Community health workers reveal COVID-19 disaster in Brazil.

Brazil has become one of the epicentres of the COVID-19 pandemic. The failure of President Jair Bolsonaro and his administration to recognise the severity of the pandemic is being compounded by the neglect of Brazil's community health workers (CHWs). In Brazil, there have been no nationwide guidelines for primary health care services in the COVID-19 response. Since CHWs in Brazil are not considered to be health professionals, only an estimated 9% have received infection control training and personal protective equipment (PPE). Unions estimate that at least 50 CHWs have died as a result of COVID-19. The number is likely to be vastly underestimated, since deaths of CHWs are not registered in Brazil's official statistics of health-care worker mortality. Moreover, CHWs have faced threats and aggression in some territories where they work. We call on the Brazilian Government and the global health community to recognise and support the role of CHWs in the COVID-19 response and to ensure their health and safety.

There are more than 286 000 CHWs in Brazil. They are the bedrock of Brazil's Sistema Único de Saúde (SUS): they provide primary health care within their territory, make house visits, and establish a relation of trust between communities and the health system. The value of CHWs stems from their local knowledge and daily contact with families.5, 6 This proximity to communities is also vital for ground-level outbreak surveillance and risk communication, as seen with the outbreak of Zika virus disease.

Despite CHWs' position within communities, they have not been provided with clear guidance about their role in the COVID-19 response. In March, 2020, the ministry of health published contradictory recommendations asking CHWs to continue visits to health-system users and provide care to those infected, but without going into the houses. CHWs were asked to use PPE, but no PPE was provided. Safety in tackling COVID-19 requires distance and isolation, which is the antithesis of CHW activity. The close contact they have with communities means CHWs are at risk of infection. In addition to being potentially seen as vectors, CHWs also risk being perceived as the face of unpopular policies. Health workers have faced hostility from Bolsonaro's supporters who are opposed to physical distancing. In a move that could further endanger their safety, Bolsonaro has called on his followers to “invade” hospitals and intensive care units to check the veracity of COVID-19 numbers.

In some municipalities, CHWs have been asked to work remotely, using telemedicine and social networks to keep in touch with families. In other municipalities, they have been tasked with responsibilities that go beyond their routine work, such as ensuring physical distancing regulations are adhered to in public spaces. CHWs with chronic diseases have been told to stay at home in some municipalities, whereas in others they have been instructed to keep doing their job.2, 3 These contradictions and inconsistencies have not been resolved, and the ministry of health is yet to provide further guidance about how primary health care should be reorganised during the pandemic. The national response is, in practice, being guided by developments at the local level, without any semblance of central coordination.

The reactions of Bolsonaro's Government to COVID-19 have ranged from denialism, peddling of unproven therapies, and attacks on his political opponents and the WHO.12, 13 Brazil has seen two health ministers leave their posts during the pandemic and a data blackout intended to cover up case numbers and mortality. The situation with CHWs reveals how lack of leadership translates into inadequate local-level responses to COVID-19. CHWs are in many respects the “canary in the coal mine” of the SUS. Their low salary and precarious working conditions reflect long-standing resource difficulties of the health system and the lack of political commitment to health as a public good. The uncertain working conditions of CHWs indicate the disarray of the SUS in the face of the COVID-19 pandemic. The failure to prepare and protect CHWs undermines physical distancing measures, places them at risk, and contributes to the neglect of marginalised groups, including the poor, the elderly, and the unhoused. As the length of the crisis increases, so will the burden of chronic diseases and mosquito-borne diseases such as dengue and Zika virus disease, which are not receiving enough attention in the pandemic. The present position of CHWs shows the full extent of the public health disaster in Brazil.

CHWs in Brazil protesting about better rights for health workers and health surveillance technicians in 2018