COVID-19 strains remote regions of PeruThe health system in Iquitos is stretched and the true number of COVID-19 cases and deaths is unclear. Barbara Fraser reports from Lima.

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recalls when his neighbor's nine-year-old son accidentally drank mercury from a bottle he found in the family's home. When the boy died two years later, his parents separated, his mother blaming her husband for not keeping the bottle out of their son's reach. It is a cautionary tale in Madre de Dios, a region in southeastern Peru where smallscale, "artisanal" gold miners like Miranda and his neighbor use mercury every day, with little or no equipment to protect themselves against skin contact or inhalation of vapor.Artisanal miners use rudimentary methods and operate largely outside the law and the formal economy. Worldwide, their labors contribute an estimated 400 metric tons (t) of atmospheric mercury every yearsabout 10% of the total, according to Kevin Telmer of the University of Victoria School of Earth and Ocean Sciences (Canada). But in this corner of southeastern Peru, where as many as 30,000 miners work, little is known about how much mercury enters waterways or the atmosphere, how far it travels, where it ends up in the food chain, or how it affects human health.Artisanal mining is grueling, hazardous work, and Peruvian environmental officials call it a "scourge" because of the deforestation and mercury pollution it causes. Miners counter that the small-scale operations employ some 100,000 laborers nationwidesfar more than the large open-pit mines that are the mainstay of Peru's export economy.Both arguments have some truth to them, and some regional officials and scientists are seeking a middle ground that would make mining more efficient and decrease its environmental impact by reducing mercury use.In an effort early this year to control mining in Madre de Dios, the Peruvian government declared a moratorium on new mining concessions. But local officials say it has had little effect because most miners operate illegally anyway, without formal title to their claims.

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Adolescence is a time of increased stress because of intellectual, physical, and sexual maturity culminating in a desire for autonomy. Chronic asthma is perceived as a burden handicapping autonomy. This is apparent in the impairment of athletic and social activity. Furthermore, there is the requirement for inhaled medications that are perceived as hampering crucial peer identification. Nonadherence is epidemic, best resolved by empathetic rapport with the adolescent, family, and peer group while maintaining the status of a culturally and ethnically sensitive professional respected by the adolescent. The adept provider negotiates treatment plans in consultation with the adolescent with mutual respect. Treatment needs to be simple; once or twice per day, with a clear action plan acknowledging when to call the provider.

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