Brazil currently has the worlds second highest number of deaths from covid-19. The lack of action from the Brazilian President, Jair Bolsonaro, and his open denial of the pandemic is widely seen as being one of the reasons for this crisis. However, while that is undoubtedly one of the causes of the high rate of infection and deaths from covid-19, we argue that the countrys underlying conditionsits deeply rooted socio-economic inequalities, the fragmentation and chronic underfunding of its public health systemare equally important factors. In the midst of a rapidly evolving public health and economic crisis, there are early signs of some form of resilience in the system, and possible lessons to be learned for the countrys future.

Although the pandemic has not yet reached its peak in Brazil, the country is at risk of being shattered by the coronavirus. The bed occupancy rate in Intensive Care Unit (ICU) is over 90% in three Brazilian statesAmazonas, Cear, and Rio de Janeiro. How did Brazil reach this point? It is the combination of the health systems flaws and entrenched inequalities, as well as President Bolsonaros denialism and lack of action that have cost the lives of so many Brazilians.

Since Brazils first case of covid-19 at the end of February 2020, Bolsonaro has denied the gravity of the pandemic and acted against public health measures such asphysical distancing. He has used words such as hysteria, neurosis and fantasy to criticize the reaction of people and the media to what he classified as a little gripe. [1] Within one month, two of his ministers of health left their position, refusing to implement Bolsonaros plans to end quarantine, and prescribe hydroxychloroquine to all covid-19 patients regardless of their health condition. But despite his antics and blunders, it is too simplistic to only blame Bolsonaro for the rapid escalation of the epidemic.

It is really the underlying conditions of Brazils health system that have allowed the pandemic to take hold and get out of control. Brazils health system is highly fragmented. Although everyone uses the public unified health system (Sistema nico de Sade SUS), 25% of the population hold private health insurance, mostly through their employment. This has created an ethical, equity, and social justice problem within the pandemic, as those who can afford it, use private health services. The large majority of those who cannot pay for an insurance, use the SUS. Long before this pandemic, Brazils SUS struggled with chronic underfunding, aggravated by the austerity measures introduced in the aftermath of the 2014-2016 economic recession. [2] Despite the universal public system, 56% of Brazils health expenditures are private. [3] In the last few years, there has been an increase in out-of-pocket expenditures, especially for medicines.

In Brazil, the pandemic started in affluent urban areas more exposed to contagion from international travel. It is now quickly spreading to the suburbs and favelas (slums). Brazils deeply entrenched social inequalities and the vulnerability of specific populations, have provided a hotbed for the pandemic. In Brazil, the wealthiest 1% of the population concentrates 28.3% of the countrys total income. About 150 million Brazilians live on an average monthly salary of 420 Reais (around $70). Roughly 13 million Brazilians live in favelas, where hygiene and sanitation is poor. [4]. The virus has also spread among more than 600,000 prisoners in the country, and there is the likely risk of rapid dissemination among the population of Indigenous people, which is approximately 800,000 people.

With such underlying conditions, it is surprising the system did not collapse sooner. Thankfully, a few mitigating factors have been able to boost resilience in the face of Bolsonaros lack of action and denialism. There are currently 478,000 active doctors (2.3 per 1,000 population) and 2.3 million nursing professionals. Despite its numerous failings, Brazils SUS still guarantees free access to all levels of health services, from primary care to specialists. Its extensive primary health care network in particular stands out: there are 43,000 Family Health teams and 260,000 community health agents in Brazil, embedded in the community. The primary care network functions as a gateway for early case identification, referral of severe cases to specialized services, monitoring of vulnerable groups such as older people, people who are immunosuppressed, chronically ill, and pregnant women. The primary healthcare system also provides surveillance of mental health disorders, rates of domestic violence, and alcoholism during lockdown.

The joint performance of professionals working in the SUS system, universities and public scientific institutions, have historically helped overcome crises and produced sound public health responses, such as dealing with the Zika outbreak, or the national responses to the HIV and AIDS epidemic [5,6] Most importantly, responsibility for the health system in Brazil is decentralized and regionalized. [5] Decentralised funds for healthcare are larger than the funds transferred by the central state. States and municipalities manage hospitals and services, buy supplies, hire human resources, and carry out health surveillance. As the spread of coronavirus occurs at different time intervals and geographical regions, such decentralisation has allowed the implementation of locally-tailored measures. This localised approach has allowed to keep the epidemic in check to a degree, stopping its spread to the rural areas.

Despite all the challenges posed by the pandemic, it would appear that the checks and balances of Brazils democracy, together with its decentralized health system, still seem to be working, and are tapping into the countrys vast, if depleted, capacity to respond to the pandemic. It would appear that strengthening its national healthcare system and preserving the existing democratic institutions are Brazils only guarantees in dealing with covid-19.

Raquel Nogueira Avelar e Silva, Department of Clinical Epidemiology, Aarhus University Hospital, Denmark

Giuliano Russo, Centre for Global Public Health, Queen Mary University of London, The UK

Alicia Matijasevich, Department of Preventive Medicine, Faculty of Medicine, University of Sao Paulo, Brazil

Mrio Scheffer, Department of Preventive Medicine, Faculty of Medicine, University of Sao Paulo, Brazil.

Competing interests: None declared

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Covid-19 in Brazil has exposed socio-economic inequalities and underfunding of its public health system - The BMJ - The BMJ