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September 4, 2020

Brazil and COVID-19—A Fleeting Glimpse of What Is to Come

Author Affiliations
  • 1Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2Hematology Clinic, Hospital da Polícia Militar, Belo Horizonte, Minas Gerais, Brazil
JAMA Health Forum. 2020;1(9):e201061. doi:10.1001/jamahealthforum.2020.1061

Since its outbreak in December 2019, the coronavirus disease 2019 (COVID-19) pandemic has reached virtually every corner of the globe. As the world’s fastest growing hotspot, Brazil has become Latin America’s most affected country, with more than 3.2 million confirmed cases and more than 100 000 deaths, ranking second to the United States.1

With a population of more than 200 million residents, Brazil ranks sixth among the most populous countries and ninth among the world’s largest economies. However, Brazil also ranks high for its significant socioeconomic disparities. More than one-fifth of its population lives in poverty, mainly Black and mixed-race individuals. Among Black and mixed race residents, 13.5 million earn only US $1.90/day, and an equal proportion live in favelas (slums), with overcrowded and poor sanitary conditions.2 Illiteracy rates remain high, reaching 20% in those older than 60 years and virtually double among Black individuals than White individuals.3 Of greater immediate concern, unemployment has affected more than 12% of the country’s workforce; informal jobs and unpaid leave account for 30% to 60% of this.4 Despite government cash-transfer schemes, including roughly US $110 per month (less than one-quarter of the country’s average monthly per capita income), many have not yet benefited from them. While logistical issues may partly explain this, fraud at various levels has also prevented financial aid from reaching millions in need. Of these, more than 10 million are rural workers who largely depend on family farming for their livelihood. One might thus expect the millions in poverty to be those who bear the brunt of the pandemic.

While a flattening of the epidemic curve following social distancing measures seems quite clear in some of the country’s first-struck states, cases continue to increase in Brazil’s innermost corners. Several states have seen both their public and private health care systems be overwhelmed, with health workers facing life-or-death choices. Manaus, the capital city of Amazonas (the north region of Brazil), was the first to see its health system completely collapse, and only now has its demand for mass graves started to subside. In Brazil’s richest region, the recent lifting of lockdown measures, coupled with the suspicion of fraud in the acquisition of medical gear for the pandemic, has raised concerns regarding whether the health care system will be capable of providing the necessary support. São Paulo, with more than 12 million inhabitants, has had more deaths than Germany alone while struggling to achieve a social distancing rate of 70% and to keep intensive care unit occupancy less than 100%. Moreover, the bulk of Brazil’s medical workforce is concentrated in its major cities, leaving other urban and rural areas largely without assistance.5,6 Overall, despite ongoing efforts to bypass the lack of health care resources—by building field hospitals at an unprecedented speed and having medical schools waive end-of-course exams to allow newcomers to work on the front lines—the health system has failed to keep pace with the escalating demand.

To make matters worse, the country has been engulfed in ever-worsening political turmoil. President Jair Bolsonaro has often found himself at odds with his own Health Ministry, which has led to 2 minister losses in less than a month. Mounting tensions among Bolsonaro’s cabinet, the National Congress, and the Supreme Federal Court have spawned great uneasiness across the nation, nourished by an ongoing concern for the stability of the country’s democratic institutions. June 13, the Feast Day of Saint Anthony, patron saint of the illiterate and the poor, was marked by fireworks launched at the country’s Supreme Court by far-right protesters demanding its shutdown and threatening its justices. Thus, Brazil’s federal government must navigate a delicate civil-military balance amid a swelling pandemic and health system overload, while residents are somewhat puzzled by the opposing views held by the government. Such political unrest is unwelcome at a time when united efforts are key to tackling COVID-19.

Since China began easing its lockdown restrictions on April 8, several countries have followed suit. Regrettably, new COVID-19 clusters have already started to appear, which raises questions about a second wave of infection. Although some might say there is no one-size-fits-all approach to reopening, on May 12, the World Health Organization advised that before easing lockdown, rates of positivity should remain at 5% or lower for at least 14 days. Because Brazil, which has begun lifting its own restrictions, falls short of the 60% to 70% herd immunity presumed to prevent an upswing of cases, dampening transmission while restrictions are tapered off will require aggressive surveillance through widespread testing and contact tracing, for which the country is still ill-prepared.7

Several strategies could be implemented in an attempt to avert critical shortages, including tax reduction policies, private investments, fee waivers for public utility charges, and donations for the most financially strained. Equity in access to resources could be improved by better mapping of critical regional trends to guide federal aid allocation to states and municipalities. Strengthening leadership roles at the local level, with greater community involvement and collaboration with nongovernmental organizations, might also help. For instance, food supplies have been made available through partnerships between small business owners, farmers, and community leaders in the favelas. Widespread continuing education of health care workers may help evidence-based and timely guidance reach the most at-risk patients. In turn, public research acceleration programs could pave the way to more direct access to future COVID-19 therapeutics and vaccines.

The COVID-19 pandemic has taken a heavy toll on a nation already battered by hardship and socioeconomic disparity. Sadly, it also seems to have entrenched partisan differences of opinion and behavior among its people. With a public health, political, and economic collapse hovering over the country, it is time for unity and concerted efforts by setting aside political dogma and taking stock of existing strengths to work toward a common goal. Dodging a pandemic would seem hard enough; having a political crisis added to it is bound to be a disaster.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Antonio Vaz de Macedo, MD, Hospital da Polícia Militar, Hematology Clinic, Rua Pacífico Mascarenhas, S/N–Santa Efigênia, Belo Horizonte, Minas Gerais 30110-013, Brazil (antoniovmac@hotmail.com).

Conflict of Interest Disclosures: None reported.

Menezes  PL, Garner  DM, Valenti  VE.  Brazil is projected to be the next global Covid-19 pandemic epicenter.  medRxiv. Preprint posted online May 5, 2020. doi:10.1101/2020.04.28.20083675
Agência IBGE Notícias. Extreme poverty affects 13.5 million persons and hits highest level in seven years. November 7, 2019. Accessed June 10, 2020. https://agenciadenoticias.ibge.gov.br/en/agencia-news/2184-news-agency/news/25895-extreme-poverty-affects-13-5-million-persons-and-hits-highest-level-in-seven-years
Agência IBGE Notícias. Continuous PNAD 2016: 51% of the Brazilian population aged 25 or over had only complete primary education. December 22, 2017. Accessed June 10, 2020. https://agenciadenoticias.ibge.gov.br/en/agencia-press-room/2185-news-agency/releases-en/19005-continuous-pnad-2016-51-of-the-brazilian-population-aged-25-or-over-had-only-complete-primary-education
Agência IBGE Notícias. Quarterly Continuous PNAD: unemployment retreats in 9 of 27 FUs in Q4 2019. February 14, 2020. Accessed June 10, 2020. https://agenciadenoticias.ibge.gov.br/en/agencia-press-room/2185-news-agency/releases-en/26914-quarterly-continuous-pnad-unemployement-retreats-in-9-of-27-fus-in-q4-2019
Miotto  BA, Guilloux  AGA, Cassenote  AJF, Mainardi  GM, Russo  G, Scheffer  MC.  Physician’s sociodemographic profile and distribution across public and private health care: an insight into physicians’ dual practice in Brazil.   BMC Health Serv Res. 2018;18(1):299. doi:10.1186/s12913-018-3076-z PubMedGoogle ScholarCrossref
Scheffer  M, Cassenote  A, Guilloux  AGA, Biancarelli  A, Miotto  AM, Mainardi  GM. Demografia Médica no Brasil 2018. Accessed August 25, 2020. http://www.epsjv.fiocruz.br/sites/default/files/files/DemografiaMedica2018%20(3).pdf
Mellan  TA, Hoeltgebaum  HH, Mishra  S,  et al.  Estimating COVID-19 cases and reproduction number in Brazil.  medRxiv. Preprint posted online August 24, 2020. doi:10.1101/2020.05.09.20096701

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    3 Comments for this article
    Politicizing COVID19
    Rolando Ceddia, PhD | University
    The author should have mentioned that the Supreme Court in Brazil, which has become an activist institution, ruled against President Bolsonaro with respect to his ability to decide how to manage the pandemic at the state level. Responsibility was given to governors and mayors to decide whether or not to adhere to the lock down, and also how to manage federal aid of approximately R $ 60.15 billion given to states and municipalities and the Federal District to strengthen actions combating the new coronavirus. President Bolsonaro has provided financial support to all states and municipalities to fight the pandemic. The author is correct to mention that corruption has become a major impediment for effective combat of the pandemic in Brazil, but forgot to say that the corruption is also being identified in states run by governors that oppose President Bolsonaro. Moreover, the narrative that President Bolsonaro threatens the stability of the country’s democratic institutions is a fallacy. This is often spoken without providing any evidence that supports it. The author should be impartial and present a clear picture of the economic and political situation of Brazil.
    Lack of Precise Data and Misinformation
    Eduardo Silva, Medicine | Hospital comum
    Both the commenter and the author of this piece are not saying anything new or helpful related to this horrible virus. No one really can say what is really is going on. The "PhD", the first commentator, just repeated what is being said ad nauseam by Brazilian media. We need data. And what is interesting is how many different vaccines are being tested.
    Brazil Lacks a Capable Leader in the Federal Government
    Roberto Garcia, PhD | Research Institute
    We were lucky to have governors and mayors that tried to follow the WHO recommendations. Of course, their management of the crisis was far from perfect. But if we were in the hands of the president, it would have been much worse. What does he do except "prescribe" chloroquine for everybody? And give bad examples of how not to behave in the middle of the pandemic?