Brazil: Catastrophic COVID-19 outbreak is affecting the most neglected communities

To help ease the pressure on the hospitals, MSF team opened a 48-bed COVID-19 treatment unit with an ICU and a ward for patients with severe symptoms in the 28 de Agosto hospital to supplement their existing COVID-19 treatment capacity. MSF brought in specialist ICU staff—some with prior experience treating COVID-19 in other countries—and implemented new protocols for non-invasive oxygen treatment, providing a safer space for improved clinical care. Since the medical activities started on May 28, MSF’s wards have been at 80 percent capacity or higher. Although it is still too early to draw conclusions there are signs that an increasing number of patients will be cured, even those with very severe symptoms.

Manaus is a busy city of more than two million people, which makes physical distancing difficult. The markets have lots of traders coming from outside of town, making them potential hotspots for transmission of the virus. Manaus has a population of about 30,000 indigenous community members representing 30 different ethnicities and speaking 20 languages. They are often neglected by the health care system and were neglected in most COVID-19 response plans.

An MSF health education team is working with local organizations and community leaders to provide these communities with advice on how to protect themselves from COVID-19 and conduct active screening for potential COVID-19 patients.

In partnership with the municipality, MSF also runs a residential medical center for patients from the Warao indigenous community showing mild symptoms of COVID-19. Warao people have lived in shelters in Manaus for several years, after migrating to Brazil from Venezuela looking for economic opportunities.

There are signs that the peak of transmission may have passed in Manaus, but the situation remains critical. There is a huge need for psychosocial support for medical staff who were struggling to cope during the peak of the outbreak.

Outbreak peak moving to rural areas

The peak of the outbreak has moved on further into rural Amazonia, where the numbers of cases are on the rise. Indigenous communities are extremely vulnerable to this disease and have minimal access to standard prevention tools such as personal protective equipment and very few health care options. They often have to travel long distances to regional hospitals or clinics, which carries the additional the risk of transmitting the virus on crowded public transport.

It takes one-and-a-half days by boat to reach Tefe from Manaus. Tefe is a thriving port town on the banks of the Amazon river. When MSF’s team arrived, they were shocked by the situation. “When I visited to assess the situation, the hospital management team were telling me that almost 100 percent of their COVID-19 patients needing critical care had died,” said Dr. Janssens. “They did not have enough specialist staff to care for the very sick patients that were arriving at their door.”

While MSF plans how to efficiently and responsibly engage with remote communities in rural Amazonia we have launched an initial emergency response to provide moderate and intensive care in Tefe and São Gabriel da Cachoeira. The hospital in Tefe has requested MSF’s assistance. MSF plans run the ICU—where a high number of COVID-19 patients are dying—and provide medical care in six peripheral health centers. This will hopefully reduce the need for indigenous communities to make the long journey to Manaus to seek treatment.

In São Gabriel da Cachoeira, a city that lies further north on the Amazon river, MSF will open a treatment center to supplement the hospital’s COVID-19 capacity and partner with a local organization to spread health education messages to the community.

The highest new infection rate in the country

Boa Vista, the capital of Roraima state, currently has the highest new infection rate in the country—more than a quarter of the residents have been infected with the disease.

MSF has expanded its project for Venezuelan migrants and refugees in Roraima to include COVID-19 preparations and health promotion. The public hospital is entirely overwhelmed—patients are being treated in corridors or sent away with no treatment as the hospital is full. A new 700-bed field hospital has been set up to respond to the outbreak. MSF is supporting the hospital with training in the ICU and supervision.

“Right now, we are facing an acute phase in the COVID-19 crises in Boa Vista,” said Michael Parker, MSF field coordinator for the Roraima project. “MSF has responded by increasing our medical work beyond support to refugees—providing doctors and nurses for a field hospital and taking charge of training and supervision for severe cases at this very critical moment.”

Rio de Janeiro and São Paulo’s neglected communities

COVID-19 reportedly arrived in Brazil via wealthier communities who had travelled abroad and returned to major cities, such as Rio de Janeiro and São Paulo. For several weeks, the spread was contained to wealthier areas. But transmission gradually spread to poorer neighborhoods and had devastating impacts. Homeless people, drug users, the elderly in nursing homes, and people living in favelas and informal residential areas already faced barriers to accessing health care. COVID-19 has made the situation even more dire, putting these communities at risk of dying with little possibility of assistance.

“Like in many countries, the pandemic has resulted in many people losing their jobs,” said Dr. Ana Leticia Nery, MSF project coordinator in São Paulo. “But in São Paulo there were already 24,000 homeless people. With the health system stretched to its limits, the barriers preventing these extremely vulnerable population from accessing health care in Brazil have become even [worse]. The pandemic has thrown more people into extreme poverty, leaving them homeless. Drug use, addiction, and underlying medical concerns such as tuberculosis, heart disease, and HIV add to their vulnerability. Seeing people who are suffering and have difficulties accessing the normal health system is heartbreaking, but there are things we can do to help give these people access to the same treatment any other citizen would have.”

In São Paulo, MSF teams are assisting homeless people in the streets of downtown neighborhoods as well as people living in slums in the outskirts of the city where the disparity between wealth and poverty is striking. In partnership with local organizations and the São Paulo municipality, MSF runs medical activities in two isolation facilities for homeless people who have tested positive for COVID-19 and show mild or moderate symptoms. MSF is also running a health education and assistance program for people dependent on alcohol and drugs.

In Rio de Janeiro, teams have trained health centers and hospitals in infection prevention and control, and have provided health education at the municipality’s restaurants. We are actively monitoring for people who show COVID-19 symptoms. In Rio’s favelas, MSF found that the already stretched health capacity is reaching the breaking point—several health centers have had to close. Living conditions make physical distancing almost impossible, so the risk of the virus spreading is high.

MSF is undertaking a range of health promotion, screening, and diagnosis activities in most of its project locations and is providing technical advice on infection prevention and control (IPC) to medical facilities and nursing homes. At the same time, MSF teams are scaling up psychosocial support for medical staff who have experienced trauma associated with the high mortality rate and the painful way that many people die from the disease. A team is also looking into opening a palliative care unit in São Paulo, to provide dignified end-of-life care for critical patients who are too sick to be cured in other hospitals.

Our teams continue to look at ways to expand activities with local health authorities, but we are reaching the limits of our capacity. More concerted national efforts are necessary to bring the outbreak under control.