A continental country with 212 million inhabitants, Brazil is one of the most important laboratories on the COVID-19 pandemic evolution in the developing world. COVID-19 has spread rapidly in the country, reaching 4,579 confirmed cases and 159 deaths as of March 30th, a death toll of 2.8%. The Southeast is the most affected region, as Sao Paulo and Rio de Janeiro display the largest share of cases. Considering only the most acute patients are being tested, the consensus is that there has been a systematic underreporting of cases. The most pessimistic forecasts so far have projected that, in the absence of effective isolation measures, the death toll due to COVID-19 could well reach 1.1 million.
The main Brazilian asset at this point, which distinguishes the country from similar countries, is the existence of a state-funded single health system (SUS). Built up over three decades and based on the constitutional guarantee of free and universal access to healthcare, SUS covers almost all of the national territory. Nevertheless, this advantage may be outweighed by three major constraints: the deterioration of chronic deficiencies in healthcare equipment and supplies; the obstacles to isolation measures due to social and economic inequalities; and the inability of the federal government to lead an effective response.
SUS has been underfunded since its creation and competes with a robust private healthcare sector that collects massive fiscal incentives and competes for public resources with the system serving most of the population. In 2016, at the peak of a political and economic crisis, a constitutional amendment (n. 95) set a cap on public healthcare expenses which, according to the National Health Council, resulted in a £3.4 billion loss between 2018 and 2020.
The fact is that the shortage of intensive care beds, personal protective equipment, and other materials – including ventilators – existed prior to the pandemic. The underfunding has caused health facilities to close down, mainly in peripheral zones, as well as long waiting lists on consultations, exams and health proceedings. There are frequent complaints of corruption and poor management, waiting lines and avoidable deaths. In many cities, successful primary care programs, such as the Family Health Strategy and the Community Health Agents, which could be decisive in mitigating the pandemic in low-income communities, have been undermined by mismanagement and theft. Moreover, health surveillance has not received the necessary investments over the last few years, and its performance has been heavily criticized.
The pandemic adds to the endemic diseases already challenging SUS, particularly dengue. In 2020, as of March 14th, 390 thousand cases of dengue had been reported in Brazil. In 2019, 1,544,987 cases were reported. More than the absence of progress, there are setbacks in tackling diseases like tuberculosis. Although there was a steady decrease from 2010 to 2016, the TB-incidence coefficient rose from 2017 to 2018 compared to the previous period, at 73,864 new cases in 2019.
The rise of the extreme right in 2018 to the presidency has brought a coarsening of policies and rhetoric toward democracy and human rights not seen since the end of the dictatorial military regime (1964-1985). The outbreak of the pandemic coincided with demonstrations against the legislature and judiciary branches of government. Supporters of President Jair Bolsonaro were calling for the closure or weakening of both branches of government as institutional checks on executive power. Although being himself a suspected COVID-19 case, the President attended one of the demonstrations on March 15th. And despite efforts to downplay the threat of the virus, more than 20 members of the federal government have tested positive to SARS-CoV-2; some of them have ignored the recommendation for isolation and social distancing.
Throughout the changes in government, the Ministry of Health (MoH) has remained a highly qualified technical body, which cooperates with international institutions and local governments. The current minister, the Dr Luiz Henrique Mandetta, has managed to engage with the Congress and the main public and private healthcare institutions. A few days after the PHEIC by WHO and weeks prior to the first reported case in Brazil, MoH declared COVID-19 a national emergency and set up a strategic response along with state and municipal governments. On February 6th, Brazil adopted a law allowing the MoH and local governments to implement isolation measures, quarantines, compulsory exams and treatment, and to raise private support to respond to the emergency. Public universities and research institutes also mobilized quickly and provided thousands of tests and the genome sequencing of Coronavirus only 24 hours after the first reported case.
However, insofar as the pandemic took over the political agenda, the president adopted an openly aggressive and contradictory strategy.
First, there has been conflict inside the government itself, as the President systematically contravenes MoH recommendations. He has strongly politicized the recommendation for social isolation in cities where there was local transmission and downplayed the disease, even in official statements and prematurely announced chloroquine as a cure for COVID-19, in clear-cut contradiction of MoH recommendations. As a result, the health minister’s statements have become erratic, at times seemingly to please the president and at others to follow scientific evidence. The net effect has been to mislead the public and jeopardize the ministry's credibility. There are rumours that the minister and his team might resign altogether at any given moment.
The second main conflict occurs between the federal and the state governments, particularly with the governor of Sao Paulo, Joao Doria, and Rio de Janeiro, Wilson Witzel. Former allies of the president’s, they are now regarded as his likely opponents in presidential elections in 2022. Doria and Witzel lead the COVID-19 epicentre regions and adopted quarantine-like measures as soon as there was local virus transmission, based on scientific evidence. Schools and shops were closed and gatherings suspended, yet essential services have been maintained. If there is no drop in the incidence curve, the MoH itself foresees a collapse of the healthcare system by late April.
According to the president, however, such measures should be reversed, because they harm the economy. Instead he argues that the main focus should be the isolation of just the elderly and at-risk groups. He believes the protection of the economy would justify the death from five to seven thousand people, as the deceased would be elderly or those near-death anyway. The federal government has even developed a campaign named ‘Brazil cannot stop’, urging the public to ignore the quarantine and resume work. At the request of federal prosecutors, the courts have banned the campaign, because it contradicts scientific evidence and violates the principles of precaution and prevention. Yet, the president has supported public demonstrations against the isolation, organized by extremists in many Brazilian cities and even crossed the capital city and made personal contact with supporters.
Opposition to the president’s policies has emerged in other government branches. The president of the Chamber of Deputies, Rodrigo Maia, has become a major figure by mediating conflicts caused by the executive branch. And the Congress has passed an additional £777 million investment in SUS, but the funds have failed to trickle down to lower levels. On March 24th, 26 out of the 27 state governors attended a meeting with Mr. Maia, and defined an agenda to respond to the crisis. The federal executive was notably absent. As a result, the chamber passed social protection measures that may be crucial to the success of the pandemic response in Brazil.
The most relevant of the government’s response is a minimum income of £93 during three months, to one or two members of the same family. The Senate just passed the bill and the executive will likely sign it. The Supreme Court, for its part, has admitted 404 COVID-19-related legal cases and ruled on 194 of them. One of the most important among them suspended an executive branch order to limit access to information from government agencies during the pandemic, which many interpreted as a breach to allow the federal government to conceal the number of cases and deaths.
It is clear for now that the system of checks and balances has been working to minimize the mistakes and loopholes of the federal government. Even so, the lack of an accountable and efficient coordination at the national level implies a waste of time that may prove fatal to thousands of Brazilians. The fragmentation of initiatives, besides challenging local governments to perform a role in principle corresponding to the federal government, hinders positive results. One example is Consorcio Nordeste – an alliance of the nine states in the Northeast region, where the president lacks popular support – which has sought direct cooperation aid from China.
The president constantly attacks the press, which he claims has provoked unnecessary hysteria. Social movements are ignored or ostensibly harassed by the government. The health of indigenous peoples is of particular concern. And concerning science policy, public higher education and research institutions are undergoing an unprecedented attack in the country’s recent democratic history, due to continuous funding cuts, including previously granted scholarships.
Recent polls signal high approval and compliance rates with the quarantine measures, despite the president’s messaging. Yet over time, the risks to the economy and economic security may prevail over science and public health if the quarantine is not coupled with urgent policies to shore up social safety nets. In 2018, Brazil had 13.5 million people living on under £1.5 daily income, the threshold of extreme poverty according to the World Bank; a quarter of the population (52.5 million people) lived on less than £65 per capita monthly. Poverty affects mainly the Afro descendant and indigenous population, who make up 72.7% of the poor or 38.1 million people, and women from those groups compose the biggest share of people in extreme poverty, 27.2 million. Poverty limits the access to drinking water, sanitation and decent living conditions, which precludes the basic hygiene and social distancing recommendations, particularly to sick people.
Overcoming institutional conflicts is paramount to directing a robust response and focusing on the reduction of avoidable deaths resulting from the system overload. Only an effective coordination from the national response can assure that the extraordinary funding will reach their destination, that healthcare workers and vulnerable people get protection and the quarantine measures are encouraged all across the board.
We hope the pandemic may leave at least three legacies to Brazil: the increase and the consistency of public investment in the healthcare sector and in science; the recognition that economic and social inequalities, mainly those related to race and gender, besides being ethically unacceptable, jeopardize health security in the whole country; and that effective social engagement in a huge democratic front, even at a time of crisis, represent the only chance to avoid the loss of thousands of lives. It is a hope, but it is one for long-term change that may come out of this crisis.