Coronavirus in Brazil: The heavy weight of inequality and unsound leadership

As of early July, Brazil had over 1.6 million confirmed COVID-19 cases and the death tool passed 65,000. The lack of testing nationally suggests the overall figures may be about six times higher than the official count [[1]Universidade de Pelotas: EpiCovid19 2020. Available at: http://epidemio-ufpel.org.br/uploads/downloads/19c528cc30e4e5a90d9f71e56f8808ec.pdf.Google Scholar]. With a nominal GDP of $1.87 trillion, Brazil is the ninth-largest economy in the world, but also one of the world's most unequal - 20% of its population lives in poverty. An estimated 12 million inhabitants live in overcrowded “favelas”, lacking piped water and proper sanitation. SARS-CoV-2 is spreading faster in these deprived neighbourhoods and indigenous communities, where access to adequate care is extremely limited [[2]Lobo A.P. Cardoso-Dos-Santos A.C. Rocha M.S. Pinheiro R.S. Bremm J.M. Macário E.M. Oliveira W.K. França G.V.A COVID-19 epidemic in Brazil: where we at?.Int J Infect Dis. 2020; (S1201-9712: 30479-3)https://doi.org/10.1016/j.ijid.2020.06.044Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. This scenario of deep inequality and its detrimental health effects is not new [[3]Ahmed F. Ahmed N. Pissarides C. Stiglitz J Why inequality could spread COVID-19.Lancet Public Health. 2020; 5: e240https://doi.org/10.1016/S2468-2667(20)30085-2Summary Full Text Full Text PDF PubMed Scopus (488) Google Scholar]. Previous outbreaks of dengue fever, chikuvgunya, Zika Virus, and H1N1 also disproportionately affected the poor. In Brazil, like so many other global contexts, the pandemic has laid bare systemic inequities [[4]Shamasunder S. Holmes S.M. Goronga T. Carrasco H. Katz E. Frankfurter R. Keshavjee S COVID-19 reveals weak health systems by design: why we must re-make global health in this historic moment.Glob Public Health. 2020; 15: 1083-1089Crossref PubMed Scopus (79) Google Scholar]. President Jair Bolsonaro's (mis)handling of the pandemic served to further divide the country. Two health ministers - both doctors - left their posts in the first two months of the epidemic. Both urged the population to observe social distancing and follow proven health treatments while Bolsonaro promoted unproven treatments, publicly broke social distancing recommendations by socializing without a mask and participated in protests in favor of his government. The interim Brazilian health minister is Mr. Eduardo Pazuello, an army general with no health expertise [[5]Folha de Sao Paulo. Brazil's interim health minister improves relationship with states, but Covid data crisis ensues 2020. Available at: https://www1.folha.uol.com.br/internacional/en/brazil/2020/06/brazils-interim-health-minister-improves-relationship-with-states-but-covid-data-crisis-ensues.shtml.Google Scholar]. In early June, the Bolsonaro administration removed comprehensive numbers on coronavirus cases and deaths from the Health Ministry's website, claiming, without evidence, that state officials were inflating figures to secure more federal funding. The data were later reinstated after a Supreme Court justice ordered the government to stop suppressing them. The president's communication office (SECOM) continues to highlight daily number of Brazilians “Saved” and “Recuperated”, while omitting the number of daily confirmed COVID-19 deaths. Following U.S. President Trump's own dismissal of COVID-19, when the crisis started, Bolsonaro referred to COVID-19 as ‘a little cold’ and continued to belittle its gravity. As Brazil's Covid-19 death toll rose, Bolsonaro claimed that Brazilians could bathe in excrement “and nothing happens” [[6]The guardian. Jair Bolsonaro claims Brazilians 'never catch anything' as Covid-19 cases rise 2020. Available at: https://www.theguardian.com/global-development/2020/mar/27/jair-bolsonaro-claims-brazilians-never-catch-anything-as-covid-19-cases-rise.Google Scholar]. He has openly disagreed with public health recommendations, frequently arguing that the economic impact of lockdowns would be more detrimental than the health impact of the virus itself. On several occasions, his social media posts were removed for being identified harmful and false content [[7]Bloomberg. Facebook, Twitter, Youtube remove posts from Bolsonaro 2020. Available at: https://www.bloomberg.com/news/articles/2020-03-31/facebook-twitter-pull-misleading-posts-from-brazil-s-bolsonaro.Google Scholar]. In July 7, 2020 Brazilian president Bolsonaro tested positive for COVID-19 [[8]New York Times. President Bolsonaro of Brazil tests positive for Coronavirus 2020. Available at: https://www.nytimes.com/2020/07/07/world/americas/brazil-bolsonaro-coronavirus.html.Google Scholar]. Bolsonaro's inept handling of the epidemic occurs as the Brazilian Unified Health System (SUS) is suffering from long term shortages in resource allocation, understaffing and austerity policies [[9]Massuda A. Hone T. Leles F. de Castro M.C. Atun R The Brazilian health system at crossroads: progress, crisis and resilience.BMJ global health. 2018; 3e000829Crossref PubMed Scopus (234) Google Scholar]. Regional disparities in access to healthcare services has meant that poorer regions and lower socioeconomic groups rely almost exclusively on the SUS. The precarious nature of the system has thus been even more detrimental to these populations and concerns that the health system will be unable to cope with the increasing number of cases due to shortages of ICU beds and ventilators continues to rise. In Rio de Janeiro, for example, the state government promised field hospitals would be built by April, but yet in July, several are still under construction and the entire process has been marred by delays and corruption allegations. Despite structural inequalities, the government's response has been marked by exalting individual freedom over collective interest and public health guidelines [[10]Ortega F., Behaguel D.P.[O que a medicina social latino-americana pode contribuir para os debates globais sobre as políticas da Covid-19: lições do Brasil] In Portuguese. Available at: https://www.ims.uerj.br/wp-content/uploads/2020/04/physis30_2_a05.pdf.Google Scholar]. Phrases defending the “right to come and go” have been repeated as mantras against lockdown as well as unproven medications promoted as an individual “right”. The limited prevention information produced by the government has prioritized individual actions, such as hand washing - while millions lack clean water. The government has extended a minimal monthly payment of $110 (raised by Congress from their original proposition of $38), yet at the same time they have continued to pursue a neoliberal economic agenda, sought to reduce workers’ rights, refused to revert a 2016 Constitutional Amendment that froze health spending, and consistently negate the racial, ethnic and gendered dimensions of the country's inequality. The role of Brazil's inequalities in fueling COVID-19 transmission remain unaddressed. Lack of infrastructure, poor leadership and corruption has created a public health disaster. As new cases and the death curve continue to accelerate while the country continues to re-open, Brazil should learn from the United States that the worst is yet to come. None

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