Brazil’s Health System Isn’t Ready for the Coronavirus

RIO DE JANEIRO—Brazilian President Jair Bolsonaro made the move to fire his health minister just as cities and states in the country’s poorer northern regions began to run out of critical care beds, their public health care systems crumbling under the weight of the novel coronavirus.

While other world leaders have called for urgent action, Brazil’s far-right populist leader has dismissed the deadly virus as a “little flu.” He has railed against lockdowns, shaken hands at rallies, and encouraged people to return to normal life. In recent weeks, he repeatedly clashed with ousted Health Minister Luiz Henrique Mandetta, who defied Bolsonaro and urged Brazilians to self-isolate.

It is still too early to tell if Brazil will shift its strategy on the coronavirus following the departure of the popular minister last Thursday. Mandetta’s replacement, Nelson Teich—a respected doctor and entrepreneur—said he was “fully aligned” with the president but assured Brazilians he would not make radical changes. But the shake-up left many wondering if Brazil could afford to waste any more time cobbling together a response to a health crisis that is already in full swing.

Despite Bolsonaro’s fervent denial of the severity of the coronavirus outbreak, his stance has been a lonely one. Governors and mayors in much of Brazil have scrambled to counter the president’s denialism by shutting nonessential businesses and telling citizens to stay home.

[Mapping the Coronavirus Outbreak: Get daily updates on the pandemic.]

But the mixed messaging seems to have had an impact. “The problem was that the discourse was so contradictory,” said Cecilia Machado, an economist and professor at the Fundação Getúlio Vargas in Rio de Janeiro. “So the efficacy of the social isolation may not have been as potent.”

Data showed the number of people complying with social isolation in São Paulo fell from a peak of nearly 70 percent on March 22 to just 47 percent on April 15, undermining efforts to slow the spread of the virus and ease pressure on the health system. Scientific studies show that roughly 70 percent compliance is needed for social distancing to be effective.

For the millions of Brazilians working in the informal sector the lockdowns have been painful. Suddenly unable to earn a living as street vendors or domestic workers, many poorer Brazilians have seen their economic frustrations echoed in Bolsonaro’s lambasting of social distancing measures.

“The tone at the top matters,” said Brian Winter, the vice president for policy at Americas Society/Council of the Americas. “Bolsonaro, through his own rhetoric, has greatly wounded the efforts of governors and mayors to buy Brazil some time.”

The coronavirus has infected more than 38,000 Brazilians and claimed the lives of some 2,400—although a woeful lack of testing means the true toll is likely much higher. In the northeastern state of Ceará, intensive care unit (ICU) beds have already run out, and authorities are projecting 250 deaths per day in the state capital next month. In Rio de Janeiro state, public hospitals are at 88 percent ICU capacity, and the system is expected to collapse this month. In São Paulo—the epicenter of the crisis in Brazil—more than 80 percent of ICU beds in public hospitals are full.

The crisis has further tested an already stretched public health care system in many parts of the country. In the northeast, for instance, public hospitals have just 0.8 beds per 10,000 people, data from Brazil’s Federal Council of Medicine shows. In the northern state of Amapá, one of Brazil’s poorest, there are just 0.33 beds per 10,000 people. This is compared to an already low national average of just one public ICU bed per 10,000.

“All the public hospitals, they are struggling already,” said João Amadera, a doctor and professor at the University of São Paulo Medical School. “And that’s just the beginning of the curve” for patients who contracted the coronavirus in the community.

The fragmented response by states may also ultimately be hurting the battle against the coronavirus by preventing effective coordination, Machado noted. Without a unified approach, for instance, it is difficult to shift ICU beds or ventilators from less needy states to ones overwhelmed with cases. Such resource sharing has been deployed in Europe, where German hospitals have absorbed some Italian and French patients, providing relief for health care systems in those harder-hit countries. “We need some coordination. We need a national policy in some way,” Machado said.

Brazil has not been the only country with a sluggish response to COVID-19. Elsewhere, including in the United States, a slow mobilization by authorities has had a devastating effect. But experts warn that the delay may be even more costly in Latin America, where overburdened health care systems are plagued by deep inequality.

Investment in public health care has plummeted since former President Michel Temer’s government ushered in an austerity package in 2016, freezing public spending for two decades.

The coronavirus crisis also comes at a time of year when public hospitals are already typically grappling with high rates of hospitalizations for other illnesses like dengue fever and influenza. So far this year, Brazil has reported nearly twice as many cases of dengue—a mosquito-borne viral disease that typically reaches peak transmission between January and May—compared with the same period in 2019.

Sharp cuts to health spending in recent years are partly what has put Brazil on the back foot. Investment in public health care has plummeted since former President Michel Temer’s government ushered in an austerity package in 2016, freezing public spending for two decades. Meanwhile, private health care—once intended to supplement the public system—has boomed, widening the disparity in the care available to Brazilians.

Brazil has one of the largest free universal health care systems in the world, which operates alongside a vast private sector accessible to Brazilians with insurance plans or those willing to pay out of pocket. Although some lower-income Brazilians have access to additional health insurance, the country’s wealthier citizens make up the majority of patients at private hospitals.

Now, as the country prepares for the peak of the crisis, the gap has come into sharp focus. About half of all ICU beds in Brazil are in private hospitals that serve just a quarter of the population. In these facilities, there are four for every 10,000, data from the Federal Council of Medicine shows.

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Disparities are even more stark between rural and urban settings and between the poorer northern states and the wealthier southern ones, noted Carmem Leitão, a professor in the Federal University of Ceará’s public health department.

In northeastern Brazil, just 12 percent of people have access to private health care—and the number drops to just 6 percent for those living in rural areas, data from Brazil’s National Agency for Supplementary Health. By comparison, 35 percent of Brazilians in the wealthier southeast have access to private health care.

The shortages in critical care beds are most likely to impact the most vulnerable Brazilians who rely on the public system. “We are confronting this pandemic within a difficult context, with a lot of inequality socially and economically,” Leitão said. “And the availability of critical care beds is clear proof of the inequality that we have within our health care system.”

Private hospitals, meanwhile, are already facing less pressure as the first wave of patients—many of whom were wealthier Brazilians who contracted the coronavirus while traveling abroad—is cured and discharged. “The curve of those patients peaked, so the private hospitals are already beginning to see these cases diminish,” Amadera said. “And at the same time, public hospitals are getting full.”

Brazil has struggled to source equipment, including ventilators, from abroad amid fierce competition with the United States and other affected countries.

For weeks, health authorities have been mulling how to integrate the two systems, with some states looking to contract ICU beds from private hospitals. Under such a scheme, public hospital patients who need critical care would be allocated to ICU beds in some designated private hospitals.

But the process has lagged, and the two systems are yet to be integrated, according to Amadera. The federal government announced only on April 9 that it would start requiring both public and private hospitals to record coronavirus cases into the same system, streamlining communication. Still, this only extends to facilities that already serve some public patients, and it does not include hospitals that exclusively serve private patients.

Similarly, the federal government struck its first deal for the domestic manufacturing of 6,500 ventilators on a national scale only in early April, more than six weeks after the first case of the coronavirus was confirmed in the country. Brazil has struggled to source equipment, including ventilators, from abroad amid fierce competition with the United States and other affected countries.

As the number of cases climbs at a dizzying speed, the crucial test on Brazil’s health care system will come when the virus begins spreading within informal settlements in major cities—known as favelas—which are made all the more vulnerable by crowded housing, poor sanitation, and lack of running water.

“Once it hits the favelas, it is going to be a major disaster,” Amadera said. “Then we will see the full effect of the crisis.”