No end in sight for the Brazilian COVID-19 crisis.

As The Lancet Microbe went to press, the number of Brazilians to have died from COVID-19 had passed 350 000. Only the USA has a higher death toll. The pandemic has brought Brazil's health-care system to the verge of collapse. By the end of March, 2021, intensive care units in 17 of the country's 27 states were at more than 90% occupancy (seven others were at more than 80% occupancy). Supplies of drugs and oxygen are running short. On April 15, Médecins Sans Frontières warned of a “humanitarian catastrophe” in Brazil.

The second wave of COVID-19 started to take hold in Brazil in November, 2020. The trend has been sharply upwards ever since. On a single day in March, 2021, Brazil recorded more than 100 000 new cases of the disease. On two separate days in early April, the country saw more than 4000 deaths. The P.1 variant of SARS-CoV-2 appears to be driving the surge. It is thought to be at least twice as transmissible as the wildtype strain and can infect people who have previously contracted the virus.

“There seems to be a higher proportion of people who get sick after being infected, and we are also seeing more young people get very ill, very rapidly”, said Ester Sabino, associate professor in the Department of Infectious Disease at the University of São Paulo Medical School. “But we still need to figure out how much more pathogenic this variant is; it could just be that younger people are more exposed to the virus.”

Brazil currently accounts for more than a quarter of the world's weekly deaths from COVID-19. Yet this is a country with universal health care, albeit with a great deal of regional variation; lengthy experience in dealing with disease outbreaks; and a well established immunisation programme. “We could have used the health system in a smart way to do contact tracing and to inform the population. But this did not happen”, explains Miguel Lago, executive director of the Institute for Health Policy Studies in Rio de Janeiro.

“There has been no planning; everything is totally disorganised”, adds Sabino. “This new variant comes out from the city of Manaus [in the Brazilian Amazon], and we allowed planes to keep running out of there. There were movements of people starting the epidemic everywhere.” Surveillance efforts remain far below what is required and only 11% of Brazilians have received the first dose of the COVID-19 vaccine.

“At the beginning of the pandemic, there was a lot of effort to mitigate the transmission of the virus and to reduce the mobility of the population”, recalls Daniel Villela, a research scientist at Rio de Janeiro's Fundação Oswaldo Cruz, or Fiocruz. “In bits of the country we observed flattening of the curve. But with this second wave, people are becoming fatigued with the restrictions.” Public transport is packed, as were the beaches of Rio de Janeiro, until they were finally closed late in March.

“Brazil had a lot of opportunity to address the pandemic successfully”, said Lago. “We cannot blame the health system or the shortages. The man to blame is Jair Bolsonaro. He has tried to sabotage any kind of response.”

The Brazilian President has called COVID-19 “a little flu”, has undermined face-masks and the vaccine, and suggested that Brazilians “stop whining” about the pandemic. He has vetoed legislation aimed at controlling the spread of SARS-CoV-2 and designated a host of services as “essential”, including gyms, leaving them exempt from any attempt to impose a lockdown. A scheme providing emergency monthly stipends for low-income families was ended in December, 2020, incentivising people to go out to work just as the second wave of COVID-19 was gathering pace. Three ministers of health have left since the start of the pandemic.

“It is so easy to break the confidence in disease control measures, and this is what our President has done”, said Sabino. “His supporters will not accept any lockdown now. People are going out without any precautions.” Health in Brazil is devolved to the states and municipalities. But the central government exerts strong influence. Bolsonaro has refused to introduce a national lockdown and described governors and mayors who have done so locally as “tyrants”.

Lago reckons that the President's arguments against lockdowns on economic grounds have prevailed. “Bolsonaro has won the rhetorical narrative. He has raised the political cost of imposing the kind of restrictions we need to combat COVID-19”, said Lago. “We saw in last year's municipal elections that even mayors who are in opposition to Bolsonaro are afraid of losing votes by advocating rigorous measures. That is why we have not had any true lockdown, in over a year of the pandemic. It is not politically viable. No-one is defending the idea of lockdown.”

The sluggish rollout of the COVID-19 vaccines has exacerbated matters. Fiocruz has an agreement with AstraZeneca to produce their vaccine but there have been supply problems. They are still not ready to start production at scale. “Until we can get the vaccines rolled out, we need to have strict control measures for enough time that they can be effective”, said Villela. Few people expect this to happen. “With this president, it is hard to see how Brazil can come out of this crisis”, Sabino told The Lancet Microbe.