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For Brazil’s Poor, the Pandemic Is Far From Over
As coronavirus cases there exceed 1 million, the country’s poorest are struggling to access medical care.
RIO DE JANEIRO—When Luiz Paulo Santos’s persistent cough grew deep and dry, his children begged him to see a doctor. As the novel coronavirus ravaged Rio de Janeiro’s Complexo do Alemão area in April, the 57-year-old Uber driver was still taking passengers across the sprawling patchwork of favelas in Rio’s poor northern zone. Some were heading to the hospital themselves, sickened by symptoms of COVID-19.
The 16 critical care beds in the urgent care clinic serving Complexo do Alemão’s 70,000 residents were all full when Santos sought help in late April. Desperate, his family took him to another facility in Manguinhos, a nearby favela with a violent reputation. There, his lungs failing, Santos waited in the reception area for two days before giving up and returning to his house in the Morro da Baiana favela.
“He couldn’t breathe, he was getting worse there, and he was scared,” his son Rogério Ferreira Santos recalled, noting his father was suspected to have COVID-19 and had a history of pneumonia. “And they weren’t doing anything to help him. So he left.”
Santos’s condition quickly deteriorated at home. His children once again rushed him to the nearby emergency room just hours later as his breathing weakened. With no available critical care beds or ventilators at the time, the doctors hooked him up to a nebulizer in a bid to ease his labored breathing. There, Santos joined hundreds of others waiting for an intensive care unit bed across Rio de Janeiro state.
Rogério got the news that his father had died the next day, April 24, as he marked his 30th birthday with a homemade cake in Complexo do Alemão. “I just couldn’t stop crying,” he said. “My dad didn’t even get to meet my son. He was born just a week before he died.”
With nearby public cemeteries full, city authorities tried to take Santos’s body to a plot across the city. Determined to bury their father in the neighborhood he called home for over three decades, his children paid a private funeral agency 4,000 reals (about $750). “We had to sell some of his things to bury him. And we’re still in debt to the funeral home,” Rogério said. “But the important thing is that he’s here with us.”
Santos was one of the many Brazilians who have fallen victim to a pandemic that has placed crushing weight on public hospitals. Brazil now has the world’s second-worst outbreak, with over 1 million cases and more than 48,000 deaths according to a consortium of media outlets that began compiling daily data after the federal government stopped publishing it. Hit by shortages of ICU beds and ventilators, hospitals have been overwhelmed by patients. The health system collapsed in parts of the country in April and May, and some cities in the poorer north opened up mass graves to bury the dead.
“Whoever has had to rely on public hospitals was damned—there’s no beds, there’s no one to care for you,” Rogério said. “It’s what happened to my dad. If it wasn’t for this, he would still be here with us.”
Meanwhile, the government response has been sluggish and chaotic. The country has lost two health ministers since the start of the crisis, as Luiz Henrique Mandetta was fired in April and his successor, Nelson Teich, resigned just weeks into the job. The post has now been formally vacant for over a month. Both ministers appeared to clash with far-right President Jair Bolsonaro, as he downplayed the virus, flouted social distancing measures, and called on Brazilians to go back to work.
The controversial president has also accused states of inflating the coronavirus toll—despite a severe test shortage signaling the opposite. A recent study estimated coronavirus cases may be about six times higher than the official count—meaning as many as 5.4 million Brazilians may be infected. Bolsonaro also recently tried to halt the release of data showing total cases and deaths, although a Supreme Court ruling forced the government to resume publishing the numbers. Last week, he urged his supporters to “invade” hospitals and take photos proving there are vacant ICU beds—a call to action that some actually tried to carry out in Rio.
In a country plagued by deep inequality, the pandemic has hit poor communities the hardest. In Rio, the virus has swept through favelas with lethal force, aided by a lack of running water, poor sanitation, and cramped housing. Isolation has been impossible for many residents who work in the informal sector, cleaning homes or delivering food. An analysis of official data showed confirmed COVID-19 patients in Maré’s favelas are dying at a rate that’s three times higher than in Rio’s wealthy Leblon district.
Favela residents have reported being turned away from packed hospitals or discouraged from seeking medical attention. Activists say that, at times, poor infrastructure bars ambulances from reaching these neglected neighborhoods. Across Rio state, the number of people waiting for ICU beds swelled above 1,000 in May.
In Nova Iguaçu, a working-class area on the fringes of Rio, one resident said her 84-year-old grandfather died at home last month, after health authorities refused the family’s repeated pleas to hospitalize him. “They totally dismissed the possibility of taking him to the hospital,” said the resident, her voice breaking. “They said it could be COVID but there was no space in the hospital and they couldn’t take him because he was elderly.”
A spokesperson for Rio de Janeiro’s Municipal Health Secretariat said the public health network is ready to treat anyone who seeks assistance in any public medical facility. The spokesperson noted that the municipal system has added 1,252 hospital beds exclusively for COVID-19 patients since the beginning of the pandemic, with 248 of those being ICU beds. In May, 526 beds were added, with 77 equipped to treat critical care patients.
The Nova Iguaçu resident, who asked to remain anonymous to protect her family’s privacy, also said authorities did not test her grandfather for COVID-19 following his death. “On the death certificate, they put the cause as respiratory failure,” she said. “It looked like they didn’t want to do a test, so that the number of cases doesn’t rise.”
City officials dismissed questions about this particular case but said “serious cases of hospitalized patients and deaths suspected of being caused by coronavirus have been tested according to Ministry of Health recommendations.” The city received 53,000 rapid tests from federal and state authorities, the spokesperson said.
The devastating toll of the virus—especially among the most vulnerable—has demonstrated that the public health system “wasn’t able to prepare itself for this pandemic,” said Luna Escorel Arouca, a coordinator with Redes da Maré, a local organization helping residents of Complexo da Maré cope with COVID-19. The organization counted 768 suspected cases and 94 deaths in Maré due to coronavirus up to June 8. Of those, only 241 cases were officially confirmed and 65 deaths were registered as coronavirus-related.
Health experts have argued the destructive impact of the virus could be curbed with a strict lockdown. But, while mayors and governors across Brazil were quick to impose quarantine measures in a bid to counter the president’s denialist message, many have since caved into pressure to restart economic activity. With an eye to municipal elections in October, few mayors have dared to impose strict lockdowns. Instead, many are doing the opposite: Shopping malls, churches, bars, and gyms are already opening in cities like Rio de Janeiro and São Paulo.
The pressure on hospitals has eased in Rio and São Paulo in recent weeks—partly due to fewer people seeking treatment for light symptoms—but the public health systems in poorer northern states such as Amapá, Pernambuco, and Maranhão remain under strain. The government has added 8,575 ICU beds to the public system across the country since April, the Ministry of Health said. Rio de Janeiro state promised to open seven field hospitals by the end of April, although several are still under construction. The projects have been marred by delays and corruption allegations, with Rio’s governor now facing impeachment proceedings partly due to charges of foul play in the bidding for field hospitals.
Authorities have rolled out measures specifically targeting favelas too. A CT scanner was installed in Maré about two weeks ago, but Arouca says it is still not functioning. There is also a bigger push to test residents in a bid to gauge how widespread infection is in the community. But, according to Arouca, the city sent just 500 tests to Maré, which is made up of 16 favelas that are home to nearly 130,000 people. “The actions have been superficial really. The state has still not made any structural changes,” she said.
The number of deaths continues to climb in Brazil, and health experts warn it could still be weeks away from its peak. Now, as cities and states relax quarantine measures, the fear is that vulnerable people, who were already struggling to access emergency care or quarantine effectively, will be dealt another blow.
“These residents are already at twofold risk due to their living conditions and their work conditions,” Arouca said. “The fact that … the choice of the government is to relax measures will only add another layer of risk for people.”
Rio’s health secretariat said the decision to relax quarantine measures was based on technical studies “focused mainly on the supply of beds in the city and the occupancy rate of these beds.” It said it has observed the gradual decrease in the number of patients admitted with COVID-19 and in the deaths of patients from the virus.
“Today, the [public health] network’s ability to respond with the provision of beds exceeds the need for hospitalizations,” a spokesperson said in a statement, noting that the occupancy rate for ICU beds is currently at 81 percent while hospital wards are 40 percent full.
But health workers warn that the crisis is far from over. Some hospitals—mainly those serving poorer areas—have been more overwhelmed than others and have yet to see patient numbers drop dramatically. And while field hospitals have eased some of the pressure on the public health system, critical care units remain under pressure, said Gustavo Treistman, an emergency room doctor who works in a clinic in the Magalhães Bastos neighborhood in Rio’s west zone.
“There are now hospital beds in the field hospitals,” he said. “So for now, it has unburdened emergency clinics in a sense. But there is still a lack of critical care beds, which remains the key problem.”
Fewer people circulating has meant less chance of mass contagion, buying hospitals some time. But now, with quarantine measures easing, the worry is that the public health system could once again collapse.
“With this premature reopening, we are truly worried that we’ll return to a situation where hospitals are packed and there are no hospital beds again,” Treistman said. “And our concern is that it will now become even worse than it was before.”