Dr Jo Robays is a general practitioner, a researcher and director of LuxOR, the operational research unit of Médecins Sans Frontières (MSF) based in Luxembourg. From 30 May to 3 July, MSF sent him on a mission to help fight coronavirus in Manaus, the capital of Amazonas State, the biggest state in Brazil. Amazonas State alone is twice the size of France.
How is the coronavirus epidemic developing in Brazil?
The north of Brazil – which is where Amazonas province is – has a high level of infection with Covid-19. The situation is very serious, because in that region the only way in which it is possible to travel is by using river transport, and people crowd onto boats for journeys that take five or six days at the minimum, providing the virus with an ideal environment for transmission. It is thought that, in some places, 50 to 60% of people may be infected.
But, although the rate of infection remains very high, the situation is gradually stabilising, and the number of infections is beginning to fall. In the north, the epidemic has already passed its peak: in fact, it did so in April. The epidemic spread relatively slowly there because of the distances involved and because the region is very sparsely populated. Unless you go by helicopter, it takes nearly a week to reach the remotest villages.
We are anticipating many more deaths, and we are preparing for the grim situation which is likely to develop.
Dr Jo Robays, coordinator of LuxOR, MSF’s operational research unit in Luxembourg
However, it is difficult to predict how things will develop, because people’s sense of discipline is slackening somewhat, just as it is in Luxembourg! Two months ago, everybody was wearing masks and on the whole sticking to the rules. But in recent weeks, people have been meeting outside cafés, forgetting about social distancing. Wearing a mask may create a false sense of security. But it is necessary first and foremost to maintain social distancing and, where that is not possible, to wear a mask. This is to say nothing of the fact that in that region it is very hot, sometimes more than 40°C, which makes it difficult constantly to wear a mask in the correct way.
Meanwhile, the virus is moving southwards. We are anticipating many more deaths, and we are preparing for the grim situation which is likely to develop. We are really concerned about that region, which is far more densely populated than the north. There are a lot of poor people, who have to go to market to earn a little money; the churches are still open and Masses are being held which are attended by large congregations, to say nothing of the demonstrations against President Jair Bolsonaro, which are not helping to limit the spread of the virus.
What preparations can be made for dealing with its spread?
One can follow the rivers and try to establish a presence in certain strategic areas before the first cases arise. But the whole country will be infected sooner or later. It is a huge country, and the logistics involved in setting up a hospital, for example, are by no means straightforward. That is why MSF is analysing the situation to see where it would be best to set up facilities.
We are also trying to transfer to the south the experience gained in the north, by providing information to hospitals about how to look after patients and organise themselves. We are also carrying out a public information campaign, particularly in the social media. Because in Brazil, even people with very little money have access to the Internet. And there is a lot of fake news, so it is vital to get the right message across.
What kind of experience have you had during your mission to Manaus that you wish to transfer to the south?
The problem in Brazil is that health agencies have a tendency to use quick tests, which may give misleading results because those tests look for antibodies to coronavirus but it may take anything up to 14 days after infection for antibodies to appear. So we need to persuade the teams concerned not to use them. They are not reliable enough.
We have also taught healthcare workers to protect themselves against infection by applying the same safeguards that were adopted in response to the Ebola epidemic. In addition, we have trained them to communicate with people more effectively, and shown them how to set up a hospital. It has also been necessary to correct certain treatments. For example, initially, patients attached to machines did not survive, but that was actually because staff did not have enough experience.
It is vital to maintain safety in hospitals, which must be divided into separate zones: those where there is infection and those where there is not. And to train staff to comply with certain rules and to keep repeating things, to organise services in such a way that each person knows exactly what his role is and where he is, or is not, permitted to go. Issues of detail often make a big difference, for example, having pedal-operated bins.
Is the epidemic being handled in the right way in Brazil?
The level of care is not the same as in our own countries, but we are still able to look after patients properly. The problem is that sometimes it is difficult to transport sick people quickly enough from very remote areas. Moreover, some refuse to be taken to hospital because initially, when we first arrived, the mortality rate was very high there. People knew that, and refused to go, imagining that it would mean certain death. We had to organise an information campaign to explain that in the meantime the situation had changed.
Are the public sufficiently protected, bearing in mind that the President seems to be denying the seriousness of the situation?
Brazil is a federal state: most health policies are decided by the states themselves. They are far closer to their people and aware that the problem exists. The municipalities also have a lot of autonomy. It was also easier for us to engage in dialogue with them, as they were directly confronted with the situation. In the north, measures were therefore taken, and plenty of masks are available, because wearing a mask is compulsory there – anyone who fails to do so may even be arrested by the police. We hope that it will be possible to cooperate to the maximum with the southern states, rather than with the federal government.
We have to quarantine ourselves for 14 days before having any contact with indigenous population groups.
Dr Jo Robays, coordinator of LuxOR, MSF’s operational research unit in Luxembourg
Are indigenous people less exposed to coronavirus?
There are various kinds of indigenous people. Some of them, living in extremely remote areas, have not yet come into contact with those who are infected. That has given them some protection. But, for others, the problem is that, once one of them has the virus, the whole village will catch it within just a few days, because they live very close together. In addition, they often refuse to be taken to hospital because, for cultural reasons, they prefer to die at home. That greatly limits the effectiveness of our operations. Particularly because we do not want to infect them ourselves. The assistance that we are able to provide is delayed in any case, because there are very strict regulations requiring us to remain in quarantine for 14 days before having any contact with indigenous population groups. But that is a good thing.
You have been working with MSF since 1992 and in particular were sent to help tackle Ebola. How did that differ from your experience in Brazil?
Brazil has the advantage that it is not among the poorest countries in the world. It also has a surveillance system which, although not without its problems, is perfectly effective.
On the other hand, inequality between rich and poor is extreme there. For example, in Manaus, the first people to catch the virus are poor people who are compelled to go onto the boats to earn their living. The poorest of the poor also have far more risk factors, such as diabetes or obesity. In the north, the number of very obese people is striking. In rural Africa, there is no such obesity epidemic: despite everything, people are very active, especially in agriculture. Statistics bear this out: far more people aged between 35 and 55 are dying of Covid-19 in Brazil than in Europe. Other social groups are less infected and know how to protect themselves.
I might add that in my opinion some healthcare staff are not sufficiently afraid of coronavirus. Everyone is frightened of Ebola. In the case of Ebola, everyone knows that, once infected, there is a 60% risk of dying of it. Everyone therefore needs to be very careful. But when staff have worked with Covid for a long time, some of them assume that they must already have been infected, and are a bit too relaxed about the fact. When it is necessary to take constant precautions, a certain fatigue may set in once a few weeks have passed. Yet it is important to stay alert right to the end. That has made it necessary to remind people, and persuade them, to remain careful. The fact is that people need to wash their hands up to 40 times a day, even if that does not make life easy.
Translation of an article by Tatiana Salvan published in Le Quotidien on 18 July 2020.