For the original article in Portuguese by Ligia Guimarães published on BBC News Brazil click here. This is our latest article on the new coronavirus as it impacts Rio de Janeiro’s favelas.
Having just turned 77 years old this week, oncologist Drauzio Varella says that he regrets having been optimistic regarding the new coronavirus. At the time when information had just begun surfacing regarding the virus in China, in December last year, he says that, like many others, he considered it a disease with low mortality, as the available data appeared to indicate. “I shared this optimism and I blame myself for this today.”
Considered part of the high-risk group for Covid-19 due to his age, the doctor, writer, and communicator has been leading an intense professional routine over the last few weeks, without leaving his house. He runs the daily morning meetings of the recently created group “All for Health” (Todos pela Saúde) as one of seven technicians working to allocate a R$1 billion (US$174 million) donation from Itáu Unibanco bank to combat coronavirus. The meetings are on top of the demands he experiences as a doctor, answering questions and providing guidance about the disease.
Combating the advance of the pandemic in Brazil, he believes, will involve different strategies and obstacles than those observed in countries in Europe and Asia. The main distinguishing factor in Brazil is its immense social inequality, which creates very different living conditions for the rich and poor, limiting the access of a large part of the population to the practices that prevent the spread of disease, such as washing hands, buying hand sanitizer, and practicing social isolation.
There are 35 million Brazilians without access to the potable water network, according to 2017 data from the Trata Brasil Institute. In 2018, before the coronavirus crisis, the number of Brazilians living below the extreme poverty line, on less than R$145 per month (US$37 at year-end 2018, now US$25), was 13.5 million.
It is this context that will undoubtedly drive the country to a “national tragedy” during the pandemic, according to Varella’s prediction.
“I think we are going to have a very large number of deaths, we are going to have a huge impact on the economy, for an extended period,” he predicts, highlighting that the historical normalization of the country’s social struggles will be the key determinant of such a tragedy.
“Now we are going to pay the price for this social inequality that we have lived with for decades and decades, accepting it as something almost natural. Now the bill has come due. Because this is the first time that we are going to have an epidemic spreading on a large scale in a country of continental dimensions with so much inequality,” he said in an interview with BBC News Brazil via videoconference.
During the pandemic, social inequality’s dangers to all segments of society are more evident, in the doctor’s perspective. “As long as we have this disease spreading in places unfit for human life, you won’t get rid of the virus. And it is this virus which threatens everyone, all the time,” said Varella, who predicts that the pandemic will cause profound changes in society.
“I think suffering is an impetus for learning. We are all going to lose friends, many will lose family members, and this will teach us that it is not possible to live the way we have been living up to this point.”
A staunch supporter of social isolation, one of the only measures proven to be effective against the virus (in addition to frequent hand washing, for example), he warns of the possible severe consequences for critically ill patients who, due to a lack of infrastructure, may eventually be left unattended, even while experiencing worsening breathing problems. “You can’t go home, suffer a little, and then get over it. No, not being able to breathe is the worst symptom there is. Because if you have pain, you take painkillers, if you have a cough, there is a way to stop it. Now, not being able to breathe is a horrible death. Horrible.”
Read key sections of the interview:
BBC News Brazil: Currently there are at least two versions of quarantine in Brazil. There are those people who are at home, with the family, managing to work from home, even experiencing a moment of peace, spending time together with the family. And then there are many people who are either homeless or in very crowded houses, without food, without money. How do you think that this situation influences the Brazilian fight against coronavirus?
Drauzio Varella: We are going to find out now. Now we are going to pay the price for this social inequality that we have lived with for decades and decades, accepting it as something almost natural. Now the bill has come due. This is the first time that we are going to have an epidemic spreading on a large scale in a country of continental dimensions with so much inequality. In Europe, we are seeing the problems that they are encountering, but they are countries that have a relatively well-organized social structure, which makes it easier.
Now [April 20] we are getting the beginning of the epidemic which happened among the people who introduced the virus to the country, who came from abroad, from international travels, and brought the virus here. And now we are seeing what happens in the cities that had a greater influx of those Brazilians who traveled abroad. São Paulo, Rio de Janeiro, Fortaleza, Manaus too, we are getting this first impact.
We will inevitably see the spread of this epidemic to the most disadvantaged social classes. This is what is happening in New York currently, where black people are greatly over-represented in [coronavirus] deaths in the city. We do not yet know what will happen when the 13 million Brazilians who live in precarious housing conditions and poor health conditions also become infected. We do not know what is going to happen; we will now learn the hard way. I travel around the country a lot. I’ve seen the peripheries of almost all major Brazilian cities. And when you enter these houses, it’s poverty on another level…
BBC News Brazil: Not hygienic conditions?
Varella: Not at all. And you have a room where four adults and three or four children live. During the day, that room is the dining room, at night the table gets put in the corner and the mattresses come off the wall and onto the floor, and people sleep there. You don’t even have the minimum conditions for separation. They say ‘stay at home, don’t go into the street.’ How can these people not go into the street?
And beyond this level of poverty, you can see what is happening: in two, three days they have nothing to eat. Because it is a struggle to go out and get to the supermarket and take something home, every day. Imagine that the money you have won’t last two, three days in isolation, because you won’t have anything to eat. And government aid, of course it is important, but it is also difficult to organize. People say ‘Oh, but the money should have come.’ Yeah, go and organize it yourself to see how it is. It’s not easy.
BBC News Brazil: Some of the countries that had more problems with the disease had their own peculiarities. For example, Italy had many elderly people. And the United States lacks a public health system. Do you think that these issues of inequality and poverty will be our main weaknesses?
Varella: I think they will be. I think this will be the great difficulty that Brazil faces. Because the virus is democratic, [in that] it affects everyone. So I said that we are going to pay the price for all this social inequality because as long as there are people living in these conditions, getting infected and transmitting the virus to each other, the virus will reach everyone, because people are all connected in one way or another, or share communal spaces in one way or another.
I, sincerely, I was optimistic, you know? I think in the beginning we all were. The whole world was optimistic. And I shared that optimism and I blame myself for it now. Because we received the news from China and that news was very sporadic, and it didn’t give an idea of what the epidemic was really like. This was in late December, when they reported the first cases, although the disease had already been spreading there. Then in January, the news we were getting was of mortalities. And the data they were claiming wasn’t too worrying.
BBC News Brazil: There was a lot of talk, then, of the low mortality rate…
Varella: Low mortality. It was only high 80 years and older, getting up to around 15%. When the epidemic arrived in Italy, which is a democratic country, with free circulation of information, we saw it at the beginning of February, around February 12 or 15.
Then we became aware of the seriousness of the problem. And you see that countries have not had time to organize themselves. The United States, with all its money, all the resources, and everything, was taken by surprise.
BBC News Brazil: And do you think that given the precarity in which a significant portion of the [Brazilian] population lives—we are not talking about a small group—being a longstanding, historic condition, do you think this is avoidable? Or are we doomed to a social tragedy?
Varella: There is room to do a lot, of course. When you feel the scale of the problem, everyone gets scared, everyone thinks that something has to be done. I have seen mobilization in every corner, but the problem is that the disease’s transmission is very fast. I believe there will be a national tragedy, I have no doubt about it. I think we are going to see a very large number of deaths, we are going to see a huge impact on the economy, we are going to experience this for an extended period.
You see that even now we are not able to define when we can relax. How much time? Two months? Three months? Six months? Nobody knows. Nobody dares to take responsibility for saying anything. We don’t know. This is a new virus, there has never been a situation like this.
But, ‘Ah, the Spanish flu.’ It doesn’t compare. They are different situations, the world was different over a hundred years ago. We don’t know, we are learning now, we are seeing what is happening in different countries. But the reality of one country is not the same everywhere.
BBC News Brazil: When you talk about many deaths, of course you can’t make a prediction, but when you think about this bad or likely scenario, what do you see?
Varella: Think about what the disease is like. You take a virus, which spreads very easily, this is proven worldwide. It starts and never stops. It has a phase that is very calm, a little bit of a sore throat, an irritating little cough, the person loses his or her sense of smell, a light fever, nothing very significant. This period lasts about five days, five to ten days, more or less. And then you have a divergence. There are people who recover, who had minor symptoms. Sometimes they were even asymptomatic.
After those five to ten days, it splits into two groups: those who will recover, in another week, the fatigue will pass, and they get better. And there are those who develop breathing difficulties. Those who develop breathing difficulties are those who have pneumonia related to coronavirus. This pneumonia has several pathophysiological explanations, but the point is: these are the patients who are going to end up in hospitals. Of those ending up in hospitals, some will recover by receiving oxygen through masks. And there are those who go into progressive respiratory failure. These people have to be put on ventilators.
So why support isolation? First, because it is the only measure where there is evidence that it has reduced the number of people who go to hospitals. We say that [there is a risk that] the health system starts collapsing. People are used to this thing of going to the emergency room and waiting to be seen, sometimes you aren’t seen, or it is badly attended and you go home.
Only now it’s a different situation. You only go to the hospital when you have difficulty breathing. And these breathing difficulties are progressive, you have to have mechanical ventilation resources at your disposal. If you don’t have these resources, what will happen? You can’t go home, suffer a little and get over it. No, difficulty breathing is the worst symptom there is. Because if you are in pain, you can take painkillers, if you have a cough, there is a way to stop it. But not being able to breathe is a horrible death. Horrible.
When you hear doctors say in Italy that they have to decide who goes to the ICU, who will have access to ventilators or not, it means that the others die because they can’t breathe. This is the real situation and this has to be communicated to the public. It is not that people will die. People will die with enormous suffering. That is why doctors defend isolation: let’s fight for this, so that people don’t have to die in this way, which is an unacceptable way.
BBC News Brazil: Isolation in Brazil has some peculiarities as well. There are protests against isolation, including out of fear of the economic impact. There are inconsistencies in government statements, in which someone says one thing and another says something else. Is our level of isolation concerning?
Varella: In some places it is going well. This is where we return to the social issue. Take someone who lives in a room with three, four children, how do you take care of these children? Look at the palafitas [stilt-houses], which are the worst places I have seen in Brazil. How do you keep those children in a wooden shed, in the North or Northeast of the country, in temperatures that reach 40, 45, 50°C [104-122°F] indoors during the day? How will people stay inside? Often without treated water, they have to go and fetch it in a bucket in some areas. And we say ‘wash your hands, pay attention to how you wash, do everything just right.’ That works for people who have a sink at home.
BBC News Brazil: Since the beginning of the pandemic, representatives of favelas have been sounding the alarm that it is necessary to have a specific plan for favelas. And they still claim that there has been no measure directed at these communities. Do you think that specific measures are necessary?
Varella: Yes, I think so. There are initiatives, but there aren’t any initiatives that come from government agencies for these populations. I have more confidence in the organizations the favelas establish for themselves. Look at Paraisópolis, in São Paulo, which is a wonderful example. They have installed an inspector in practically every block of the favela to monitor themselves. Their own society has the means to work together. What the authorities need to do is have plans providing coordination, which specify the aims of each particular plan.
Those people who say no, ‘we are going to make the children go back to school, young people who will not get the disease badly can move around in the city.’ First, this has not been done anywhere in the world, this so-called ‘vertical isolation’: separating the oldest, the vulnerable, and letting young people go to work. It wasn’t done anywhere for a reason, right? The whole of Europe, all of the developed world, including the USA where the federal government was initially against isolation, were eventually forced by the circumstances to adopt it.
There is no proof that vertical isolation works and actually, it probably won’t work, because you may be young but Brazilians are gregarious, they live very close together, you can catch the virus on the street and take it home. At this point, what we know we can do is isolate. People say: there will be an economic crisis. There already is an economic crisis. When you have an epidemic like this, if you let people go out, get infected in the street, at will, the economic crisis will happen all the same. This is irreversible. We are going to have the crisis. What the doctors defend, and what many economists defend is: we will face the crisis no matter what. So we will try to reduce the number of ill people to shorten the duration of the crisis.
BBC News Brazil: You mentioned this Itaú project, which caused a lot of buzz this week. What are you going to do, what is the focus of this R$1 billion?
Varella: This project is in its initial phase and moving as fast as possible because we do not have time to make elaborate plans, we have to adopt practical measures. We have been meeting every day, we have been dividing ourselves into priority areas which we discuss all day, with the executive role taken by Dr. Maurício Ceschin (ex-president of the National Health Agency).
We are focusing on some aspects: the first is the protection of health professionals. And this is not a corporate thing, but rather, because without health professionals we are unable to provide care for the population. If many health professionals become infected, we will not be able to replace them. A fundamental measure at the moment is that everyone wears a mask when they are on the street.
Masks are in shortage all over the world. We are focusing on a project to establish the means for national production by Brazilian companies to create the largest number of masks possible. The government has money for this, the state health secretariats have money, but they are unable to buy them at this stage. We are trying to create a regulatory stock of our own and help states procure masks for the lowest possible price.
The other effort is to check what problems we have at the moment in hospitals and state departments, creating crisis offices accordingly. They are there, firstly, in health departments to assist and to monitor the number of local cases and hospital resources. For example: let’s imagine you have something in hospital engineering that says the following: on average, in each hospital you can increase the number of beds by 20% by simply reorganizing the hospital structure, without building anything. Without investing anything in facilities, you can make this increase in capacity.
When we talk about R$1 billion, we say wow, it’s a lot of money. It would be a lot of money in our personal lives. But if you think that the SUS [Brazil’s public healthcare system] invests R$240 billion a year, the money is a great help, but it is not an unlimited sum either.
BBC News Brazil: The SUS is a strong point in Brazil, the fact that we have a free health system. What would you say are the biggest bottlenecks?
Varella: It is the inequality. The SUS is the largest public health program in the world. Brazilians undervalue the SUS. When I see the English, who put that acronym NHS (National Health Service) everywhere, their NHS is a joke compared to the SUS. England has money, a highly educated population, and a country with 66 million inhabitants. I want to see you give free health to 209 million people in a country as unequal and poor as ours. I want to see it.
Imagine if at this moment we did not have the SUS. So if you have good health insurance, it gives you access to the best hospitals, then great, you can relax. No, no you can’t. Why? Because the wonderful hospital to which you are ‘entitled’ may not have space for you. Look what is happening in the USA. Why are so many more black people dying there than white? Because black people have less money. And they avoid going to the hospital because they know that doing so could result in the bankruptcy of their whole family, because they don’t have a SUS. They will have to pay for at least part of the care they receive. And in the end they say well, am I going to die in the hospital and leave my family in debt? So they hold out, and only go to the hospital as a last resort.
The SUS, in fact, is a perfect system. What has always been the problem? The lack of resources. The federal government has been reducing its participation in the SUS for years. Theoretically, it should have to cover 50% of SUS expenses, the municipalities 25%, and the states another 25%. The federal government has been decreasing its share and is now giving about 44%. And the municipalities, because mayors are in contact with other mayors, are increasing their shares in the SUS and they don’t have as many resources. We have maintained the SUS while facing insufficient financing and poor management.
Why did Brazil arrive at this situation? In the last ten years, we have had 13 health ministers. The average tenure in office was ten months, because the Ministry of Health was used as a political bargaining chip. For some political party to support the government, if they want the Ministry of Health, give it to them. What do you do in ten months in a country of this size? The ministry has a very good technical staff, with trained professionals who have held on throughout this whole political issue. Now we have to get organized very quickly and that is a problem.
BBC News Brazil: Is it worrying to change the minister this late in the game?
Varella: Of course it is. The ministry [under the management of Luiz Henrique Mandetta] has behaved very well, has obeyed the guidelines of the World Health Organization, has respected the measures that were taken in other countries with health systems much more organized than ours, as is the case in Germany, the United Kingdom, and France.
I think that to remove a minister who is doing a good job at this time… Because it is not just one minister, it is his team as well. You remove a team that is doing a job very well, to remove this team for political reasons, that’s really rough. [Mandetta was fired by President Bolsonaro just days before this interview was originally published.]
BBC News Brazil: You are in the at-risk group, living in quarantine and working. How are you handling anxiety?
Varella: It is difficult because I, since I realized that a tragedy was going to happen in Brazil, I wake up in the morning in anguish already, in permanent anguish. For the work in education, in health, that I have been doing for many years, I feel responsible, you know. Because I know what it’s like, as if I were the Minister of Health. Seeing what I have to do, what we can do to help, how my work can be more useful for the people.
So they call me from the Rio Negro, in a region I don’t know much about, which is São Gabriel da Cachoeira. ‘Ah, can you do some messages for us, for the indigenous people to stay at home,’ in their communities. I can’t say no, so I prepare the messages, which takes time. Things are coming my way from everywhere and I try to pick and see where my actions can have the greatest impact. But this situation is very difficult.
I remember the AIDS epidemic, which my generation lived up close. I was doing a traineeship in a hospital in New York and I realized that this was going to happen in Brazil. And I was very distressed then as well.
I said this disease is going to spread across Brazil. At the time there was no cure, nor was it known what the agent was. HIV hadn’t been discovered yet. And I remember that I had the same feeling. But then, there was one problem, because you had to target sexual behavior. Okay, it is very difficult too, but there was a specific intervention point. Not here, it’s a virus that spreads through the air, it can reach everyone. I can’t really stay calm.
BBC News Brazil: Are you careful with your mental health? Any routine in that regard?
Varella: Look, for meditation I don’t have that wisdom (laughs). Because if I stop and meditate I am just going to think about the problems, where it is now. I am worried about Amapá. There is no structure there, there is no ICU. So it doesn’t work for me. What I try to do is study, follow what is happening closely.
For the first time in my life, I think I stopped studying oncology, which is my specialty, and I’m only studying the epidemic. I sometimes read something about oncology, but I can’t stay focussed for very long. I try to read a lot, I keep an eye on everything that is being published in international magazines, which have now become widely available, you no longer need to be a subscriber to the magazine to see everything that refers to coronavirus.
And I try to stay calm about it, write a little bit in between. And act, the way I can, while still in isolation.
BBC News Brazil: Returning to the question of inequality with which we started the interview, do you think that with this problem evidenced by the quarantine, when the pandemic passes, do you believe that, from the point of view of society, will something change? How will this influence society?
Varella: I think so, I think we are going to move on from this experience differently. I think suffering is a catalyst for learning. We will all lose friends, many will lose family members, and this will teach us that it is not possible to live as we have done until this point.
You see, years ago, we decided to host the World Cup and the Olympics in Brazil. Beautiful, right? So we built these white elephants, which today are a problem for the state governments, who maintain them with difficulty. At the time we used to say, but this money has to go to health, education, there is no sense in building stadiums. And what did they say? That we were part of the elite, that we wanted to deny the poor the joys of football. Very well. Now what are we taking these stadiums and making them into? Into hospitals.
This social irresponsibility that we have had for so many years is leading us to a very difficult situation now, and that will leave a path for learning. First: the SUS will never be the same, because we are now aware of its importance. How long have we been writing and saying that SUS is fundamental? I always quote a phrase from Gonzalo Vecina Neto (ex-president of Anvisa, Brazil’s health regulatory agency), who is a public health engineer, highly respected by all of us, which is: ‘Without the SUS, there is chaos.’ Now imagine what it would be like if we didn’t have the SUS?
It cannot be relegated to third, fourth place amongst government concerns. It has to be given priority. Health must be given priority, because we will not be able to build a civilized country with this disparity in access, where some have access to better technology, better doctors, better hospitals, and others are relegated to what is possible to give them. And what is possible to give them is not much, because the investment is small and the management is precarious. I think we’re going to come out of this differently.
BBC News Brazil: Is there anything else you would like to address that I did not ask about?
Varella: Look, I think that at this moment we have to give great importance to masks. Children have to wear masks, because teaching children will teach adults. Wasn’t that the case with the seatbelt? The child would get into the car, pull on the seatbelt and look at the father: ‘dad, put your seatbelt on.’ The father would be embarrassed that his young son was telling him to put his seatbelt on and would start to use the seatbelt as a result. It was like that with the cigarette too, wasn’t it? Teach the children that you can’t smoke, that you’re going to die, you’re going to have serious illnesses. The child would arrive home, ‘oh dad, you’re going to die, stop smoking, I don’t want to lose you.’ A strong stimulus, a child who says things like that. The same thing has to happen with the masks. We don’t have money, we can’t find a mask at the market. Make one at home.
BBC News Brazil: And is it something that we will have to use for a long time?
Varella: A long time. Because this virus will be with us for a long time. Not with the characteristics that it has now, with this absurd mortality, but it will take a long time to disappear from contact with humankind.