By Lucia Brugnara, MD and Prof. Michael Marx, MD (University of Heidelberg)
In this blog series we are giving a voice to practitioners, implementers and policy-makers involved in national COVID-19 responses in low- and middle-income countries. These posts seek to facilitate timely cross- learning by sharing opinions, insights and lessons on the challenges and actions taken by those on the COVID-19 front line.
In science, there is a general tendency to publish statistically significant results and to report “what works”. Yet, policy makers and health stakeholders should also analyze mistakes and mismanagements in public health and learn from their consequences, especially during new public health threats as the Covid-19 pandemic. In March 2020, when Brazil had registered not even 150 deaths due to the disease, it was clear that a strong response and evidence-based policies were necessary to fight this new disease. Yet, by August 24th, based on data from the World Health Organization (WHO, 2020), Brazilians had more than five times the chance of dying of Covid-19 when compared to the world’s population since the beginning of the pandemic. This blog delves into six mistakes in the Brazilian response to the pandemic that has worsened the situation in Brazil to date.
Six lessons from Brazil
First, a coordinated response among different administrative levels and interest groups with strong national stewardship, and communication strategies adapted to the context are necessary in an outbreak context. However, in Brazil, until now, no national plan has been implemented or published. Since April, two Health Ministers have resigned, and the position is currently vacant while a military general acts as interim minister. The messages regarding the pandemic are conflictive and a culture of blaming is damaging the current public discourse. Authorities and the population are not putting differences aside to fight together against the disease and the divides between political and social groups are deepening.
Second, surveillance and contact tracing are necessary to control the disease spread. Data should be reliable and transparent. However, case detection through testing is a “major failure” in the country according to the Médecins Sans Frontières; and the information on the numbers of cases and deaths due to Covid-19 had been even omitted for some days in May. The Brazilian Supreme Tribunal Court had to enforce the Ministry of Health to publish the aggregated national data related to the disease.
Third, case treatment is a key to the outbreak response and should follow an evidence-based approach. However, some Brazilian authorities and even health specialists are suggesting the use of treatments with no confirmed effectiveness, giving a false sense of safety to the public and even putting the lives of the population at risk due to unforeseen auto-medication side-effects.
Fourth, the protection of marginalized groups should be prioritized in a pandemic due to their higher vulnerability. A Brazilian parliamentarian group proposed an emergency law to protect traditional communities of slaves’ descendants (“quilombolas”) and indigenous populations, but the federal executive power vetoed many part of the new draft law. A higher disease impact in vulnerable ethnic groups is already reported.
Fifth, health staff should be fully supported during such stressful and unprecedented times and feel safe, both economically and physically, to better provide health care. On the 4th August, the Brazilian government vetoed a parliamentarian law stipulating financial compensation for health workers and their families in case of permanent incapacity or death due to Covid-19. Because of the precarious relationship between the health workforce and some private health entities, staff often do not dare complain about poor working conditions or lack of personal protective equipment. In some cases, coronavirus-infected health staff are even losing their jobs and income because they have been employed on temporary or casual basis without social security. Furthermore, the well-being and integrity of health staff and patients has been underlined after the president made a public call to his followers to “inspect” intensive care units (usually restricted access) to check if beds were actually occupied by Covid-19 patients, implying that hospitals, local authorities and the press were providing false information to the public.
Sixth, funds should be disbursed fast and appropriately to the different administrative levels and health service providers for the implementation of strategies. By June 22nd, Brazil disbursed less than 30% of the Ministry of Health`s annual budget and less than 44% of the Covid-19 emergency budget, which was mainly used to pay pending debts.
The world is expecting one of its largest recessions in history and there is a fear of economic loss caused by restriction of movement. Social distancing is a key strategy to control the pandemic until a vaccine is developed and distributed. This strategy may even contribute to economic stabilization. For example, South Korea rapidly controlled the spread of the disease by heavily restricting movement and enforcing the isolation of cases and contacts. By the 18th August they had lost only 306 people to Covid-19 and experienced the lowest impact on gross domestic income this year among the Organization for Economic Cooperation and Development (OECD) member-countries. In Brazil, the economy will shrink by 9% in 2020 according to the same organization, while suffering the loss of more than 110,000 lives to the disease so far. The suffering related to these losses cannot be expressed in monetary terms.
Many of these losses – economic, lives, suffering – could have been avoided. A pandemic process depends on the natural cycle and physiological aspects of a disease, but it depends just as much on the public policies employed. Brazil has the knowhow to implement strong and robust public health policies as showed by the Global Burden of Disease Study, that identified a significant improvement of the health status and life expectancy of Brazilians over the last three decades . Yet, a stronger and more adequate Covid-19 response is now necessary and changes are needed, including clear pressure from the international community as the disease is not only causing large-scale loss of life in Brazil, but it is a hot spot from where the virus can spread to neighboring countries and other parts of the world. Other countries may learn from the Brazilian experience and take outbreak control more seriously, launching or strengthening policies and considering recommendations based on scientific knowledge. In “Chronicle of a Death Foretold” by the Colombian author Gabriel García Márquez, a murder was predicted, yet no one was able to stop it. In the case of Brazil, the impact and deaths from Covid-19 were in fact predicted already in March. We appeal that the Brazilian officials change their current attitude, and that policy makers worldwide learn from their mistakes.
The authors thank Andrea Düren Centeno, MD for her contributions and productive discussion, and the Brazilian Federal Congressman Henrique Fontana, MD, for confirming the information published in the Brazilian and International press used as reference in this blog.