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Paper short abstract

The pandemic exposed weaknesses in Peru’s health system, producing care poverty for older adults with COVID-19. This paper analyses how this deficit generated extra-institutional care strategies that, though unequal and risky, sought to sustain life with limited resources.

Paper long abstract

This paper analyses the production of care poverty through the reorganisation of care when older adults with COVID-19 were unable to access institutional healthcare in Peru, where near-universal insurance coverage coexisted with the highest COVID-19 mortality rate globally.

This paradox reflects long-standing structural weaknesses. Before the pandemic, Peru’s health system—fragmented, unequal, privatised, and underfunded—lacked the capacity to meet the needs of an ageing population. During COVID-19, these conditions produced severe barriers to care, including misinformation, mistrust of public hospitals, failures in emergency response, and informal age-based triage in overwhelmed facilities.

Drawing on qualitative research for a doctoral thesis—including 59 in-depth interviews with older COVID-19 survivors, relatives of deceased patients, and healthcare workers, and analysis of 119 policy documents—this paper traces care-seeking trajectories from symptom onset to exclusion from formal healthcare. As hospitals became inaccessible, families became primary care providers, generating extra-institutional arrangements ranging from unsupervised home care to privately supported and hybrid forms involving primary care or community actors.

While these responses reflected moral commitment and efforts to preserve dignity and proximity, they were shaped by unequal economic and social resources, relied on women’s unpaid labour, and carried high emotional and financial costs. In moderate and severe cases, home-based care resulted not from cultural preference but from cumulative exclusion, often leading to delayed hospitalisation or death outside institutional settings. By foregrounding lived care trajectories, the paper conceptualises care poverty as a relational and moral process, contributing to ethnographic debates on care inequalities, ageing, and health systems in the Global South.