South America prepares for the impact of COVID-19.

Although the coronavirus disease 2019 (COVID-19) pandemic reached South America a little later than other regions, such as Europe and the USA, every country in the continent has now recorded cases of COVID-19. The under-resourced public health systems of these middle-income or lower middle-income countries are inadequately prepared for any large-scale pandemic; many countries hope that the stringent social distancing and quarantine measures adopted will suppress at the least the first wave of cases.

The leader of one country stands out for the wrong reasons. Jair Bolsonaro, President of Brazil, is facing protests for his perceived poor handling of the crisis. Despite Brazil having the most cases of COVID-19 across the continent (almost 41 695 cases and 3000 deaths by April 22, 2020), he has consistently downplayed the severity of the pandemic, calling it a “little flu”. He has repeatedly and publicly clashed with state governors around Brazil for their strict implementation of social distancing measures, including the banning of public gatherings and the closure of schools. He has appeared regularly on television addressing the nation regarding the pandemic and has used phrases such as, ”get back to work” and “people die, that's life”. As recently as April 19, he attended a protest against social distancing in the capital Brasilia.

On April 17, he fired his embattled federal health minister Luiz Henrique Mandetta, who had won widespread praise for his strictly scientific handling of the pandemic, trying to follow WHO guidance on social distancing. Frequently forced into contradicting the President, many felt it was only a matter of time before Mandetta was dismissed. The new health minister, Nelson Teich, is an oncologist with management experience in the private health system.

“Obviously, many doctors are really sorry that the differences between the President and the previous health minister could not be resolved”, says Luciano Cesar Azevedo, Professor of Critical Care and Emergency Medicine at the University of São Paulo and based at Hospital Sirio-Libanes, São Paulo, Brazil. “However, the new health minister is a highly reputable doctor and administrator, with an important scientific background. We believe he and the President will come to an agreement, and that the Ministry of Health will continue to request social isolation and research the best measures to fight COVID-19.”

Across Brazil, the public health system has 7·6 intensive care unit (ICU) beds per 100 000 population, rising to 25·5 in the private system, although efforts are underway to create new emergency hospitals, use capacity in hospitals for armed forces, and repurpose wards and increase ICU beds in existing hospitals. For now, three quarters of Brazil's 210 million population can only access the public health system, and there are already signs of strain. João Doria, the Governor of the most populous state of São Paulo, decided on April 17 to extend the lockdown measures to May 10, saying that hospitals both public and private had begun to struggle with the rapid influx of cases.

Bolsonaro's stance has also met opposition from other governors, including those he previously considered political allies. Two governors, of the states Rio de Janeiro and Pará, have announced they themselves have COVID-19, underlining the threat to all Brazilians. In this conflict between federal and state governments, Brazil's Supreme Court has confirmed that ultimately, whatever Bolsonaro's opinions, the power to lift lockdowns lies exclusively with state governors and mayors, and the President cannot overrule them.

As in all countries in South America, Brazil has insufficient access to testing, meaning there are likely to be a huge number of unreported cases. Worryingly, compared with previous years, Brazil saw an almost 10-times rise in hospitalisations during March this year of influenza-like symptoms, reported to Iinfogripe, a public-health reporting system. “We do not yet know how much of this increase is due to COVID-19 because test results are taking 2–3 weeks to be returned in some parts of Brazil, since official laboratories are overwhelmed”, explains Azevedo. “The fact that this is happening during summer months, not our regular influenza season, makes it a strong possibility that many of these hospitalisations are non-detected COVID cases.”

It is thought that many COVID-19 infection clusters across South America began with wealthy travellers returning from Europe. However, Azevedo and his colleagues fear that the demographics of Brazil could see cases soar in poorer populations: almost half the population do not have access to sanitation, and one quarter live in poverty. The cities of Brazil have rich and poor areas side by side, and in the poorest favelas there can be 8–10 people sharing a 2–room house, with no prospect of social distancing. “Add to this our existing problems with dengue fever, malaria, and continuing outbreaks of yellow fever, and you can understand our fears”, he explains.

Brazil is also conducting several drug trials for COVID-19, including hydroxychloroquine, which has received much media attention (although there is no evidence as yet to suggest it is effective). The trials involve a coalition of major centres of excellence, including Hospital Sirio-Libanes, and will extend to up to 70 hospitals nationwide. These trials are studying the efficacy of hydroxychloroquine with azithromycin, corticosteroids, and tocilizumab on long-term outcomes of patients with COVID-19 patients. “The studies on hydroxychloroquine were the ones that started first”, explains Azevedo. “We have close to 150 patients enrolled in two trials, but so far we cannot find evidence of an effect. We hope to have the first results by end of May.”

Elsewhere in South America, lockdowns have been imposed in all countries, but at different times. In Argentina, the lockdown, which began on March 20, and will extend to at least late April, so far seems to have prevented an explosion of cases—about 3892 cases and 192 deaths at the time of writing. There are fears of an outbreak taking hold among the country's thousands of port workers and grain handlers involved in the crucial agricultural export sector.

“Most cases are clustered in big cities; many cases are due to having travelled abroad and contacts of those people. However, now viral circulation in the wider community has begun”, explains Eliza Estenssoro, Hospital Interzonal de General de Agudos San Martin de La Plata, Buenos Aires Province, Argentina. “However, our lockdown appears to have prevented a huge surge.”

Estenssoro says the Argentinian Government is working with hospitals to increase ICU capacity by 50–100%, as well as rapidly constructing emergency facilities for moderate-severe COVID-19 cases. However, she adds: “We're afraid of running out of supplies when the number of ventilated patients grows…all doctors feel uncertainty about this. However, the increase of cases is not accelerating, so maybe—and it is only maybe—we will be able to cope with it. We feel we are preparing to go to war, but have felt like this for the last month.”

Colombia's cases and deaths are currently similar to Argentina's, after initiating its lockdown on the same day March 20. Two regions are experiencing considerable clusters of cases, the capital Bogota and the Valle del Cauca region, home to Cali, a city with a population of 2·2 million people. “We think the government-ordered confinement decreed by March 20 has caused the number of cases to grow slowly, allowing the entire health system to gradually adapt and prepare”, says Gustavo Ospina-Tascon, a critical care specialist based at Fundación Valle del Lili Hospital in Cali.

Colombia currently has a total capacity of 5320 ICU beds, all with full mechanical ventilation, and a further 3200 beds that can be upgraded to full critical care beds at short notice. “The main problem in Colombia is the high heterogeneity between hospitals and regions”, explains Ospina-Tascon. “Some private hospitals have higher capacity for adaptation and reasonable supplies than public hospitals, which have very limited capacity to respond. However, I believe the Colombian health system is in a better situation than others in South America because the whole population has at least some access to health services.”

His major concern is the possibility of running out of personal protective equipment (PPE) as the pandemic increases. “A lot of resources have been mobilised. We have received direct contributions from private enterprises to support the crisis to come”, he says. “But none of us know if it will be enough. We have watched as the health systems of high-income countries, such as Spain, Italy, and even the USA, have been overwhelmed. PPE will always be a key point. Will we have enough in 2 or 3 months?”

In the rest of South America, governments are battling to control the pandemic while also facing the economic and social consequences of lockdowns. Paraguay, widely applauded for its early lockdown and low numbers of cases and deaths, faces another huge problem: some two thirds of its working population work informally, and thus cannot access the benefits announced by the government to help tackle the social impact of the pandemic. The population does not want to die of starvation while avoiding COVID-19.

And Ecuador is struggling with a large outbreak in its largest city Guayaquil, where public health authorities have been overwhelmed by the number of cases and deaths, with tragic reports of many bodies being collected from homes days after the person's death. Cases have now accelerated beyond 10 000, with over 500 recorded deaths, but both are thought to be considerable underestimates. The Ecuadorian Government said 6700 people died in the Guayas province (home to Guayaquil) in the first 2 weeks of April, far more than the usual 1000 deaths seen during the same period in previous years. There are reports across the country of authorities struggling to enforce the lockdown. As in other countries, there is deep inequality, which means not everybody is able or willing to socially distance and stop going to work.