Bill Pan, Axel Berky, Joel Meyer, Ernesto Ortiz at a biological station

The flight from Lima to Cusco takes an hour and twenty minutes, and the road from Cusco into the highlands climbs to nearly 20,000 feet. From there it descends, unpaved and passing along cliffs and through cloud forest and eventually into jungle over the course of ten, twelve hours. At the bottom is a little town, and from there one travels by river, because there are no more roads.

The Rio Madre de Dios flows through a Peruvian department, or state, of the same name. Bill Pan, a joint Duke Global Health Institute and Nicholas School of the Environment associate professor of global environmental health, and Ernesto Ortiz, senior manager of programs at DGHI’s Global Health Innovation Center, have traveled this Amazon tributary, studying methylmercury exposures related to widespread artisanal gold mining. It’s a complex public-health issue with no easy solution. Consider: The activity that is poisoning the soil, the river, the people is also one of the only livelihoods in the rainforests of Madre de Dios.

“They don’t have any other way to bring food to the table,” Ortiz says.

Nestled in a remote corner of Peru and bordered by Brazil and Bolivia, the South Carolina-sized region (with a population smaller than Durham—much smaller) of Madre de Dios has historically been neglected by authorities and racked with poverty. For centuries, it has attracted outsiders who extract resources, then leave, with locals doing the dangerous work. First they came for rubber, in the 1800s. Then they came for timber. Since the 1960s, it’s been small-scale, largely unregulated gold mining—artisanal gold mining, as it’s commonly called—which requires mercury for the extraction process. Pervasive exposure to this heavy metal has resulted in high rates of anemia and likely affected fetal development.

Yet that single public-health thread—methylmercury exposure— leads to a tangle of others. Miners live crowded together and work in unsanitary conditions; alcohol, prostitution, HIV, and tuberculosis are rampant. Away from mining towns, tiny indigenous communities are seeing emergency-level mercury exposures—fish, a dietary staple, carries the toxin. Beyond that, the majority of mining is illegal, and attracts other illegalities, such as narcotrafficking. Peru, too, remains highly centralized, so all policy decisions are made far away, in coastal Lima, where the government turns over quite often. And international demand for gold—for jewelry, for electronics—remains the driving force behind the entire crisis.

A Duke team led by Pan and Ortiz has been at the forefront of science-based change in the region for ten years, exhaustively studying mercury exposures in rural Madre de Dios and advising the Peruvian government on public-policy interventions. This was all interrupted by COVID-19, and the Duke team found itself absent from Peru for far too long. Many gains made in Madre de Dios—which hardly thrives during a good year—were lost.

Yet Pan and Ortiz are ready to return. They’ve remained connected to rural communities and the Peruvian government; they’ve continued the work as best as possible from a distance. With artisanal gold mining on the rise again, though, they know there’s no substitute for another trip to Madre de Dios.

“Even though some of the research activities have slowed down, the nexus with the communities and even authorities is still going,” Peruvian colleague Ana Maria Morales says in Spanish, as translated by Ortiz. Duke “is very sensitive to the needs of the community,” she says, adding that “the region has benefited a lot” because of the evidence generated from, and communicated locally by, the researchers.

Although Morales has held her share of high-profile public- health positions over the span of three decades—currently: executive director of Peru’s Central Nacional de Salud Intercultural at the National Institute of Health of Peru; previously: regional director of health directorate in Huánuco, head of epidemiology at the Peruvian Ministry of Health, founder of Madre de Dios NGO CENSAP, to name a few—she is first and foremost a doctor in her home region of Huánuco. She is also Duke’s primary liaison and closest ally in its work in Madre de Dios.

Pre-pandemic, Pan would travel to Peru every other month. He was supposed to return last summer, but a visa issue coincided with U.S. embassy closures. Now, he’s aiming to finally return in January or February. There’s a pediatric study of in utero mercury exposure, for one, that has been paused since February 2020 and needs restarting.

“I hope Duke continues the work, or actually gets more presence in the region, because things have slowed down a lot,” Morales says.

Ortiz was born in Pittsburgh to Peruvian parents. The family returned to Peru after his physician father finished his residency, and from the age of four, Ortiz was raised in Lima. He didn’t spend too much time outside the capital as a child thanks to terrorism, violence, and economic crisis. By his late teens, Peru had stabilized, and Ortiz found a passion for travel. Then he attended med school, through which he got to know his country’s rural interior.

Ortiz returned to the United States for a master’s in public health from the University of Iowa, where he remained for five years to study infectious diseases that transmit from animals to humans. In 2007, he returned to Peru, researching tropical infectious diseases at Naval Medical Research Unit Six (NAMRU- 6) in Lima.

Pan started working in Peru in 2004 and met Ortiz during his four years at NAMRU-6. Pan, who was with Johns Hopkins University at the time, originally studied malaria, child diarrhea, and cysticercosis in the country. In 2011, Pan and Ortiz both came to Duke.

That year, Pan investigated how the construction of the Interoceanic Highway through Madre de Dios affected malaria rates. Environmental disturbance such as new road construction brings people in contact with disease vectors like insects and wild animals. Pan oversaw a two-stage population study along the new highway, but a high attrition rate among field workers dragged what should have been two or three months of data collection into more like nine.

“A lot of them said, ‘Well, we can make more money in gold mining,’ ” Pan recalls. “After about two weeks, we lost three field workers out of ten. After four weeks we lost eight field workers out of ten. And these weren’t people that were uneducated. We had nurses. We had biologists. We had a veterinarian.”

Pan found no malaria in the region—and he’s not sure why—but when he returned to Durham, he sought researchers at Pratt and the Nicholas School experienced in issues related to small-scale gold mining and mercury. He met with Ortiz, and they planned a 2012 return to the region.

“I was like, ‘Hey, you know, I know that area pretty well,’ ” says Ortiz, who averaged monthly Madre de Dios trips during his time at NAMRU-6.

Pan and Ortiz and their team traveled the Rio Madre de Dios by boat, stopping at small communities of 100 or 200 people to test for mercury exposures. Nobody knew them or were even expecting them in many cases. The team planned ahead, though. It helped that Ortiz is Peruvian American and an M.D., and he wore a white coat to ease first impressions. Before descending into the river basin, the team had presented its study to the health directorate of Madre de Dios, so Ortiz carried printed letters signed by the regional health authority.

He would start with the local health provider, who would then introduce him to the community authority. In indigenous villages especially, the team would then present the study to the entire community, and without the authorization of everyone, it could not proceed. “We did this in every community,” Ortiz says.

Some communities pushed back. Some communities said no. Another researcher came a year ago, residents would say. They took samples and never came back. Why should I trust you? The Madre de Dios region has historically been forgotten by authorities, Morales notes, so there’s a lot of mistrust.

A large percentage of the population is indigenous, of various ethnicities, and there was often a difference of cosmologies between scientists and residents. Research practices could clash with tradition, Morales adds. In some cultures, a baby’s first haircut is given by what amounts to their godfather. Taking a hair sample from an infant violates this tradition.

“There’s lot of communication that has to happen,” Morales says. “There’s an intercultural approach we have to take and an intercultural dialogue, because we have to understand very well and be very humble in the way we approach them.”

In gold-mining towns, the nature of the study—mercury exposures related to artisanal gold mining—made miners wary. You’re going to shut us down, they said. You’re against us. You’re environmentalists. “And we’re like, ‘No, we’re not environmentalists. We are taking care of your health,’ ” says Ortiz. “We just want to come up with recommendations of how to make your work safer for you and your family.’ ”

In its comprehensive map of mercury exposures across the watershed, the team found clear spatial clustering of high levels. It was high in locations where mining occurred, naturally, but also in indigenous communities that had no mining activity. Fish is a major dietary staple in these communities, which leads to increased mercury exposure. Across the region, 62 percent of the population’s mercury levels exceeded the EPA’s threshold of one microgram of mercury per gram of hair, or, 48 percent exceeded the WHO’s threshold of two micrograms.

“It was extremely high among women of childbearing age and very high among children,” Pan says.

By now it was 2015, and these data were the result of three studies over the course of several years in Madre de Dios. The Duke team shared its results with the Peruvian government— no response. Morales, terrified by the findings, stepped into action. “She began contacting all the people that she knows in the Ministry of Health and said, ‘You need to pay attention to this, because this is a major problem,’ ” Pan says.

By May 2016, Morales had organized a meeting in Lima with multiple government ministries. Ortiz, Pan, and collaborators Luis Fernandez of Wake Forest University and Beth Feingold of SUNY Albany (formerly of Duke’s Nicholas School and Global Health Institute) presented their preliminary data, meeting with ministers and outlining different interventions to limit or reduce mercury exposures. “That day they declared a state of emergency in Madre de Dios,” Pan says.

It accomplished nothing.

First off, it was the Peruvian government’s usual intervention, says Morales: Send in the military and blow up mining equipment, which neither helps miners find alternative livelihoods nor builds partnerships with communities. Secondly, Pan says, the minister who declared the state of emergency was out of power by July, and the new minister defunded it.

Beyond that, an attendee at the meeting in Lima leaked the mercury exposure map to The Guardian, which published it. As a result, Pan says, three journals rejected the paper. Peru— or any country—needs peer-reviewed, published scientific research to set long-term policy, he explains. With the paper delayed, so were science-based interventions in Madre de Dios. “It really hurt Peru,” Pan says.

Duke teams continued to travel to Peru, such as the 2018 Bass Connections project that brought Chris Lara (M.I.D.P.’19) to Rio Madre de Dios. After a career with the United Nations, where he worked in political affairs and humanitarian diplomacy during crises, Lara attended Duke as a Rotary Peace Fellow and is now a DGHI senior policy adviser with a focus on science diplomacy.

That was the year of the second meeting of the Conference of the Parties to the Minamata Convention on Mercury (COP-2) in Geneva, Switzerland, which had ratified an international treaty six years prior to limit mercury pollution. Lara attended as a representative of the Duke Gold Team. He had decided to stay involved in Peru, but from the diplomacy side.

“In 2019, we came back [to Peru], now with a bigger team from Duke,” Lara says, “and with a closer relationship with the Ministry of Health and the Ministry of Environment.”

When Lara joined, Pan says, his UN experience brought theories of change and science diplomacy to the team. Lara identified connections with non-government entities that partner with government entities and opened new channels to government ministries. “Universities and research institutions have many of the assets that [policymakers] might actually need to back up decisions and be stronger,” Lara says. “But everything is about building bridges.”

By this point, there was a new health minister in Lima. Another state of emergency was declared in 2019. Rather than destroy mining equipment, the military was sent in as a police presence to enforce existing laws relating to where and how legal mining can take place. Out of this state of emergency came an attempt at a formalization process, which would make it easier for illegal miners to operate legally.

“It was a good effort, but it just didn’t work,” Pan says. “They came at it from a much more community partnership point of view than they did the first time, which was good.”

Indeed, Duke-led science diplomacy—the use of peer-reviewed research to drive public policy—was gaining incremental ground in Peru. The second state of emergency slowed down artisanal mining in Madre de Dios in 2019, Pan says. The team was seeing results. “Now, 2020 hit. COVID comes, and mining anecdotally is going back up pretty rapidly.”

In Peru, the pandemic-driven economic crisis is pushing people back into mining, Morales says. Duke has played a major role in generating evidence of artisanal gold mining’s health impacts, but with fieldwork paused and research funds lacking, there is a growing gap of evidence being generated, she says. He and Ortiz speak glowingly about the contributions of their colleagues at Wake Forest University— any success in Madre de Dios is a success, period. And the Duke team remains as active as it can from a distance.

“Our work started on something and has gone beyond that specific work on heavy metals,” Morales says. “No one has created a relationship with the community we have.”

Aside from documenting anemia’s prevalence in mercury- exposed communities, Morales continues, Duke researchers would give residents rapid tests and inform the local health post of individual cases. In indigenous communities, the Duke team also found and reported hepatitis-B outbreaks that would have otherwise gone undetected. Duke has intervened to have critically ill villagers rushed to regional hospitals. In September 2021, in fact, Ortiz and Morales contacted Peruvian officials on behalf of two sick infants in remote Manú National Park, and they are in part responsible for the rapid dispatch of a Peruvian Army helicopter that airlifted the babies to the Puerto Maldonado hospital.

Around the same time, Pan was also contacted by the former Peruvian minister of health, who was connecting him with a person in the ministry who wants to take action on gold mining and mercury exposure. On top of that, Pan is an appointed scientific team member for a Ministry of Environment group related to the Minamata Convention on Mercury. Indeed, high-level work continues, and connections to Madre de Dios remain strong, even as a return trip to Peru is critically overdue. And the Duke team keeps the driving force behind this crisis in mind as it pushes for better outcomes.

“There’s a lot of demand for gold,” Ortiz says. “As long as there’s the high demand and not awareness, and the end users are us, we should make sure that we demand from our sellers to track where their gold is coming from.” 

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