Brazil is recording more COVID-19 deaths each day than any other country in the world. Having never really recovered from either its first or second wave of infections, the country is in the grip of a third wave which is worse in terms of both its case figures and its death figures.
There have been 13,758,093 cases and 365,954 deaths from COVID-19 in Brazil at the time of writing. Even adjusting for population sizes Brazil is faring far worse than any of its South American neighbours or other countries with similar population sizes such as Indonesia and Pakistan. (1) (2)
Brazil's president, Jair Bolsonaro, continues to attract severe criticism both at home and internationally for his refusal to acknowledge the seriousness of the pandemic. From the early days of the pandemic the Pan American Health Organization (PAHO) cautioned the different governments of Latin America about the virus and made clear that restrictive measures to curb its spread were needed. Whilst most countries heeded the call, the PAHO expressed frustration that Brazil and Mexico did not. (3)
Brazil has a universal health-care system and has run successful vaccination programmes in the past. This should have helped in the response to the pandemic. (4)
However Bolsonaro has continually played down the threat of COVID-19 and refused to instigate measures such as national lockdowns, social distancing or the wearing of face masks in public. Having recovered from COVID-19 himself, he describes it as a "small cold." (5) (6)
He has also declared that he will refuse a COVID-19 vaccine claiming it will masculinise women, feminise men and, most bizarrely, that it could turn people into crocodiles. (7) (8)
To add to this grim picture, one of the most concerning variants of the coronavirus has originated in Brazil.
So where has it gone wrong?
Lack of Lockdowns
President Bolsonaro has repeatedly rejected nationwide lockdowns describing individual state governors and mayors who tried to impose local lockdowns as "tyrants."
Despite Brazil’s soaring case numbers he continues to oppose lockdowns and has not changed his stance on the wearing of masks and use of social distancing.
People have been encouraged to continue as normal, including gathering in large groups and crowds.
This has allowed the virus to spread unabated and hospital intensive care beds across the country are full or close to capacity. Dr Miguel Nicolelis, a Brazilian professor of neuroscience at Duke University in the USA, told the BBC: "The country is in a nationwide hospital collapse right now - it's the first time in history the public health system has collapsed.” (9)
Vaccination
At the time of writing it is estimated that just 7% of the population have been vaccinated with their first dose of a vaccine.
Vaccination only began on 17 January 2021, many weeks after other Latin American countries.
The vaccine, China’s Sinovac, has an efficacy of only 50% and was not the government’s first choice but it has been left in a position of not being able to choose.
Brazil intends to manufacture 100 million doses of the AstraZeneca vaccine itself but this has suffered repeated delays. It is yet to produce any vaccine as it lacks vital ingredients that have to be ordered and shipped in from other countries before production can start.
The Health Ministry, which consists of predominantly military men rather than doctors or scientists, has also been slow to sign deals with any other vaccine makers.
In August 2020 it turned down an offer from Pfizer to purchase up to 70 million doses of its vaccine. It has now ordered 100 million doses from Pfizer but these are not expected to arrive until the second half of 2021.
Reuters news agency discovered that the Health Ministry instead focused on hydroxychloroquine, the anti-malarial drug touted as a possible treatment for COVID-19 despite no evidence that it is effective. The Health Ministry continues to promote hydroxychloroquine telling people to take it as soon as they have any symptoms of COVID-19.
It did not have to be this way in Brazil. It has a vast amount of experience in running vaccination programmes and is capable of manufacturing enormous quantities of vaccine.
As Professor Marcia Castro, from the Harvard T.H. Chan School of Public Health in Boston and originally from Brazil, explained, “The federal government squandered those advantages. It’s a succession of errors that began from the start of the pandemic, and sadly, we’re measuring those mistakes in the number of deaths.”
In January 2021 President Bolsonaro boasted he would never procure vaccine from China, citing its low efficacy rate. The Health Ministry has now announced a deal to purchase up to 100 million doses of Sinovac from China. (10)
The politician Silvio Antonio Favero, a vocal critic of COVID-19 vaccines and who used his social media accounts to play down the pandemic, introduced a parliamentary bill to prevent mandatory vaccination of the population against COVID-19. The bill is yet to be reviewed but Favero has since died from COVID-19 on 13 March 2021. (11)
Ironically, Brazil is one of the least anti-vaccine countries in the world. Public confidence in vaccines generally is high and, if they were available, the vast majority of the population would receive one. (12)
Humanitarian Issues
There are other factors that have contributed to the high COVID-19 figures for Brazil.
Poverty, crowded slums and poor living conditions all provide ideal conditions for a virus to spread.
Around 231 million people across Latin America were living in poverty by the end of 2020 and more than half the workforce is employed on a casual basis with no state regulations or safety nets over income. Locking down and staying home is not a viable option when it means no income. Informal workers also have less access to health care. (13)
Unemployment has been exacerbated by the pandemic and food prices have soared leaving many at risk of hunger. The cost of rice has increased by 70%, the cost of cooking oil by nearly 90%.
Renato Maluf, the president of the Brazilian Food Sovereignty and Nutritional Security Research Network said, “It’s a tragedy that was totally foreseeable.”
Poor nutrition reduces the ability of the immune system to fight infection leaving people already vulnerable to infection through their living conditions even more at risk.
During 2020 the Brazilian government paid a monthly allowance to enable families to buy food but the payments were gradually reduced and then stopped at the end of 2020. (14)
Brazilian Variant
The rapid spread of the Brazilian variant of the virus is a grave concern. The variant is more transmissible and is driving the surge in infections there.
In January 2021 it was estimated to be responsible for at least 70% of cases in Brazil.
Known as the P.1 variant it is spreading across Latin America and has been identified in other parts of the world.
Younger people in Brazil are developing serious COVID-19 and over half of the people on the country’s ITUs are now under the age of 40. (15)
Infections in people aged between 39 and 59 have increased by over 300% from the beginning of 2021 to the middle of March. Deaths in this age groups have also increased by more than 300% over the same time period.
The collapse of the health system came as the new variant took hold. As well as being more infectious, the P.1 variant is capable of re-infecting people who have already been ill with earlier strains of the virus.
In the south of the country nearly half of new infections are in the 20 to 39 age group.
Brazil is only vaccinating people over the age of 60. (16)
Most worrying is that children and babies are also becoming extremely unwell and dying, something that has not been seen elsewhere in the world.
This is a very alarming shift given that the one silver lining throughout the pandemic has been that children and younger people seemed to be less affected.
Dr Fatima Marinho, from the University of São Paolo and a senior adviser to the international health NGO Vital Strategies, estimates that COVID-19 has killed 2,060 children under nine years old, including 1,302 babies, in Brazil.
The very high number of COVID-19 cases across the country may have increased the risk of babies and children becoming infected.
Dr Marinho also explained that there were often delays on diagnosing COVID-19 in children saying, "We have a serious problem detecting cases. We don't have enough tests for the general population, even fewer for children. Because there is a delay in the diagnosis, there is a delay in care for the child."
However, poverty and lack of access to health care are also contributing to the high rates in children with Dr Marinho pointing out, "Most vulnerable are black children, and those from very poor families.....crowded housing conditions make it impossible to socially distance when infected, and because poorer communities do not have access to a local ICU. These children are also at risk of malnutrition, which is terrible for the immune response.” (17)
Scientists at the University of Oxford have been closely studying the effectiveness of both the AZ and Pfizer vaccines against several new variants including the South African, UK and Brazilian ones.
All the current vaccines appear to have some effectiveness against the variants but at lower levels. In particular, of the variants studied, the vaccines retained the most effectiveness against the P.1 variant meaning that vaccination will still provide some protection against P.1 infection. (18)
What is happening in Brazil should act as a caution to all.
The situation reflects what COVID-19 is capable of doing when very few or no measures to contain its spread are in place. It is sobering to reflect on the fact that the UK came perilously close to the collapse of its NHS in January 2021 and many countries across Europe are facing that threat right now. Without the combination of lockdowns and vaccination the unfolding picture in Brazil could happen anywhere.
(11) https://www.euroweeklynews.com/2021/03/15/brazilian-anti-vax-politician-has-died-from-covid-19/
(14) https://www.aljazeera.com/news/2021/4/11/tragic-combination-millions-go-hungry-brazil-covid-crisis
