In mid-March, Brazil took what seemed to be a forceful early strike against the coronavirus pandemic.
The Health Ministry mandated that cruises be canceled. It advised local authorities to scrap large-scale events. And it urged travelers arriving from abroad to go into isolation for a week. Although Brazil had yet to report a single death from COVID-19, public health officials appeared to be getting out in front of the virus. They acted on March 13, just two days after the World Health Organization called the disease a pandemic.
Less than 24 hours later, the ministry watered down its own advice, citing "criticism and suggestions" it had received from local communities.
In fact, four people familiar with the incident told Reuters, the change came after intervention from the chief of staff's office for Brazil's President Jair Bolsonaro.
"That correction was due to pressure," said Julio Croda, an epidemiologist who was then the head of the Health Ministry's department of immunization and transmissible diseases. The intervention by the chief of staff's office has not been previously reported.
The about-face, given scant attention at the time, marked a turning point in the federal government's handling of the crisis, according to the four people. Behind the scenes, they said, power was shifting from the Health Ministry, the traditional leader on public health matters, to the office of the president's chief of staff, known as Casa Civil, led by Walter Souza Braga Netto, an Army general.
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Brazil has lost two health ministers in the past six weeks - one was fired, the other resigned - after they disagreed publicly with Bolsonaro over how best to combat the virus. The interim leader now in charge of the Health Ministry is another Army general.
More importantly, the revisions underlined the hardening of Bolsonaro's view that keeping Brazil's economy running was paramount, the people said. Bolsonaro, a far-right former Army captain, has never wavered on that stance formulated during a crucial few days in mid-March, despite domestic and international criticism of his handling of the crisis, and a snowballing death toll.
Brazil now has the world's second-worst outbreak behind the United States, with more than 374,000 confirmed cases. More than 23,000 Brazilians have died from COVID-19.
"So what?" Bolsonaro said recently when asked by reporters about Brazil's mounting fatalities. "What do you want me to do?"
Casa Civil said changes to the March 13 guidance were made by the Health Ministry, following input from states and municipalities.
The Health Ministry said there had been a divergence of views due to differing situations in states and cities nationwide. It said the implementation of physical distancing measures was the responsibility of local health authorities.
"The strategy of the Brazilian response to COVID-19 was not impaired at any point," the ministry said.
Bolsonaro's office declined to comment for this story.
Reuters interviewed more than two dozen current and former government officials, medical experts, healthcare industry representatives and doctors to paint the most complete picture yet of Brazil's missteps in containing the coronavirus outbreak in South America's largest country.
They described a response that began promisingly, but which was soon hobbled by the president's clashes with Health Ministry and cabinet officials who could not persuade him that Brazil's economic fortunes ultimately hinged on how effectively it tackled its public health emergency.
Health experts were sidelined, the people said, and Bolsonaro embraced an unproven remedy to treat COVID-19 infections. Federal coordination foundered. State governors – some of whom Bolsonaro regards as re-election rivals – were left to set their own physical distancing policies and secure much of their own tests and equipment, the sources said.
Some experts said Brazil's stumbles are all the more shocking because of its previous success containing malaria, Zika and HIV.
"One thing that has been a shining light in Brazil has been their public health system," said Albert Ko, a professor at the Yale School of Public Health who has decades of experience in Brazil. "To see that all disintegrate so quickly, it's just been very sad."
'THE FRIDGE IS EMPTY'
When Brazil's first coronavirus case was confirmed on February 26, the Health Ministry had been preparing for nearly two months.
Its personnel were running models to estimate when and how to implement stay-at-home orders in collaboration with state and local officials, sources said. The ministry was the command center for an emergency committee coordinating the federal response across multiple agencies.
Brazil's vast size, underfunded public hospitals and widespread poverty were vulnerabilities. But the country boasts top medical scientists and a competent private healthcare sector. It had weeks of advance warning, as the virus hit countries like China and Italy first. Those on the frontline thought Brazil was in good shape to respond.
But the people who spoke with Reuters said things began to unravel along two main fronts: Bolsonaro's opposition to shutdown measures favored by the Health Ministry and the government's inability to scale up testing quickly.
Cabinet members tried numerous times to persuade Bolsonaro to endorse a nationwide lockdown, according to a person with direct knowledge of the discussions. Bolsonaro refused, the person said, believing the virus would soon pass and that health officials were exaggerating the need for physical distancing that had proved effective in other parts of the world.
"The masses aren't able to stay at home because the fridge is empty," Bolsonaro said to the media on April 20 outside his official residence in Brasília.
Bolsonaro's office declined to comment on why he prioritized the economy. He faced pressure to do so, however. Members of his conservative base have protested in cities across Brazil against lockdowns that threaten his promise to rekindle economic growth.
Yet Bolsonaro's economic advisors appeared slow to grasp the scale of the crisis. Economy Minister Paulo Guedes, a hardline free-market advocate, in mid-March told CNN Brasil that the nation's economy in 2020 could "reasonably grow 2% or 2.5% with the world falling" because of coronavirus.
That prediction was far off the mark. Manufacturing activity has collapsed, unemployment is rising and Brazil's currency is down around 30% against the dollar this year. On May 15, Barclays cut its 2020 gross domestic product forecast for Brazil to -5.7% from -3.0%. It cited Brazil's "ineffective" policy in dealing with the pandemic.
The Economy Ministry now projects GDP will contract by 4.7% this year. In an emailed statement, it said its forecasts have evolved in line with the gravity of the situation.
Guedes declined a request to comment on his earlier prediction.
A Guedes ally, Solange Vieira, who was involved in the government's landmark pension reform last year, likewise showed little urgency when presented with forecasts in mid-March from the Health Ministry, according to epidemiologist Croda. The ministry predicted widespread fatalities among Brazil's elderly if the virus wasn't contained.
"'It's good that deaths are concentrated among the old," Croda recalled Vieira saying. "'That will improve our economic performance as it will reduce our pension deficit.'"
Croda's account was backed by another official, speaking on condition of anonymity, who was told what happened but was not in attendance.
Vieira did not respond to a message on LinkedIn. The Superintendence of Private Insurance, which she leads, said in response to questions about her comments that she attended the mid-March meeting at the invitation of then-Health Minister Luiz Henrique Mandetta to understand the ministry's projections.
Vieira observed the impacts of various scenarios "always with a focus on the preservation of lives," it said in a statement.
PRESSURE FROM ABOVE
For a few days in March, it looked like the fallout from a trip to Florida to meet U.S. President Donald Trump might have altered Bolsonaro's thinking on coronavirus.
Just after returning from the visit, on March 12, Bolsonaro's press secretary tested positive for COVID-19. In the following days, nearly two dozen Brazilians who had made the trip would test positive, embarrassing the government and sparking fears that both Bolsonaro and Trump might have been infected.
After undergoing a coronavirus test on March 12, Bolsonaro called on his supporters to suspend nationwide rallies planned for March 15 for fear of worsening the spread. The following day, he said his test came back negative. The Health Ministry, meanwhile, announced its initial social distancing recommendations at a press conference in the capital.
Then things changed.
Shortly after the new guidelines were issued on March 13, Croda said he got a call from his former boss, Health Surveillance Secretary Wanderson Oliveira, who said he was "under lots of pressure from Casa Civil and had to change the communique" published by the ministry outlining the measures. Croda said Oliveira did not say specifically who at Casa Civil had demanded the guidelines be weakened.
Within 24 hours, the ministry had changed the recommendations on its website. It removed guidance on self-quarantines for travelers and the cancellation of cruises, saying those measures were up "for review." And it revised the cancellation of large events to apply only to areas with local transmission.
Oliveira did not respond to requests for comment. He recently left the Health Ministry.
On March 15, Bolsonaro ignored his own pronouncement from three days earlier discouraging mass rallies by his supporters. He met with a friendly crowd of demonstrators outside the presidential palace. Wearing the Brazil national soccer jersey, the president bumped fists and posed for selfies.
"It was the first time we saw that totally different stance," then-Health Minister Mandetta told Reuters.
The next day, on March 16, Bolsonaro formalized the shift of power away from the Health Ministry, creating an inter-governmental "crisis cabinet" led by Braga Netto, the Army general heading Casa Civil. Brazil registered its first coronavirus death on March 17.
In a response to Reuters' questions, Braga Netto's office said the group was formed because the pandemic "transcended" public health.
Three people familiar with the situation told Reuters the new cabinet effectively superseded the cross-agency group that had already been set up inside the Health Ministry. The big difference, they said, was that Braga Netto now had the final say, instead of public health experts, and that economic concerns were given more weight.
The Health Ministry said it would not comment on economic matters. It said the response to coronavirus cut across government departments.
Croda left shortly after the creation of the new command center. He told Reuters he did not want to be held responsible for "excessive deaths."
In the weeks that followed, policy differences between Bolsonaro and Health Minister Mandetta broke out in the open. Mandetta continued to advocate for stay-at-home measures in defiance of the president. He also urged caution about the malaria drug chloroquine. Bolsonaro, following the lead of U.S. President Donald Trump, was increasingly promoting the drug as a possible cure for COVID-19 despite little evidence of its efficacy.
Mandetta's popularity added to the tension. An early-April survey by pollster Datafolha showed that the Health Ministry under his leadership had a 76% approval rating, more than twice that of Bolsonaro.
On April 16, after days of mounting speculation, Bolsonaro fired Mandetta. He replaced him with Nelson Teich, a respected oncologist and healthcare entrepreneur with no public health experience.
Two recently departed Health Ministry sources said the last half of April was lost while Teich "found his feet." Decisions on testing and new equipment were delayed, they said. More than 15 public health experts, including experienced epidemiologists, left with Mandetta, one of the sources said. Many were replaced by military personnel.
"These changes greatly affect the capacity, speed, and the very quality of the response," said José Temporão, a former health minister who led Brazil's crisis response to the 2009 swine flu epidemic. "It was a disastrous decision."
The Health Ministry denied that its response was hampered by the changes.
On May 15, Teich resigned after less than a month on the job. Bolsonaro had criticized him for being too timid in promoting the re-opening of Brazil's economy and the usage of chloroquine.
Teich did not respond to a request for comment.
In a televised interview with GloboNews on Sunday, Teich said Bolsonaro's desire for a rapid expansion of the use of chloroquine in Brazil was what led him to quit.
Teich's departure accelerated military influence within the Health Ministry. Eduardo Pazuello, an active-duty Army general with no medical background, is now interim health minister. Of the eight people at the top of the ministry, only one had a military background in March. Now three of them do. At least 13 military personnel also have been appointed to lower ministry positions.
Days after Teich's departure, the ministry cleared the way for the widespread use of chloroquine to treat patients with mild cases of COVID-19.
The armed forces are widely respected in Brazil and often help with logistics during emergencies. But Wildo Araujo, a former Health Ministry official who co-authored one of the country's first major COVID-19 studies, said military personnel were being placed in unsuitable roles.
"I have the utmost respect for the armed forces, but I pity those entering now because they have no idea what to do," he said. "They don't know how to deal with the Brazilian public health system."
Brazil's Army declined to comment, referring questions to the Health Ministry, which also declined to comment on the military's role.
Bolsonaro's opposition to social distancing and refusal to support local authorities in their attempts to impose lockdowns have helped erode compliance with those measures, experts said.
A Reuters analysis of Google mobility data, which collates cell phone movement and compares it to a pre-pandemic benchmark, showed a far smaller reduction in people coming and going from transit hubs and places of work in Brazil than in European countries such as Italy, France and the United Kingdom where shelter-in-place measures have been effective.
Reuters also found Brazil's mobility reduction was less than that of other developing nations, for example Argentina, India and South Africa. Reuters analyzed data from 17 countries across Africa, Europe, Latin America and Asia for the month of April.
Like other countries, including the United States, Brazil has also struggled to secure the tests it needs. That's a major failing, some epidemiologists say, which has made it harder to track and control the virus in Brazil.
The shortage of tests is due in part to the Health Ministry's over-reliance on one institution.
According to an internal Health Ministry document viewed by Reuters, the ministry began purchasing diagnostic test kits through the Oswaldo Cruz Foundation (Fiocruz), a respected public health institute, between January and February.
By April 7, however, Fiocruz had only delivered 104,872 - or 3.5% - of the roughly 3 million kits the ministry had ordered, the document said. Croda and others said Fiocruz struggled to acquire crucial reagents on the international market. Industry sources said years of budget cuts may also have been a factor.
The Health Ministry should have established a broad network of private and public labs, one source said, which would have improved the ability to procure reagents and process tests.
In a statement, Fiocruz said it had met all its obligations to the Health Ministry.
It said it surpassed an initial target of 220,000 tests by April 13 and delivered nearly 1.3 million tests by the last week of that month. It said it expects to deliver 11.7 million tests by September.
"The worldwide competition for this type of test was very large," it said, "which caused a shortage of products."
Bureaucracy also hamstrung Brazil. A batch of 500,000 antibody tests, used to determine who has had the virus, got stuck at São Paulo's Guarulhos airport for 9 days as the health regulator processed an exception for them to be distributed without Portuguese labels, two people with knowledge of the situation told Reuters.
The Health Ministry declined to comment on the incident. It said it has increased testing capacity and will conduct 46.2 million tests, without specifying a time frame. "The initiative is part of efforts to find new purchases in the national and international market," it said.
As of May 12, however, Brazil had processed just 482,743 tests. Of the 10 countries with the highest COVID-19 death toll, only the Netherlands had tested fewer people than Brazil - a country with a twelfth of the population.