The number of confirmed COVID-19 cases has exceeded 3.68 million. The COVID-19 disease, first reported on December 31 in the metropolis of Wuhan, China, has spread to almost all countries and the death toll has crossed 258,000.
The number of cases is rising steadily in Brazil. As of May 6, the number of cases has crossed 116,000 and the number of deaths has almost touched 8,000. According to a recent survey by the Federal University of Pelotas, the infection rate is at least seven times the reported one.
None of this, however, seems to concern president Jair Bolsonaro. Since the beginning of the health crisis, the Brazilian head of state has shown little inclination to adapt his behavior to the demands of the position he holds. On the contrary, he has doubled down on his political brand, which is to provoke conflicts. From the very beginning, he actively disputed facts about the disease, which he characterized as a “small flu.”
Thus, the health crisis and the economic crisis have created a new political crisis, forming a perfect storm in Brazil. Bolsonaro relies on the most irrational members of his government, a group known as the “hate office,” to inflame his supporters against the scientific community, governors, mayors, parliamentarians, the media and even members of his own government.
In recent weeks, the president waged a noisy war against his own Ministry of Health for disagreeing on physical distancing recommendations. He also jumped on the bandwagon of the US president by celebrating the supposed curative powers of chloroquine and hydroxychloroquine, drugs that are still on clinical trials.
Since February, the president and his “hate office” had been encouraging demonstrations against Congress and the Federal Supreme Court, the country’s highest judicial court, which were scheduled for March 15. That day, Bolsonaro left his isolation at the official residence and attended the demonstration. Not only that, he greeted supporters, gave hugs, and took selfies. The act precipitated a chain reaction involving parliamentarians, who submitted impeachment requests in the following days.
Since then, Bolsonaro has done everything in his power to escalate the crisis and exacerbate the conflict. Together with the hate office, he prepared a statement on a national radio and TV network that shocked even those already used to the president’s non-orthodox behavior. “We must return to normality,” he said, introducing an idea that would become the foundation of his speech: “The risk group is that of people over 60.” He even boasted of his “athlete’s record” (he was a paratrooper in the Army for many decades), saying that if he were infected, he would be “at most, afflicted with a cold or a small flu”.
The statement, coupled with Bolsonaro’s appearance at the March 15 demonstration, precipitated a popular movement against the president. In several Brazilian cities, the population began to protest by banging pots, blowing whistles and shouting slogans against the government. In some capitals, protests occurred on a daily basis.
Throughout the crisis, Jair Bolsonaro was perhaps the only national leader who literally invested public resources to encourage the free circulation of the virus. On March 26, the government launched, at a cost of R $4.8 million, an advertising campaign with the slogan: “Brazil cannot stop.” This brought memories of a campaign in Milan, Italy that was subsequently cancelled in the wake of the crisis. The campaign was banned by the courts as it went against the recommendations of the WHO and the Ministry of Health.
Despite losing some important battles – Bolsonaro saw his popularity drop , even among his electoral base -, the clash within the government ended on April 16 with the resignation of Luiz Henrique Mandetta and the appointment of another minister of Health, businessman Nelson Teich, who publicly promised “complete alignment” with the Brazilian president. According to the new minister, who has no experience in public affairs, his mission is “to work for society to resume, more and more quickly, a normal life”.
Freed from Mandetta, who was his main antagonist, Bolsonaro and his supporters went on to attack the president of the Chamber of Deputies, Rodrigo Maia, author of a bill that seeks to provide emergency aid from the federal government to States and municipalities that have incurred losses amid the pandemic. Though, according to the Brazilian head of state, a coup attempt is underway to remove him from power.
Whether it be paranoia or political strategy, the fact is that in recent times, Bolsonaro and his political allies, who together, intend to found a new party – Alliance for Brazil – have called for conventions calling for military intervention, closing of Congress and the Supreme Court, and a “new AI -5 ”against quarantine. Institutional Act No. 5 was an instrument of state terrorism during the Brazilian military dictatorship and gave the president powers to intervene in States and municipalities. On April 19, when Brazilian Army Day was being celebrated, Jair Bolsonaro participated in person in a demonstration with these demands in Brasília and, by telephone, in another in São Paulo.
The groups behind the demonstrations are now being investigated by the Supreme Court in the same inquiry which involves the “hate office”, which has Carlos Bolsonaro, the one of the president’s sons, as a key figure. The fear of this investigation made Jair Bolsonaro intervene in the federal policy, and this precipitated the resignation of Sergio Moro as justice minister. Moro was the judge behind the Car Wash Operation and the sentencing of former president Lula. While resigning, Moro accused the current president of corruption. Now, the political atmosphere is more complicated than ever and maybe, with the COVID-19 crisis, we will see another impeachment process.
Brazil was slow to act
We do not know exactly when the Brazilian Ministry of Health was notified about the disease, which, at that time, had not even received the name of COVID-19. However, we know that the World Health Organization (WHO) office in China received, on December 31, the warning about the mysterious lung disease. And on January 2, the WHO activated the incident management system, which turns on the warning signal at its regional and national offices. In that first week of 2020, the international media had already started reporting about it, realizing that dozens of people had been infected in the city of Wuhan that would soon become the first epicenter of the SARS-Cov-2 pandemic. On January 23, Wuhan – a city of 11 million – went into lockdown.
What did Brazil do about it? The answer is not simple. The emergency was followed by a divergence in approaches by the president on the one hand and the health minister’s office and the governors on the other hand, with the latter putting in place quarantine measures. The health ministry also did not support Bolsonaro’s campaign against physical distancing and his endorsement of anti-malarial drugs before any clinical trials.
Instead, a few weeks after the declaration of a health emergency, the government passed a bylaw suspending the access to public information related to response times [to crises]. In Brazil, a national law on access to public information guarantees wide access to data and information on measures by the government. Furthermore, a search for the news published on the Ministry of Health website reveals that the authorities decided to delete from the feed everything that was published between December 12 and February 27.
If we rely on the little information that has been disclosed, the ministry began to act just three weeks after the Chinese alert to WHO, on January 22. Its first action was to activate the Emergency Operations Committee, a technical body which specializes in public health response and preparedness, with an aim to prepare the public system to handle possible cases in Brazil. By doing so, the minister promised a “ united and immediate response to the entry of the virus into Brazilian territory ”.
Going back to our brief chronology, on January 23, when Wuhan entered into lockdown, Brazil went into a Level 1 alert with regard to the risk of the transmission of coronavirus (on a scale that goes up to 3). At a press conference, authorities stated that the Brazilian laboratory network was prepared “to carry out the tests and make the diagnoses”. In March, it was already clear that there were neither enough reagents nor workers to handle so many samples. In April, the number of tests awaiting diagnosis was close to 100,000. This is even as the number of tests conducted by Brazil was insufficient, as the UFPEL conclusion shows.
On January 29, the Ministry started to update the situation of the disease in Brazil daily . At that point, the federal government was monitoring nine suspected cases. The search was restricted to people who had traveled to China 14 days before – which turned out to be a mistake since the first confirmed case was infected in Europe. The office also recommended that companies not hold meetings with people from China (but did not provide guidance on the need for these people to stay at home, maintaining quarantine, as Singapore did once the virus was transmitted between humans). That same day, Germany reported the first case of local transmission outside Chinese territory.
On January 30, the WHO declared a Public Health Emergency of International Importance. In Brazil, the date marked the announcement that the Ministry of Health would open a bidding process to allocate 1,000 new beds in referral hospitals that had been allocated by state governments . The promise was that the beds would be installed in a maximum of 40 days – which did not happen. The Ministry of Health also signaled that, if there was a need, the number of beds would be increased – which happened. By that time, the Chinese health system was already under pressure from the exponential growth of the epidemic. An article published in Lancet with an account of the first 99 patients at Jinyintan hospital in Wuhan reported that everyone had developed pneumonia. By April, the ICU occupancy rate in several Brazilian states – such as Ceará, Amazonas, Pernambuco – and important capitals, such as Rio de Janeiro, reached or approached 100%. There are no respirators, nor enough workforce to open new beds to meet patient requirements.
The Brazilian health system and its challenges
Crises such as these make the need for universal access to health systems all the more clear. We are talking about not just a universal service able to meet the population’s needs, but also a unified system able to monitor issues related to health and ensure preparedness for emergencies. Brazil is one of the few countries in the Global South that has this system. The Unified Health System (SUS) is public, free and guarantees right to health-based universal access and has as its core principles: comprehensive care, equity, preventive measures and social participation.
SUS was created in 1988 within the new democratic constitution, which reestablished democracy in Brazil and was the result of an intense process of social mobilization, involving grassroots movements and academy – the so-called Health Reform (Reforma Sanitária, in Portuguese). The VII National Health Conference in 1986 was a milestone in this process. The event took place in Brasilia and was chaired by the then president of Fiocruz, one of the main health research institutions in the country.
The Federal Constitution of 1988 recognizes health as the right of all and a duty of the State and was an important step towards universalization. In its more than 30 years of existence, SUS has achieved important victories. Today Brazil has an immunization policy and universal pharmaceutical assistance. It has an integrated surveillance system and has internationally reputed health research institutions, such as Fiocruz, which was recently accredited by WHO as a reference laboratory. However, there are still serious challenges to fulfilling the right to health. The pandemic has highlighted four of them, which are the following.
The Right to Health and the challenge of financing
Any debate on SUS should take as a starting point its current underfunding. And today, the public health system has been weakened by years of austerity. Brazil invests 3.6% of its GDP in its public systems, well below the OECD average of other countries with universal systems. Still, 75% of the population has no other means of access to health than SUS. Moreover, the other 25%, who have private insurance, are entitled to use the public system and often do, especially for accessing complex procedures and expensive drugs.
SUS’ funds come from three levels of the Brazilian government: Union, states and municipalities. The constitution establishes minimum allotments from the three entities to cover the costs. The Union, as the richest entity, should increase transfers to health. This debate has been going on since the year 2000, when the minimum percentages of allotments were established. The National Health Council has pointed out how local governments are overburdened, while the federal government could spend more on health. Currently, the federal minimum is 15% of current revenue. The Council supports the spending of at least 22%.
The biggest attack, however, on health financing came in 2015, with the approval of Constitutional Amendment no. 95/16, which set a ceiling on all federal public spending for 20 years. This is one of the most severe austerity measures in the contemporary world and is one of the main threats to the Right to Health, as it prevents new transfers to the system.
As if that were not enough, the current minister of economy has already stated before the pandemic he wants to end the constitutionally-mandated minimums. The private insurance system, on the other hand, has received strong government aid during the pandemic, with the release of more than 15 billion reais (about USD 3 billion). Even as this crisis reaffirms the need for a universal health system, the threat that austerity policies pose to the right to health in Brazil become even more evident.
The Right to Health and the challenge of economic sovereignty
The sustainability of SUS demands an active economic policy for the local production of health technologies that supply the system. South Korea, one of the countries that handled the pandemic relatively well, has a wide range of industrial hospital supplies. External dependence is thus an important threat to the right to health.
In the field of research and development, Brazil today lives a contradiction. The country has one of the only two WHO COVID-19 reference laboratories in the Americas, IOC-Fiocruz (the other is the CDC in the USA). It is among the about 45 countries that are conducting clinical tests for the WHO Solidarity Project, which seeks to find a treatment for COVID-19. In 2014, it was a pioneer in the response to the Zika virus.
Universities and researchers, on the other hand, are increasingly persecuted for ideological reasons and austerity measures restrict funding for research, which results in a significant brain drain and the dismantling of structures.
In the field of production, Brazil has a set of 23 public laboratories, capable of producing even high-tech drugs, such as monoclonal antibodies and the well-known chloroquine.
However, the domestic industry is heavily dependent on foreign products, including active pharmaceutical ingredients, and is susceptible, especially now, to political decisions from other countries, such as when recently a cargo plane from China with respirators and masks was detained in Miami.
The Right to Health and the challenge of the workforce
Brazil lacks a strategic policy for the health workforce planning. Currently, the regulation of health professions is strongly concentrated in the hands of professional councils, which are self-regulated public bodies formed by health professionals themselves who define rules with great autonomy, including on the scope of practice.
The problem is especially severe in vulnerable territories. Currently, the country has fewer doctors and nurses than recommended by the WHO, and they are poorly distributed across the territory. A policy established in 2014, which was strongly opposed by doctors, but was supported by PAHO/WHO was the “Mais Médicos” program (more doctors for Brazil). It tried to tackle this problem by reforming the educational system and allowing exchanges with other countries.
The project was canceled at the beginning of the current government. Its most controversial aspect was the exchange of Cuban doctors. Its abrupt and poorly planned end has left a gap. Recently, amid the COVID-19 crisis, the former health minister, who was once a strong critic of the program for its alleged ideological orientation, was forced to re-engage doctors from Cuba to face the pandemic.
The great challenge of SUS
Despite its challenges, SUS has already given enough evidence that it is the best option. The COVID-19 crisis only reinforces the argument about the importance of a public and universal health system, with sufficient resources, to respond to crises and ensure efficient care.
The system’s role in handling the pandemic highlights its importance. Even the recently fired minister of health, Mandetta, a former health insurance executive and hitherto a supporter of the private sector, was able to become popular by tapping the capacities of the SUS.
This project, which was born out of community participation, has always faced the challenge of its ideas reaching all sectors of society: the population in general, media, public sector, private sector, unions and academia. This battle of ideas has not always gone in favor of the SUS.
The public health system’s potential is huge. But in order for it to be achieved, in addition to addressing the challenges listed, the whole of society must give it utmost priority in terms of access to health.
A Right to Health project based on equity requires efforts from all sides, resources, adaptation to local realities and social participation. May the challenges of our time reveal to us that the answers to all health problems are closer than we thought. It is a matter of believing and struggling.
Matheus Falcão and Maíra Mathias actively work on issues of public health and are members of People’s Health Movement-Brazil