- Brazil's contagion rate remains high and may continue to spike as it starts to reopen.
- The response was bungled by the federal government, local experts say.
- The virus was consistently undermined as a "little flu," even as vulnerable people got sick and died.
CNBC is looking at how places around the world have tackled Covid-19. By talking to a wide range of experts, as well as everyday citizens, we're taking stock of what's gone well — and what hasn't.
Brazil, has confirmed more than 2.1 million cases of Covid-19 and more than 80,000 deaths in a population of about 209 million. Brazil's mortality rate per 100,000 is among the highest in the world. Brazil has struggled with a lack of tests, ventilators and ICU beds in many regions, and its lack of data has made it challenging to understand how quickly the virus is spreading. Dozens of health-care workers have died after getting infected with the virus. The interior of the country is now perceived as particularly vulnerable.
By way of comparison, the U.S., with about 330 million people, has had more than 3.9 million cases and 143,000 deaths.
Grassroots community efforts
Locals say that many low-income neighborhoods in Brazil, known as favelas, were left to their own devices when it came to Covid-19.
But some took matters into their own hands. In Paraisopolis, Sao Paulo's largest slum, so-called street presidents helped their neighbors get food, health care and other necessities, and residents converted a public school into a space for people to stay who had tested positive for the virus.
But elsewhere, the virus has continued to spread unabated. Social distancing, particularly in the poorest areas of Brazil, is a near impossible challenge.
"We have a lot of poor families that live in small homes with one bedroom for everyone, making it almost impossible to socially distance," said Dr. Larissa Fogaca Doretto, a researcher with the Federal University of Sao Paulo. In the state, people of color are 62 percent more likely to die from Covid-19 than their white counterparts.
Coordination between public and private hospitals
In Sao Paulo, Brazil's largest city, public hospitals at the peak of the pandemic almost hit capacity. To prevent widespread chaos, the best private hospitals started to work closely with the hospitals in the poorest parts of the city to share resources, supplies and expertise. The municipal and state health agencies — working with the private sector — also helped open up hospital beds.
Dr. Sidney Klajner, president of the Albert Einstein Jewish Hospital in Sao Paulo, noted that there's been a lot more coordination in recent months. His health system donated alcohol, face masks and face shields to more than 100 hospitals in the lower-income areas to help protect health-care workers. It also prepared early for the pandemic. "We were able to transform almost 300 beds to Covid," he said.
However, in other regions of Brazil, public hospitals have been further strained by the virus and are struggling to access sufficient ICU beds and ventilators, while the hospitals that treat wealthier patients have beds to spare. Many are calling for a national, or federal policy, to coordinate the response.
The rise of telemedicine
"Telemedicine was barely happening in Brazil," said Emilio Puschmann, founder of Amparo, a telemedicine and primary care provider based in the country. "There were a few providers running operations, but it was difficult."
Now, he says, the Ministry of Health has temporarily green-lighted certain forms of virtual medicine to allow doctors to see patients at home.
"With Covid-19, this all changed," Puschmann said. But he said more quality controls are needed to ensure that low-quality players don't rush into the market. "Everyone is building software, and it's difficult for the payers to distinguish between good and bad."
Varied state government responses
In Brazil, the states have stepped up to manage the Covid-19 response. The wealthier ones with more resources at their disposal, like Sao Paulo, tended to perform better than others. And throughout Brazil, the death rate tends to be higher in poorer cities than in richer ones.
In the poorest areas, like the Amazonian city of Manaus, the situation reached a crisis point. There, at a cemetery, thousands from remote areas were buried in group graves after dying while trying to get treatment. Now, concerns are increasing about the south.
Dr. Luisane Vieira, a clinical pathologist based in Brazil, explained: "We feel the pandemic is going south, where winter time is more cold, and to smaller cities, most of them do not have intensive care units, as required."
In late March, Economy Minister Paulo Guedes announced that Brazil's most vulnerable workers would receive a monthly salary relief of about 600 reais (around $118). That has made a difference, locals say, although it hasn't been perfectly distributed. According to reports from late May, long queues formed to access the relief.
It's even more challenging for rural residents, who risk exposure to the coronavirus as they travel to the cities, wait in a busy line, and return home. It's unclear whether this relief will continue, and for how long.
Brazil had a lot of potential to manage Covid-19 well, experts say, but it faltered. Instead, President Jair Bolsonaro has repeatedly played down the virus, even as cases continue to rise.
"Brazil lost a good opportunity to control the pandemic," said Dr. Paulo Lotufo, director of the Center for Clinical and Epidemiological Research at University of Sao Paulo, Brazil. "In the second week of March, Brazil was in a good position to start social isolation, ... and the response of the population was amazing. (But) 10 days later, Bolsonaro went on national television to tell supporters to boycott isolation, saying it was just a little flu."
Earlier this month, Bolsonaro was diagnosed with Covid-19 himself.
Confusion and misinformation
Health ministers haven't lasted long in the job since the onset of the pandemic. Dr. Nelson Teich, an oncologist, quit in late May after a month. He had replaced Luiz Henrique Mandetta, who was fired by the president in April after a series of disagreements about the pandemic.
Brazilians say things haven't changed much since Bolsonaro was diagnosed with the coronavirus, and the messaging is still confusing for many people.
"We are definitely not in a good place in Brazil," said Natasha Vianna, a writer from Brazil now based in San Francisco. "It was the health ministers who did a good job encouraging people to stay home and wear masks."
With the changing of the guard — and the consistent downplaying of the virus on the federal level — Brazilians say that guidelines aren't as consistent as they could have been.
"We don't have clear policies," said Dr. Cristiano Englert, an anesthesiologist and co-founder of a start-up accelerator in Brazil. "And we could have been more prepared."
"A lot of it is aligned with politics," added Gary Monk, a British health consultant who has been based in Brazil throughout the pandemic. "Some take it seriously and others are quite relaxed, and there are pro- and anti-mask camps."
Lack of protection for health workers
Covid-19 has spread quickly among health workers, with data indicating that they have been disproportionately affected by the pandemic. Dr. Antonio Bandeira, director of the Brazilian Society of Infectious Diseases, estimates that in some regions, as many as 10 percent of people diagnosed with the virus were health workers.
One of the major problems in Brazil, researchers have reported, is insufficient protective equipment and training. Nurses, in particular, have caught the disease and died faster than anyone else in the world, according to a report from late May.
Lack of testing
Brazil is not conducting nearly enough tests, its public health officials and clinicians say.
"Brazil is currently testing at around a third of nearby countries like Peru and Chile, which themselves aren't doing enough," said Michael Touchton, an assistant professor of political science at the University of Miami, who helped built a tracker for Covid-19 in the Americas. Without testing data, it's high challenging for the medical system to reduce exposure and get ahead of potential supply chain shortages. Moreover, locals generally agree that it's far easier for wealthier people to access tests via drive-through centers.
"We do not have an adequate program of molecular testing and contact tracing for isolating contacts and COVID-19 patients," said Vieira. "We are among the countries in the world that have tested less."
Treatment of Indigenous people
"The Indigenous population has been in dire straits," said Touchton.
As he explained, there hasn't been adequate medical care for sick people. And The New York Times is reporting that the limited support provided to communities from the federal government may have done more harm than good. The report indicates that thousands of people likely originally caught the virus from medical workers who were sent out to these remote areas without adequate protective equipment. At least 500 indigenous people have died since the onset of the pandemic.
The response — or lack thereof — to Indigenous people is part of a broader policy of neglect toward the region.
"The administration has made it a cornerstone of their environmental policy to mine and log their way through the rainforest," Touchton said.
Vulnerable population without access to health care
In theory, Brazil could have been set up for success. Its health system, SUS, serves about 80 percent of the population.
But that system has been increasingly overwhelmed by the virus. The lack of enforcement around masks and social distancing is particularly troublesome, experts say, when the health system isn't designed to serve a massive influx of sick people. That becomes even more challenging with the high proportion of people with preexisting conditions, which puts them at risk for more severe outcomes.
"A lot of people don't have access to primary care," said Klajner. "They aren't on the correct meds for their hypertension and diabetes, and they get seen in the health-care system too late."
Brazil's health authorities have pushed the unproven antimalarial drug hydroxychloroquine, despite increasing scientific evidence that it's not effective as a treatment for the coronavirus.
U.S. President Donald Trump touted the drug, claiming at one point to be using it himself as a preventative measure. Bolsonaro likewise endorsed hydroxychloroquine, even going so far as to post a video of himself washing it down with water after declaring that he had been infected with the virus.
Bolsonaro's critics have expressed concerns that this behavior would encourage more people to take the drug, and resist precautions to avoid getting sick.
We asked every expert we spoke to for their score out of 10. (1 is the extremely poor and 10 is ideal.) It's an extremely subjective measurement, but the average across all of them was 3.
'"I would give the response from society a 9 or even a 10," said Bandeira, the infectious disease expert. "And I'd give many of the states a high number. But I'd give the federal government a 1 or a 2."
"I'd give Brazil a 2 because there is a country in the Americas that has done worse — and that's Nicaragua," said Touchton. "At least in Brazil, the states and municipal governments have taken up the mantle of responsibility and tried to fill the gap."
With additional reporting by Michelle Gao