BRAZIL’S COVID-19 RESPONSE
An Account of Coordination Failure, Data Suppression, and Corporate Philanthropy
November 2020
ABOUT ITPC ACKNOWLEDGEMENTS The International Treatment Preparedness ITPC recognizes the tireless efforts of all Coalition (ITPC) is a global network of involved in the COVID response in Brazil. people living with HIV and community We express our particular thanks to people activists working to achieve universal access who have survived COVID, Brazilian to optimal HIV treatment for those in need. colleagues, health and humanitarian Formed in 2003, ITPC actively advocates for workers, and government officials who treatment access across the globe through were involved in data collection. ITPC also the focus of three strategic pillars: appreciates support from the Robert Carr Fund, the Open Society Foundations and Treatment education and demand the Bridging the Gaps Programme. creation (#TreatPeopleRight) COORDINATION Intellectual property and access to medicines (#MakeMedicinesAffordable) Project and Research Managers Wame Jallow Community monitoring and ITPC Director of Global Programs accountability (#WatchWhatMatters) & Advocacy
To learn more about ITPC and our work, Helen Etya’ale visit itpcglobal.org. ITPC Program Coordinator
ABOUT WATCH WHAT MATTERS Report Writers This publication is part of Watch What Dr. Fifa Rahman Matters, a community-led monitoring and Matahari Global Solutions research initiative to gather data on access Principal Consultant to and quality of HIV treatment globally. To learn more, visit our website, and use FOR MORE INFORMATION hashtag #WatchWhatMatters to join the Please contact us at [email protected] global conversation.
ABOUT THIS REPORT ITPC’s 2020 Brazil’s COVID-19 Response: An Account of Coordination Failure, Data Suppression, and Corporate Philanthropy, available here. This brief summarizes findings of an in-depth examination of key features of the Brazilian response from January to August 2020, drawing upon the testimony of clinicians, public health specialists, civil society, indigenous rights groups, data from government portals, mass media, academic literature, as well as insights into strategies by Ministries of Health, governors, and mayors of selected cities and states. CONTENTS
Executive Summary 1
The Socio-Economic Context in Brazil ...... 5
The Beginning of the COVID-19 Outbreak in Brazil . . . 8
Late March Onwards: Tensions between Bolsonaro and Ministries of Health ...... 15
Hydroxychloroquine Rhetoric and Impact . . . . . 20
Testing Policies, Underreporting, and Impact on Brazilian Surveillance and Response 23
A Lack of Health Data and Communications Transparency ...... 27 Impact on Indigenous Populations 28 Impact on Women ...... 30
Analysis, Conclusions, and Recommendations 33
Endnotes ...... 35 LIST OF ABBREVIATIONS AND ACRONYMS
AHF . . . . . AIDS Healthcare Foundation APIB . . . . Articulação dos Povos Indígenas do Brasil (Brazil’s Indigenous People Articulation) COE-nCoV . . Centre for Emergency Operations on COVID CONASS . . . Conselho Nacional de Secretários de Saúde (National Council of State Health Secretaries) COVID-19 . . Coronavirus disease 2019 ESPIN . . . . Emergências em Saúde Pública de Importância Nacional (public health emergency of national importance) FIND . . . . Foundation for Innovative New Diagnostics GDP . . . . Gross domestic product GNI . . . . . Gross national index IBOPE . . . . Instituto Brasileiro de Opinião Pública e Estatística (Brazilian Institute of Public Opinion and Statistics) IFF . . . . . Instituto Fernandes Figueira INESC . . . . Instituto de Estudos Socio-Economicos ICU . . . . . Intensive care unit ITPC ...... International Treatment Preparedness Coalition LGBT . . . . Lesbian gay bisexual and transgender MOH . . . . Ministry of Health MSF . . . . . Médecins Sans Frontières NGO . . . . Non-governmental organization PAHO . . . . Pan-American Health Organization PCR . . . . . Polymerase chain reaction PDT . . . . . Partido Democrático Trabalhista (Democratic Labour Party) PPE . . . . . Personal protective equipment RDT . . . . . Rapid diagnostic test SESAI . . . . Secretaria Especial de Saúde Indígena (Special Indigenous Health Department) STF . . . . . Supremo Tribunal Federa (Brazilian Supreme Federal Court) SUS . . . . . Sistema Único de Saúde (Brazil’s publicly funded health care system) TCU . . . . . Tribunal de Contas da União (Brazil’s Federal Court of Accounts) WHO . . . . World Health Organization questions aboutreopening early. in European countriesraising important despite newsof‘secondwaves’occurring week, to anaverageoflessthan450deathsper writing, pursuanttoareduction ofdeaths slowing oftheepidemic.Attime the numberofdeaths, however, there wasa23% reduction in one thousanddeathsaday. InSeptember, weeks—Brazil registered anaverageof until lateAugust—fourteenconsecutive Health Security Index,whicherroneously rates. Infact,theJohnsHopkins Global States, andRussiahavehad higherdeath some countriessuchasBrazil, theUnited and politicalcontextaskey factorsastowhy have alludedtoauthoritarian governments phases ofreopening businesses. underfunded For acountrywithcelebrated—albeit COVID-19 deaths. earlier intheyear, Brazilregistered 34,013 registering muchlowerdeath ratesthan In August2020,withmanycountries disparities inaccesstohealthservicesforindigenouspopulations, numbers, misinformationcomingfromthehighestlevelsofgovernment, The BrazilianCOVID-19responsehasbeenmarkedbyhighdeath EXECUTIVE SUMMARY while anumberofglobalhealthexperts health equity, to betterhealthoutcomesandimproved inhabitants andcontributedsubstantially brought qualityhealthcare tomillionsofpoor the in the world in terms of both the most COVID-19 cases and deaths. in theworldtermsofbothmostCOVID-19casesanddeaths. nearly 170,000officialregistereddeaths,makingitthesecondcountry report, Brazilhasrecordedmorethan6.1millionCOVID-19caseswith shortages ofessentialhealthtechnologies.Attimepublicationthis (SUS), which has Sistema ÚnicodeSaúde (SUS),whichhas 4 manystatesinBrazilare invarious 7 8 —public healthcare system, this came as a shock to some, thiscameasashocktosome, 2 From mid-Mayuntil 3 suggestinga 5 6 Thisis
9
There isalsohighincome inequality. its owncomplicationstotheresponse. population (212millionpeople)lends almost halfofSouthAmerica,andlarge The vastnessofBrazil’s territory, occupying and response. truly influencepandemicpreparedness raises importantquestionsaboutwhatfactors Latin AmericaandtheCaribbean. Brazil asfirstinpandemicpreparedness in in pandemicpreparedness, alsoranked United Kingdomasrankedfirstandsecond categorised theUnitedStatesand and political instability. In2015,Brazil All thisexistsinanenvironment ofeconomic registered deathsrelated tocoronavirus. uncontacted communities inBrazilhave due topoorsurveillance measures, even logging activitiesduringthepandemic communities, andwithanincrease inirregular an initiativetobringdoctorsintopoor indigenous populations. with adisproportionate effect onBrazilian those ofthewhiteBrazilianpopulation, rates ofblackpopulationswere higherthan October 2020,incidenceandmortality also hasracialjusticeimplications.Asof and poorreceive COVID-19 services,but inequality inevitablyaffects howtherich of programs suchas“MaisMédicos”, 12 After the abolition Aftertheabolition 10 This This 1 11 and and 13 This This
1 BRAZIL’S COVID-19 RESPONSE economy. jobsorworkinginthegig in informal 41% oftheworkingpopulationparticipating given uponthejobmarket,andaround rate, withalmostfivemillionpeoplehaving of 2019,Brazilhadan11%unemployment some timetotryandrecover GDPrates. had implementedneoliberalpoliciesfor indigenous rights,inheritedacountrythat anti-establishment, pro-family, andanti- himself asacandidatewhowasanti-LGBT, Jair MessiasBolsonaro, whopresented approval ratings. Bolsonaro continuestoenjoy comfortable handling oftheCOVID-19response, in thefinancialsector. Despiteshambolic evangelicals, themilitary, andthoseinvolved of Economy, andoverallappealingto at theUniversityofChicago,ashisMinister Guedes, whostudiedneoliberaleconomics neoliberal policiesbyappointingPaulo public health specialists,civilsociety, drawing uponthetestimony ofclinicians, January 2020through toAugust2020, features oftheBrazilianresponse from conduct anin-depthexamination ofkey Hence theobjectiveofthis report wasto levels. at governmental and theimpactofideologicaldisagreements illustration ofBrazil’s decentralisedresponse Brazilian response, weseektoprovide an to detailalltheaspectsanddetailsof to theoutbreak, andwhileitisimpossible in howdifferent citiesandstatesresponded of federalleadershipalsosawasymmetries response andpandemicpreparedness. Alack layers ofcomplexitytothecountry’s COVID institutional andeconomiccrises,adding crisis are graveco-occurring political, In otherwords, intandem withtheCOVID-19 by more than4%. in thefollowingyearGDPfellagain registered aGDPcontractionof4.3%,and improvement of1.23%, The result ofthis,otherthanaminorGDP 17 Bolsonaro hascontinued with 18 14 In October 2018, InOctober2018, 16 was that by the end wasthatbytheend 15
In summary, thissituationalanalysisfinds: a 68-yearold(white)malepatient. workers whorequested anonymity, aswell Hospital SírioLibanês),twohumanitarianaid (INESC), DrRafaelSaad(StrategyManager, Instituto deEstudosSocio-Economicos and SpecialAdvisorforIndigenousMatters, de Janeiro), LeilaSaraiva (anthropologist University Hospital,apublichospitalinRio (general practitioneratPedro Ernesto Programs, AHF),Dr. Debora Fontenelle Benzaken (SeniorMedicalDirector, Global Professor, UniversityMato do Sul),DrAdele (Infectious DiseasesSpecialist,Fiocruz,and key stakeholders,includingDrJulioCroda insights were obtainedon theresponse from testing data,numberofhospitalbeds,crucial data suchasthoseonbudgetsforCOVID, While there were issueswithfidelityofsome COVID-19 response. (STF peritsPortugueseacronym) inthe notably theBrazilianSupreme Court country leadersandinitiativesbythejudiciary, report alsolookedintorelevant actionsby mayors ofselectedcitiesandstates.The and by MinistriesofHealth,governors, literature, aswellinsightsintostrategies portals,massmedia,academic government indigenous rightsgroups, datafrom
experts outinto thecountrytoprovide Sirio Libanês,thisinitiative sentmedical Pela Saú the response byfundingthe Todos bank, ItaúUnibanco,tosupplement A lackofcoordination ledamultinational coordination intheresponse; and anoveralllackofleadership to thefiringofseveralhealthministers philosophies onhydroxychloroquine, led and lockdownpolicies,aswell Health officials onsocialdistancing the President andMinistryof Fundamental disagreements between de initative. Led by Hospital initative. LedbyHospital
2 BRAZIL’S COVID-19 RESPONSE inadequate; in particularhadbeennotedas and supplyofhealthtechnologies risk areas, planningforprocurement ventilators, andICUcapacity. Inhigh- included, butwasnotlimitedto,oxygen, and insomecasesinfrastructure—this by shortagesofhealthtechnologies The Brazilianresponse was marked contact tracing; comprehensive the inabilitytoperform to outbreak containment,particularly decision-making processes inregard testing policyledtodifficulties in The non-implementationofacoherent private-owned hospitals; ICU equipmenttopublichospitalsand kits, medications,ventilators,andother donating sanitisinggel,PPE,diagnostic authorities, aswellprocuring and Secretariats andmunicipalhealth technical supporttoStateHealth
present infectionrisks. land byindividualsandgroups who and duetoillegalintrusionsintoreserve due todifficulties inaccessinghealthcare populations inparticularare athighrisk ICU bedsinhigh-riskareas. Indigenous policies ofthestatesuchasavailability owing toingrainedracismandthe disproportionately affected byCOVID— Non-white populationsinBrazilare 3 BRAZIL’S COVID-19 RESPONSE PHOTO: Shutterstock of 1.23%, there hadbeenaminorGDPimprovement Minister ofEconomy. economics attheUniversityofChicago,ashis Paulo Guedes,whostudiedneoliberal place, andcontinuedthembyappointing country withtheseneoliberalpoliciesin the presidential electionsandinheriteda October 2018,JairMessiasBolsonaro won designed torecover theseGDPrates.In the implementationofneoliberalpolicies jobs orworking inthegigeconomy. working populationparticipating ininformal up onthejobmarket,and around 41%ofthe with almostfivemillion people havinggiven registered anunemployment rateof11%, fell againbymore than4%, of 4.3%,andinthefollowingyearGDP In 2015,Brazilregistered aGDPcontraction social policyfortwodecades. EC 95/2016froze additional investmentsin based onactualneed.Inotherwords, the relation totheinflationrate, ratherthan for thoseareas couldonlybeadjustedin 20 years,specifyingthatbudgetceilings security policiesforaperiodofthenext spending inhealth,educationandsocial constitutional amendmentthatlimitedpublic aim wastheapproval oftheEC95/2016 Akeymeasure implementedtowards this with theimplementationofanaggressiveneoliberalagenda. resulting fromashiftineconomicandsocialpolicybeginning2016, growing inequality.Thisisowingto,perhaps,agraveeconomiccrisis Brazil, anationofover212millionpeople,hasinrecentyearsfaced THE SOCIO-ECONOMICCONTEXTINBRAZIL in 2021. suffer adisinvestmentofalmost US$6billion that duetotheEC95/2016,SUScould Nacional deSaúdeinPortuguese)indicate by theNationalHealthCouncil(Conselho 20 23
but on the other hand, Brazil butontheotherhand,Brazil 22 By the end of 2019, Bytheendof2019, 21 catalysing catalysing 19 Estimates Estimates 24 Black Black lost employmentduringthepandemic, unemployed atthestartofpandemicor people livinginfavelaswere eitheralready economically activepopulation,45%of the samestudyshowedthatoutof 47.8% of black women having informal jobs. 47.8% ofblackwomenhavinginformal women are disproportionately affected, with nor showers. and 11.5%ofthehouseshadneithertoilets water from sources outsideoftheirhouses 9% ofthepeopleinfavelashadtoobtain out byFGVinRiodeJaneiro foundthat contexts). ASeptember2020studycarried slum neighbourhoods,generallyinurban populations livinginfavelas(low-incomeor The COVID-19pandemichasheavilyaffected in Brazilwere livinginextreme poverty. By theendof2019,almost14millionpeople healthcare viaprivatehealthservices, population (40millionBrazilians)accessing resulting inasizeableproportion ofthe not evenlydistributedthroughout Brazil, key inequalities.Forexample,theSUSis The SUSischaracterisedbyanumberof unemployment averageof11%. figure significantlyhigher thanthenational of thetotalhealthexpenditure. with theprivatesectorrepresenting 57.6% also significant regional differences, with in solely25%ofthepopulation. There are national expenditure onhealthare invested for healthcare, butthatmore thanhalfof 75% ofthepopulation)rely solelyonSUS approximately 170millionpeople(around 27 In terms of economic impact, ofeconomicimpact, Interms 30 Hence, Hence, 29 and and 26 28 a 25
5 BRAZIL’S COVID-19 RESPONSE ventilators andICUbeds. a report surveyingcoverage ofmechanical development, highlightedfurtherdisparityin education institutionfocusedoneconomic Portuguese), athinktankandhigher Foundation (FGV, asperacronym in In March 2020,theGetúlioVargas health system. importance ofawell-functioningpublic São Paulo,three richestneighbourhoods, study showingthatinBrazil’s largest city, within particularstates,withaFebruary2020 (approximately 10-20%), healthcare region coverageintheNorthern private healthcare, andlowerprivate as RiodeJaneiro andSãoPauloaccessing more than30%ofpopulationsinStatessuch region. hospital bedsinareas ofthe Northern the SouthofBrazil,butwithnoavailable de Janeiro, SãoPauloand somestatesin beds availableper100,000residents inRio described anadequatenumberofhospital 33 Theseinequalitiesare also observed 31 32 emphasising the emphasisingthe Thereport SUS. inhabitants, only7.1bedsbelongedtothe that outof15.6bedsavailableper100,000 recommended levels. the country, ICUbedswere belowrequired nationwide inparticularfoundthat70%of mechanical ventilatorsandICUbeds ICU beds. the populationlive,there were noavailable neighbourhoods ofSãoPaulo,where 20%of findings ontheCOVID-19 response inBrazil. entire city. had 60%ofSUSICUbedsallocatedforthe populated by9.3%ofSãoPaulo’s population, inhabitants. the numberofhospitalbedsper1,000 2017, there hasbeenan8%decrease in Technologies showingthatfrom 2009to andHealth and ScientificInformation a report bytheInstituteofCommunications seen areduction inpublichospitalbeds,with Since 2009,evenwithGDPgrowth, Brazilhas 38 Theserealities underline the following 35 34
36 Whereas insevenofthepoorest AMarch 2020report mapping 37 Thereport found 6 BRAZIL’S COVID-19 RESPONSE PHOTO: Shutterstock On 28 would beheadedbyCroda. the nationalresponse onCOVIDandthatit (COE-nCoV), whichwouldbecoordinating Centre forEmergency OperationsonCOVID the MOH,announcedplanstocreate the of theInfectiousDiseasesDepartment Mandetta andDrJulioCroda, then-Director The firstpress conference, helmedby was takingtocontainthepandemic. scientific findings,andactionstheMinistry on thepandemicinBrazil,todescribemajor conferences toprovide thepublicupdates and histechnicalstaff held dailypress Minister ofHealth,LuizHenriqueMandetta nCoV), and listed its key objectives as (to): nCoV), andlisteditskey objectives as(to): Emergency OperationsonCOVID(COE- employed tosetuptheCentre for Ordinance wasalsothelegalinstrument of NationalImportance(ESPIN).This Beginning the23 for thepandemicandkeepcitizensinformed. taken anumberofactionstoprepare In themeantime,Brazilianauthoritieshad Department ofSãoPaolo. positive forCOVIDon25thFebruary2020,accordingtotheHealth 61-year oldmanwhohadreturned fromLombardy,Italy,hadtested be acoupleofmonthsbeforethefirstcasewasreportedinBrazil—a several casesofacuterespiratorysyndromeinWuhan,China.Itwould At theendofDecember2019,Chinesepublichealthauthoritiesreported OUTBREAK INBRAZIL THE BEGINNINGOFCOVID-19 was released. set upandthefirstEpidemiologicalBulletin # 188 41 th declared aPublicHealthEmergency January 2020, the COE-nCOV was January2020,theCOE-nCOVwas 40 On2 rd ofJanuary2020,thethen- nd February, Ordinance 39
The COE-nCOV establishedthree levels data from countriesonthepandemic. and behaviourofvirus,epidemiological suchascaseprognosis available information and laboratorypersonnel andsystematising training sessionstohealth professionals the focusofCOE-nCOVwastooffer that betweenJanuaryandMarch 2020, Interviewed forthisreport, DrCroda stated ganize, coordinate andcontrol
plan, or set bytheMinisterofStateforHealth; ESPIN, inaccordance withtheguidelines the measures tobeemployed during services needed in the ESPIN. services neededintheESPIN. and theacquisitionofgoods hiring policiesforhealthprofessionals actions needed,includingtemporary Ordinance alsoestablishedalistof Minister ofStateforHealth.42The propose, inajustifiedmanner, tothe to thepublic;and onESPIN disseminate information ongoing administrativeactions; Health technicalreports on ESPINand forward totheMinisterof Statefor municipal SUSmanagers; articulate withstate,districtand
8 BRAZIL’S COVID-19 RESPONSE including thelackofemergency regulations. civil societyactorsonanumberofmatters, this time,there were growingfrom concerns equipment (PPE)anddiagnosticsupplies.At started toplanbuypersonalprotective cases, whileotherorgans of theMoH COE-nCOV wastomonitorandidentity (January toMarch 2020),thepriorityfor Dr Croda, intheearlydaysofpandemic the viruswasalready circulating. According to atthisstage,itwassuspectedthat confirmed already inlevel2.Whilenocaseshadbeen returning from abroad, thecountrywas based onMOHsurveillanceofindividuals At thetimeCentre startedtooperate, acorresponding determine courseofaction. is localtransmission),andeachlevelwould cases),andlevel3(whenthere or confirmed (imminent danger—whenthere are suspected were nocasesyetinthecountry),level2 of operations,level1(alert—whenthere Janeiro commented: aid professional from MSFbasedinRiode response. Onthis,asenior humanitarian significantly affected the timeliness ofBrazil’s somefeelcould’ve up pharmacies—that professionals andauthorization toset- example registration procedures forhealth other aspectsoftheCOVIDresponse, for COVID technologies,butthisleftgapsin enable emergency public procurement of In March 2020,legislationwasenactedto professionals)... there wasnofast (andotherhealth nurses, pharmacists regulatory bodies)forphysicians, talking aboutcouncils(professional bureaucracy ofStateentities—Iam And Iamnottalkingonly aboutthe bureaucracy wasincredibly bad. make thingshappen,theBrazilian have togetlocationsquicklyand an emergency response, where you but whenyou’re goingtoorganize This maynotseemsoimportant, 43
Brazilian government: Brazilian government: organisations alertedandengagedbythe circumstances, MSFisusuallyoneofthefirst especially giventhatinprevious emergency responsiveness oftheBraziliangovernment, expressed regarding concern delays in A seniorhumanitarianaidprofessional Infectious DiseasesfortheMinistryofHealth: theDirector NGO,formerly of international for AIDSHealthcare Foundation (AHF),an Benzaken, MedicalDirector, GlobalPrograms preparedness work.According toDrAdele echoed similarsentimentsasregards Other expertsinterviewedforthisreport and intubation. and intubation. nor enoughmedicationforsedation no (allocation)ofhealthprofessionals, preparation ofadequatehospitalbeds, the ICUsstartedtofillup.There wasno Brazil onlystartedpreparations when professional registration procedures. week andahalf,duetodelaysin with 90%mortalitybyaweekor had topostponeenteringanICU Absolutely nothing…We [MSF] professional regulatory bodies). State administrations,and facilitated (bythegovernment, illegally registered. Nothingwas councils toensure thattheyaren’t records ofthesepeopleinstate need tovalidatetheprofessional professionals from otherstates-you professionals soyouneedtobring have achronic deficiencyofhealth professionals—and someplaces the logisticsarriveveryquickly, hire open apharmacy, somehowmake arrive inaStatewhere youneedto a brutalpandemiclikethat.Soyou track foranythinginthemiddleof
9 BRAZIL’S COVID-19 RESPONSE and measles: and measles: focused more onthethreat ofdenguefever disease askeytocontrolling thepandemic, Brazilian expertiseindealingwithinfectious the dangerofCOVID-19andhighlighting Brazilian MoHpress release whilerecognizing efforts infacingtheimminentpandemic.A gathered inAsunción,Paraguaytocoordinate On February20 the official declaration beginning of the year: beginning oftheyear: than COVID,wereinthe themainconcerns in interviewthatdengueandmeasles,rather public hospitalinRiodeJaneiro, confirmed physician from Pedro Hospital,a Ernesto Dr. DeboraFontenelle,generalpractice Brazil, in six daysbefore case thefirstconfirmed community transmissionofCOVID-19and 14 deaths.” registered inthecountry, with 1st, 94,100denguecaseswere In relation todengue,until February measles and1deathfrom thedisease. already casesof has338confirmed America. However, in2020,Brazil coronavirus inthecountry orinSouth is stillnocirculation ofthe new such asmeaslesanddengue.There important epidemiologicalchallenges, coronavirus, Brazilhaseven more of infectionscausedbythenew are onChina,duetotheoutbreak Even thoughtheeyesofworld COVID inMarch. that Brazilstartedtomoveinrelation to Honestly weonlystartedtobeaware in thestartof theyearandwewere aboutdengue and measles concerned disease, somevirus…We were very prepare) forawaveofsome infectious Every summerwealways expect(and 45 theministersofhealthMercosur 46
th , nearlyonemonthbefore 44 by the MoH of bytheMoHof
the outbreak. making andimplementersforcopingwith least, establisheddifferent levelsofdecision- speed ofcontagion,itcouldhave,atthevery would nothavebeenabletopredict the specialists notedthatwhileawrittenstrategy foregone inplaceofspeedy action,Brazilian a writtenstrategicplancouldhavebeen is noreason forpanic.” issued anote,stating“Brazilisready—there individual returningfrom Italy), theMOH COVID-19 inBrazil(theaforementioned of ofthefirstcase plan, afterconfirmation pandemic. that theCOVID-19outbreak wasaglobal #5 MOH issuedEpidemiologicalBulletin events cancellations, andmobilityrestriction several oftherecommendations, suchas the MoHissuedanewpublication removing hours afterthepublication ofthisdocument, this documentwouldnot last.Lessthan24 On 12 closed spaces. recommendations tocancelofalleventsin event attendanceandgatherings, advice toauthoritiescancelworktravel, abroad, thecancellationofcruisetravel, quarantine fortravellerscomingfrom measures forcitizens,includingself- respond tothepandemic. document orstrategicplanestablishedto thatatnotimewasany of whichconfirmed emergency plansforthisrespiratory virus,all Ministries forestablishedcontingencyand requestsof information tosixgovernment 2020 byValente freedom describesformal inBrazil.AnarticlewrittenMay confirmed taken bytheMOHbefore thefirstcaseswere priorities, actions,andpreparedness work There isnodocumentedevidenceon started inthelastweekofJanuary. The training(related toCOVID)only campaigning formeaslesvaccination. , which describedanumberofnew th March 2020,theWHOannounced 50 OnMarch 14 48 Despite the lack of a strategic Despitethelackofastrategic 51 However, thecontentsof 49
47 th , theBrazilian Whilearguably 10
BRAZIL’S COVID-19 RESPONSE report, elaboratedonthese tensions: Chief ofStaff. DrCroda, interviewedforthis and headedbytheOffice ofthePresident’s Braga Neto. President’s ChiefofStaff, headedbyGeneral resulted from pressure bytheOffice ofthe interview toReutersthatthesechanges recommendations. DrCroda saidinan Impacts (created byBolsonaro onMarch 17th Supervision andMonitoringofCOVID-19 the COE-nCOVandCrisisCommitteefor these tensionsarose predominantly between isolation forpandemiccontrol, andthat began toariseabouttheimportanceofsocial It wasaroundtensions thistimethatinternal political. political. fragile anddecisionsbecame more the MOHtechnicalstaff becamemore From thatmomenton,thevoicesof meetings attheCrisisCommittee. ministries begantobeinvolved in to theChiefofStaff office. Other management movedfrom theMoH was created andsomehowthecrisis moment thattheCrisisCommittee these distancemeasures. Itwasatthis Office oftheChiefStaff regarding support from thePresidency andthe noise began,becausethere wasno measures, andsomeimportantpolitical municipalities startedtoadoptthese After thisbulletin,manystatesand guidance regarding socialdistance. That wasthefirstdocumenttoprovide until theend.We published bulletin#5. first, andthiswasalwayshisposition isolation, asallothercountriesdidat cases anddeathswouldbesocial to mitigatethenumberofreported the onlymeasure thatcould betaken which weneededtomakeavailable.So the numberofnecessarytestsnorPPE because atthattimehedidnothave social distancingfrom the beginning He [MinisterMandetta]defended 52
) health agencieswere threatened. initiatives betweentheFederalandLocal Crisis Committeemeantthatcollaborative early March 2020,thecreation ofthe continued tobethecaseinFebruaryand technically andfinancially. of supportingstatesandmunicipalities continued tohaveresponsibility interms however, theSTFstatedthatMoH in theBrazilianPresident. On thedecision, centralize thepowerofCOVIDresponse the Provisional Measure thatintendedto argument andsuppressed thearticlesof In mid-April2020,theSTFaccepted be preserved. the decisionsrelated tothepandemicshould the autonomyofstatesandmunicipalitieson Organic Law(Law#8.080/90) and,therefore, already definedintheConstitution, inSUS’ Janeiro). Alsoonthe20 in onlytwostates(SãoPauloandRiode casesand11deaths, had 904confirmed (PDT) Supreme Court(STF)bya politicalparty Measure waschallenged in theBrazilian transportation restrictions. ThisProvisional quarantine, socialisolation,andpublic his office thepowertodefine,interalia, bodies andagencies,grantinghimself cooperation dynamicsbetweenthefederal but alsotoredefine the responsibilities and COVID-related technologiesmore flexible, 926/2020) tomakepublicprocurement of President issuedaProvisional Measure (MP professional from MSFelaborated: jeopardised. Asaseniorhumanitarianaid technologies andservices were being coordination ofsupplyessentialCOVID While thispolitickingwasongoing, On 20 transmission hadbegun. issued anofficial declarationthatcommunity 54
March 2020,theMinistryofHealth whoargued thatsuchpowers are th 53 ofMarch 2020,the 55 At that time, Brazil At thattime,Brazil While this Whilethis 56
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BRAZIL’S COVID-19 RESPONSE called asset holdings, created aprivateinitiative the secondlargest bankinLatinAmericaby response. InApril2020,ItaúUnibancoBank, corporations investingin thenationalCOVID local healthauthoritiesresulted inprivate The lackoftechnicalsupporttowards elaborated furtheronshortages: and oftenrequiring logistics viaboat) predominantly composed oftropical jungle, bordering Colombia,Peru andVenezuela, Brazil(thelargest Northern Brazilianstate, COVID-19 intheStateofAmazonas, to bepartofatechnicalcommitteeon Ministry ofHealth,whohadbeenappointed and infectiousdiseasesdepartmentofthe headofHIV Dr AdeleBenzaken,former ICU beds. I am talking about oxygen. ICU beds.Iamtalkingaboutoxygen. Cachoeira. Iamnottalkingevenabout was nooxygeninSãoGabrielda Health Secretariat becausethere pressure ontheStateofAmazonas particular daywhenwewenttoput There wasnooxygen.There wasa end oflife. in pain.There wasnodignityatthe extremely serious.Peoplewere dying pandemic suchasthisone,was of medicinesforICUinBrazil.Ina we knewthere wouldbeshortages of medicines(byothercountries), Knowing thatthere were monopolies Todos pelaSaúde(AllforHealth) Saúde: of thetechnicalassistance byTodos pela anonymity, furtherdescribed theimportance interviewed forthisreport butwhorequested A humanitarianaidprofessional, whowas the response: Sírio Libanêsdescribestheirinvolvementin Dr. RafaelSaad,strategymanagerofHospital elites. country andoftenattendedbyBrazilian to beoneofthebestratedhospitalsin by SírioLibanêsHospital,generallytaken coordination ofTodos pelaSaúdewasplaced prison conditions,andsocialwelfare). Overall selling authorandcommentatoronhealth, (infectious diseasesspecialistandbest- of HealthSãoPaolo)andDrauzioVarella as GonzaloVecina Secretary Neto(former number ofnotedpublichealthexperts,such Surveillance Agency president ofAnvisa(theBrazilianHealth institution, (Brazil’s foremost publicbiochemicalresearch health, includingspecialistsfrom Fiocruz assembled theglitteratiofBrazilianpublic towards thisinitative.Todos pelaSaúde and donatedR$1billion(USD$200million) intentioned toprovide thistechnicalsupport, making in crisis situations. making incrisissituations. ability tomobiliseforquickdecision crises). Whileothersdidnothavethe had know-how(todealwithhealth noticed wasthatafewstatesalready needed. Oneofthefirstthingswe facilitated avisionofwhatwasreally with the[State]healthsecretaries expansion ofbeds.Closeconversations support decisionmakinginrelation to to by localmanagers,information support technicaldecisionmaking cases. We stillhaveteams stillto states duringtheperiodofrising We hadteamsfrom ‘Sírio’inallthe ), a former created in1900),aformer , created in1999),anda 12
BRAZIL’S COVID-19 RESPONSE than the MoH itself, for example. than theMoHitself,forexample. because theywouldhaveabetteridea staff ofTodos pelaSaúde,from Sírio, it wasindicatedthatwelookforthe including peoplefrom theministry, support. Talking toseveralpeople, it from thebeginning,givingtechnical person wastheonewhofollowing have apersonfrom Síriohere’, andthat whom Ispoketheyalwayssaid‘we and inRoraimaotherstateswith I remember thatbothinAmazonas states, in thestates.Theywere in26or27 staff tofollowthecrisiscommittees actions, theywere sendingtechnical Not onlywere theyfundingCOVID 57 whenIarrivedontheground, COVID-19 outbreak. how effectively thecountry handledthe wouldultimatelydependon performance convince thePresident thatBrazil’s economic that thesehealthofficials were unableto local authorities. authorities, namelyministersofhealthand conflicts betweenthepresident andother promising, butwasderailedbypolitical Brazilian response inthebeginningwas health authoritiesandspecialists,thatthe two dozenofcurrentBrazilian andformer opinion from reviews ofstatementsfrom over Some commentatorsopine,derivingtheir failure inCOVID-19response coordination. These testimoniesillustrateacatastrophic 58 The authors further state Theauthorsfurtherstate 59
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BRAZIL’S COVID-19 RESPONSE PHOTO: Shutterstock the closure oftheSupreme Court, in anumberofmassgatheringsfocusedon Portuguese) byorganising andparticipating the Supreme Court(STF, asperacronym in collision coursewithboththeCongress and growth. ThePresident thenset abouta down wasnotthewaytoachieveeconomic recovery, andinhisview, shuttingcities Bolsonaro wasprimarilyfocused oneconomic grew considerably. distancing measures tocontrol thepandemic andmayorstakingsocial MoH andgovernors of furtherinfection.Tension withboththe reported deaths,butthere wasaclearrisk time, Brazilhadonly310casesand12 only thoseabovetheageof60.Atthat who were mostvulnerable toCOVIDwere the ageofsixty, andemphasisedthatthose he tooktomeanisolationforadultsabove what hecalled“verticalisolation”,aterm In thesamespeech,Bolsonaro defended On March24th,vianationalbroadcast, BOLSONARO ANDMINISTRIESOFHEALTH LATE MARCHONWARDS: TENSIONSBETWEEN of Health, and municipal and local health of Health,and municipalandlocalhealth the MinistryofHealth,State Secretaries of Healthmanifestedinan inabilityfor the office ofthePresident and theMinistry Divergent philosophiesemerging from the virus. indicating hisapathyasregards thespread of mass confinement.” mass confinement.” “the prohibitionofpublictransportation,closingstoresandshops back tonormality.Afewstateandlocalauthoritiesmustabandon must bekept.Livelihoodsoffamiliespreserved.Weget because ofhis“athletichistory”andstated:“Our livesmustgoon.Jobs COVID-19 as“justalittleflu”thatwouldnotcausehimanyharm 61 further further further: further: collaboration. DrCroda describedthisgap this report, saidthere wasa“hugegap”in Dr DeboraFontenelle,inherinterviewfor effective manner. DrRafaelSaadelaborates: authorities torespond ina coordinated and 60 north andnortheast regions.” tragedies thatoccurred mainly inthe to prevent excessdeaths,toprevent when citiesshouldenter alockdown, should havealsobeworked on,i.e. measures. Thetechnical criteriaforthis ofimposingsocialdistancing in terms ofintensivecare in terms bedsandalso municipalities thathadgreater difficulty ofsupportingstatesand in terms to havehadagreater leadership wassupposed The federalgovernment antagonistic andatoppositepoles. making stakeholdersthatwere often of theprocess. We haddecision- come outasadefactocoordinator team... atnotimeanyoftheseactors the minister, anotherbythetechnical position bythepresident, anotherby of alignmentfrom thebeginning. One The Federallevelwasabsolutelyout the president Bolsonaro defined thepresidentBolsonarodefined
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BRAZIL’S COVID-19 RESPONSE recommended becauseitwouldcause the Marcos Espinal,todeclare thatthis“isnot of theWHORegional Office (PAHO), without lockdowns,which ledtotheDirector keep thecountryand economyopen, antibodies”. 70% ofpopulationare infectedandget Our nationwillgetridofthispandemiconce 70% ofyouwillgetit.Noonesaysotherwise. and supporters:“Thisvirusisliketherain, COVID-19 strategy, declaringtojournalists was relying onherd immunity as hismain casesand327officialconfirmed deaths. beds. aware ofany over-capacity as regards hospital reopening ofcities,arguing thathewasnot On 2 collaboration ascatastrophic: professional from MSFdescribesthelackof (of Amazonas)’.Aseniorhumanitarianaid avoided evolutionofinfectionsintheState to stagesofoutbreak, whichcould’ve dictate ‘proper coursesofactionaccording didnot stating thatthefederalgovernment Dr AdeleBenzakenwasofasimilarmind, On 3 recipe fortragedy. agree withthestateauthorities, thisisa authority distortsreality or doesnot very importantspread. Ifthe federal self-preservation, totry blocka for measures suchassocial isolation, to follow, whetherforvaccinationor are measures thatyouneedpeople believe intheState,becausethere health authorities.Peoplehaveto to anepidemicisthecredibility of an importantpartoftheresponse MSF operatesintheworld—isthat that istrueineveryepidemic saying sincethebeginning-and This issomethingthatwehavebeen responses thatwe[MSF]haveseen. Maybe itwasoneoftheworst rd nd 62 April 2020, he made it clear that he April2020,hemadeitclearthat April2020,Bolsonaro defended the Atthatpoint,Brazilhadaround 8,000 64 Hefurtherrecommended to 63 the MoH,effectively consolidatingand any healthexpertisetokey positionsat nominated severalmilitary menwithnary and infectiousdiseasesexperts, and technical staff, includingepidemiologists he proceeded tofire amajority ofthe Health on16September2020. days, wasofficially appointedMinisterof been interimministerformore than100 Teich resigned. speed onwhathadandhadn’t beendone. understand thesituationandcomeupto lost weeks,becauseTeich wasstilltryingto declared thatthelasttwo weeksofAprilwere deaths ofmillionspeople”. country. the President’s intentionstoreopen the use asbothtreatment and prophylaxis, and of hydroxychloroquine forgeneralpublic opposed tothePresident’s endorsement Minister ofHealth.Teich, likeMandetta,was oncologist andpublichealthconsultant,as the appointmentofNelsonTeich, asenior due toabovementionedtensions,and Minister. for theBrazilianarmy, asInterimHealth a parachutistandlogisticscoordinator appointed GeneralEduardo Pazuello, conflicts onhydroxychloroquine, Bolsonaro April 16 hundred daysandcounting. MinisterofHealthforone a permanent of eventsthatwouldleaveBrazilwithout Luiz HenriqueMandetta,settingoff aseries generate tensionswiththeMinisterofHealth, as atreatment forCOVID-19—beganto hydroxychloroquine shouldbewidelyused social distancingwasunnecessary, andthat President Bolsonaro’s beliefs—i.e.that least 800,000COVIDdeathsnationwide. Bolsonaro’s strategywasaimedtowards at On 16 stood at530deathspermillioninhabitants, mortality ratescurrent toOctober2020 th May 2020, perhaps to avoid further May2020,perhapstoavoidfurther th 67 70 , 2020 saw the firing of Mandetta , 2020sawthefiringofMandetta Afterlessthanamonthinoffice, General Pazuello, who had GeneralPazuello,whohad 68 Two staff former oftheMoH 65 71 Given that Giventhat As interim, Asinterim, 69 66
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BRAZIL’S COVID-19 RESPONSE the MOH has only spent only 12% of the the MOHhasonlyspent12%of juncture. TheTCUreport furthershowsthat COVID response hadbeenspentatthat of theFederalbudgetapproved tofundthe agencies,showsthatonly30% government financial andoperationaltransactionsof body responsible formonitoring andauditing per acronym inPortuguese), anoversight report from theFederalAuditCourt(TCU, the localhealthservices.A25thJuly2020 of deploymenthealthtechnologiesto didn’t seemtobemakinganimpactinterms Meanwhile, Pazuello’s logisticsbackground President’s ChiefofStaff. Crisis CommitteeundertheOffice ofthe response, ofthe initiatedwiththeformation public healthleadershipintheCOVID-19 finalising aprocess intendedtoeliminate governor,” heasserted. COVID-19 deaths—“gotoyour(State) concerted actionfrom him dueto40,000 this inresponse toacitizenwhodemanded Health. InJune2020Bolsonaro confirmed rather thanaresponsibility ofhisMinistry response wastheresponsibility ofthestates, STF judgment,thatCOVID-19pandemic Bolsonaro’s viewwasthat,pursuanttothe As timeprogressed, itbecameclearer that 73 72
telling us: telling us: into June2020,withahumanitarianworker The lackofcoordination continuedwell budget relative totheirmortalityrate. disproportionately littleofthisallocated Brazil,andRiodeJaneiro)Northern received those withhighestmortalityrates(Pará,in been deployed. allocated tostatesandmunicipalitieshad and thatonly40%oftheavailableresources budget approved tofundfederalactions to workwhenMSFputdoctorsthere. work—so muchsothatitonlystarted didn’t have(enough)employeesto already there. (Before that)thehospital professionals arrivefrom Brazilwithme send professionals; onlyinmid-Julydid long timefortheMinistryofHealthto was decided.InRoraima,italsotooka coming from theMinistry of Health the employmentoftheseprofessionals Health justarrived.Idon’t knowhow then thenursesfrom theMinistry of on theCOVIDfloorofthishospitaland doctors, nursesandnursingtechnicians Manaus, wehadalready placed (W)e were workingatahospitalin 74 In fact, two states among Infact,twostatesamong
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BRAZIL’S COVID-19 RESPONSE immediately seekhealthcare assistance.Inhisownwords: symptoms, beginningwithcoughing,butdidnot On March 18 located betweenhishometownandfinaldestination. was declared andheunfortunatelyhadtostayinacity travels onMarch 13 interviewed forthisreport. Thepatienthadbeenon from a68-yearoldmaleCOVIDpatientwhowas The lackofcredibility wasalsoseeninthistestimonial Affects PatientDecision-Making How HealthCommunications Patient Testimonial Highlighting to the supermarket. OnMarchto thesupermarket. 27 he lefttheaccommodationwasstayingattogo that Ididnothave…OnApril1 if Ihadafeverandshortnessofbreath, symptoms orientation wastostayathomeandonlyseekcare the healthauthoritieswasverygoodbecause I didn’t considerthattheguidanceordirections by not even how I went to the hospital. not evenhowIwent tothehospital. anything, from themomentIcollapsedin flat, I wasintubatedfor20days.don’t remember straight toICU,where Istayedforabout20days… Alegre, andIwasadmittedunconscious.went me down.Iwastakentoaprivatehospital inPorto 8pm, Ihadaveryhighfever, whichsuddenlybrought th —the datehebelievedwasinfected— th , 2020.OnMarch 15 st th , atapproximately , he started having , hestartedhaving th , quarantine , quarantine
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BRAZIL’S COVID-19 RESPONSE PHOTO: Shutterstock updated thrice,withthemostrecent version 2020, testimony. towards Brazilian government expert demonstrating generaldisregard ofthe find effective COVID treatments, further from useinitsglobalSolidarityTrial to that itwaswithdrawinghydroxychloroquine even havesideeffects”. COVID-19 andthattheproposed drugmay the “guaranteeofpositiveresults for or hydroxychloroquine doessoevenwithout that apatientwhoagrees totakechloroquine for downloadontheMOHwebsite,stating recommendation. isavailable Aconsent form This wasinitiallypublishedon20 with mildsymptoms. combination withazithromycin inpatients or hydroxychloroquine tobeusedin protocol recommending chloroquine minister enabledpublicationofa Appointing Pazuelloasinterim recipients ofhigherdosehydroxychloroquineregimens, President Bolsonaroactivelydisregardedevidenceoffatalityamong health officialswhoopposedthewidespreaduseofmedication. of conflicting MOHprotocolsonhydroxychloroquine,andfiring endorsement ofhydroxychloroquine,thepublicationmultiple As seenabove,theBrazilianresponsewasmarkedbyhigh-level AND IMPACT HYDROXYCHLOROQUINE RHETORIC dated 20 hydroxychloroquine in early stages of disease. hydroxychloroquine inearlystagesofdisease. campaigned toestablishaprotocolendorsingtheuseofchloroquineand despite WHO’s 4 These recommendations were maintained 76 and by October 2020 had been andbyOctober2020hadbeen th August 2020, maintaining this August2020,maintainingthis 79
th July 2020 announcement July2020announcement 78
th May May 77
chloroquine. raw materialfortheproduction of (approximately USD$300,000)inpurchasing have investedmore thanR$ 1.5million From March onwards, thoselaboratories and theairforce. forces—navy,that belongtothearmed army laboratories, amongstwhichare thethree protocols. Brazilhasawide networkofpublic far beyondthepublicationofclinical expertise, hasmanifestedintoactions anddomesticscientific both international The pushforthesedrugs,contraryto numerous localhealthauthorities. without prescription, underinstructionof These medicationswere oftendistributed 4.5 millioninstockfordeployment. to 4millionchloroquine pillsandhadalmost July 2020showthatBrazilhasdistributedup Sirio’s efforts to reduce misinformation: distributed oftenwithout prescriptions, and described howthesemedications were in thefield.DrRafaelSaad,hisinterview, Sirio staff, amongothers,torebut thiswhen 80 Available statisticsupto 24 75
and and
82 It fell on Itfellon 81 th
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BRAZIL’S COVID-19 RESPONSE even withoutprescription. a bagofmedicinesbeingdistributed in Amazonas.(Theyare) simplygetting distribution tovulnerablepopulations efficacy… weare nowseeingabundant that there wasno[scientific]proof of the protocol, andwealwaysreinforced that expressed interest indiscussing doing thisfieldworkwiththestates There wasateamfrom ‘Sírio’whowas underlined thepushforhydroxychloroquine: Dr. Croda theorisedthateconomicmotives because youhaveeffective medication. is noriskofgoingtotheICUordying life,i.e.there can returntoyournormal message tothepopulationthatyou is aneffective drug,yousendthe and themomentyousaythatthere the economyneedstoreturnanyway, towards theeconomy, (theidea)that The insistenceisbackedbyvalue 21
BRAZIL’S COVID-19 RESPONSE PHOTO: Shutterstock that COVID-19 can also be diagnosed based that COVID-19 canalsobediagnosed based in June2020 statesinlieuofPCRdiagnosis, Surveillance Guidepublished bytheMOH results. Forexample,anEpidemiological withdataaround other concerns positive PCR results topatients,there are several In additiontorelatively latedeliveryof anonymity) toldus: Ahumanitarianaidworker(whorequested health workerstorespond effectively. "was sub-par, compromising theabilityof diagnostics coordination and surveillance of thisreport (August-September 2020), At thetimeofdatacollectionandwriting at arateof74.87testsper1,000inhabitants and Panama,withahigherGNIpercapitacomparedtoBrazil,istesting capita toBrazil,istestingatarateof51.09testsper1,000inhabitants, tests. Bywayofcomparison,Colombia,withaslightlylowerGNIper per 1,000inhabitants,despiteutilisingbothPCRandrapiddiagnostic As of31August2020,Brazil’stestingrateisrelativelylowat22.57tests AND RESPONSE AND IMPACT ONBRAZILIANSURVEILLANCE TESTING POLICIES,UNDERREPORTING, had already passed. go andstarttheresponse, thepeak decision andmobilizedthepeopleto late… (bythetime)wemade the situationwasthatwewere always Whenwegottoastate information. ofepidemiological behind interms I thinkwe’re alwaystwoor three weeks because epidemiological information collect. Andyoucan’tthe confirm youcan the typeofinformation of aPCR,andthenthatalonedelays four workingdaystohavetheresult In RoraimaandManausyouneeded
(RDTs). positive results ofrapiddiagnostic tests positive testscombinesPCRresults with scientists in Brazil: scientists inBrazil: oversaw thesetrialsincollaborationwith Access Officer atFINDdiagnostics, who 80%. According toSergio Chief Carmona, a numbershowingsensitivityratesofabove have undergone clinicaltrials inBrazil,with October 2020,anumberofantigenRDTs results. Itshouldbenoted thatcurrent to far andtherefore theaccuracyofpositive about thequalityoftestscarriedoutthus by theWHO,there are real questions diagnostic testshavejustbeenprequalified tomography. on, interalia,symptoms,x-rayresults, and to reduce therisk oftransmission. testing positive canisolateimmediately settings are vitaltoensure that people in primarycare orevencommunity quality teststhatcanbe conducted proportion ofthepopulation.High- PCR testingisnotaccessible foralarge countries likeBrazil,where lab-based RDTs willbeagame-changerin management. High-qualityantigen to goodclinicalandpublichealth has emerged ascentrallyimportant Fast accesstoreliable testresults 85 . 83 Given that at time of writing rapid Giventhatattimeofwritingrapid
84 Secondly, MOHdataon
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BRAZIL’S COVID-19 RESPONSE trials. of thereport, thisinitiativeisstillundergoing application wasdeveloped.Attimeofwriting beginning ofAugust,whenasmartphone properly implementcontacttracinguntilthe bemoaned by a number of health authorities, bemoaned by anumberofhealthauthorities, on reopening ofcities.Thisapproach was of thepandemicandtomake decisions number ofdeathstomeasure thespread have utilizedICUoccupation ratesandthe andmayors contact tracing,governors Due tolowtestingratesandineffective system, whichisverygoodinBrazil.” We didn’t takeadvantageoftheprimarycare testing andthesurveillanceteamtodothis. we don’t contacttrace,asitdependson tracing. Hestated:“Ifwedonothavetests, testing rateaffected theabilitytodocontact Dr JulioCroda tooexplainedhowthelow from MSF: of aseniorhumanitarianaidprofessional close contactwithpositivecases.Inthewords proactively isolatingindividualswithreported reacting towhere fullICUswere ratherthan and first responders inmanycaseswere tracing strategymeantthatmedicalstaff example Niterói, theexceptionofafewcities,for With time, you lose lives. time, youloselives. not beenabletodothisforalong your logisticstothatpoint.Ifyouhave think aboutoxygen(and)youdirect will collapse(inacertainplace),you well. Ifyoucanhaveevidencethatit better. AndthathappenswithSUSas if youhaveagooddatacansee 90% (capacity),theyshouted.Whereas the cryofICUs.Whentheyreach exploded. Inactualfact,Brazilfollowed things, peoplegotworseandthenit took alongtimetogettheheartof you couldn’t stopthatfocus. (We) testingandcontacttracing) (Without 87 Thelackofacomprehensive contact 86 nor was Brazil able to norwasBrazilableto safer reopening ofcities. who statedthatmore testswouldenable Portuguese acronym CONASS),CarlosLula, of StateHealthSecretaries (knownbyits including theheadofNationalCouncil underreporting isoccurring.On3 analysis, there are anumberofindicatorsthat In additiontoanecdotesinthissituational income have22%. of seroprevalence andhouseholds withlow households withhighincome showed9% seroprevalence. Inrelation toincome, non-white peoplehavea 34%COVID-19 populations. While18%istheaverage, a disproportionate impactonpoorandblack school years,gender, andage,showed approach, segregating databyincome,race, The studyalsoemployedasocio-economic and philanthropic institutions. Paulo andwascarriedoutbypublic,private SoroEpi MSP, tookplaceinthecityofSão serological surveys.Thefirst initiative,called actual scopeoftheCOVID-19outbreak via two initiativestoinvestigateanddocument Underreporting oftesting datahasledto misreported asnon-COVID deaths. causes ofdeathare being underreported or access care andasaresult died,orthat meant thatindividualswere notableto that resources beingdirected toCOVID-19 average. Thiscouldmeanacoupleofthings; in 2020comparisonwiththelastfiveyears’ more peoplehavediedfrom naturalcauses In absolutenumbers,anadditional92,000 to theaverageinprevious fiveyears. more deathsfrom naturalcausescompared On average,in2020,Brazilisregistering 23% 2015 to2019withthefigure in2020thusfar. number ofdeathsfrom naturalcausesfrom monitor, intendedtocompare average Secretaries released a“mortalityexcess” 2020, theNationalCouncilofStateHealth population hasCOVID-19antibodies. results indicatethat18%ofSãoPaulo’s 91
88 89 Preliminary rd August August 90
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BRAZIL’S COVID-19 RESPONSE This surveyalsoshowsasignificantdifference official MOH reported casesbysixtimes. persons livingwithCOVID-19surpasses study suggeststhattheactualnumberof of 76%seroprevalence. Importantly, the the firstphasetothird, there wasincrease 0% prevalence andotherswith20%from 3.8% nationwide.Thesurveyfoundcitieswith average COVID-19seroprevalence foundwas Brazilian regions, from MaytoJune2020.The interviewed andtested89,397peopleinall commissioned bytheMOH.Thisinquiry Pelotas inpartnershipwithIBOPE,astudy was carriedoutbytheFederalUniversityof The secondinitiative,calledEPICOVID19-BR, 3.27% versus1.1%amongwhiteBrazilians. non-white Brazilianshadaseroprevalence of populations thisfigure was1.5%,while COVID seroprevalence of3.3%,forricher June 2020,whilepoorer populationsshows on theEPICOVID19-BRdatafrom Mayto a nationwidescale.Onaverage,based by theSoroEpi MSPstudy, althoughon inequalities inraceandincomeshown The EPICOVID19-BRalsocorroborates region 0.16%. a seroprevalence of7.7%,whiletheSouthern (where Amazonasstateislocated)hasshown among regionsregion inBrazil.TheNorthern 92 25
BRAZIL’S COVID-19 RESPONSE PHOTO: Shutterstock human rightsinanemergency context.” and publicpoliciesthatcould guarantee to COVID,butalsonon-execution ofbudget not onlysuppressing important datarelated include that “theactionsofthegovernment require themandatoryuseof masks, stating COVID-related bills,suchasonethatwould Act,andforvetoingimportant Information for itsattempttoamendtheAccess forsuppressing government healthdata, Court onHumanRights,denouncingthe reported BraziltotheInterAmerican Also inJuly, sixcivilsocietyorganisations on thewebsite. however didnotrestore breakdown byrace MOH wascompelledtorestore thedata, On 6 gender andrace,amongothersindicators. total numberofcases,deaths,mortalityrate,brokendownbyregions, a websitespecificallycreatedtopublishdatarelatedCOVID,suchas From thestartofoutbreakuntilearlyJune,MOHhadmaintained particularly asregardsracialbreakdownsofCOVID-19infections. The responsewasalsomarkedbysuppressionofhealthdata, AND COMMUNICATIONS TRANSPARENCY A LACKOFHEALTH DATA display dataasitpreviously was. Court decisionthattheMOHshould parties, resulting inaJuly 2020Supreme transparency actionbyBrazilian opposition deaths. Thisprompted the filingofadata daily countofCOVIDcasesand individuals whohadrecovered anda download ofdata,leavingonlydataon inhabitants), andthetoolallowingfor the infectionrate(casesper10,000 the totalnumberofcasesanddeaths, way datawaspresented by removing th June2020,theMOHchanged 94 The 95
than 30,000deathswere left uncategorised, occurring amongthewhitepopulation.More deaths, with31.3%ofofficial deaths accounted for42.6%ofofficial COVID indicated thatthenon-whitepopulation progressed, andMinisterschanged, precautionary measures. As thepandemic day at5pm,detailingnumber ofcasesand COE-nCOV heldpress conferences every In theearlystagesof pandemic,the beginning ofthepandemic. severe acuterespiratory syndrome sincethe only availableforindividualshospitalisedwith data changed,withbreakdowns bygender became MinisterofHealth,presentation of June 2020onwards, whenGeneralPazuello men infectedwithCOVID.However, from portal hadshownpercentages ofwomenand Up toJune2020,theMOHofficial COVID reportsgovernment COVIDdatabygender. There havealsobeenchanges tohowthe numbers. raising questionsaboutveracityofactual week of30 epidemiological bulletin(#30)detailingthe finalisation ofthis report, themost recent MOH, usuallypublishedweekly. Attimeof epidemiological bulletinspublishedbythe Breakdown byraceispublished in
93
th Augustto5 th September 2020, September2020,
96
27
BRAZIL’S COVID-19 RESPONSE inconsistent withscientificevidence, social mediatospread messagesthatwere intellectual religious leaders hadtakento widespread Anti- COVIDdisinformation. At thesametime,Brazilwasstrugglingwith communications: secretary incharge ofgovernment who wasappointedBolsonaro’s government Luiz Eduardo Ramos,afour-star general army the numberofrisingdeaths.Inwords of communications wasdesignedtoobfuscate persons recovered from COVID.Thisshiftin the emphasiswaschangedtonumberof the takeoverofGeneralPazuelloasMinister, COVID casesandnumberofdeaths.With announcements were focusedonnumberof Mandetta’s tenure asMinisterofHealth, there wasachangeinapproach. During were identifiedasbeingmisleading. deleted byFacebookandTwitter afterthey presidential postsonthepandemicwere posts byPresident Bolsonaro. Anumberof these were amplifiedbywayof retweets and patients) were cured. The ministerwillsaythat56percent (of disclose thenumberofpeoplecured. happening. We are goingtobegin you, there are somanypositivethings (the figures, but)…Iurge you,Ibeg here issayingthattheyhave tohide deaths… Thatdoesn’t help. Nobody it’s coffins andbodies,it’s numberof and abody. Intheeveningpaper, body. Atlunchtime,itisacoffin again, paper, itis(talkingabout)acoffin,a allduerespect, inthemorning With 97
98 99 and and peoples. According toanotebyAPIB: representing aninfectionrisk toindigenous logging activitiesinindigenous areas, a lackofregulation andcontrol onillegal As aresult ofthesepolicies, there hasbeen populations. figures show877deaths among indigenous number ofdeathswas484,whereas APIBs indigenous populations—theofficial figures government ondeathsamong 2020 highlightsadiscrepancy between Curiously, APIBdatafrom November (National IndianFoundation)orFUNAI. such astheFundaçãoNacionaldoÍndio regulations, policiesandcontrolling organs, expansion andtheattackagainstprotective the administration’s supportofagribusiness the rightsofindigenouspopulationsvia there hasbeenbrazendisregard toward since thestartofBolsonaro government, environment around indigenousissues; Underlying thesefigures is atensepolitical were cases. almost32,000confirmed of indigenousgroups, showed thatthere Brazil andinfluencepoliticsaround therights established tounifyindigenouspeoplesin Portuguese acronym), anorganization Indigenous PeopleArticulation(APIB,per September 2020,monitoringbyBrazil’s in villagesandruralareas. COVID infectionforindigenouspersonsliving miners continuetobethemainriskfactorof peoples, theactivitiesofillegalloggersand organizations workingclosely toindigenous among allexaminedpopulations. peoples was5.6%,thehighestprevalence COVID prevalence amongindigenous EPICOVID19-BR project hasfoundthat Recent surveillanceconductedviathe disproportionately affected byCOVID. Indigenous populationsinBrazilhavebeen Populations Impact onIndigenous 102 According tocivilsociety 103
100 In In 101 104
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BRAZIL’S COVID-19 RESPONSE 19. protect indigenouspeoplesfrom COVID- demanding aspecificcontingencyplanto In April2020,APIBissuedastatement was notgranted, i.e.theremoval ofinvaders in manyaspects, onespecific request ofAPIB Despite theimportance of theSTFdecision Socioeconômicos (INESC): on indigenousmatters,InstitutodeEstudos Saraiva, anthropologist andspecialadvisor indigenous populations.According toLeila to therightsanduniquevulnerabilitiesof todevelopaplanspecific government decided infavourofAPIB,compellingthe August 2020,theSupreme Court(STF) invaders from indigenouslands. of a‘sanitarybarrier’andtheremoval of specific measures suchasthecreation be wipedoutbyCOVID,andcalledfor cautioned thatentire ethnicgroups could constituted atruegenocide. omissions) ofthefederalgovernment andthattheactions(or government, plan beinstitutionalisedbythefederal demanding thatthisspecificcontingency parties petitionedtheSupreme Court July 2020APIBandsix(opposition)political and destroy ournature? grabbers continuetoviolateourrights invasions byloggers,minersandland communities, buthowcanwedothisif Health Organization (WHO)istoisolate The recommendation oftheWorld attempt of genocide. attempt ofgenocide. currently experiencingadeliberate decision, wealready haveandare important… Infact,withoutthisSTF themselves, andthisisvery the indigenouspeoplerepresented positions. Itwasthefirsttimethat legitimate agenttodemandSTF because itrecognized APIBasa This decisionbytheSTFishistoric 106 Thisdemandwasignored, andin 105
107 They 108 On8 populations in urban contexts: populations inurbancontexts: MSF wasconstrainedtoworkwithindigenous to treat peoplediagnosed withCOVID-19, any organisation toenterindigenousvillages didnotgrantauthorisationfor government professional from MSF, asthefederal According toaseniorhumanitarianaid system, theSESAI(acronym inPortuguese). areas, there isaspecificindigenoushealth is reflected alsoinurban contexts. Inrural The vulnerabilityofindigenouspopulations rationale forthis: from indigenouslands.Saraivaexplainedthe strengthen theSUS. that momentwe(knewwe) neededto collapsed andwehadno option,at thing wenoticedwasthat theICUshad when wearrived(inManaus),thefirst And thatwouldbeacatastrophe… So they couldreceive supportfrom SESAI. from thecitytovillages,sothat exodus oftheseindigenouspeople organisations thatthere wouldbean a fearfrom indigenousand beds. Attheverybeginning,there was population, tofightforthesameICU same (health)serviceasthegeneral in thecitieswere goingto havethe the [indigenous]peoplewhowere indigenous people.We realized that Manaus, there are atleast30,000 people livingincities.Inthecaseof There isahugenumberof indigenous decision. This wasauniquefailure oftheSTF we willcontinuetoseecasesrising. (invaders), whatwillhappenisthat If youdonottakeactiontoremove were there transmitting(COVID-19). got there, itwastheminersthat vector ofcontagion.Before themilitary Land intrusionsare averyimportant 29
BRAZIL’S COVID-19 RESPONSE communities. for indigenousandquilombola(Afro-Brazilian) state lawstoguaranteeaccesshealthcare some stateshaveresponded byenacting a federalplanforindigenouspopulations, any specificactionsortimelines.On22 sense oftheword asthey didnotprescribe these documentswere not‘plans’inthestrict There are nostudies,numbers,nothing." neglect wedon'tevenknowtowhatextent. affected (byCOVID)andbecauseofthis politics andpublicservices.Theyare strongly more andmore are excludedfrom social others thatliveinmore remote areas, now ribeirinhos (riversidepeoples)andsomany and Communities",likethequilombolas, mobilise. Butother"Traditional Peoples visibility,international however, theycan rest ofthepopulation.Since there is been showntobehigherthaninthe indigenous people,whichofcoursehas "We talkalotabouttheimpact on A humanitarianaidprofessional toldus, health andsanitarymeasures. and districtpublicsecuritybodiestomake payments andallowancestopublicservants (FUNAI) wastemporarilyauthorisedtomake stated thattheNationalIndianFoundation #1.005 issuedinSeptember2020—interalia these documents—theProvisional Measure Court forendorsement.Thesecondof indigenous populationstotheSupreme two ‘plans’pertainingtoCOVID-19and the Bolsonaropresented government Pursuant totheSupreme Courtdecision, 20 daystopresent anew plan. and imprecise’, andgave the government to endorsethe‘plan’dueitbeing‘vague Court, LuísRobertoBarroso, decidednot October 2020,theMinisterforSupreme 111
109 110 In any case, Inanycase, In lieu of Inlieuof nd
observed in the UnitedStatesandItaly. necessary policereports, aphenomenonalso are unabletovisitpolicestationsmake home withtheirpartners (andaggressors) a FBSPhypothesisisthat womenlockedat bodily injuriesfacedbywomen,leadingto the loweringofpolicereports onassaultsor period in2019.Thesefigures contrastswith March toJune,incomparisonwiththesame Portuguese), femicidesrose by22.2%from of PublicSecurity(FBSPperitsacronym in violence cases.According totheBrazilForum COVID-19 hasseenagrowth ofdomestic of universalbasicincome. more measures, permanent suchasaform in theworld,researchers haveproposed in theseventhmostunequaleconomy and doubleforfemaleheadsofhouseholds, workers ofUSD$113(BRL$600)permonth three monthemergency incomeforinformal as theintroduction ofthe ‘coronavoucher’, a support womenduringthepandemic,such In Brazil,whilethere hasbeensomeeffort to beginning October2020onwards. amount provided underthe coronavoucher, of Economy, PauloGuedes,halvingthe seem tobematerialising,withtheMinister finalisation of report, however, thisdidnot economic consequencesofthepandemic’. a disproportionate ‘bruntofthesocialand responsibility inthehome,therefore bearing economy,the informal andbearmore to men,more womenparticipatein less womendiefrom COVIDcompared elsewhere hasshownthatwhileoverall impacted bythepandemic.Research Women toohavebeendisproportionately Impact onWomen conducted byanintimatepartner. (or killingofwomen),with50%cases Brazil rankedfifth inthe world forfemicides due todomesticviolence.Before COVID, isolation bringsuponwomeninstability In additiontoincomeinsecurity, home 113 At time of Attimeof 115 114
116
112
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BRAZIL’S COVID-19 RESPONSE women in Brazil is 12.7%, the highest in the women inBrazilis12.7%,thehighest fatality rateamongpregnant andpostpartum died duetoCOVID,andthattheCOVID and postpartumwomengloballywhohave COVID, accountingfor77%ofthepregnant pregnant orpostpartumwomendiedof inBrazil)untilJune18th,124 was confirmed between lateFebruary(whenthefirstcase of GynecologyandObstetricsshowsthat Journal in Brazil.AnarticletheInternational impact onpregnant andpostpartumwomen COVID hasalsoshownadisproportionate infection COVID whowere notpregnant atthetimeof 3.1% ofwomenwhowere hospitalisedwith of hospitalisation due to COVID. of hospitalisationduetoCOVID. and risksassociatedwithpregnancy andrisk COVID were hospitalized one-third ofpregnant womeninfectedwith women infectedbyCOVID,approximately of womenandchildren, showsthatamong Fiocruz focusedspecificallyonhealthcare Figueira(IFF),aninstituteunder Fernandes world . 117 Inaddition,areport byInstituto , 119 highlighting unique vulnerabilities highlightinguniquevulnerabilities , 118 versus only versusonly 31
BRAZIL’S COVID-19 RESPONSE PHOTO: Shutterstock abdication of responsibility andleadership at environment where there wasanear- roles thatnon-stateactorsplayedinan The report alsounderlinesthe crucial While someactors sanctioned publichealthmeasures.” promote, andfinanceinternationally Brazilians hasledtoafailure tocoordinate, pandemic tothehealthandwellbeingof consequently, oftheseriousness government’s denial ofscienceand, commentary intheLancet:“Thefederal scholars andcommentators,includingthis This findingiscorroborated bymultiple actors tofillthegapleftbygovernment. needs ofindigenouspopulations,andtheinterventionprivateCSO data inadditiontoinsufficienttestingcoverage,adisregardofunique a lackofhealthpolicycoherenceandcoordination,underreportingtest The BrazilianCOVIDresponsehasbeencharacterisedbydisinformation, AND RECOMMENDATIONS ANALYSIS, CONCLUSIONS, of approximately sevenmillionpeople. budget, despitehavingapopulationincrease approximately thesameamountas2014 budgets, the2019SUSbudgetwas other monitorsthespendingofgovernment organization basedinBrasiliathat,among In fact,according toINESC,anon-profit that hasbeenchronically underfunded. factors atplay, suchasapublichealthsystem groups suchasMSF—there are alsosystemic response, andthefailure toengagekey leadership inputtingtogetheracoordinated peddled bypoliticalleaders,thelackof some correlation viathedisinformation COVID deathrates—andthere iscertainly asakeypredictor governments ofhigher the executivesummary, pointtoauthoritarian , 121 as mentioned above in asmentionedabovein 120
122
in Malaysia, xenophobic approaches tomigranthealth discuss, incomplete orsuppressed data reopening economies.Notably, asothers and isarguably akeyimpedimenttosafely significant issuethatmust beaddressed, and latecommunication oftestresults isa Test datasuppression, poortestingpolicies, an infectionrisk. of indigenouslandscontinuestoconstitute Brazilians, aswelltheactiveencroachment suppression ofdatapertainingtoindigenous communities intheUnitedKingdom. black, Asian,andminorityethnic(BAME) cramped conditionsintheUnitedStates, low-income communitiesofcolourlivingin numerous othercountries, includingthrough racism. Thishasbeenshownasafactorin has beenhighlightedelsewhere; systematic contributor toCOVID-19infectionratesthat Notably, thereport highlights akey in theSUSandmore coherent coordination. underlying theneedforincreased investment have beentheresponsibility ofthestate— indigenous populations.Alltheseshould equipment, orindefendingtherightsof technologies, andessentialprotective technical guidance,humanresources, health Frontières, andABIP, infillingthegap and HospitalSirioLibanês,MédecinsSans the federallevel—whetherbyItaúUnibanco
124 and COVID disparities among andCOVIDdisparitiesamong 125 The The 123
33
BRAZIL’S COVID-19 RESPONSE greater outbreaks ofdisease’. tooquicklyandrisking‘even back tonormal relying onpatchydatacanresult ingoing map thetruescopeofepidemics—and leads topoliticalleadersbeingunable are asfollows: In summary, conclusionsofthisbriefreport PCR tests. addition toslower(albeitmore accurate), antigen rapiddiagnostictestsinlieuor Amazonas, thatwouldbenefitfrom validated has hard-to-reach ruralareas, forexamplein strategy; failure incontacttracingimplementation/ There wasinadequatetesting, anda hadfailedtocoordinate; government pandemic response inareas where the bodies, playedkeyroles in theBrazilian Frontières, ABIP, andothertechnical Hospital SirioLibanês,MédecinsSans Non-state actors,suchasItaúUnibanco, and science-basedresponse; deliver acoordinated, comprehensive, was asignificantfactorintheinabilityto Political andeconomicinstabilityinBrazil 126 Brazilalso
continue to be particularly vulnerable; continue tobeparticularlyvulnerable; Indigenous populationsandwomen response; impedes comprehensive disease significant datasuppression that There was,andcontinuestobe, investments; requires urgent additionalandlong-term The SUSischronically underfunded,and government; but hasbeenignored bythefederal in particularindigenouspatientrights, check-and-balance forpatientrights,and The Supreme Court(STF)isanimportant technologies andpersonnel. to increase spendingonessential health Independent scrutinyisurgently needed COVIDbudget. in thegovernment There isasignificantunderspend 34
BRAZIL’S COVID-19 RESPONSE 9 cia CCastro, AdrianoMassuda,andothers, 8 7 6 5 4 3 2 1 ENDNOTES
pe-54728893> accessed29October2020 < https://www.bbc.co.uk/news/world-euro- pe confronts secondwave’(29October2020) thinkglobalhealth.org/article/all-bets-are-mea- Global Health (30 June2020) orld Bank. GDPpercapita(current US$)|Data 27 August2020 riferias%20das%20grandes%20cidades> accessed programa%20Mais%20Médicos%20foi,nas%20pe- grama-mais-medicos&Itemid=347#:~:text=O%20 tent&view=article&id=5662:folha-informativa-pro www.paho.org/bra/index.php?option=com_con- grama MaisMédicos’(November2018) BRAZIL’S COVID-19 RESPONSE 23 18 20 22 21 19 17 16 , Kreuz LRC,RoznaiY, Kreuz LRC.Con orld Bank.GDPpercapitagrowth (annual orld Bank.GDPpercapitagrowth (annual orld Bank.GDPpercapita(current US$)|Data eleições:26. Anual ANPOCS.2018;GT17-Mídias,políticae ghtml> accessed20August2020 go-fica-em-11percent-em-dezembro-diz-ibge. com/economia/noticia/2020/01/31/desempre- IBGE)’ G1(31January2020) edo JO,PradoNMdeBL,MedinaMG, -EAESP AL,TETO,‘COVID-19:Dificuldades ghtml> accessed20August2020 go-fica-em-11percent-em-dezembro-diz-ibge. com/economia/noticia/2020/01/31/desempre- IBGE)’ G1(31January2020) BRAZIL’S COVID-19 RESPONSE 42 38 43 41 40 39 37 Disponível em:https://www.in.gov.br/web/dou 2020[citado31deagosto de2020]. nal [Internet]. DE FEVEREIRO2020-DOUImprensa Nacio- FEVEREIRO DE2020-PORTARIA N -presidencia-da-republica-governadores-e-con- demia-do-coronavirus-e-o-brasil-carta-aberta-a- noticias/posicionamentos-oficiais-abrasco/a-pan- March 2020) 2020 gresso-nacional/45789/> accessed1September 2020 mento-do-novo-coronavirus> accessed28August de/46412-brasil-apresenta-acoes-para-enfrenta- BRAZIL’S COVID-19 RESPONSE 54 61 60 59 58 57 56 55 53 52 emo Tribunal Federal(FederalSupreme 2020 sao-comunitaria-nacional> accessed25August de/46568-ministerio-da-saude-declara-transmis- tps://www.saude.gov.br/noticias/agencia-sau- Transmission Nationally)’(20March 2020) 2020 htm?cmpid=copiaecola> accessed1September -comercio-com-uma-canetada-semana-que-vem. bolsonaro-diz-que-pode-determinar-abertura-do- economia.uol.com.br/noticias/bbc/2020/04/02/ of aPen’NextWeek)’ UOL(2April2020) BRAZIL’S COVID-19 RESPONSE 76 78 75 77 74 73 72 71 ribunal deContasdaUnião.Destaquesses mudaprotocoloainá Farfan,‘Governo eautoriza tworkopen.2020.8857 Open Networke208857:doi:10.1001/jamane- A RandomizedClinicalTrial’ (2020)3(4)JAMA Syndrome Coronavirus 2(SARS-CoV-2) Infection: Severe AcuteRespiratory ts HospitalizedWith Diphosphate asAdjunctiveTherapyforPatien- ‘Effect ofHighvsLowDoses ofChloroquine meida Val, Vanderson SouzaSampaio,andothers, pdf> accessed25August2020 pdf/2020/August/12/COVID-11ago2020-17h16. VID-19 Diagnoses)’ orldinData. Coronavirus (COVID-19) Total pdf> accessed25August2020 timento-Hidroxicloroquina-Cloroquina-COVID-19. pdf/2020/May/20/Termo-de-Cie--ncia-e-Consen- BRAZIL’S COVID-19 RESPONSE 95 91 96 94 93 92 90 89 88 87 86 , GrupoFleury, Semeia,IbopeInteli -longevo-da-historia/> accessed21August2020 eduardo-pazuello-e-o-49o-ministro-interino-mais- 2020) - - , - 97 102 98 104 103 101 100 99 é deSouza,PaulaFerreira, andRenataMariz, o CuriHallal,Bernardo LHorta,andothers, VID-30.pdf September/09/Boletim-epidemiologico-CO- em: https://www.saude.gov.br/images/pdf/2020/ de setembro de2020].ReportNo.:30.Disponível Brasília-DF;2020set[citado16 05/09) [Internet]. COVID-19 -SemanaEpidemiológica36(30/08a GICO ESPECIAL30-DoençapeloCoronavírus info/> accessed26August2020 Public, the Media and the Virus’ LSE(17 Public, theMediaandVirus’ Laura GuimarãesCorr 20 September2020 sitivos-do-novo-coronavirus-24449501> accessed de-muda-comunicacao-tenta-ressaltar-dados-po- 2020) April 2020) April 2020) > - 40 BRAZIL’S COVID-19 RESPONSE 107 106 111 110 109 108 105 esident oftheRepublic,Provisional Measure onavírus: APIBArticulacomGoverna accessed 26August2020 -protecao-aos-povos-indigenas-de-todo-brasil/> b-articula-com-governadores-estrategias-para-