COVID-19: lessons from Brazil

Brazil did not have a good time of it during the COVID-19 pandemic and it had one of the highest death rates in the world, accounting for >700 000 deaths [1], with large social inequalities in mortality rates [2]. There were also some remarkable events, including the ravaging of an area of the Amazon by COVID-19 infections that ripped through the population with little resistance [3]. On the other hand, Brazil excelled in COVID-19 research, including the aforementioned Amazon studies, a number of studies of vaccine effectiveness and safety [4], and many others. There is therefore much that we can learn from the Brazilian experience and in comparisons with other countries [5].

In this issue of the Journal are published four further important contributions to the COVID-19 Brazilian literature [1, 6–8]. The papers are too broad-ranging to attempt a comprehensive summary here. Rather, we will comment on a few key themes that emerge.

Firstly, and unsurprisingly, there are substantial socio-economic and ethnic differences in COVID-19 vaccine coverage [8], as was the case in other countries. It is perhaps relevant that, during the COVID-19 pandemic, Brazil also suffered from institutional misinformation about the COVID-19 vaccine and COVID-19 disease from the Bolsonaro government [9]. Nevertheless, the country managed to achieve a high level of vaccination coverage (>88%), largely due to the well-established immunization programme. The levels of inequality in Brazil are particularly high and, correspondingly, the differences in vaccine coverage are also very high. Vaccine coverage increased with age, was higher among women and White people, and was strongly associated with education levels and wealth. Coverage was substantially lower in evangelicals compared with Catholics, and there were important regional differences from the Southeast to the Northwest. This is not just a Brazilian problem; rather, it is not surprising that societies that have high income inequality also have high health inequalities and major differences in vaccine coverage. They come in a package and cannot be addressed simply by focussing on improving access to vaccination. In this context, the pandemic also resulted in inequalities in income reduction, with the North and Northeast regions, which have the highest levels of community-level and individual-level poverty in Brazil, being the most impacted [10].

Secondly, Pellanda et al. [7] examined the impacts of the pandemic on Brazilian families. Death from COVID-19 was reported to be particularly high in more affluent families. This probably just reflects the difficulties in case identification and the classification of cause of death in less affluent communities, as epidemiological analysis of the severe acute respiratory infection surveillance system has shown a higher risk of mortality in low-income and non-White populations in Brazil [11]. Strikingly, 15% of respondents reported the death of a family member due to COVID-19. Debates in Western countries often stressed the low death rate from COVID-19 overall (∼1% of those infected, but with large differences by age) and some argued that the older generations could at best be shielded and at worst could be abandoned to their fate, while younger people got on with their lives. This was never going to work—complete shielding of older populations cannot be, and never has been, successful and a single infection introduced into a ‘shielded population’ can be catastrophic. More importantly, there has been little to no recognition of the value of older persons to the community. This is particularly the case in indigenous and other traditional societies, in which old people are precious and make major contributions to family and community life. People live in families and communities, not in convenient epidemiological categories. The idea that old people were expendable on the basis of epidemiological calculations is one that many would find offensive, as well as not making any sense in public health terms. In particular, the death of an elderly relative affects the entire family and this can particularly be the case if the infection came from younger family members; this is devastating to all.

Thirdly, Wehrmeister et al. [1] report the findings of a countrywide survey of post-COVID-19 conditions. They find that a high proportion of individuals who suffered from COVID-19 still reported symptoms 4 years after the commencement of the pandemic. The symptoms reported are mostly very vague and general, and will undoubtedly continue to be the subject of some controversy, as is the case for other post-viral syndromes. Nevertheless, Wehrmeister et al. clearly show that, for whatever reason, the post-COVID-19 condition exists, with the average number of current symptoms for those with a COVID-19 history being 7.2 compared with 2.8 for those without a COVID-19 history. As the authors note, further research is required to better understand the epidemiology and causes of this serious condition.

Finally, Brito dos Santos et al. [6] report on the history of self-reported COVID-19 cases and hospitalizations in the Brazilian population. The survey used the most populous city within each intermediate region in Brazil, covering a total of 133 cities (out of 5570), making it generalizable to the urban population, but largely missing the rural areas and people living in smaller cities with less healthcare infrastructure. Once again, reported cases were higher in more wealthy participants (probably reflecting differences in case ascertainment), but there was little socio-economic difference in the occurrence of hospitalization. As the authors highlight, this should be interpreted carefully considering the difference in healthcare access and higher in-hospital mortality of Black and Mixed-Black populations and the intersection between lower socio-economic status and race/ethnicity. The authors call for targeted public health interventions to address vulnerabilities, but addressing these vulnerabilities would require more than just public health interventions, as systemic racism in Brazil is directly related to socio-economic inequalities [10]. These public health interventions are clearly worthwhile, but one might question how effective they can be in a society that remains highly unequal.

Overall, the authors are to be congratulated on this excellent and important set of studies on the impact of COVID-19 in Brazil. There is much that the rest of the world can learn, from both the disastrous Brazilian COVID-19 experience and the accompanying outstanding research programmes that it produced. These four papers continue this trend.

Author contributions

N.P. drafted the paper and T.C.S. contributed to revisions.

Conflict of interest

None declared.

Funding

T.C.-S. acknowledges funding from the Royal Society (NIF\R1\231435).

Data availability

Not applicable.

Use of artificial intelligence (AI) tools

No AI tools were used in preparing this paper.