HEPL blog series: Country Responses to the Covid19 Pandemic

Brazil’s response to the coronavirus pandemic

Elize Massard da Fonseca, São Paulo School of Business Administration, Getulio Vargas Foundation (FGV)
Francisco Inácio Bastos, Oswaldo Cruz Foundation (Fiocruz)

Brazil is known for its successful control of communicable infectious diseases, such as HIV/AIDS and hepatitis (Barreto et al. 2011). However, despite the steps taken by Brazil’s regional governments and Ministry of Health to quickly respond to the outbreak of the novel coronavirus, the chief of the executive branch, President Jair Bolsonaro, has made controversial decisions that could seriously threaten the country’s ability to curb the COVID-19 (or SARS-COVID-2)  pandemic (The Lancet 2020). We discuss the positives as well as the limitations of Brazil’s response.

The first confirmed case of COVID-19 in Brazil was a man returning from northern Italy, who was diagnosed in São Paulo on February 25, 2020. São Paulo, one of the largest cities in South America, was the initial epicenter of the virus in Brazil. Brazil has a comprehensive public health system, covering 75% of the population, with the remaining 25% enrolled in private health insurance. As the first wave of the pandemic hit Brazil’s upper middle class, treatment was offered in private luxury hospitals. Middle-class and poor Brazilians were initially less affected by the virus.

On March 20, Brazil’s Ministry of Health declared that there was community transmission (i.e. one which is no longer driven by interactions with foreign countries) of COVID19 in the country, and suggested social distancing measures for those with respiratory symptoms. A few days before the health minister’s statement, states like Rio de Janeiro and São Paulo had already developed quarantine strategies in an attempt to contain the spread of the virus.

As in other countries, a key concern in Brazil is the capacity of the country’s health system to treat patients at severe stages of the disease. On April 14, five states reported more than 1,000 coronavirus cases, which have increased the demand for hospital beds. A recent study suggests that a scenario where 10% of Brazil’s population was infected with COVID-19 during a period of six months would lead to a shortage of 40,770 intensive care unit (ICU) beds and would cost the public health service R $7.33 billion (approximately US $1.4 billion) (Rache et al. 2020). Several public hospitals are already reporting shortages of protective personal equipment (PPE), respirators, and healthcare professionals. Major cities in the country have prepared field hospitals, predicting increased demand.

Over the past five years, a political and economic crisis in Brazil has resulted in constraints on public expenditure, which have affected healthcare, social protections, and science and technology—three important areas of public policy in the fight against the coronavirus pandemic. COVID-19 has forced the federal government to invest more than US $2 billion into the Ministry of Health to respond to the crisis, but has also increased the number of families assisted by the conditional cash transfer program and has provided financial support for informal workers, who are an important component of the Brazilian labor force (Agencia Saude 2020). These are crucial social policies that allow poor families to quarantine for longer periods.

One of the key pillars of Brazil’s response to infectious diseases in the past was the integration of local production of healthcare products, such as drugs and vaccines, with public health policies. Brazil has undertaken various science and technology initiatives to combat the COVID-19 pandemic. Brazilian scientists were able to sequence the COVID-19 genome in the first case reported in the country within two days—a record period. Brazil also has one of the most comprehensive and self-sufficient vaccination programs in the world, and several research institutions have been working with international collaborative networks to develop a vaccine against the novel coronavirus. The Oswaldo Cruz Foundation, which is based in Rio de Janeiro and is one of the largest biomedical research institutes in Latin America, has developed and distributed diagnostics kits to supply the needs of the Ministry of Health.

Yet despite these efforts, President Bolsonaro has opted not to follow the guidelines issued by the World Health Organization or other evidence-based health policies. As Brazil has a highly decentralized healthcare system, its 27 state governments were authorized to make their own decisions regarding crisis management measures. In addition, the Ministry of Health has historically been managed by healthcare professionals. This organizational identity helps to explain the institution’s autonomy vis-à-vis the opinions of the President. As such, in addition to the uncertainty surrounding the disease, the limitations of the healthcare system, and financial constraints, a key challenge in responding to the coronavirus pandemic in Brazil has been the lack of coordination between the health minister, the state governors’ coalition, and President Bolsonaro and his staff.

It is not the purpose of this brief analysis to explore the motivations or arguments of each of these actors. So far, however, the lack of agreement between government authorities in Brazil has facilitated the spread of fake news about the pandemic, support for treatments that have yet to be clinically assessed, and great misunderstandings over which guidelines the population should follow. Moreover, advisors to the President have supported initiatives that do not have any specific meaning in terms of public health, such as “vertical isolation” (meaning quarantine only for the elderly population; in a misinterpretation of some highly criticized models first suggested by researchers from Yale University, USA; different from what is being suggested in Brazil) or even “intermittent isolation” (where a person works for four days, then quarantines for six days; again grossly misunderstanding the recent model published by the Harvard team; Kissler et al. (2020)). In terms of epidemiological response, there is no evidence that such measures would reduce the spread of the epidemic.

As there is no prospect of mass testing in Brazil, and as the disease expands to poorer neighborhoods, it will become increasingly challenging to control the outbreak. As this report was being written, President Bolsonaro dismissed Brazil’s health minister, Henrique Mandetta. The health minister had been popular for his response to the epidemic, but challenged the President about the timing to end the quarantine and the relevance of malaria drugs as a solution to COVID-19. Replacing the country’s health minister in the middle of a pandemic may serve as a warning that the worst may be yet to come.

References

Agencia Saude. 2020. “Governo do Brasil libera R$ 9,4 bilhões para combate ao coronavírus.” April 3. https://www.saude.gov.br/noticias/agencia-saude/46651-governo-do-brasil-libera-r-9-4-bilhoes-para-combate-ao-coronavirus.

Barreto, M, M Teixeira, F Bastos, R Ximenes, R Barata, and L Rodrigues. 2011. “Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs.”  The Lancet 377 (9780):47-60.

Kissler, S, C Tedijanto, E Goldstein, Y Grad, and M Lipsitch. 2020. “Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period.”  Science:eabb5793.

Rache, B, R Rocha, L Nunes, and A Massuda. 2020. Para Alem do Custeio: Necessidades de Investimento emLeitos de UTI no SUS sob Diferentes Cenarios da COVID-19. Sao Paulo: Instituto de Estudos para Politicas de Saude.

The Lancet. 2020. “COVID-19: learning from experience.”  The Lancet 395:1011.

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