 2020, just as the first coronavirus cases started appearing in Iquitos, Peru went into a strict nationwide lockdown.
Flights linking Iquitos back to the capital were cancelled. Boat navigation on the Amazon River, the main source of traffic in and out of Iquitos, was also officially banned although some boats still moved surreptitiously on the massive murky brown waterway.
Portelli says part of the problem at that point was that the region was also being hit with a spike in dengue cases.
"We were kind of like, 'Is it dengue or is it something else?'" the doctor-priest says. "Then the whole thing erupted."
Like much of the rest of Peru, Iquitos was ill-equipped to deal with an eruption of COVID cases. Doctors had no way to test for the virus. There was no known treatment.
And at the time there were only 12 ICU beds in the vast Loreto Province, where Iquitos is the capital – an astonishingly low number for a region that stretches across 500 miles of rainforest, pushing up against Ecuador, Colombia and the Brazilian state of Amazonas.
Seven of those beds were at the Loreto Regional Hospital in Iquitos, which was designated as the hospital for treating COVID.
By mid-May of 2020 that hospital was on the verge of collapse. The hallways were filled with patients on Army cots.
Dr. Juan Carlos Celis Salinas, the head of infectious diseases at the hospital, says the facility was completely full. "Beds, beds, beds, beds," Celis says, pointing out where cots had been set up in the main lobby of the hospital. Some people were even lying on cardboard on the floor.
Mariana Leguia, the infectious disease expert at the Pontificia Universidad Católica del Perú, says part of the perfect storm that made COVID so bad in Peru was its dependence on imports. Like many middle-income countries, Peru doesn't produce much of its own medical supplies.
"That means that all the PPE, all the tests, all the molecular tests, all the antibody tests, absolutely everything comes from someplace else," she says. "At the beginning of the pandemic, it was basically impossible to compete for these things because everybody wanted them."
Every country in the world was scrambling to buy up masks, protective gear, ventilators. Peru was not only competing against neighboring South American nations for pandemic supplies but against wealthy nations like Germany, the United States, South Korea and Saudi Arabia. Peru didn't have the cash or the clout to compete in that frantic market.
Other factors in Peru's COVID storm were an underfunded public health-care system, overcrowded living conditions and a huge informal economy. An estimated 70% of Peruvians survive off informal jobs, making it nearly impossible for them to adhere to the nationwide lockdown. Nearly a quarter of Peru's 33 million citizens live below the poverty line.
"So when the shutdown came, these people are completely out of a job," notes Leguia. "In a situation like that, your priority becomes having something to eat for the day, not staying at home and trying not to get the virus."
During the pandemic Peru also lacked the stable political leadership needed to address the crisis at home and negotiate for medical supplies from abroad.
"Last year, I think we had four presidents, five presidents. I lose count," Leguia says. The correct number was four. But whether it was four or five, she says the political situation made it nearly impossible for the government to effectively respond to this huge medical, economic and social crisis. "Because there's massive turnover of the authorities happening every three months," she says.
The coup de grâce for Peru was a lack of oxygen. Peru not only didn't have sufficient supplies of medical oxygen to treat patients, it had restrictive, cumbersome regulations on bottling oxygen that had limited the market to just a few local companies.
"In the context of the pandemic, the main driver of deaths was actually lack of oxygen," says Leguia.
And that's also what led to the avalanche of deaths in Iquitos, she says.
In Iquitos in early May of 2020, the sole oxygen plant at the regional hospital broke down.
Dr. Celis says it was the darkest moment of the pandemic.
"When a patient is without oxygen," he says. "They don't scream. They die as if a candle were being blown out."
Patients who probably could have been saved just with supplemental oxygen instead slipped away, says Celis.
The surge in deaths led to chaos. The hospital's morgue was full. The city's crematorium also couldn't keep up and eventually shut down. Mortuaries had been taking in bodies but then in the midst of the lockdown couldn't schedule funerals. In addition, several funeral directors got infected and died.
Meanwhile, staff at the hospital were working long shifts, sweating in the tropical heat with only a single mask. Doctors and nurses, including Celis, started getting infected. Sixteen staff members including 6 doctors from the hospital didn't survive.
As oxygen tanks drained with no way to refill them, Celis says all his staff could do was try to make patients comfortable.
"You weren't doing something heroic," he says. "You were just resisting because you had to do your job. You felt responsible to be there but with this immense fear for your children, your wife, your family."
In Iquitos, the story of an isolation center captures the mounting tragedy – and a possible path forward.
At that same time that the main hospital in Iquitos was overrun with COVID patients, Padre Raymundo Portelli was overseeing a church-run isolation center for what were supposed to be mild to moderate COVID cases.
"I was attending nearly 70 to 80 patients hospitalized there," the doctor-priest says.
But more and more people kept testing positive. And many the patients in the isolation center were getting progressively sicker. Given that services at the main hospital had collapsed Portelli had nowhere to transfer them.
"Patients were dying for lack of oxygen," he says. "And I was sitting here, I remember I'd said mass for them. But I didn't know what to do."
Then a friend in Lima suggested that Portelli should take up a collection to buy a new oxygen plant and bring it to Iquitos. Portelli laughs as he recalls the conversation. He was skeptical. He didn't know how much an oxygen bottling plant would cost, or even if he could get hold of the industrial compressors and other materials needed for one as it was becoming clear around the world that oxygen was a key treatment for COVID. Nonetheless, he posted a request for donations on his Facebook page.
"And in one day, one day! there was a million soles in my accounts." Portelli was amazed.
A million Peruvian soles is about $250,000. Within two weeks Padre Raymundo along with the local health department had bought the equipment in Lima for a new bottling plant, arranged to fly it to Iquitos and assembled it at the regional hospital. At first the demand for oxygen was so great from health workers and citizens lining up with cannisters for a sick family member that the city had to station police officers at the plant to keep a semblance of order.
Padre Raymundo's fundraiser continued, and he eventually raised enough money for four more plants for Iquitos.
Health authorities also built a temporary 150-bed COVID ward on what used to be a soccer field behind the regional hospital. It wasn't finished until after the first wave of the pandemic had subsided over several months, hitting a low in November. But Dr. Celis says it was literally a lifesaver during the second wave that swept in to the Amazon region in January 2021.
Peru's second wave of cases peaked in April of this year. Cases and deaths have now plateaued at relatively levels. Health officials say they've been bracing for a third wave that so far hasn't arrived. The problem now, Dr. Celis says, is that the regional hospital is once again packed ... but not with COVID patients. People with cancer, HIV, TB and other medical issues who'd put off seeking care for months are streaming in for care.
Yet the hospital has far fewer staff to treat them.
"Medical staff is not something that's increased," Celis says. "It's decreased. Doctors have died. Nurses have died. And people are exhausted. Some don't want to be in high risk areas anymore. So instead of more health personnel, you have less."
The problem isn't just in Iquitos. The first two waves of COVID were incredibly lethal in Peru. Despite having a population that's less than half the size of the United Kingdom, Peru's registered 50,000 more deaths than the U.K. The pandemic so far has killed more than 200,000 people in the South American nation.
The impact of the pandemic on families who lost loved ones and on Peru as a whole will likely be felt for years. The novel coronavirus exposed and exploited the vulnerabilities in the emerging South American country.
Despite this, Padre Raymundo says people are eager to move on.
"They want to forget," he says. Forget the wave of death that arrived just a matter of weeks after many people in the city first heard about a disease called COVID-19 that was spreading thousands of miles away in Asia.