Brazil Against COVID-19 Pandemic: A Timeline Review

By James Tiburcio

While the Brazilian government’s response to the COVID-19 pandemic seems to be dictated by the circus show put up by the Brazilian President, Jair Messias Bolsonaro and his four sons, the real response on the ground and on the frontlines is being coordinated by federal level ministries, state level departments and municipal level secretariats through the Unified Health System, SUS.

Brazil has long been the country of tomorrow, forever destined for future greatness, ignored but hard to ignore as the ninth-largest economy of the world (it was the 6^th in 2011 when it overtook the United Kingdom), 7^th most populous country, and home and guardian to most of the largest rainforest on planet Earth, the Amazon. The present health crisis could be the catalyst to a general institutional crisis, as it threatens the President and opens the door to a military-led government.¹ Brazil’s simultaneous crises have relegated the Brazilian health apparatus handling of the situation to the back pages, as it is undermined by those who should be bolstering it. The Unified Health System, known by its Brazilian Portuguese acronym, SUS, is the spearhead facing an invisible enemy that has, at the time of writing this, killed more than 8,000 Brazilians.

The SUS was created in the context of the Brazilian federal system, a complex and unique federation that has been successively a free territory, a Portuguese colony, a monarchic empire, an oligarchic republic, a military dictatorship, and since 1985, a multiparty democracy. The first idiosyncrasy of the Brazilian system is the relevance of the municipalities, which are considered federative entities sharing multiple responsibilities with states and the federal state. Their diversity in terms of size, political, economic, and social development, tax and institutional capacities generate a considerable number of public health policies and implementation strategies. The institutional setting of SUS is found in the 1988 Federal Constitution of Brazil, the one that defined the country as it eviscerated itself from a 20-year-period of military dictatorship. According to the National Health Survey of 2013, an estimated 80% of the Brazilian population is SUS-dependent for their healthcare. However, even those who have a private health insurance use SUS directly or indirectly, for various services, from the least expensive ones, such as vaccination to high-cost medicines, surgeries and transplants that are almost exclusively performed by SUS in Brazil.²

Political response
On a national level, the political response has been nothing short of a fiasco. The international press has extensively chronicled the way the Brazilian President bungled the start of the reaction, being labelled as ‘the worst’ national leader in the fight against the pandemic,³ the leader of the coronavirus denial movement worldwide,⁴ and he has remained in denial and in contrast to his peers (except those in Turkmenistan,⁵ and the like), has stubbornly refused to acknowledge the seriousness of the matter.

His insistence on foiling his own government’s actions have led to Brazil, as of now, being on an epidemiological curve that is worse than that of some countries that have so far had the worst mortality rates, such as Italy, Spain and France. While state and municipal authorities raced to prepare their defence lines, the President seemed to do everything in his powers to undermine their efforts. Repeatedly, he took part in public demonstrations immediately after the federal district authorities had made public guidelines advising against agglomerations.

He amped his antics by allowing his four sons (he also has a nine-year-old daughter), three of whom hold political offices, to engage their social media and fake news arsenal to condemn physical distancing recommendations claiming they were destroying the Brazilian economy, much earlier than similar manifestations came into being in the United States,⁶ While even the American President was still half-heartedly supporting shelter-in-place guidelines in the United States, Bolsonaro was already openly and vocally condemning any and every kind of preventive action against the pandemic, advocating the reopening of schools and businesses notwithstanding the rapid advance of the virus in the country. He has engaged in an acrimonious feud with the media in general, and with anyone that dared to contradict his views, blaming them for a supposedly hysterical reaction to an inoffensive virus.

Compounding the health and political facets of the Brazilian perfect storm, an economic situation that was already far from ideal is weighing the government down. The Brazilian Real, the national currency, collapsed in the international markets, in the wider context of the global economic recession, taking with it the stock and bond markets, purporting a general economic collapse catalysed by the health crisis. The Minister of the Economy, the Chicago School of Economics trained, Paulo Guedes, who was already having a difficult time trying to balance the political agenda of Mr Bolsonaro with the diminishing returns of an economy pegged to the Chinese economy, saw his job becoming even more untenable. The country’s economic stagnation has turned into recession, and the government’s promises of making Brazil grow again as it did during the military dictatorship, seem to be destined to fail. The economic situation seems to be leading to an almost inevitable setback, where the social conquests of the last decades will be reset.⁷

As the crisis unfolded, the then Minister of Health, up to that point a political ally of the President, Luiz Henrique Mandetta, increasingly detached himself and his ministry from the presidency’s narrative. In the second week of April, Mandetta, a paediatric orthopaedist and politician, was dismissed by the President following an acrimonious public battle over physical distancing, quarantines, lockdowns, and the severity of the pandemic. In the preceding weeks, the two had clashed repeatedly, both openly and behind the scenes over President Bolsonaro’s advocacy of unproven medicines, such as hydroxychloroquine, his mocking of public health systems and professionals, and insistence on diminishing the danger of the virus.

National health system
Article 196 of the Brazilian Federal Constitution affirms that ‘health is a right of all and a duty of the State’ and defines the universality of the coverage of the Unified Health System. The constitutional framework was constructed around the publication of Decree number 99,060, of March 7, 1990, which transferred the previous system based on provisions around the formal workers’ health system from the Ministry of Social Security to the Ministry of Health (MoH), and paved the way to the establishment of the Unified Health System through the enactment of Law 8,080 in September of the same year. That law in its second chapter establishes as one of the central principles governing SUS is the universality of access to health services at all levels of assistance, and in this way, consolidated the legal edifice for Brazil’s unified and universal health system. Therefore, all Brazilians, from birth, are entitled to free health services as the Brazilian Unified Health System – SUS, the only one in a country with more than 100 million inhabitants guarantees free assistance to its citizens and foreigners in the country.

Because of its decentralized structure – SUS is run on a tripartite basis, that is, financing is a common responsibility of the three levels of government, federal, state and municipal – one cannot speak of a national response to the crisis, rather, there are multiple responses that are being loosely coordinated by the MoH, that has a somewhat autonomous management process in spite of being under the President’s office. At the same time, this response happens in a context of institutional crises around the Federal Government, that are not affecting directly the stability and actions of state and municipal governments.

The SUS has always been under pressure, and services have suffered particularly in the last decade. As a candidate in 2018, Bolsonaro went against all studies and evidence presented to him and advocated that the national health system did not need more resources. Numerous studies have shown that SUS lacks funding, and therefore insufficient resources are the structural weakness that prevents it from improving its service level, and not funds management itself. The President also erroneously claimed that the Brazilian system received investments that were compatible with the Organization for Economic Co-operation and Development (OECD) average, and his team seems to have purposefully omitted any policy aimed at the most vulnerable segments of the population.⁸

Created during the first term of Fernando Henrique Cardoso as President in January of 1997, the Provisional Contribution on Financial Transactions (CPMF) was the main instrument specifically earmarked to fund public health, the social security system and the Fund to Fight and Eradicate Poverty. Its rate varied between 0.25 and 0.38% of all financial transactions. However, a proposal to extend the compulsory contribution was rejected by the Senate in December 2007.

In September 2007, the then-congressman, Jair Bolsonaro, voted ‘nay’, and helped to bury the CPMF. At the time, the press labelled it ‘the greatest political defeat’ of President Luiz Inácio Lula da Silva, who was in the first year of his second term. To avoid the worst, the government even submitted a proposal to modify the destination of the contribution resources, to ensure that all the money would be directed to the MoH. Until then, half reached the sector and the rest went to, among others, the Social Security system, to a program to fight hunger and the Treasury. But the change was not enough, and the government ended up defeated in the Senate. The government failed to raise, in 2008 alone, around R$ 40 billion for the sector.⁹

José Gomes Temporão, the Minister of Health at the time (2007-2011) and Fiocruz researcher ¹⁰, explained the chronic underfunding of SUS in a recent interview:

Of course, today there isn’t enough money to fight the coronavirus. This is socially constructed. In 2016, if I’m not mistaken, the insurance plan sector had R$ 200 billion to serve 50 million Brazilians. In the same year, SUS had R$ 150 billion to serve 150 million Brazilians. There is a brutal underfunding of SUS. And now we are experiencing a paradox. The population in fear, feeling fragile, begins to reflect, ‘is it not important to keep SUS funded?’ But now that source doesn’t exist. This will have to be discussed again.¹¹

Another former health minister, Alexandre Padilha (2011-2014), took aim at the infamous Constitutional Amendment 95, made law in December of 2016 which limited public spending including on health care for 20 years:

There were two losses determined by the National Congress and that deepened the underfunding of Health, which was chronic since the creation of SUS [in 1988]. The end of the CPMF [Provisional Contribution on Financial Transactions] and Amendment 95, which removed from the Ministry of Health [budget], from 2017 to date, R$22.5 billion [around 4 billion USD]. Last year alone it took out R$9 billion [around 1.6 billion USD]. In practice, it destroys the constitutional commitment of a free public system for the entire nation. […] In the last pandemic, in 2009, SUS had 8,500 ICU beds [Intensive Care Units]. Today, SUS has 22, 23 thousand ICU beds and 5,500 intermediate care beds. The entire expansion happened only until amendment 95.¹²

A year before the arrival of the SARS-CoV-2 pandemic to Brazil, there were further deep cuts to the budget of the SUS, which was already under stress as the need to hire specialists and generalists, source more ICU beds, and personal protective equipment aggravated.¹³ In a recent study entitled ‘New funding for a new Brazilian Primary Health Care,’ the authors contended that ‘vaccination coverage fell, child mortality reduction slowed down, a large proportion of preventable hospitalizations was noted, as well as the enormous difficulty in managing chronic diseases, ageing, and coping with syphilis and HIV’ were plaguing the national health system.¹⁴

In spite of all the funding shortcomings and service lags, the Ministry of Health started to network with SUS state and municipal managers to do whatever it could to ramp up the country’s defences as the arrival of the virus proved inevitable. At first, some professionals discussed how SUS should focus on the diagnosis and the performance of professionals who would be taking care of infected people. Specific attention was directed to infectious disease physicians on how to treat people infected with COVID-19.¹⁵

On January 22, the Ministry of Health set up an Emergency Operations Centre (COE-nCoV) to monitor the situation and coordinate actions to prepare the Brazilian health response to an eventual emergency situation in Brazil. The Centre is composed of the congregation of the General Coordination of Health Emergencies, the national immunization program, the public health laboratories, the Executive Secretariat, the Specialized Care Secretariat, the Primary Health Care Secretariat, the National Health Surveillance Agency (Anvisa) and the Advisory and Communication Centre of the MoH and provides a command and control unit as well as management and coordination. In addition, it allows a simplified organization, clearly establishing the lines of authority and conduct, and allows management training for the third echelon and teams of doctors and administrators of areas of expertise in intensive care units.¹⁶ At that time, Brazil had two reference laboratories for the diagnosis of the new coronavirus, Central Public Health Laboratory (Lacen) and to the National Influenza Centre (NIC).¹⁷ By the end of March, the Federal and state governments started speeding up the accreditation of public university laboratories for testing.¹⁸

The Tripartite Interagency Commission (CIT), a negotiation and agreement forum between federal, state and municipal managers regarding the operational aspects of SUS, met on February 5, along with the National Council of Municipal Health Secretariats (Conasems), the representative entity of municipal entities in CIT to deal with matters related to health, as well as the 20 municipal health secretaries of state capitals. All notifications regarding the novel coronavirus that had been evaluated and discussed, case by case, with the health authorities of the states and municipalities were presented and discussed. There was a general understanding that this was not a common occurrence and that the country’s health system needed to take it as seriously as possible.¹⁹

Despite the CIT, among the difficulties of the Ministry of Health is maintaining a single command, with State and Municipal Health Secretariats sometimes carrying out initiatives that are not aligned with central guidelines. In addition, the SUS is a chronically underfunded system, that is, the ICUs and respirators that are both discussed today as a necessity should have already existed regardless of the current pandemic scenario.²⁰

Then, in the last week of February, an infectious disease physician, Rivaldo Venâncio, Coordinator of Health Surveillance and Reference Laboratories at Fiocruz, was interviewed by Agência Brasil, Rio de Janeiro – an official agency of the Brazilian government. He defended the government stating that Brazil was better prepared to deal with COVID-19 than it was in 2009 to face the H1N1 flu pandemic. In spite of the disruption, in some locations, of the SUS network, a reduction in the coverage of assistance by the Family Health Strategy over the years, which is the first level of care in SUS, the institution had evolved over the past 20 years to deal with public health emergencies, such as SARS in 2002, H1N1 in 2009, and seasonal and ongoing outbreaks of dengue, zika and chikungunya.²¹

Spread of the disease: A timeline
At the time (February end), there was only one confirmed case, a 61-year-old Brazilian man who had returned from Italy on February 26, and infected others, while thoroughly recovering sometime later. Fellow passengers were traced, but authorities decided against placing them in a segregated quarantine facility.²²

Roughly a month later, on March 22, there were more than 1,500 confirmed cases and 25 confirmed deaths. Specialists were already pointing out that primary health care professionals were in line to become the anonymous heroes against the coronavirus.²⁴ On that same day, the Brazilian President seemed to be actively undermining his own government and the efforts of the MoH and SUS, by declaring on a live televised interview that the novel coronavirus was nothing but sniffles. He went on to say that state governors were overreacting and that their measures could cost millions of jobs. The President also said that there is no reason to panic.²⁵

By then, different public hospitals in the country were already reporting a situation that was bordering on chaos: hospitals that had no soap for handwash or paper towels to dry, intensivists that lacked alcohol gel, goggles or a mask. The increase in demand for services caused by the pandemic of the novel coronavirus was already testing the weakened capacity of the SUS.²⁶ The 42,000 health centres that serve the population free of charge were just barely managing to deal with common issues in the period leading to the pandemic. An estimated 1,53,000 deaths per year in Brazil were caused by poor quality care and 51,000, due to lack of access to healthcare.²⁷

For example, in the state of São Paulo, the most prosperous and developed, 47,000 workers in the SUS health sector are distributed in 45 hospitals, most of them aged between 50 and 60 years. For close to 20 years, due to austerity measures, the government has stopped investing in both services and workers and has not hired new health workers, and for almost 20 years, there have been no public exams for hiring staff, the so-called ‘concursos públicos’. To add insult to injury, Fiocruz researchers have shown that the number of beds in the SUS is falling, having decreased by 5.5% in the surveyed period (2009-2017. In 2019, the health budget was 147 billion reais. In 2020, this value dropped to 136 billion, according to data from the Federal Comptroller General.²⁸

At the outset of the crisis, the city of São Paulo, a metropolis of 1.22 crore inhabitants, had only 3,830 ICU beds, of which only 38% are in SUS hospitals, which already had an occupancy rate of more than 80%. The reference hospitals already faced a dire situation: Instituto Emílio Ribas (100% capacity),²⁹ Hospital das Clínicas (83% capacity), Hospital Geral de Pedreira (87% capacity), Hospital da Vila Nova Cachoeirinha (86% capacity) and the Tatuapé Municipal Hospital (77% capacity).³⁰

As the World Health Organization declared the global pandemic, the MoH had authorized only 10% of the intensive care beds it had planned for in case of a pandemic in January. By March 11, only 100 extra beds were available. The Brazilian Association of Intensive Medicine warned the government that the system was already overloaded and that any emergency would lead to a collapse.³¹ And, unfortunately, the events had justified the prediction, and their predictions proved true.

Support and prevention
Compounding the problem, there is also low adherence to lockdowns particularly in the large favelas (slums) in São Paulo, Rio de Janeiro, Manaus and Fortaleza. Interestingly, most slum dwellers favour the quarantines according to a poll, however, they simply cannot survive without government help. According to the same survey, one in three favela residents in Brazil will have difficulty buying basic products, such as food, due to the quarantine against the new coronavirus pandemic. The survey showed that, for 72% of residents, a week without work is enough to make their life support systems collapse, which was already low before the pandemic. Close to half of these workers are self-employed (about 47%) and therefore are not included in the government’s financial aid intended for those with a formal work contract.

In addition to the data, the research report made recommendations to the government, including supplying families with food during the months of March, April, May and June; the institution of the Minimum Income Program for families enrolled in the Federal Government’s Single Registry – an instrument that identifies and characterizes low-income families, used as a criterion for inclusion in social programs such as Bolsa Família; support for water, electricity and gas companies that exempt families with an income of up to four minimum wages for four months; and specific financial support for the families of children who will be prevented from attending day-care centres.³²

Sadly, despite the fact that the favelas are some of the most vulnerable areas in the present pandemic, as there is a lack of space, scarcity of resources, savings, food supplies and basic sanitation is often non-existent making it almost impossible to maintain the necessary hygiene conditions and physical distancing to prevent the spread of the disease, they were not considered in any specific national plan to prevent and fight COVID-19.³³

Notwithstanding the President’s stance, the Federal Government has adopted a plethora of measures to put a fight against SARS-CoV-2.³⁴Among these were:

• an emergency aid of R$ 600 for 54 million Brazilians, informal workers, the unemployed, individual microentrepreneurs who integrate low-income families, in addition to intermittent workers who are currently inactive and, therefore, without receiving;
• R $ 1,200 to mothers who are the sole earners supporting their families;
• an emergency job and income maintenance program to preserve up to 8.5 million jobs, benefiting around 24.5 million formal workers;
• an online dashboard to monitor the number of beds and supplies, such as tests, masks, gloves, among others, available in each state; the suspension of the annual drug price adjustment for the year 2020;
• connecting all public health care units to the internet by the end of the month of April;
• creating a group that intends to unify actions and experiences so that riverside, quilombola and other communities can receive support and conditions to fight the coronavirus, with the mobilization of inputs for health treatments, food security, social and other actions to work in a coordinated way with the participation of the Federal Government;
• a plan for the ministries of Science, Technology, Innovations and Communications (MCTIC) and Health (MS) to invest 50 million in research on new methods of diagnosis, treatment and interruption of transmission in the country of the coronavirus (COVID-19);
• Ministry of Women, Family and Human Rights (MMDFH) has released booklets in foreign languages with recommendations for tackling the new coronavirus (COVID-19) for immigrants and refugees living in Brazil;
• Ministry of Women, Family and Human Rights is taking emergency measures with the launching of digital platforms for the service channels of the National Ombudsman for Human Rights, which expands the reach of telephone services, as aggressors and victims under the same roof 24 hours a day, victims will be able to call for help without raising their voices; and
• about 10,100 Brazilians have already been repatriated by the government from places like India, Australia, Portugal and South Africa.

Given the situation SUS finds itself in, President Bolsonaro seems to be advocating a self-deafening policy. Most experts agree that unless there is an unexpected reversal in the pandemic, Brazil is headed to an almost certain health catastrophe. As of May 6, the country had recorded more than 110,000 cases, and 7,500 deaths distributed throughout the continental 8,5 million square km territory (Figure 1).

Figure 1: The distribution of the pandemic in Brazil (May 5, 2020)
Source: Ultimo Segundo. Available at https://ultimosegundo.ig.com.br/brasil/2020-03-21/coronavirus-no-brasil-acompanhe-a-situacao-no-pais-em-tempo-real.html

Time for national unity
Finally, at the time of writing this, Brazil had moved into being the global epicentre of the pandemic according to a University of São Paulo – Ribeirão Preto Medical School study based on the estimation of underreported cases of COVID-19. The total number of those infected with coronavirus in Brazil would be close to 1.5 million, and not the 1,50,000 currently officially accounted for by the MoH. The researchers based the Brazilian estimate on the lethality rate of COVID-19 in South Korea, a country that is testing the population en masse, unlike Brazil, which has been applying tests only in severe cases. Using the South Korean index as a basis, the study adapted the lethality rate (fatality) and redistributed it among Brazilian age groups, reaching 1.11% of the expected rate. Thus, the adjusted case fatality rate represents a more real lethality rate by adjusting the rate calculation by the average time between confirmation of the case and death, that is 10 days.³⁵

It is not hard to imagine how things could get worse. The SUS is rapidly being overwhelmed by a desperate and frightened population. The number of infections continues to rise, while the number of dead is anyone’s guess. Meanwhile, President Bolsonaro remains stubbornly alienated to the enormity of the tragedy, and rabidly fights his own government and people. He is doing all he can to restart the economy at whatever cost, sacked his minister of health, forced the resignation of the minister of justice, at the same time as he interferes in the federal police to obstruct ongoing investigations against his sons.

This should be a time of national unity, a time for all political agendas to be set aside, and a government of national unity and solidarity to enable the country to survive to be put in charge. To survive the COVID-19 pandemic, Brazil must not only protect our SUS but place it as the number one priority in every government policy. The President must be circumvented as capable ministers, governors, directors, technocrats on the federal, state and municipal levels face the pandemic and save lives. If, however, we accede to petty electoral ambitions of power-hungry dictatorial politicians, Brazil will cut short dozens, maybe even hundreds of thousands of lives. Now is the time to act, let’s get this done together.

AUTHOR
James Tiburcio is a researcher and translator between São Paulo and Bangalore. He works on Public Policy and its application to Food Security in Brazil and India.

Disclaimer: The views and opinions expressed in this article are those of the author/s and do not necessarily reflect the official policy or position of Azim Premji University or Foundation.