Editor's note, 16th June 2020: This article was updated to correct the daily death figures.
The coming weeks will be dramatic for Brazil. The country has the second highest number of cases of COVID-19 in the world. On June 4th official statistics reported 614,941 confirmed cases, 34,021 deaths, and 254,963 people recovered. During the past few weeks, the country has recorded more than 1000 deaths per day, in an ascending epidemic curve. Due to underreporting and low testing rates, the actual numbers are unknown.
Making it even harder to control the pandemic situation, the Brazilian Ministry of Health started making changes to the number of cases reported. First, it changed the disclosure schedule from 5pm at the beginning of the pandemic to 7pm, and then 10pm, causing challenges for the media. Then, on Friday June 5th it started reporting only new cases, without showing the total number of infected or of deaths, which generated sharp criticism from the scientific community, the health authorities, and the media, increasing the levels of tension under which the country has been living. Links to data downloads in table format had also been removed from the official website, such as the curve of new cases by notification date and epidemiological week. On Sunday June 7th after intense protests and questions from the Federal Prosecutor, the government said it would rerelease the balance sheets, but presented conflicting figures, corrected a few hours later. Throughout June 8th the official panel offered only data for the same day, without the totals. Another serious decision by the government is to disclose only the deaths that occurred on the day, without including in the data the deaths registered in previous days, whose confirmatory lab results were reported on the disclosure date. This creates a large gap. The policy is understood to be a government ploy to distort data, and forcibly open up the economy. In a press conference on June 8th the government technical team said it would launch a platform with all the data in the next few days, highlighting the deaths on the current day. It is not as it seems.
"The Ministry of Health is undergoing a military occupation that believes in keeping war secrets. Not letting the pandemic figures reach the press is a narrow-minded and stupid measure. It is like shooting the messenger. These numbers require transparency," said former Health Minister Dr Luiz Henrique Mandetta in an interview on Sunday evening (June 7th) to the TV channel GloboNews. Dr Mandetta, who was fired in the middle of April, had established a daily routine press conference as part of a policy of transparency. Those interviews were discontinued under the current administration of the interim minister, General Eduardo Pazuello.
Independently, universities, organisations, and websites began to release the figures from the pandemic. The Conselho Nacional de Secretários Estaduais de Saúde (National Council of State Health Secretaries) announced it would release the information daily by late afternoon. In response to restrictions on the access to the data imposed by the government, the country's largest media outlets decided to join forces to collect information from the state health secretariats of 26 states and the Federal District. They will then jointly release the numbers on the infection cases and deaths every day at 8pm. It is unprecedented. On Monday 8th June the independent media consortium reported 849 new deaths registered due to the COVID-19 in the last 24 hours. The Ministry of Health released conflicting data, reporting 679 new deaths on the day (170 fewer than the number released by the Consortium).
The Executive Director of the World Health Organisation (WHO) Health Emergencies Programme, Dr Michael Ryan, was asked at a press conference whether Brazil should display transparency in disclosing data: "It is imperative… that the messages on transparency and disclosure of information are consistent. We have to be able to count on our partners in Brazil to provide this information to us, but more importantly, to their citizens. They need to know what is going on," said Dr Ryan. He hopes the country will swiftly find solutions to the misinformation issue. The agency said it would continue to support the country, where the situation is indeed concerning.
The increasing number of cases in Brazil, Peru, Chile, Ecuador, and Venezuela places Latin America as the current global epicenter of the disease. The situation will worsen further until Brazil reaches the peak of the epidemic curve, which does not seem to have happened yet. An estimate for America released at the end of May by the Institute for Health Metrics and Evaluation (HMI), connected to the University of Washington, US, calculates that the death toll in Brazil is expected to exceed 165,960 in early August.
The Director-General of the World Health Organisation (DGWHO), Dr Tedros Ghebreyesus, has reinforced his concern about the widespread transmission of the coronavirus in Brazil, and the pressing need to adopt efficient measures of social distance to stop the rapid dissemination of the disease. Contamination rates among health professionals are also high, with 31,700 confirmed cases, and more than 200,000 people on leave with suspected COVID-19. According to the International Council of Nurses, the deaths of nurses and health professionals are above other countries with high transmission of the virus.
"In many countries, when the virus contagion attains a certain level, it spreads like wildfire. This happened in China, in Wuhan, it happened in some European countries, and now it is happening in Brazil", said Dr Tedros at a press conference on May 25th. On Friday 5th June Brazilian President Jair Bolsonaro announced to the press that the country would leave the organisation if WHO does not stop what he called its "ideological bias."
The high speed of transmission of the virus and the difficulties in implementing social distance push Brazilians towards an unprecedented health crisis. On June 8th the country entered its second week of easing of the stricter social distancing measures adopted in the state capitals, and the cities with a high transmission rate. In some places, such as the metropolis São Paulo, the quarantine was extended until June 15th. The reopening of public transport and services has provoked reactions from specialists and mayors of the counties in the metropolitan areas of large cities.
Given this complex scenario, it is not an overstatement to say that the country may have the world's highest number of deaths, in absolute numbers. How did Brazil get into this dire situation? In an attempt to understand Medscape interviewed influential health policymakers from the past few decades on a range of issues.
1. The Health Crisis Exacerbated Inequalities
Brazil is a country of 210 million inhabitants and a third of the country's wealth is in the hands of 1% of the population. Women have an income 41.5% lower than men. There are 12.8 million unemployed, 40 million working as freelancers, or informally, without a regular income. The tremendous social inequality that marks the country is the core of understanding the spread and the damage produced by the disease in Brazil.
"We are an emerging country, with per capita income well below the central countries, and with one of the deepest inequalities in wealth distribution," says Dr José Carvalho de Noronha, former Secretary of Health to the State of Rio de Janeiro. He was also chair of the Associação Brasileira de Pós-Graduação em Saúde Coletiva (ABRASCO, Brazilian Association of Post-Graduate Studies in Public Health).
Access to health reflects these inequalities. Inspired by the British NHS the Brazilian system was created to universally treat diseases and promote health, and to only be complemented by the private network. However, this is not how it developed. Today, 25% of the population with medium and high-income pay for health care plans and insurances to be served by an extensive private network of services with excellent hospitals, clinics, and laboratories. The remainder 150 million people depend on the care provided by a public and universal system, the Sistema Único de Saúde (SUS, Unified Health System), which has long been underfunded. It is a population that already has high rates of chronic diseases that target most precisely those with the lowest income. Four out of 10 Brazilian adults have hypertension, diabetes, respiratory diseases, heart disease, and cancer, according to the Instituto Brasileiro de Geografia e Estatística (IBGE, Brazilian Institute of Geography and Statistics). Before the pandemic, chronic diseases were the leading cause of death in Brazil.
"It is over this unequal society and an overburdened health system that suffers from the lack of professionals, equipment, and hospital beds to serve about 150 million Brazilians, that the COVID-19 pandemic fell," says Dr José Carvalho de Noronha.
Given this context, it was possible to predict that the disease would affect the poorest much more severely. The fact that SARS-CoV-2 arrived in Brazil by airplane, through the most privileged class, only gave planners more time to try to organize the system. The first patient, a 61-year-old businessman who tested positive on February 26th, had recently returned from Lombardy, Italy, a country that was beginning to face an explosion of cases of the disease. Four days later, the press reported an emblematic case of the country's social contrasts: a domestic worker who worked in Leblon, a high-class neighborhood on the south side of Rio de Janeiro, died of COVID-19 after being contaminated by her employer, who had recently returned from a trip to Italy and was waiting for the test result to find out if he had the virus. The result was positive. The disease is currently fully expanding on the outskirts of the large cities, reaching areas with the highest concentration of poverty.
2. Lack of Coordination and Agility
When the first COVID-19 cases were confirmed in late February, it did not seem that things would go so wrong. After more than 3 months, the country is paying the bill for the lack of integrated coordination in crisis management.
"This epidemic suffered from a lack of leadership from the Ministry of Health and some states. There were two replacements of the minister of health, and many replacements of state and county health secretaries," points out Dr Gonzalo Vecina, founder and former President of the Agência Nacional de Vigilância Sanitária (ANVISA, National Health Surveillance Agency), former municipal secretary of health of São Paulo, and former superintendent of the Hospital Sírio-Libanês. He is also a professor at the Universidade de São Paulo and Fundação Getúlio Vargas, an essential academic and research centre.
The lack of leadership was mirrored in the lack of solutions to the national problems that intensified, such as the slow delivery of test results analysed in public laboratories. For Dr Vecina, this is a sign of the myopia of the Ministry of Health, which should have designed a national testing policy.
The absence of central coordination also had an impact on the purchase and distribution of respirators and protective equipment, a task assumed, for the most part, by states and counties. In an international scenario full of uncertainties and aggravated by the Brazilian diplomatic gaffes, orders for batches of mechanical respirators were called off, and there were delays in deliveries. Only on May 25th did the São Paulo government receive part of the respirators purchased from China at the beginning of the pandemic. 183 units out of the 3000 units of equipment ordered have arrived. This is now under judicial investigation.
"The federal government did not have, and does not have, any concrete participation of leadership and harmonious and firm coordination, which gives security to society," says former Health Minister Dr José Gomes Temporão who was Brazil's minister of health from 2007 to 2010 when he faced the epidemics of dengue, yellow fever (both of which return every year), and the arrival of H1N1 flu.
"We learned a lot from the H1N1 pandemic in 2009. We created a crisis cabinet where many ministries had a seat, the ANVISA, the Civil House and the Ministry of Defense", says the former minister, who at the time left an epidemic containment plan in place.
The slowness to consolidate measures is deadly. At the beginning of June, the government had not yet completed the actions announced between March and April, such as the delivery of most of the 2000 hospital beds of quick-install intensive care units (ICUs). The respirators' problem is also severe. The four Brazilian companies contracted to produce 14,100 respirators have a delivery period of up to 90 days. So the respirators may not arrive until November.
One of the explanations for the delay in reacting was the difficulty of the Brazilian health authorities in believing that the pandemic would reach Brazil, says Dr Ana Costa, PhD in Public Health, postgraduate level professor at the Escola Superior de Ciências da Saúde and executive director of the Centro Brasileiro de Estudos de Saúde (CEBES, Brazilian Center for Health Studies), at the Fundação Oswaldo Cruz (FIOCRUZ, Oswaldo Cruz Foundation), and part of the team that designed the SUS.
"It is unacceptable that Brazil has not been properly prepared. We have had time since the situation in China was announced in December. This strategy characterizes omission by the federal government regarding this tragedy."
In the professor's assessment, the slow response also involves more complex questions: "Good preparation would involve a set of social protection measures that would conflict with the highly orthodox economic policy that Brazil has been implementing."
3. Testing Rate Still Low
According to official data, until May 26th, the country performed 871,800 tests for the new coronavirus. There were 460,100 reverse transcription polymerase chain reaction (RT-PCR) tests to identify viral RNA performed by public reference laboratories. Another 411.7 thousand tests were performed by the five leading private laboratories in the country (47% of the total). Countries like Italy and Germany have performed millions of tests, and China has announced that it performed 6.6 million tests in the city of Wuhan in 12 days to monitor the risk of a second wave of COVID-19.
"Brazil is already managing to reach a certain level of testing. It is not yet the ideal amount, it is not the required amount for the size of the country, but it is much better than in previous months," said the new substitute secretary of Health Surveillance of the Ministry of Health, Dr Eduardo Macário. In March, the country performed an average of 8000 tests per week. Now the number is 46,000.
"These are extremely low numbers compared to the average for other countries. Brazil could be better prepared for the pandemic for testing, which is one of the Achilles' heels of this crisis", says Dr Vecina.
Brazil's low testing rates have been blamed on a dependence on imports and a lack of national production. Brazil was held hostage by the need to import reagents for testing, mechanical ventilators, and personal protective equipment (PPE).
The expectation is that by September, the government will receive 10 million tests manufactured in the country and the remainder of the 13.9 million batches of RT-PCR kits purchased from foreign companies.
If everything goes as planned, the estimate is that the average number of tests performed will reach 70,000 per day. "The problem then will be the ability to read the results," warns Dr Vecina. Until very recently, the country had very slow machines with low automation capacity. At the end of March, for every 1200 tests that arrived daily at the public reference laboratory Instituto Adolfo Lutz, in São Paulo, only 400 results were released. This delay led to a queue of almost 20,000 tests, and a waiting time of 2 weeks or more. The problem affected the entire network of public laboratories in the country, forcing different states to seek their own solutions.
4. Records Cannot Be Trusted
The underreporting of COVID-19 cases is massive. Researchers calculate the actual numbers can be, on average, 7 to 12 times higher than those of the official record. A recent study funded by the federal government and issued on May 25th, brought insightful data in this matter. Researchers at the Universidade Federal de Pelotas (UPFEI), in Rio Grande do Sul, visited 133 municipalities and collected more than 25,000 blood samples to find out how many people had antibodies against SARS-CoV-2. The results revealed high rates of infection and underreporting. In the capital city of Recife, in Pernambuco, and also in the city of Rio de Janeiro, the actual contagion may be 13.4 times greater than the figures reported. In Manaus, up to 20 times. In São Paulo, 11 times. In Breves, on Ilha do Marajó, located in the state of Pará, in northern Brazil, the number of people who had contact with the virus is 87 times higher than the official data reported. The researchers will return to the field two more times.
More data that points to a huge underreporting is the increase in the number of severe acute respiratory syndrome (SARS) cases compared to the same period last year. As tests are lacking, many people are treated and buried as victims of the syndrome. According to data available in the system InfoGripe, which monitors this syndrome, there were 23,112 cases of SARS throughout 2019. However, from the beginning of 2020 until May 30th, the number was 211,638. Out of that total, to date, 73,679 people had tested positive for the SARS-CoV-2 virus, which causes COVID-19. The number of deaths reaches 47,000. The delay in capturing the information on tested and confirmed cases in the database also affects the statistics.
In order to draw a closer picture of the reality of the pathways of the disease, and to support better decision making, there is a great effort led by initiatives such as the platforms MonitoraCovid-19 and the Observatório Covid-19 Br.
"After all, if the cases are not registered, the disease disappears in the numbers, but it persists in society. In this scenario, the pressure for the loosening of isolation measures grows, which is a big mistake at this moment, when the disease is spreading to inland, and persists in the capitals," says epidemiologist Dr Diego Xavier, a researcher at the Instituto de Comunicação e Informação Científica e Tecnológica em Saúde, FIOCRUZ and from the system MonitoraCovid-19.
5. No ICU for Everyone
The Brazilian health system began to collapse long before the pandemic peak, estimated between May and June. The first state affected by the lack of hospital beds to treat patients with severe symptoms was Amazonas, in early April. Data published in the press show that the state has 1.24 intensive care beds per 10,000 inhabitants. At least 2.4 beds would be needed to the same number of inhabitants, according to the Associação de Medicina Intensiva Brasileira (AMIB, Brazilian Association of Intensive Care) to face the pandemic. Also, there is a lack of ventilators, and personal protective equipment and a lack of physicians and health care professionals trained to perform procedures such as intubation.
The situation is an example of the inequity in the distribution of health resources. The health system, which combines public and private assistance, has 7 ICU beds per 100,000 inhabitants for users of the public network and 35 beds per 100,000 inhabitants available to about 25% of the wealthiest population who can afford private plans or insurance—five times more.
The solutions found by the state governments in the face of these circumstances were the most diverse. In the state of Maranhão, the governor resorted to an emergency health law to request beds from the private sector, providing financial compensation in the future. In São Paulo, the government has rented hospital beds from the private sector. In the city of Rio de Janeiro, the city hall chose to build field hospitals, despite the existence of empty beds in at least six federal government hospitals that were not treating patients with COVID-19. Most are not yet ready, and the contract is now under investigation for corruption.
In early May, more states had occupancy rates for ICU beds in the public system above 80%, the level considered critical. At the same time, as the disease started in the wealthier classes (and which adhered more to quarantine), the ICU occupancy rate in private hospitals began to stabilise. Given the lack of public hospital beds and vacancies in the private system, a national campaign was launched for the use, control, and management by the public authorities of all the hospital capacity existing in the country in an emergency setting, especially hospitalisation beds and ICUs of private hospitals. Another proposal of the campaign is the formation of a single queue, which already exists for organ transplants.
6. Isolation Weaknesses
Although the number of infected people is growing, adherence to measures to restrict circulation is decreasing. On May 26th, the mean social isolation of the major Brazilian capitals was 46%. The ideal, to reduce contamination and postpone the collapse of the health system, is 70%. In the same period, ten states that had enacted strict social distancing measures in some regions began loosening the restraint rules.
A determining factor for the low adherence of Brazilians and the lack of understanding of the relationship between social isolation and the collapse of the health system was the ambiguous tone of the guidelines. While the then Minister of Health, Dr Luiz Henrique Mandetta, and several governors advocated for measures of protection and social distancing, President Jair Bolsonaro said he was concerned about the health of the economy and stated in interviews that the country could not stop. Bolsonaro leads a movement against science. He defends the immediate use of chloroquine by patients with mild symptoms, despite the lack of evidence. He minimises the pandemic and goes outdoors without a mask, embracing citizens. His supporters, who currently represent about 30% of the population, hold public rallies against social distancing.
The former minister Dr Mandetta himself, made a feeble defense of social isolation, says Dr Costa. "He did not go on television to warn that if the population did not engage in social distancing, the epidemic would kill many more people."
The invisibility of the most vulnerable populations in the eyes of the government is yet another structural failure in tackling the pandemic. It translated into the absence of public policies to fight the new coronavirus in the slums and the outskirts. Thirteen million people are living in high-density populated areas, and in settings that make isolation difficult, often in small spaces shared by many people, and without basic sanitation.
"At the beginning of the pandemic, the media and the health authorities recommended preventive measures such as isolation and handwashing, for I do not know how many times, hand sanitiser use, and work from the home office. I wondered—which country do these people live in? Will there be any measure that will take into account what a favela (slum) is?" says researcher Sônia Fleury, MSc in sociology, PhD in political science, and coordinator of Dicionário de Favelas Marielle Franco.
"There was, for example, no training of primary care professionals or referral centers for assistance services to work together with community leaders to guide residents with suspected contamination." On the contrary, the few measures of aid to the poorest taken by the government generated situations of greater exposure, such as the immense queues at the doors of the state bank to withdraw the emergency aid of $600 in local currency to the disenfranchised.
This lack of assistance and an ever-increasing number of infected people has been the cause of conflicts and demands among slum leaders and public authorities across the country. In the Paraisópolis favela, in São Paulo, the community hired doctors and ambulances during the pandemic and trained residents as rescuers. In Rio de Janeiro, the network, Nós Por Nós Contra o Coronavirus (Us for Us Against Coronavirus), distributed funds, spread information about preventive measures, created brigades to sanitise the favelas, hired doctors, and created its own emergency care network.
7. Multiple Crises
Many argue whether the health crisis sparked the political crisis or whether the political crisis worsened the health problem. "The country had previously negative growth and faced a great challenge in economic recovery," says Dr José Noronha. With a pandemic, the Gross Domestic Product (GDP) shrank 1.5%. It has been the worst result since the 2nd quarter of 2015 and places the country in recession.
The growing political polarisation makes it increasingly difficult to control the pandemic. President Bolsonaro harasses governors who have adopted isolation measures, is slow to release money to states, and has changed two ministers of health in less than a month. The orthopaedic specialist Dr Luiz Henrique Mandetta was dismissed from office on April 16th. On top of disagreements over social distancing and the use of chloroquine, the President would have been irritated by the minister's popularity. Unknown to the majority of the population, he embodied what society expected from a pandemic health authority. When the dismissal came, he had an approval rate of 76%. The next minister, the oncologist and entrepreneur, Dr Nelson Teich, spent 28 days in office and resigned due to disagreements with the President on social distancing and chloroquine. Due to these events, the Ministry was paralyzed for almost a month, while the disease cases roared. Dr Teich was succeeded by his executive secretary, General Eduardo Pazuello. As soon as he was appointed to occupy the seat temporarily, the general complied with the President's wishes and authorised the use of chloroquine to treat patients with mild symptoms. The general also intensified the replacement of technical professionals in senior management positions by the military. Experts warn that the Ministry would be undergoing a "militarisation" with the intention of destroying a highly trained health technocracy which resists the health project advocated by the government.
The forecast is that Brazil will continue having new cases until October. After that, say the researchers, the country will have much work to rebuild its health system. After the peak of the COVID-19 cases, the SUS will probably absorb an even greater number of individuals.
"In 2018, about 4.5 million people lost access to the private sector and started to use the SUS exclusively," says Dr Sidney Klajner, private sector leadership and chairman of the Conselho do Hospital Israelita Albert Einstein (HIAE). For him, the pandemic's impact on the reduction of jobs and the family income will make many people migrate from the supplementary network to the public system.
"This will further burden an already underfunded system, which practically treats diseases and fails to act as it should in prevention, which is increasingly important," says Dr Sidney.
In addition to regular consultations and surgeries, SUS pays for highly complex procedures, such as transplants, prolonged hospital stays, and high-cost drugs to treat cancer and some rare diseases.
"It needs twice as many resources," says Dr Costa. She warns that there are relatively recent changes underway in the financing model for family health care and primary care that may further undersize the system.
"The transfer of funds started to be made as the population enrolled in the primary health care centers, and no longer the population of the county," he explains. So the funding will cease to cover everyone who needs the service and is not yet enrolled, precisely as it is happening to the patients affected by the new coronavirus.
The agenda for discussions over the future after COVID-19 includes issues such as the disruption of the health actions among several levels of government, the relations between the public and private sectors, the most significant concern with epidemiological surveillance and the control of zoonosis, the need to discuss the taking over of the national production of essential medicines, and a plan for autonomy and health security. On the positive side, the balance of the pandemic is a greater understanding of SUS's central role.
"The pandemic is showing the Brazilian society the need for the SUS (unified health system). It is not a service to those who do not have resources, but the agency responsible for public health in the whole country," says Sônia Fleury.
Translated and adapted from Medscape's Portuguese and Spanish Editions.
