DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance.
Date of interview: 4th June 2020
Number of confirmed cases at time of interview: 555,383
Number of deaths at time of interview: 31,199
Population: 209.5 million
As family doctors, we witness real human suffering on a daily basis. We are with our patients during the hardest times in their lives which can be a real privilege but, at all times, we need to recognise our human fallibilities. This week, I have cornered Dr Pedro de Paula from São Paulo , to discuss the Brazilian response to the coronavirus. We met at the Kyoto WONCA conference last year during his FM360 exchange to observe Japanese primary care. Pedro works in a private hospital in São Paulo which has converted two of its floors to COVID wards. At the beginning of the pandemic, he put himself forward to work on these wards because he wanted to do something – as he says, he wanted to bear witness to this virus and not just let it pass through.
He gives me a quick 101 on Brazilian healthcare. Universal Health Coverage is written into their constitution but he says that it is overused, insufficient and not sustainable. The private healthcare system has popped up to fill in the gaps. Pedro says that there is a saying where he is from, “there are many Brazils in Brazil” which I think is a great phrase that celebrates their diversity but also their disparity. Having followed some of the news about the Brazilian pandemic response, I wanted to know if it was bad as the media was reporting. I know we are not ones to talk in the UK about embarrassing politicians and high death rates but the lack of insight by their president, Bolsonaro, seemed like the country was really in trouble. They are currently on their third Health Minister since the start of the pandemic with the previous two resigning due to personal differences with the President. Pedro informed me that, even before COVID, the nation was already showing a diminishing trust in their leaders. The pandemic has unmasked a lack of national authority and the State Governors have responded by stepping up. In Pedro’s State, lockdown was announced on the 15th March; schools, stores, restaurants and gyms were promptly closed. He thinks they were at their peak last week and the number of admissions at his hospital is starting to fall. There have been campaigns to keep people indoors and it has only really started to open on the 1st June with estate agents, car-sellers, general offices and shops being allowed to open with heavy restrictions. Pedro describes a five-point plan where the next step would be restaurants and beauty salons opening with restrictions, followed by the gyms and religious services following suit. The fifth and final stage would allow theatres, cinemas and events with large groups to open.
I have to be honest and say that, from all the sensationalised media reports, I was expecting a system in disarray and I have to reproach myself for my feeling of disappointment when I realise that his experiences seem near identical to mine in the UK. The desperate pleas by Brazilians on news reports in the UK made me feel like they were facing a horrific death toll in an unbearable environment surrounded by death and disaster. Since speaking to Pedro, I looked up deaths per capita caused by COVID and realised that the UK had over three times the number of deaths per million in comparison (UK 618.57 deaths per million and Brazil 189.43 per million) and this certainly put me in my place. Being a global pandemic, it sometimes feels that each country is being pitched against each other in terms of public health policy, economic strategy and, of course, lives lost but data can be misleading and I have been having some pretty strong thoughts on how the media has been reporting this pandemic. I am a proponent of free speech and holding the government accountable but I lament somewhat at the exoticisation and luridness of headlines and articles in order to hold our attention. The more conversations I have with family physicians across the world, the more I realise that we are facing similar every-day issues and my conversation with a Brazilian GP was no different.
What was interesting, however, was how our chat became very candid about human suffering and the guilt that we feel and the human mistakes that we make in times of hardship. Human suffering is as much part of life as joy and celebration but we have had more than our fair share in recent months. I respect his vocation and his mission to show compassion and to relieve distress where he can and I feel that, unlike me, he has been staring COVID in the face on the acute wards that he is working on. I have heard from other sources about the trauma of being in hospital and facing mortality without loved ones and I cannot imagine the loneliness and anguish of dying alone in hospital. Pedro tells me a story of an 88-year-old with multiple co-morbidities that he cared for who had come in with urosepsis and then caught COVID as an inpatient. Every day, he would have to remind her in her confused state that she was in hospital and that he was her doctor and it was all a bit touch and go. Until one day, she recognised him without prompting. I think we have all experienced that feeling of joy that Pedro felt at that moment over what must have felt like the smallest of wins in times of darkness.
We also talk about our own suffering. I believe that, as doctors, we are trained to have emotional distance at work and we can observe pain with equanimity. However, with coronavirus, it has affected us personally as well and this is where we become human. Pedro became an uncle two weeks ago and, although he is happy that his sister has brought a healthy baby into the world, he is incredibly heartbroken that he is still yet to meet his niece in person. I get the impression that he is being very careful about physical distancing because of his high-risk role in the hospital and making his decisions on the assumption that he is already infected. He is also missing his Church, having attended every day before lockdown, and the ability to connect with God within his community of fellow church-goers. I didn’t grow up with a religion and I have always been fascinated how religion and religious residues play in other people’s lives – the Friday night dinners amongst my Jewish friends, Christmas for my British friends (even my non-religious friends “practise” Christmas), Ramadan and Eid for my Muslim friends. It’s always about bringing people together and being part of a community and having a spiritual connection and a wider sense of purpose that I feel like I missed out on. Admittedly, in the modern world, people have other religions like the gym or charitable work but I think religion spells out these rituals of community best. I can only imagine how hard this is for Pedro to not be able to connect with this side of himself and how he is having to find other networks of support during this time. He has just started daily prayers (where all faiths are welcome) at his hospital which fills that void somewhat.
In the UK, NHS staff have been heralded as superheroes and I have always found this trope uncomfortable. Like lambs to the slaughter, the deifying of healthcare staff felt like society’s justification of their continued existence in this time of death and distress. The disconnect between the expectations laid on me by the public as “frontline staff” and how I was actually feeling on the inside (which is a weak human being) is a guilty secret. Even as doctors, we are as human as the next person and the superhero trope almost takes away that permission to be so. I’m sure most of us have bent the rules a little during lockdown, especially as it is easing for the sake of our mental health. Pedro calls these moments of weaknesses “transgressions” and I think that it is the perfect word – a singular act that goes against the rules – that encapsulates the feelings of guilt that go with it.
We talk about what next for Brazil. He says that the Brazilian personality is joyful, warm, welcoming and tactile so he hopes to return to that. He suspects that once things go back to near normal, there will be protests and he predicts that Bolsenaro will not be re-elected. He feels that there is a wind of change and that COVID-19 may be the catalyst for political tranformation, even if it is a step at a time. I also ask him about what he thinks about the UK response. He says that he was very sad when Brexit happened for everything that it represented but he also said that he found it bizarre that the British public stayed out home ‘to protect the NHS’. When I think about it, he’s totally right. The entire campaign was centred around a love for an institution that provides free healthcare for all at the point of access and it made me feel a little emotional. Although it can be a thankless task working for an underfunded public system, I think COVID has really shown how much the British love the NHS and the principles that underpin it and that is, to me, very British. Pedro says that, for him looking at the UK from the outside, the only thing that seems to rival the love for the NHS is the love for the Queen!
Thanks to Pedro for his time and his honesty. I cannot wait to hop over the Atlantic to share some sushi rolls (and more importantly, churrasco) with you!