Political and institutional perils of Brazil's COVID-19 crisis.

Political scientists would presume that during a pandemic, political leaders will seek to use the situation to increase their power and electability. In the case of Brazil, however, President Jair Bolsonaro has not been able to achieve this, partly due to the government's poor policy response to COVID-19, which is shaped by Bolsonaro's political ideology. Yet Bolsonaro operates within a strong democratic institutional context that limits his policy authority. Brazil's Federal Supreme Court, for example, consistently upholds state physical distancing policies that the Bolsonaro administration opposes. State-level health systems investments, such as efforts to rapidly expand emergency bed capacity in intensive care units, have also sustained Brazil's universal public health system in the context of weak federal coordination and management.

Since his election into office in 2018, President Bolsonaro has shown an authoritarian leadership style and emphasised traditional family values, Judeo-Christian morals, and a strong economy.3, 4 He has questioned the role, efficacy, and legitimacy of democratic institutions, including the National Congress of Brazil, the Federal Supreme Court, and political parties, reinforced by his past history of repeatedly switching parties and currently not having any party affiliation. Bolsonaro's unwavering principles that economic growth and prosperity trump other policy priorities have influenced the response to COVID-19. Bolsonaro has said he views unemployment as worse than COVID-19 itself. To prioritise opening the economy sooner and garner support for his views, Bolsonaro stated that there would be chaos from unemployment and food shortages at home due to school and work closures. This strategy supports his aims to rejuvenate the economy, sustain business community support, and, above all, secure re-election in 2022.

These fear tactics have not helped to consolidate his power. Bolsonaro's general approval rating is low. Opposition parties have accused him of obstructing justice over a federal police investigation into his family and associates' dissemination of disinformation and fake news during his presidential campaign. Playing to the public's fears during a pandemic does not seem to have strengthened his political support and authority. Although Bolsonaro maintains a strong following in favour of his approach to COVID-19, his adherents make up about a third of the population. Without a congressional majority, Bolsonaro and his administration have had to resort to negotiating political favours to gain the support of centre-right parties.

Bolsonaro has repeatedly resisted recommendations made by scientific experts and governors to engage in physical distancing while his administration initially restricted testing to only the worst COVID-19 cases and patients who were hospitalised.11, 12 In April, Bolsonaro fired his Minister of Health, Luiz Henrique Mandetta, after disagreeing over physical distancing policies. His next Minister of Health, Nelson Teich, resigned from office by mid-May after policy disagreements and refusing to yield to Bolsonaro's pressures with respect to the use of hydroxychloroquine as a COVID-19 treatment. Worse still, Bolsonaro appointed Eduardo Pazuello, an Army General with no medical experience, as the interim Minister of Health, a post he has held since early June.

Bolsonaro and his administration's response to COVID-19 reveals ongoing political realities in Brazil. He is not the first president to politicise the Ministry of Health: previous presidents, including Fernando H Cardoso, Luiz Inácio “Lula” da Silva, Dilma Rousseff, and Michel Temer, used the appointment of health ministers for political compromise and coalitions. To help avoid these challenges, civil society needs to pressure elected politicians for greater autonomy and technical expertise to be ceded to Brazil's Ministry of Health.

The impact of COVID-19 has been devastating in Brazil, with more than 87 000 deaths and 2·42 million confirmed cases as of July 26, 2020, second only to the USA. Yet the country's democratic and health institutions have taken measures to protect society. Alongside consistently voicing opposition to Bolsonaro's COVID-19 policies, the legislative and judicial branches of government have resisted attempts to pursue the president's impeachment; this helps authorities and different agencies remain focused on the business of government. The Federal Supreme Court has consistently recognised the legality of physical distancing policies imposed by state and municipal governments. This decision was important in the early months of the pandemic because it limited Bolsonaro's attempts to weaken workplace closures.

Brazil is a large middle-income country characterised by deep social and economic inequalities, but it has a reasonably well structured universal health-care system. Although its infrastructure is unevenly distributed and there have been continued cuts in health spending, the public health system has continued to function during the COVID-19 pandemic. In many cases, this is because state governments have worked to increase intensive care units in the public health system or in emergency field hospitals, transfer cases from metropolitan to other locations where there is a lower demand for health services and vice versa, and even resorted to routing patients with COVID-19 to the private health system where there is additional intensive care unit availability.

The COVID-19 pandemic is likely to continue to exact a heavy toll on human lives in Brazil during the coming months. Now is the moment for democratic institutions to be resilient and to work with society and the scientific community to protect the health of the nation and overcome a president and administration that are failing to effectively lead in the political arena and in the response to COVID-19. Despite Bolsonaro's recent diagnosis with COVID-19, this has not motivated him to alter his policy position. There is still a need in Brazil for more testing, contact tracing, and isolation. State and municipal governments must not shirk from their responsibility to protect local populations given that the nation's president seems determined to abstain from this role.