The already challenging scenario in Brazil is getting tenser day by day with the still uncontrolled pandemic and the political crisis faced by the Bolsonaro administration. On July 10, the death toll surpassed half a million. With less than 3% of the world’s population, Brazil has reported about 13% of the global COVID-19 deaths. These numbers illustrate the inadequacy of the country’s response.
New lows for Bolsonaro
On April 27, a Parliamentary Inquiry Commission was opened at the Senate to investigate possible infractions committed by the current administration in the context of the pandemic response. One of the commission’s main lines of investigation is not about negligence but rather whether a deliberate strategy existed on the part of the administration to disseminate the virus, aiming to achieve so-called herd immunity.
The acts under investigation include a variety of behavior by president Bolsonaro himself, such as supporting and attending public events that do not adhere to public health measures, denying the threat represented by the virus, and promoting therapies without proven efficacy and thereby creating a false feeling of safety.
Such a strategy was previously investigated by the Health Law Research Center of the University of São Paulo (Cepedisa). A recent study has shown that approximately 3,000 acts and bylaws by the federal government during the pandemic were grounded in an explicit attempt to spread the virus.
The bad situation of the economy, including unemployment, food insecurity and increasing levels of hunger, along with one of the worst pandemic responses in the world, has led to opposition from different sectors, as well as a drop in the popular support for the federal government, especially among the poor and the young. Brazil’s right-wing president was unexpectedly elected in 2018 with 55.13% of the valid votes. Recent polls indicate that almost 60% of the population now disapproves of his politics.
The ailing SUS
The federal administration’s policies have not only affected the pandemic response, but also the Brazilian Unified Health System (SUS), one of the biggest universal access health systems in the world. A poll in May 2021 in the country’s biggest city, São Paulo, showed that the healthcare system is considered the best public service. At least 75% of the population relies only on the public system for healthcare. The SUS provides universal free care, including medicines, while receiving less than half of the domestic budget for health. Besides that, it includes public health measures, health workforce education, and manufacture of medicines, making it a comprehensive national strategy to realize the right to health.
Underfunding remains one of the main challenges for SUS. In 2019 the federal budget for health remained at the same level it was in 2014, despite a population increase of seven million. On the other hand, although the parliament, in 2020, authorized the minister of health to spend an additional R$ 64 billion (US$ 12.52 billion) for handling the pandemic, R$22 billion (US$ 4.30 billion) remained unspent. Even existing provisions meant to guarantee the functioning of the SUS have been under attack. The constitution mandates a minimum of 15% of the federal budget be directed to healthcare. Bolsonaro’s economy minister has criticized this provision and stressed his plans to propose its revocation.
It is not only budget constraints, but also mismanagement that has harmed the system. Since the pandemic started, Bolsonaro changed the health minister four times, mainly following disagreements over treatment approaches with unproven efficacy, such as Chloroquine and Ivermectin. Among the most terrible outcomes of this botched approach were the two shortages of sedatives for intubation in April 2021, and of oxygen in January 2021, which led to more avoidable deaths.
Planning, strategic procurement and campaigns under SUS are the main prerogative of the federal government. But these are exactly the things that were not done. Such lack of leadership led to tragic consequences. According to a study, at least 120,000 deaths could have been avoided as of March 2021 if proper measures had been put in place, especially strengthening public healthcare and preventive non-pharmaceutical interventions. The study covers the first year of the pandemic, before the period of biggest mortality (between March and May of 2021). Yet it shows that about 20,000 people lost their lives queuing up for healthcare. Among those deaths, 40% could have been avoided if proper public health measures had been in place.
Obstacles on the way to immunization
Brazil took pride in the past in having one of the best immunization programs of the world, vaccinating more than 10 million people per day against polio in the 1990’s. The well-structured system, based on primary healthcare and state-owned pharmaceutical companies that manufacture both medicines and vaccines, faces budget constraints and bad planning at the federal level, just like the pandemic response.
The Senate commission is looking into issues concerning administrative mismanagement of the vaccination drive, such as avoidable delays in vaccine procurement, failure to promptly set up an efficient immunization plan, and lack of health-system strengthening planning. More recently, the commission started to look into allegations of corruption in the case of the purchase of the Covaxin vaccine. A member of the parliament claimed that bribes were paid for overpriced purchases.
Yet, the two main vaccine courses available in Brazil, Coronavac from China-based Sinovac, and Covishield, the Oxford Vaccine, are both produced at public laboratories, Butantã and Fiocruz’s Bio-Manguinhos, respectively. (Recently the Janssen and Pfizer vaccines have also become available). Vaccine production, however, still relies on import of the active pharmaceutical ingredients (API) from China and India, and political clashes with these countries have been another factor in delaying vaccination in Brazil.
To address such issues and scale-up vaccine production, civil society in Brazil has pushed for the National Congress to pass a bill that aims to facilitate compulsory licensing and technology transfer for vaccines. In a major victory for health activists, the draft law was approved by an overwhelming majority at the Chamber of Deputies on July 6. It now awaits final review from the Senate and presidential sanction. The movement aligns itself with the efforts to suspend intellectual property protection enshrined at the World Trade Organization – the TRIPS waiver proposed by South Africa and India. Bolsonaro has opposed this, going against the historical position of Brazil in global health debates,
The situation in the country remains challenging and uncertain. The mismanagement of the pandemic is only the visible element of deeper crises with many kinds of social impact: years of austerity measures in public services, the dismantling of policies regulating food supply, technological innovation and education, and attacks on science and academia during Bolsonaro’s administration have weakened institutions and made our society more vulnerable.
Still, there are initiatives that show that ground can be regained, such as the recent victory with the pro-TRIPS waiver bill. As Brazil grieves losses of lives and perspective for a better future, the stakes in the 2022 presidential elections are growing higher. Not only do they represent the election of a new government, but also the possibility of shaping a political project able to rebuild the nation’s structures and hope, of which a comprehensive national strategy to realize the right to health ought to be a centerpiece.
Matheus Z Falcao is associated with the People’s Health Movement in Brazil.