Voices of Covid-19 Part Four: Brazil

One Doctor

Andréa Oliveira Hintz glances out the window of her high-rise apartment in the city of Salvador, state of Bahia, Brazil. Birds are singing in the lagooned courtyard below and she is preparing for her Sunday at the Hospital Geral do Estado, a trauma hospital, as a pediatric surgeon. She takes careful precautions as she prepares for her day. She lives with her adolescent son, who already has had Covid, and her husband who is in a high-risk category since he has diabetes. She carries her clothes for work separately and says, “My husband thinks I’m too careful.”

Andréa has been a pediatric surgeon for 28 years. She later studied Jungian psychology and somatic psychotherapy as it relates to sympathetic and parasympathetic responses in the body through the work of Peter Lavine. She has taught and lectured internationally on these topics. She currently does tele-health psychotherapy sessions four days a week and works at the hospital in pediatric surgery on the weekends.

“The physical body is very connected to the mental condition. I used to fix bodies. Now I work with souls!” Andréa declares. “Traditional medicine does not always see this connection. I have been able to help patients and their parents through difficult times. I can help with medication that balances both physical and emotional health.”

Medicine in Brazil differs from the system in the United States. Everyone who lives in Brazil, and can get to a medical facility, has access to medical care. It is considered a human right by the country’s constitution. Sistema Único da Saúde, or SUS for short, is one of the largest public healthcare systems in the world. Three quarters of Brazil’s population rely on the system for their healthcare needs, although the system has been struggling with funding cuts because of corruption in recent years. Despite this, Andréa says that the public health system is very good, though somewhat minimalist. There are offerings of private healthcare for people who can afford it. Private healthcare provides a larger spectrum of care.

Overworked and Frightened Medical Staff

Andréa says that since the arrival of Covid, her medical colleagues are scared. Their team is the first line of contact with the Covid patients. “It is common in Brazil for doctors to work 12-hour days, five to six days a week, but at several different hospitals. I was working in eight different hospitals. Seven were private and one was public.”

Because medical professionals work between several different locations, the virus can more easily and quickly spread from place to place. This only builds on the stress that doctors already have in Brazil. “You see, doctors in my country have been emotionally sick for years. There is a lot of pressure to save lives, no matter what. Because of this, they worked too much before Covid. Now they are being asked to do much more.”

An anesthesiologist from Porto, Portugal has made a website for care for doctors and medical professionals on the front line. Andréa has done a video for this channel to remind doctors that while they are on the front line that they are using the sympathetic systems in their bodies. “It is so important that when we are home we relax and engage our parasympathetic systems in order to help our immune systems.” What this really means is to take some down time and relax.

Andréa states that another problem she sees with many doctors in her country is materialism. They work long hours and earn large amounts of money. Because of this, they often begin to focus on material goods: larger cars, more homes, fancier vacations. She says she began to get caught up in that cycle, but when she started studying psychology, she made a realization.  She realized some of the stress in the medical community exists because of doctors needing to work more to pay for their lifestyles. Andréa also realized that her son was needing more of her time. She has cut back drastically on her material items in order to live a more peaceful life and to volunteer more. This is when she also decided to stop the lecturing circuit, reduce from eight hospitals to one public hospital, and to spend more time with her son. “I decided that my heart is with the poor people and so I reduced my surgical work to just the public hospital and continued there.”

Covid-19 and the Brazilian Healthcare System

I wondered if patients are tested for Coronavirus as they enter the hospital for other issues. Andréa said it is a pretty standard procedure in the private hospitals but not in the public hospitals. “There is no money. I had a patient who needed a tracheotomy and I had no idea if he had Covid.”

She went on to say, “When I worked at the private hospital, they would provide everything, masks, gowns, all the protective coverings. At the public hospital, you have to buy your own. In March the public hospitals started to help. They started to hand out the 3M-N95 masks to doctors and nurses. But they will only give one every 30 days. You cannot use the same mask for 30 days. People don’t want to work in the public hospitals.”

Andréa went on to explain that, “Public hospitals do not always have the right equipment. I had to do a life-saving surgery on a newborn. I needed a newborn cautery pad to place under the infant’s back to keep the laser from burning the wrong place. I had to use one that was adult-sized in order to perform the surgery.” Despite of these inadequacies she states, “it would be so much worse for the poor people if they did not have public medicine.”

Andréa also shared that she purchased three pulse oximeters to let her patients borrow. She told them that if their oxygen gets to 95 or below that she wants to see them for a CT scan of their lungs. She said at 95 you will not feel breathless, but it is low enough to get checked.

As in the United States, there is a controversy around the drug that US President Trump is endorsing for Coronavirus, hydroxychloroquine. Having read that the Brazilian government is pushing for its usage I asked Andréa about its use. She said that half of the doctors say yes, and the other half say no for its usage. She said she lost a colleague who was using the medication. Andréa believes that the medication can be useful, but only under specific circumstances.

“A patient needs to have their heart and liver checked first, to make sure there are no problems with either. The patient should be in the first week of infection. If the patient is still in the viral replication process, the drug can slow replication. But if the patient is past the viral replication and is in the inflammation stage or pneumonia stage, then the drug appears to have no benefits. In my state, a patient cannot be given this medication unless they are staying at the hospital. They can’t take it at home.” She goes on to say that there are other medications that can be given to limit viral replication if the heart and liver do not check out well for hydroxychloroquine. However, these results have only been proven in a test tube. Human responses have not been fully tested.

In the second week of Covid infection, the patient usually goes into inflammatory stage and other medications may be needed against the disease. Again, hydroxychloroquine appears to have no benefit at this stage. However, it is important to follow-up with your doctor in the second week of the infection again. Usually, those who are hospitalized for extended periods of time have not been diagnosed with Covid-19 until they are already in the inflammatory stage of the virus. Catching it early is key.

Poor Brazilian Populations

Poor Brazilians live in “slums” called favelas, usually built on steep hillsides outside of large cities. Generally, the people in the favelas have no infrastructure, which means no paved roads, no running water, no electricity. Police do not generally go into these areas. Education is typically low or non-existent. Sanitation is scarce and sickness and disease are common. Infant mortality rates are high in these communities. Gangs and crime run high as well. People in the favelas often do not have access to medical care because of distance or lack of transportation. Local governments and people outside the favelas are bothered by them because the poor people are considered squatters and do not own the land they are sitting on. Overall, it is estimated that six percent of Brazilians live in such favelas, or more than 11 million people nationwide.

Video of a favela outside of Salvador, Bahia shows the sheer massive size of these communities.

Andréa shared that some of these people work in the city for wealthy families. Women work as maids for little pay. Some of these families have stopped having their maids come to work for them over Coronavirus concerns. This is bad for the poor families who rely on the meager incomes. Other families, who do not believe the virus is a concern, still have their maids come. Even if the maid does not feel well. These maids do not have cars and so have to ride public buses, which both take a long time, and is a place where the sickness can easily be passed on. Additionally, the people in the favelas may not have heard of the virus and probably do not understand how to protect against it.

“People here mostly know about Covid, but they don’t understand how bad it is. There is a lot of ignorance.” This is because, in part, the Brazilian government is attempting to diminish the severity of the outbreak. I wanted to know Andréa’s take from the perspective of a Brazilian doctor.

Government Denial

When I asked about the federal government, Andréa laughed. “We are living in a fanatic time. I tell other doctors, if you know everything you do based on science, why do you listen to this psychopath?” She shared that on March 17 there was a demonstration against the stay-at-home orders. She asked her doctor friends why would be against a stay-at-home order. In spite of the negativity and cover-ups, she says she tries to stay positive.

She is talking about the controversy brought about by Brazilian President Jair Bolsonaro and his covid-denying regime. It is estimated that the number of cases in Brazil have been severely undercounted. In the same article as above it was said that Brazil had been testing at a rate 32 times less than in the United States, where testing has also been a challenge. The current president of Brazil, Jair Bolsonaro, is minimizing the Coronavirus outbreak by calling it a “little flu.” Bolsonaro fired his minister of health, Luiz Mandetta, a well-liked doctor, for contradicting him when Bolsonaro stated that the numbers looked like the virus would be leaving Brazil soon. Mandetta was attempting to strengthen stay-at-home orders. All this while doctors, researchers, and data teams estimated that the Coronavirus numbers were anywhere from eight to sixteen times more than reported.

Bolsonaro hired a second minister of health, Nelson Teich also a doctor who, at first agreed that the quarantine measures hurt the economy, but later began to disagree with Bolsonaro as the numbers of cases and deaths in the country began to rise. Teich resigned, less than four weeks after taking the position. Bolsonaro most recently appointed Edwardo Pazuello, who has no medical training, but rather is a Brazilian Army colonel.

Jair Bolsonaro criticized state lock-downs for harming the economy.  He calls it the “tyranny of total quarantine.” He has been seen mingling with hundreds of supporters not wearing a face mask. Bolsonaro has been warned by Brazilian National Intelligence Agency in late March that social distancing and increasing testing are important to protecting the population. President Bolsonaro said that he’d rather not be informed than be “disinformed” by the intelligence systems.

During the time of researching for this article, I am finding reports that the new Brazilian Minister of Health is proceeding in an act of censorship around the numbers of cases and deaths in the country. Bolsonaro does not want the numbers to look bad because he wants the economy to keep going. However, avoiding social distancing and stay-at-home orders will only serve to make the numbers of cases and deaths rise to undeniable numbers.

Amazonia

In the center of Brazil lies the Amazon Forest, also known as “The World’s Lung.” There has been a 55% increase in the deforestation of this important oxygen supplier during the first several months of this year. Efforts to protect the rainforest have been thwarted by the virus as environmentalists quarantine to protect themselves from the Coronavirus. This lack of oversight has provided opportunities for illegal deforestation efforts to increase. Sometimes logging and sometimes burning are used to clear the forest away.

The native people who live in and around the rain forest are suffering a great loss of life. Mass graves are being dug in Manaus, Amazonia, the area of the country with the largest indigenous population. There is speculation that the people dying there are being listed as white rather than indigenous. I asked Andréa why she thought that the deaths might be recorded as white rather than indigenous. She responded that the general population are more sympathetic to the Amazonian people. If the numbers were accurately recorded, there is a risk of outrage. However, after a thought she added, “But many people just want life with pleasures. With Bolsonaro supporters it doesn’t matter if someone is suffering. They imagine everything is good.”

In the rain forest there is a lack of nearby hospitals. Few roads exist to get to distant hospitals. Andréa volunteers as a tele-health doctor around Brazil which also serves indigenous communities. She says that Amazona is like a different country inside of her country because of how remotely and primitively the people there live. “The closest hospital is five hours away from the people I visit through tele-health. No one has cars. I was speaking to one man in Amazonas and told him he needed to go to a hospital. He told me, ‘If I have to die, doctor, let me die here with my family.’”

Ongoing

Andréa believes there will be four “waves” of this virus. “The first one is now. The second one will come again and there will be more deaths. The third wave will be the economic situation. And the last wave will be the psychiatric issues caused by all of this.” She believes that people need to be okay with talking about their feelings. Many are not. That needs to change. She said that even now Brazil is having an increase of suicide and domestic violence. The Brazilian government is not talking about it. Her second career in psychology is sure to come in handy as she follows her desire to help those who are disadvantaged.

Dr. Andréa Oliveira Hintz parks her car at the end of her twelve-hour shift. She sprays her shoes and feet with alcohol. The hospital shoes stay in her car. She already changed her clothes at the hospital before leaving. She wants to be careful to protect her husband and anyone she might pass on her way back up to her apartment flat. “I think this pandemic is asking us to care about others. If all of us would just think of the person next to us first, everything would change.”

(As of this writing, Brazil’s reporting places them third in deaths world-wide, with a gap of less than 300 deaths between them and second-place United Kingdom. Brazil is second after US in the number of confirmed cases. Keep in mind, the country is severely under-testing and under-reporting.)