Brazil once vaccinated 10 million people for polio in a day. What went wrong with COVID-19?

With deaths surpassing 378,000 and COVID-19 cases continuing to rise throughout Brazil, experts say vaccinating the country’s population of more than 200 million should be the top priority.

Praised worldwide for its National Immunization Program, Brazil was expected to have an edge in protecting its population against the coronavirus. Previous vaccination campaigns in the country—some vaccinating millions in just one day—have gone off without a hitch and serve as prime examples of tight immunization logistics. But erratic planning, a virus-denying president, and a vocal anti-vaccine movement have set the country up for failure as it faces wave after wave of coronavirus infections.

Brazil’s death toll is now second only to the United States. According to Our World in Data, it’s ranked first in the Americas, with 1,756 deaths per million. On its worst day since the start of the outbreak, April 6, Brazil registered more than 4,000 deaths. Then it happened again two days later.

Younger Brazilians are currently being hit the hardest, and experts suspect the P.1 variant, first discovered in Manaus, is at least partly to blame. According to the Brazilian Association of Intensive Care Medicine (Amib), 52 percent of the country’s ICU beds were occupied by patients aged 40 or younger in March, a 16.5 percent jump over the rate between December and February.

“Suddenly everything changed, and it was frightening to see the increase in cases and deaths, and especially the changes in the profile of the critically ill patients, who are now young,” says Carla Berger, a physician at a primary care health unit in the southern city of Porto Alegre. “I have kids who are 22 and 23, and I’m terrified they could be contaminated by me or my husband, who is also a doctor.”

In São Paulo, the most populous city in Brazil, most cases of COVID-19 in 2021 have been in people between the ages of 20 and 54. In the first wave of the pandemic, the municipal government reported that more than 80 percent of ICU beds were occupied by the elderly or people with chronic illnesses.

Now, as Brazilians aged 65 and up are being vaccinated, 60 percent of the beds have gone to those between the ages of 30 and 50, most without any previous illnesses.

A stellar immunization program

The National Immunization Program (PNI) was created in 1973 in the middle of Brazil’s 1964-85 military dictatorship, following the successful completion of the years-long smallpox vaccination campaign that eradicated the disease in the South American country. The campaign was born out of the country’s desire to become self-sufficient and its attempt to produce everything its citizens needed so it could cut off all imports, including of medications.

As a result, Brazil went through a “very violent process of urbanization,” says Gonzalo Vecina Neto, a professor at the University of São Paulo’s Faculty of Public Health who was previously São Paulo’s secretary of health, as well as the president of health regulatory body ANVISA, which oversees approvals of the use of vaccines and medications in the country. With that urbanization, he says, came a search for ways to “lower the country’s horrific mortality rate, particularly child mortality.”

One of the ways it found was to provide more vaccines for its population and to distribute them equally through the PNI.

Three years after its initial creation, the program was officially implemented by the federal government under decree 78.231, declaring its guiding principle as social inclusion and assisting all members of the population in all corners of the country, including rural and remote areas. It also outlined key elements that needed to be addressed, like improving epidemiological surveillance, training laboratory staff to help with diagnostics, and establishing at least one national laboratory for quality control of vaccines.

It was the first step toward universal access to healthcare in Brazil and a precursor to its public healthcare system, known as SUS, which was created in 1988. And it was SUS that allowed the PNI to attain its goal of reaching all Brazilians, thanks to its decentralized management under the coordination of the Ministry of Health and division of responsibilities among state and municipal governments.

From there, the PNI has had numerous successful vaccination campaigns, perfecting over the years the planning, organization, and promotion of the immunization of millions of people in a short period of time.

Considered one of its most efficacious, Brazil’s campaign against polio in the early 1980s vaccinated more than 10 million children in one day.

“The success came from the determination of the Ministry of Health to do mass vaccination,” says Vecina Neto.

The country’s national vaccination plan trickled down to each of its healthcare units, allowing them to use it as roadmap to tailor their own plans specific to their location and population. The national plan also included a robust promotional campaign, and incentivized people to vaccinate their children by explaining its importance and setting up clinics on Saturdays, when most didn’t work. If families wanted to receive a government benefit for children 14 and under called Salário Família (Family Salary), they had to prove they had vaccinated their children.

Yearly vaccine campaigns against the flu, as well as periodic campaigns against illnesses like meningitis, yellow fever, and the H1N1 flu strain, have also used similar strategies to successfully immunize the population quickly and efficiently.

Now, as the country faces the COVID-19 pandemic, it is the government’s lack of that type of planning that has left Brazilians in the lurch.

National Geographic reached out repeatedly to the Ministry of Health to comment for this story. They proposed multiple tentative appointments but in the end said they could not find time in the minister’s schedule.

Ad hoc COVID-19 immunizations overlook the neediest

As of April 12, 23.8 million Brazilians—just over 11 percent of the population—had received at least the first dose of either the CoronaVac or the Oxford-AstraZeneca vaccine. This is according to state data collected by a consortium of local news outlets, which have been working together since the federal government removed critical COVID-19 data from its channels last June.

Just 7.39 million—3.49 percent of the population—have been given both doses of one of the coronavirus vaccines available in the country. At the current rate, some experts say it could take as many as four years to vaccinate the entire population. Earlier this week, the Ministry of Health announced that the vaccination of priority groups would no longer be complete in May, but in September, blaming a lack of supplies and a delay in vaccine delivery.

“Brazil already had a history of good vaccination campaigns, but it was like these logistics and research centers we already had weren’t used in the best way,” says Natercia Santa Cruz, technical supervisor of radiology at Hospital Beneficência Portuguesa in the São Paulo city of São Caetano do Sul.

A failure to organize on a national level has left individual states and municipalities to make their own vaccination plans and deals to purchase the vaccines they need, which can leave some of the more vulnerable segments of the population waiting.

According to Sofia Mendonça, a physician specializing in public health and coordinator of the Federal University of São Paulo’s Xingu Project, roughly 70 percent of indigenous people living in villages across the country have received the first dose of the COVID-19 vaccination, while just 50 percent have received the second, despite being considered a priority group.

Generally, she says, the PNI provides efficient care to those living in the Xingu region, an area surrounding the Xingu River, which runs through the Amazonian states of Pará and Mato Grosso. But several factors, including a lack of planning for the COVID-19 vaccine to reach them and the spread of false information about it, has changed that.

“If you had an authority and coordinators who were really committed and responsible for getting this vaccine to the villages and who put value on this vaccine, things would be different,” she says.

A failure to plan also led to the complete collapse of the healthcare system in Manaus. Home healthcare nurse Klinger Falcão was caring for six patients there when one tested positive for COVID-19. He was concerned for the woman, who was 72 years old and already in poor health, so he phoned the hospital covered under her health insurance to see if it had any available ICU beds. It would soon, but there was another problem: That hospital, like the rest of the city and surrounding municipalities, had run out of oxygen.

Her family decided keeping her at home would be best. Falcão did everything he could to make her comfortable, even making a makeshift breathing apparatus out of a two-liter plastic bottle and a nebulizer to try to ease her pain. “I knew it wouldn’t work, but seeing someone like that, I didn’t have any options, there wasn’t anything else I could do,” he says. “I just wanted to give her a bit of comfort, so she wouldn’t suffer as much when she couldn’t breathe.”

In total, 31 people died in Manaus on January 14 and 15 when oxygen supplies ran out. Now, many cities across Brazil are also suffering a shortage of intubation kits, and the newly appointed minister of health Marcelo Queiroga has said the Pan American Health Organization will help the government purchase more. The Spanish government also said it would donate kits at the end of April.

But President Jair Bolsonaro has called COVID-19 a “little flu” and promoted the use of medications like hydroxychloroquine, which has been discarded as a treatment for the virus and is considered harmful to those who have it. He continues to attend large gatherings maskless. His words, including erroneously saying the coronavirus vaccine would turn people into alligators, have also fueled an outspoken anti-vaccine movement and maskless protests. This is undoing a lot of the work of other governments and healthcare professionals in the country and making many people doubt the existence of the virus and the importance of the vaccine.

“It doesn’t depend solely on the vaccine. It also depends on other preventative measures,” says Mendonça, referring to wearing masks, washing hands, and social distancing. “You need to believe in these things if you also want to have a good vaccination campaign.”

For now, Brazil is stuck because it lacks top leadership that wants to make a change or find a solution. States, municipalities, and healthcare workers are doing the best they can, but without a national plan, it’s everyone for themselves.