Why has Brazil failed in the fight against coronavirus?

Second worst hit country, Brazil had the time and the resources to control the pandemic. Until it did not.

Brazil reached the grim milestone of 97 thousand deaths of COVID-19 and 2,8 million confirmed cases of the new coronavirus. Both numbers are likely underreported due to lack of testing. The country lags behind only the U.S., where the new coronavirus killed almost double the number of people and infected more than 4,7 million. Over a thousand deaths registered per day were the norm for weeks in Brazil, signalling either the pandemic has peaked and the curve is now a plateau or simply that testing capacity is at the limit.

The moving average in a week of July hit a record high 1100 fatalities. Meanwhile, states are reopening its activities and most people abandoned quarantine. Many schools in the country plan to restart in-person classes in August.

It has been months since the first infected Brazilian arrived from Italy and there is no sign of the country managing to contain the virus spread— more than 54 thousand new cases were confirmed only yesterday (last available 7-day moving average indicates 44 thousand new cases per day). For comparison, in Spain, one of the most affected countries in Europe, the peak happened around 50 days after the first confirmed diagnosis and then rates declined.

The disease was initially spot in February, right after Carnival, months after the outbreak in Wuhan and Italy. Despite having the time to prepare, Brazil's trajectory during the pandemic is shameful.

It comes as a shock that Brazil is doing so poorly in containing this pandemic after global recognition of its efficient response against other epidemics. Brazil successfully handled the HIV crisis in the 90s and was the first country to find the causal link between the Zika virus and microcephaly in 2015.

Back in the 90s, Brazil was at the front line in providing HIV self-testing kits, soon made free for all. Simultaneously, Brazil has produced generic versions of the very expensive antiretroviral drugs, which eventually reduced HIV treatment costs all over the world. The country went even further by providing free access to HIV treatment since 2013.

When the unusual number of newborns with microcephaly was noticed in the Northeast region a few years ago, health authorities rushed to investigate the possible causes and quickly notified the WHO about the emergency. Brazil has also successfully eradicated a number of diseases through its national immunisation program.

That is not all. Brazil is the only country in the world equipped with an universal public healthcare system for a population of more than 100 million people (Brazil's current population is 210 million). Established 31 years ago, the Unified Health System (SUS — Sistema Único de Saúde) is part of the Brazilian welfare system, based on the re-democratization Federal Constitution of 1988.

Those examples ilustrate costly and complex public health measures. So why has Brazil failed to implement WHO's guidelines regarding COVID-19?

National vs Local Policies

Clear and centralized policies seem to have worked better than decentralized ones. Countries across Europe beated the first wave of COVID-19 by implementing nationwide measures that almost entirely curbed public life. The U.S. has never implemented a national level lockdown and the cases soared.

Federal institutions in Brazil were very late in recognizing the rapid spread of the virus. So, states and cities stepped in earlier and implemented quarantines independently. First was São Paulo, the most populous and also the wealthiest state in Brazil. The sanitary measures adopted from 24 of March in São Paulo were not received with contempt by president Jair Bolsonaro, who complained daily to the press about the danger to the economy of shutting down all activities.

The Nefarious President

President Jair Bolsonaro has handled the crisis in the worst possible way. He plays down the severity of the pandemic since its beginning by calling the virus a 'little flu', by sabotaging quarantine policies implemented by governors and mayors, by causing agglomerations with supporters every weekend, by supporting mass protests against the Congress and the Supreme Court, by expanding considerably the list of essencial services that should remain open, by resisting to wear a mask, by vetoing a law of mandatory face mask use in churches, prisons, schools and shops.

There is more.

Brazil has no Health Minister since May. Two Health Ministers resigned over disagreements with the president on how to handle the worst sanitary crisis the country is facing in a century. Currently, a military interim Health Minister with no medical or public health expertise is assigned to the role.

The gravity of the pandemic could have been avoided if coordinated nationwide action had been implemented following the WHO guidelines. This has never happened. The interim ministry actions are more aligned with President Bolsonaro’s guidelines to deal with the crisis, namely, none.

Not even national daily reports on cumulative coronavirus cases and deaths were released by the Ministry for a while. Instead, a conglomerate of media outlets have joined forces to inform daily national updates following official information given by states and cities.

Despite claiming a 'history as an athlete', Bolsonaro caught the virus himself and announced it to the press in person. Not happy enough about his proximity to people, he removed his mask during the interview. Later on, he proceeded to advertise hydroxychloroquine by releasing a video in which he claims he was taking the medication; "I trust it. Do you?" So much trust, but doctors monitored his heart twice a day to avoid cardiac arrest as a result of the drug intake; a special medical attention citizens do not benefit from if they choose to listen to the president and to self-medicate.

During his entire treatment, he advocated for the use of the medication by appearing to supporters holding the medicine box in a cult-like position (he must have watched the new version of The Lion King recently) and by offering the medicine to rheas at the garden of the presidential palace. Bolsonaro was bitten by the animals in more than one occasion when trying to feed them (not with the medicine) during his time in quarantine.

The interaction with those animals started as a way of reducing his isolation while recovering from the virus, but he noticed it caught worldwide media attention. As a populist leader, he then appeared at the presidential palace garden showing hydroxychloroquine to a rhea. The image is utterly disgraceful. Beyond stupid, it shows a complete lack of empathy with the national tragedy still unfolding due to the pandemic. Worst still, the photo goes down in history as the summary of how authorities have committed to protect Brazilians from the new coronavirus.

An article from Revista Piauí revealed that last 22 May president Bolsonaro announced to allies he would remove all Supreme Court's judges by sending troops in. In his view, the Supreme Court was interfering too much with his decisions. He gave up on the plan after being convinced by General Heleno that "it was not a good time". If true, Bolsonaro was basically plotting a coup whilst hundreds of people with coronavirus were dying daily.

Unified Health System: Underfunding and Other Issues

About 70% of the Brazilian population depends solely on the Unified Health System (SUS) and this share has been increasing in the last years. The economic crisis that started in 2015 led millions of people to unemployment and at least 3 million Brazilians have terminated their private health insurance contracts. Additional pressures to public healthcare come from population growth and population ageing, obesity and chronic diseases.

Over the decades, the system has granted access of the poor to health assistance, but not without major structural problems. Public hospitals and primary care centers have always suffered from lack of equipment, malfunctioning apparatus, understaffing, shortage of medical supplies, etc.

One reason is underinvestment. Figures of 2020 show that Brazil spends only US$ 337 per capita in health. Rich countries with universal healthcare spend 10 times more.

A constitutional amendment approved in 2016, capping federal expenses for 20 years, aggravated the problem. The law states that federal budget should not be risen above the previous year's inflation rate. The cap excludes expenses such as the public debt's interest rates. In theory, the government could still increase investment in health every year, but only in nominal terms or by reducing expenses in other areas to achieve real terms budget increase. In practice, the real expenditure per capita/year on health is below the levels of last decade.

The federal budget can be divided in two main groups: mandatory expenditure and discretionary spending. Currently, discretionary expenses cover only 6% of the budget. Pensions, federal public servants' salaries and public healthcare all belong to mandatory expenditure among other costs. What is observed is that increasing fixed costs on salaries and social security benefits every year reduce the share of the budget to SUS, even after adjusted for inflation. Recent years low inflation rates in Brazil add to the challenge of properly financing the public health system.

Comparing the first semester of 2019 with the same period in 2018, the public health budget went from US$ 3 billion to US$ 1,72 billion.

While the government keeps an inventory of millions of hydroxychloroquine pills bought from the U.S. or produced by Brazilian military, public hospitals are running out of essential medicines and substances to keep people with coronavirus alive. Brazil has enough hydroxychloroquine in stock for 18 years of use, even though international consensus states the drug is innefective against coronavirus.

Systemic Corruption

Corruption scandals in Brazil are frequent. Sadly, new ones arised with COVID-19. The pandemic opened up new opportunities for diverting public money in over-billing contracts spanning from face masks to ventilators and field hospitals.

The practice was facilitated by the so called 'Coronavirus Law', approved in February by the Congress and signed by the president, which removes the need of bidding for the acquisition of goods, services and even engineering needed to tackle the national emergency. There are more than 5000 cities qualified to spend under the new rules, but the debureaucratization adopted to avoid an oversaturated healthcare system has been used to illicit enrichment of politicians and business owners.

One of the most serious corruption scandals during the pandemic took place in Rio de Janeiro. According to the public prosecutor’s office, the State Health Secretariat in Rio is suspect of leading a scheme that overpaid almost US$ 1 million in the purchase of ventilators.

In São Paulo, an investigation regarding the purchase of equipment is ongoing. The state spent US$ 100 million to acquire 3 thousand ventilators from China.

Corruption related to the coronavirus crisis does not come only from government or businesses. Citizens not entitled to receive a temporary monthly aid (US$110), aimed for the poorest and workers in informality, have flocked the application system to claim the benefit. The majority was granted the money.

How did it happen? To provide quick access of the poor to the monthly help, the federal government built a last-minute system without any matching information with other fiscal authorities' databases. Then, millions of people could declare low income while living in comfortable houses together with high income partners or parents. Investigations so far indicate that over 1,6 million people should not have received the money. Most of them were asked to return the sum.

Social Inequality, Racism and Poverty

There is worldwide evidence that coronavirus has a more devastating effect in poor communities. The Office for National Statistics in the UK showed that black men are three times more likely to die of coronavirus than white men. In the U.S., researchers at the Centers for Disease Control and Prevention (CDC) revealed that risk factors related to pre-existing health conditions are more prevalent among lower-income workers.

It has proven no different in Brazil. The first fatality in the country was a domestic worker. She was infected at work by the house owner who had returned from a trip to Italy. Domestic workers are a clear example of the enhanced risk poorer Brazilians face. They are often not released from work by their employers at the middle and upper class, usually need to take public transportation every day and the use of face mask is the only protection measure while working.

Poor Brazilians are less likely to access private healthcare and more likely to live in cramped areas like favelas. There, high-density housing conditions, restricted access to water and sanitation and inability to keep a safe distance both intrahousehold and from neighbours form a disastrous combination.

A study released in May at the Pontifical Catholic University of Rio de Janeiro found that, in a representative sample of COVID-19 patients, non-white people had on average a fatality rate 37% higher than white people.