Brazil struggles to cope with Zika epidemic

Overstretched services

“Within the SUS [Sistema Único de Saúde or Unified Health System, the country’s version of the NHS] there are islands of excellence in teaching hospitals like Dom Pedro II and those linked to universities. But in general it leaves a lot to be desired for those in need,” says Adriana Scavuzzi, women’s health coordinator at IMIP. “Zika hit a maternity system that was already chaotic. It is desolating to see these women going through this situation when they are being so poorly looked after.”

Even in the relatively well equipped Dom Pedro II, medics report a system straining under the extra demands now placed on it by the epidemic, with anxious women demanding scans at any hint of sickness. “The demand for ultrasounds is now greater than we can meet but we are trying to do as much as possible, working extra hours, doing what we can to help the mothers,” says Alex Souza of IMIP’s fetal health unit.

As part of the problem Souza highlights the delay in getting back results of Zika tests. “We do not have the speed and agility we need. Ultrasound results are immediate, but blood and urine tests can take 15 days to a month. The authorities understand what we need but the resources are scarce.”

Zika and microcephaly are hitting poorer communities hardest as they are more likely to have poor water and sanitation services—only half of the country’s residences are connected to a sewage system. And the crisis in the public health system worsens the further you get from state capitals such as Recife. “Even before Zika the interior lacked doctors, nurses, and specialists. The ability there to identify fetuses with microcephaly is compromised by the fact many rural municipalities just have obstetric ultrasounds and for anything more sophisticated they have to be sent to us in the capital,” Souza says.

The uneven distribution of limited resources in Brazil’s public health service is not just an urban-rural divide. Recife’s Agamenon Magalhães hospital does not qualify as one of Scavuzzi’s islands of excellence. A walk through the hospital makes clear why Pernambuco’s health authorities direct visiting press elsewhere.

At Agamenon Magalhães, outpatient waiting areas are thronged from early morning while one of the maternity wards’ corridors is crowded with heavily pregnant women on trolleys and in wheelchairs, some attached to drips. Health professionals speaking off the record because they were not authorised to talk to media told of a lack of staff and resources exacerbated by the Zika epidemic.

One patient, Viviane de la Ponte, developed a fever and rash in her first trimester. She and her husband, Thiago, fear that she might have caught Zika virus, with possible implications for their unborn child. “We have been waiting a month for the test results to see what she caught. She did one test back in November and we still have not got the results. The SUS is horrible; it is so disorganised,” he says.

While praising the success of Brazil’s public health notification system, which quickly picked up the spike in microcephaly and its probable link to the spreading Zika epidemic, researchers acknowledge stresses in the system.

“In Pernambuco health authorities implemented impeccable procedures and quickly informed the population about what to do. But in terms of implementation through the SUS we are seeing a lack of resources because there has been an increase in demand for specific services,” says Laura Rodrigues, a professor at the London School of Hygiene and Tropical Medicine who is helping lead one of the Zika task forces back in her native Brazil.

She identifies delays with blood tests, shortages of computed tomography facilities, and insufficient physical and speech therapists for babies born with microcephaly. “This is all a question of budget.”

“The situation now is very demanding,” says Scavuzzi. “Because of Zika what I thought were the worst conditions possible have become even worse. But as a frontline doctor you cannot just give up.” She fears that if extra funding is not found, some doctors may leave for the private sector. This is already a problem in the SUS.

Brazil is the destination for the majority of the $56m (£40m; €52m) that the World Health Organization has earmarked for its response to the Zika epidemic. Brazil’s failure in recent years to halt the spread of dengue virus, which infected 1.6 million people last year killing over 800, does not bode well for the battle to contain the spread of Zika despite the deployment of 200 000 military personnel on the streets. Public awareness has increased because of a public health campaign, with President Dilma Rousseff saying the country will not be defeated by a mosquito. On a recent visit to Brazil WHO president, Margaret Chan, praised the government’s response. But the virus continues to spread into new regions, and WHO predicts that 1.5 million Brazilians will be infected with Zika virus this year. With a vaccine still some way off, the country is left tackling the legacy from decades of underinvestment in public sanitation—the pools of standing water endemic in poor neighbourhoods where the mosquito thrives. Though vital to defeating the disease’s vector this battle cannot be won quickly, especially in a country being forced to slash investment as a result of a severe fiscal crisis.