Community health workers reveal COVID-19 disaster in Brazil
Authors: Gabriela Lotta, Clare Wenham, João Nunes, Denise Nacif Pimenta
Journal: The Lancet (2020)

Brazil has become one of the epicentres of the COVID-19 pandemic. The failure of President Jair Bolsonaro and his administration to recognise the severity of the pandemic1Burki T COVID-19 in Latin America.Lancet Infect Dis. 2020; 20: 547-548Summary Full Text Full Text PDF PubMed Scopus (198) Google Scholar is being compounded by the neglect of Brazil's community health workers (CHWs). In Brazil, there have been no nationwide guidelines for primary health care services in the COVID-19 response. Since CHWs in Brazil are not considered to be health professionals, only an estimated 9% have received infection control training and personal protective equipment (PPE).2Lotta G Margri G Dossiati D Correa M Os impactos da Covid-19 nos profissionais de saúde pública. Fundação Getulio Vargas, Sao Paulo2020Google Scholar Unions estimate that at least 50 CHWs have died as a result of COVID-19.3Segatto C Na guerra política dentro da pandemia, o SUS precisa sair fortalecido.VivaBem. May, 2020; https://www.uol.com.br/vivabem/colunas/cristiane-segatto/2020/06/03/na-guerra-politica-dentro-da-pandemia-o-sus-precisa-sair-fortalecido.htm?cmpid=copiaecolaDate accessed: June 19, 2020Google Scholar The number is likely to be vastly underestimated, since deaths of CHWs are not registered in Brazil's official statistics of health-care worker mortality.3Segatto C Na guerra política dentro da pandemia, o SUS precisa sair fortalecido.VivaBem. May, 2020; https://www.uol.com.br/vivabem/colunas/cristiane-segatto/2020/06/03/na-guerra-politica-dentro-da-pandemia-o-sus-precisa-sair-fortalecido.htm?cmpid=copiaecolaDate accessed: June 19, 2020Google Scholar Moreover, CHWs have faced threats and aggression in some territories where they work.3Segatto C Na guerra política dentro da pandemia, o SUS precisa sair fortalecido.VivaBem. May, 2020; https://www.uol.com.br/vivabem/colunas/cristiane-segatto/2020/06/03/na-guerra-politica-dentro-da-pandemia-o-sus-precisa-sair-fortalecido.htm?cmpid=copiaecolaDate accessed: June 19, 2020Google Scholar We call on the Brazilian Government and the global health community to recognise and support the role of CHWs in the COVID-19 response and to ensure their health and safety. There are more than 286 000 CHWs in Brazil.4Minsitério da Saúde, BrasilATENÇ&Atitle;O PRIMÁRIA: Mais 20 mil novas equipes e serviços no SUS em 2020.https://www.saude.gov.br/noticias/agencia-saude/46180-atencao-primaria-mais-20-mil-novas-equipes-e-servicos-no-sus-em-2020Date: 2020Date accessed: June 19, 2020Google Scholar They are the bedrock of Brazil's Sistema Único de Saúde (SUS): they provide primary health care within their territory, make house visits, and establish a relation of trust between communities and the health system. The value of CHWs stems from their local knowledge and daily contact with families.5Nunes J Lotta G Discretion, power and the reproduction of inequality in health policy implementation: practices, discursive styles and classifications of Brazil's community health workers.Soc Sci Med. 2019; 240: 112551-112558Crossref Scopus (29) Google Scholar, 6WHOWHO guideline on health policy and system support to optimize community health worker programmes. World Health Organization, Geneva2018Google Scholar This proximity to communities is also vital for ground-level outbreak surveillance7Haines A de Barros EF Berlin A Heymann DL Harris MJ National UK programme of community health workers for COVID-19 response.Lancet. 2020; 395: 1173-1175Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar and risk communication, as seen with the outbreak of Zika virus disease.8Wenham C Lotta G Pimenta DN Mosquitoes and COVID-19 are a ticking time bomb for Latin America. LSE Blogs.https://blogs.lse.ac.uk/latamcaribbean/2020/03/31/mosquitoes-and-covid-19-are-a-ticking-time-bomb-for-latin-america/Date: March 31, 2020Date accessed: June 19, 2020Google Scholar Despite CHWs' position within communities, they have not been provided with clear guidance about their role in the COVID-19 response. In March, 2020, the ministry of health published contradictory recommendations asking CHWs to continue visits to health-system users and provide care to those infected, but without going into the houses.9Secretaria de Atenção Primária à SaúdeRecomendações para Adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente ao Covid-19.http://www.saudedafamilia.org/coronavirus/informes_notas_oficios/recomendacoes_adequacao_acs_versao-001.pdfDate: March, 2020Date accessed: June 19, 2020Google Scholar CHWs were asked to use PPE, but no PPE was provided.2Lotta G Margri G Dossiati D Correa M Os impactos da Covid-19 nos profissionais de saúde pública. Fundação Getulio Vargas, Sao Paulo2020Google Scholar Safety in tackling COVID-19 requires distance and isolation, which is the antithesis of CHW activity. The close contact they have with communities means CHWs are at risk of infection.2Lotta G Margri G Dossiati D Correa M Os impactos da Covid-19 nos profissionais de saúde pública. Fundação Getulio Vargas, Sao Paulo2020Google Scholar In addition to being potentially seen as vectors, CHWs also risk being perceived as the face of unpopular policies. Health workers have faced hostility from Bolsonaro's supporters who are opposed to physical distancing.10Saraiva A Bolsonaro supporters are becoming increasingly violent amid pandemic. The Brazilian Report.https://brazilian.report/coronavirus-brazil-live-blog/2020/05/30/bolsonaro-supporters-are-becoming-increasingly-violent-amid-pandemic/Date: May 30, 2020Date accessed: June 19, 2020Google Scholar In a move that could further endanger their safety, Bolsonaro has called on his followers to "invade" hospitals and intensive care units to check the veracity of COVID-19 numbers.11Uribe G Bolsonaro estimula população a entrar em hospitais para filmar oferta de leitos.Folha de São Paulo. June 11, 2020; https://www1.folha.uol.com.br/cotidiano/2020/06/bolsonaro-estimula-populacao-a-entrar-em-hospitais-para-filmar-oferta-de-leitos.shtmlDate accessed: June 19, 2020Google Scholar In some municipalities, CHWs have been asked to work remotely, using telemedicine and social networks to keep in touch with families. In other municipalities, they have been tasked with responsibilities that go beyond their routine work, such as ensuring physical distancing regulations are adhered to in public spaces. CHWs with chronic diseases have been told to stay at home in some municipalities, whereas in others they have been instructed to keep doing their job.2Lotta G Margri G Dossiati D Correa M Os impactos da Covid-19 nos profissionais de saúde pública. Fundação Getulio Vargas, Sao Paulo2020Google Scholar, 3Segatto C Na guerra política dentro da pandemia, o SUS precisa sair fortalecido.VivaBem. May, 2020; https://www.uol.com.br/vivabem/colunas/cristiane-segatto/2020/06/03/na-guerra-politica-dentro-da-pandemia-o-sus-precisa-sair-fortalecido.htm?cmpid=copiaecolaDate accessed: June 19, 2020Google Scholar These contradictions and inconsistencies have not been resolved, and the ministry of health is yet to provide further guidance about how primary health care should be reorganised during the pandemic. The national response is, in practice, being guided by developments at the local level, without any semblance of central coordination. The reactions of Bolsonaro's Government to COVID-19 have ranged from denialism, peddling of unproven therapies, and attacks on his political opponents and the WHO.12Schuch M Bolsonaro Critica OMS e diz que entidade "não acerta nada".Valor Investe. June 18, 2020; https://valorinveste.globo.com/mercados/brasil-e-politica/noticia/2020/06/18/bolsonaro-critica-oms-e-diz-que-entidade-no-acerta-nada.ghtmlDate accessed: July 7, 2020Google Scholar, 13Eisenhammer S Stargardter G Special report: Bolsonaro brought in his generals to fight coronavirus. Brazil is losing the battle.Reuters. May 26, 2020; https://uk.reuters.com/article/uk-health-coronavirus-brazil-response-sp/special-report-bolsonaro-brought-in-his-generals-to-fight-coronavirus-brazil-is-losing-the-battle-idUKKBN2321E8Date accessed: July 7, 2020Google Scholar Brazil has seen two health ministers leave their posts during the pandemic and a data blackout intended to cover up case numbers and mortality.13Eisenhammer S Stargardter G Special report: Bolsonaro brought in his generals to fight coronavirus. Brazil is losing the battle.Reuters. May 26, 2020; https://uk.reuters.com/article/uk-health-coronavirus-brazil-response-sp/special-report-bolsonaro-brought-in-his-generals-to-fight-coronavirus-brazil-is-losing-the-battle-idUKKBN2321E8Date accessed: July 7, 2020Google Scholar The situation with CHWs reveals how lack of leadership translates into inadequate local-level responses to COVID-19. CHWs are in many respects the "canary in the coal mine" of the SUS. Their low salary and precarious working conditions reflect long-standing resource difficulties of the health system and the lack of political commitment to health as a public good.14Nunes J The everyday political economy of health: community health workers and the response to the 2015 Zika outbreak in Brazil.Rev Int Political Econ. 2019; 27: 146-166Crossref PubMed Scopus (24) Google Scholar The uncertain working conditions of CHWs indicate the disarray of the SUS in the face of the COVID-19 pandemic. The failure to prepare and protect CHWs undermines physical distancing measures, places them at risk, and contributes to the neglect of marginalised groups, including the poor, the elderly, and the unhoused. As the length of the crisis increases, so will the burden of chronic diseases and mosquito-borne diseases such as dengue and Zika virus disease, which are not receiving enough attention in the pandemic.8Wenham C Lotta G Pimenta DN Mosquitoes and COVID-19 are a ticking time bomb for Latin America. LSE Blogs.https://blogs.lse.ac.uk/latamcaribbean/2020/03/31/mosquitoes-and-covid-19-are-a-ticking-time-bomb-for-latin-america/Date: March 31, 2020Date accessed: June 19, 2020Google Scholar The present position of CHWs shows the full extent of the public health disaster in Brazil. We declare no competing interests. Download .pdf (.82 MB) Help with pdf files Portuguese translation for the full text