Marcia Castro, Andelot Professor of Demography at the Harvard T.H. Chan School of Public Health, takes a look at the challenges Brazil—long a world leader in immunizations—faces with the distribution of the Covid-19 vaccine.
June:
Marcia Castro is a Professor of Demography in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health. She's also the chair of the department of global health and population. Her research focuses on the universal health system, as well as the social and environmental factors that contribute to the spread of vector-borne diseases. Welcome, Marcia.
Marcia Castro:
Thanks for having me, June.
June:
Everyone is talking about the vaccine and the hope it brings, but vaccine distribution is likely to exaggerate all the weaknesses and strengths of health systems. Brazil is a microcosm of all that's happening. Let's take a look at vaccine distribution in Brazil in the context of your own research. First of all, when do you expect vaccine to start being distributed in Brazil?
Marcia Castro:
We have some really good vaccines with few results coming out of the last phase, the phase three. They have to be approved by the body, which is equivalent to the FDA in the US. They have to be approved for distribution. And I hope this is coming soon. It has to be now, in December. We should have this approved in December. If we're going to have vaccines, it is starting to be distributed across the population this month or next month. I don't know for sure, but there is a chance we could start vaccination is if there's a plan.
Marcia Castro:
We will talk more about this. But there is a chance it could start in December, if not in January, for sure.
June:
Do you have any idea where this vaccine is going to be sourced from?
Marcia Castro:
Brazil has a really phenomenal immunization program, and it's connected to the health system, to the SUS. And it historically had one of the highest coverage of immunization in the world. In fact, this program, it was a model. In the past few years, what we see is a decline in coverage of immunization, which is really worrisome because we could have re-introduction of diseases that are not a problem anymore. And we had one in 2018, measles. After being certified eliminated from measles, measles was re-introduced.
Marcia Castro:
Another one that could come back is polio, if vaccination really continues to go below the minimum level to prevent the disease to circulate again. Brazil has this structure of a universal health system and a program of immunization. It will be distributed by the government free of charge for the population. The funding that Brazil has through its own health systems should support the acquisition of the vaccine. But above all, they have to make this agreements in a way that there is transfer of technology.
Marcia Castro:
Brazil has the capacity to also produce the vaccine in the country, as long as there is transfer of capacity. And right now we have two institutions, Butantan in Sao Paulo and Fiocruz in Rio, which are already the institutions in the country that produce the largest amount of vaccines that are distributed.
June:
Could you talk a little bit more about that transfer of technology?
Marcia Castro:
Whenever we have drugs being developed, vaccines being developed, all those agreements being made by Pfizer, AstraZeneca, and all those different vaccines, there are terms on the agreements that are made. And in those terms, if it's a good agreement for the country that will receive the vaccine, the transfer of technology allows the country to be able to have access to all the biology behind producing the vaccine.
Marcia Castro:
You are not just receiving some very let's say hidden instructions and then you're going to produce following those instructions, but you understand the process. You learn from it. You can use this technology in the future to also produce other things, other vaccines, other drugs. That is beneficial for both sides. Not only you're getting the vaccine, but you're getting the knowledge.
June:
Thank you. That's really interesting. Why is the rate of immunizations going down?
Marcia Castro:
Well, there are different reasons. One is the health system has been underfunded in the past few years, particularly since 2016, when Brazil had an economic crisis in 2015. It's still suffering the effects from it. There are some policies that have been implemented to freeze the funds... For austerity policies to freeze the funds for health. That's one aspect. Connected to that, the hours that the health units that provide immunization changed.
Marcia Castro:
Those places have to be open on the weekends because families that work during the week, they have to be able to take the children for vaccination on weekends and at longer hours. In some places, this is not available anymore, and it used to be. There's also some connection with local capacity and training, if you have enough agents to be able to be available and provide immunization. And unfortunately, the anti-vax movement is also increasing in Brazil, which to me is just horrible. Just to give you one example, we were in the middle of a pandemic.
Marcia Castro:
In late August, there was a survey done in Brazil and one in four Brazilians said they were not going to take the COVID vaccine and half of those that said that we're not going to take it's because they don't think the vaccine is safe. In September, we had a paper published in The Lancet that they basically do a survey worldwide on vaccine acceptancy. They showed results between 2015 and 2018, and they asked if the vaccine is safe, if the vaccine is effective, if vaccines are important, and Brazil got worse in all indicators. That's not good.
June:
Do you think that's going to affect the actual distribution of the COVID vaccine?
Marcia Castro:
It will certainly affect the uptake if people are going to take it or not. And I should say, this is an issue for the US as well. We have no idea how many people are going to show up and take the vaccine. The problem with this is if we have a very high percentage of people that do not want to be vaccinated, that can put in danger reaching that minimum level of people vaccinated in order to really contain transmission. That's what we call herd immunity. You have enough people that took the vaccine that you stopped those major outbreaks in some localities.
June:
And you're writing about the universal health system. We talked about the role of community health workers. What do you anticipate is the role of community health workers in the distribution of the COVID vaccine and also in educational efforts to cope with this fear that the vaccine won't work?
Marcia Castro:
I'm glad you mentioned the educational efforts. That's another thing that Brazil historically had been a model on communication campaigns, educating, synthesizing the population. What Brazil did during the HIV epidemics was absolutely phenomenal. I can guarantee some of those ads would never show in the US but they were phenomenal. We have nothing. We have no communication campaign right now in the middle of a pandemic.
Marcia Castro:
If you think of when we are ready for the vaccine, or let's put it this way, if you'll look at what the government is saying it's their plan for the vaccination, the plan is an example of lack of planning, honestly, because the planning includes a communication campaign so people understand why the vaccines are important. They remove fears, misconception, misinformation, and people ready to show up and take the vaccine. It includes logistics. Some of those vaccines need a cold chain. They need to be at minus 70. And there is a very limited time.
Marcia Castro:
Once you remove from there, you have this window of time to be able to use the vaccine. Otherwise, it's going to go bad. All of this logistics had to be planned for a continental sized country that has areas in the middle of the Amazon that super heavy trucks cannot even go through because we have no roads. That's that aspect of logistics. Then you need the personnel. Where are you going to have the vaccines? In hospitals? Because maybe they have the cold chain.
Marcia Castro:
If it's in the hospital, how are you going to guarantee that people are going to go to the hospital in an orderly way? Not what we saw a few years ago in Brazil when we had the few cases of yellow fever that people were packing in lines to get the vaccine. That's the last thing that we want to see happening. We don't want to see people packing. The other thing is they have to order syringes. It's not just the vaccine. And I am sorry, but Brazil hasn't ordered the syringes yet. And the companies that produce them, they have been mentioning this in a long time.
Marcia Castro:
Many steps in the logistics and we are very far from having all of them in place.
June:
Going back to the role of community health workers, these people are not being trained to educate people at this point?
Marcia Castro:
Right now, no. In fact, the community health agents were not even used as part of the response to COVID. That's one of the big problems we saw is that the government failed to use their own health system, their own network of community health agents to be right there in the community. And they could have done many different... Played many different roles, but they were not incorporated in the response, and they're not being trained now. It's not clear how they're going to be engaged into this massive efforts of vaccinating the population.
June:
You mentioned syringes and colds and education. What other challenges are being faced in the distribution of vaccine?
Marcia Castro:
So again, the other is, how do we set priorities? Of course, age is one of them, but there are different groups of vulnerable populations that includes the indigenous populations, the people without freedom, incarcerated, homeless, it's not even mentioned in the first discussion the government had, the families of former slaves that they live in communities. It's called the quilombolas. That's also a vulnerable population.
Marcia Castro:
There has to be a plan that based on whatever evidence the government has, that you can have a very clear prioritization, who gets the vaccine first and how is he going to be distributed? The challenges are the physical challenges of the country per se, are the social challenges of defining vulnerabilities that need to receive the vaccine first. And it has to do with whole is essential personnel, healthcare professionals, teachers, and you name it.
June:
What stage are those decisions being made?
Marcia Castro:
End of last week, we had something called like a plan from the federal government. But as I mentioned, the plan is really a joke because it's a PowerPoint. We don't have documents. We don't have any discussion on how those prioritizations were made. We don't have any engagement from the actors involved from the societies. There is no conversation with the different levels. For example, whatever the federal level decides has to be agreed with the states and with the municipalities, because they are the ones that are going to implement.
Marcia Castro:
This conversation is not happening yet. We have a PowerPoint, but we don't have a plan.
June:
You have a PowerPoint, but you don't have a plan. That sounds very serious. In Brazil, you have the universal health system, which we've talked about, but you also have a parallel private system. Does this fact increase inequity in vaccine distribution? Are people just going to be able to go to their private doctors and say, "Hey, I want a vaccine."
Marcia Castro:
That is a very good question. The Minister of Health said in one of those many statements that the vaccine would only be available in the public system as part of the immunization program, the national immunization program. It's not clear to me if that's going to be the case. And considering the inequalities we have in the country, if the private sector is able to acquire the vaccines, I am sure they are going to make it available. And whoever can pay, will pay for it. And this only increases the gaps between the haves and the have-nots.
Marcia Castro:
We don't know exactly how this is going to unfold, but to be very honest, I would be extremely surprised if the private sector does not have access to vaccines. But we'll see. We don't have to wait much to see that. We'll probably have this answer next month, but I don't know. But for sure if we have them available in the private sector, you're just going to... It's not going to be equitable. To address those health challenges in our country so unequal as Brazil is, if it's not an equitable strategy, you're just going to increase the gap.
June:
We think of equity in terms of income, but there's also a different kind of equity in Brazil, which is your rural areas versus your urban areas. You've worked extensively in the Amazon, and you mentioned before that many of the vaccines require cold. What other challenges are facing the Amazon? What chances does a shaman who lives in the deep Amazon have of being vaccinated?
Marcia Castro:
The very first thing is there has to be a very clear communication with the indigenous groups first to tell them why it would be important for them to be vaccinated. Many of them are scared because the incidents and mortality of COVID among indigenous is much higher than among the overall population. They are scared. They are worried about this for a reason. I have no idea if they would be willing to take the vaccine. There is something called trust. And if we don't have trust in the higher level that is trying to give you something on health, it's not going to happen.
Marcia Castro:
And at this point, it's not clear to me if distrust is there. And if you don't have any communication, any engagement, anybody that goes in there and makes them aware that it's important to take the vaccine, I don't know if they're going to take. That's one point. Another one is, this has to be done in a way that people that are going to go in those indigenous areas is not infected, because a lot of those areas had a problem because somebody show up there, sometimes a health official, and that person is infected.
Marcia Castro:
And it only takes one to create the mess that we see. That is the same for riverine communities that are only accessible by boat, and many of them had this issue. A boat came, somebody is infected. It's trust, it's information, but it's a very careful plan to make sure that whoever goes in there is a person they trust and it's a person that please is not infected, because then you're going to have a negative outcome that is not going to help at all with the strategies. There are regional challenge. There are physical challenges.
Marcia Castro:
There are social challenges. There are challenges with trust. There are racial disparities that are also important. Then you have all those issues of bias. You name it. So again, without looking at those facts and addressing them in a plan, we're just going to increase the inequalities for sure.
June:
Marcia, can you talk a bit about those racial disparities, both in terms of the experience with COVID itself and how you think or fear it may play out with vaccine distribution?
Marcia Castro:
Yeah. We all saw those numbers, those statistics, vulnerable, blacks, mixed in the US, Latinos as well, are disproportionally affected by COVID mortality. Now, this happened because of structural problems that we've had in the kids of Brazil for centuries honestly, since Brazil is Brazil. Those vulnerable populations, first, because of the social determinants of health, they probably have health outcomes that make them more vulnerable to COVID. They have higher rates of obesity and overweight. They may have high blood pressure.
Marcia Castro:
They have conditions that if they get infected, they're more likely to die. On the other hand, they are very unlikely to just work from home in remote work, because they have informal economic activity, or for whatever reason, they have to move to continue to work in generating income and then they expose themselves to very crowded public transport. It's both sides. It's almost this double exposure that makes them more vulnerable. It's not by chance and it's not a surprise that we see them being disproportionally infected.
Marcia Castro:
They are disproportionally infected no matter what kind of health challenge you look at. But in the middle of a pandemic, in the middle of an epidemic, all those inequalities get illuminated, and that's what we're seeing now. How this is going to play in the vaccine distribution, well, one is access. They may have limited access because of the same reasons that they have limited access to healthcare.
Marcia Castro:
Depending on where the vaccines are going to be distributed, they may not have the resources to be able to go to another place to get the vaccines, depending on when they are provided, again, it's the hours that I mentioned before, if they cannot leave their jobs and go. There are all of those challenges that can create a major hurdle for them to be able to be vaccinated.
June:
You mentioned before that Brazil has this amazing track record in terms of public healthcare, immunizations. And I understand from what you've told us, there are problems of being underfunded. But are there more basic problems that are preventing this... Let's say, Brazil not following up on its own history.
Marcia Castro:
Well, it's never only one reason, right? It's always a combination of things. So since the health system was created with the new constitution in '88, there are things in this idea, in this model of the health system that were never fully implemented, and one of them was the financing model. The way it was designed, the health system would have many more resources, and it never happened as it should be. One of the things is when the health system started, there was this private sector as well. And Brazil has this dual system that is not very well integrated.
Marcia Castro:
If you look at overall in the country on how much is spent on healthcare, you'll see that 75% of the population depends on the public system. But overall, of all the money spent on health, the largest fraction is spent on private sector, which makes no sense, right? That's one of the challenges is that it was never... The model, which is great, was never fully implemented. And then we had the end of the '80s, so we are done with the crisis of the '80s. The '90s come. It's a great year. But again, then you have all this other challenges.
Marcia Castro:
There are many things that will be very hard to be implemented because they challenge the private sector, and then you have a huge lobby in there to change those things. And then when a crisis come, usually in any governments, the first thing they cut are social programs, that includes health, education, social assistance. And that's what we're seeing now, but we don't have much room for cutting our health. There are other things that could be cut. We need a major political reform. There are a lot of special benefits among people that work in the Congress, in the Senate.
Marcia Castro:
If you got those, there's a lot of money that you can save. There's room to save some percentage points for the GDP and invest in health, but there has to be a willingness to make those changes and to really have an eye on social programs and an eye on inequalities. And unfortunately, the current government does not have inequality as a major word in the agenda for social programs.
June:
Are you terribly pessimistic?
Marcia Castro:
No, no, no, I'm not, because if you work in public health, you have to be optimistic. Otherwise, you better change jobs because we always hit hard walls in public health, but we keep going on. I am optimistic because I think we have local groups that are reacting. In the middle of all this disaster of COVID in Brazil, we had some local coalitions and that included philanthropy, the local government, not the federal, the local government, academic institutions, community organization.
Marcia Castro:
We see some reaction, because honestly, June, we hit such a bad, bad bottom that people have to do something. We just had local elections in Brazil. I think there was a message sent in those elections because a lot of the mayors being supported by the federal government were not elected, and I think there's a messaging there. I remain optimistic. I think we have the tools. We just have to use them. In some localities, we are doing this through the popular movement. I like to believe that the Brazilian people will react as it is reacting, started to react.
Marcia Castro:
And one of the mechanisms that we have to react to is through the vote. I'm telling you the reality and the reality is bad, but I remain optimistic always.
June:
You're also a bit of a soothsayer. A couple of years ago in an interview with the Sao Paulo office, you noted, and I'm going to quote you here, Marcia, "Controlling the spread of diseases in a highly connected world is not an easy feat. If humans move, so do pathogens. Vectors can be introduced to new areas through human movement or trade of goods. The threat of a new pandemic is very much real. The uncertainty is when it will happen and what the pathogen will be." That to me sounded like you were looking into a very wise crystal ball.
June:
And you went on to say, "To face this reality, solid surveillance systems are needed. Strong health systems are imperative, and universal health coverage is absolutely necessary." You've talked a lot about these themes during this interview, but if you... You spent a lot of your academic life, I imagine, grading students. If you had to give, first of all, a grade to how COVID is being a handled, from A to F, which grade would you give?
June:
And then if you look into your crystal ball, given the changes in local government, given international demands, what grade do you think we'll see for vaccine distribution?
Marcia Castro:
In Brazil?
June:
In Brazil.
Marcia Castro:
The grade for the COVID response in Brazil is a really big red F, honestly. And what is sad about this F, it's almost like this student that is bright, has potential, has everything in front of him to do a good job, and fails to do. That's the kind of F Brazil gets. For the vaccine distribution, based on everything I heard so far coming from the government, it's not looking good. As a midterm, because I can't give the final grade yet, as a midterm, it's a D. I'm not going to give an F. It's a D as a midterm, but there is a chance to do better.
Marcia Castro:
I dare to say that... I mean, the statements that are coming from the president and the minister are so bad that they may end up ruin everything that... Especially the president ruined his chances to continue to be popular because of what's happening now. I don't know. But so far it's a D. I hope it improves because we cannot continue to afford the number of deaths that we are affording. And the only way out at this moment is to have a vaccine.
Marcia Castro:
For the sake of all the lives lost and for the many that we can save, I hope that if you asked me this question in a couple of months, I could at least tell that it's a B.
June:
Thank you, Marcia. We've been listening to Marcia Castro. She's a Professor of Demography in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health. Thank you for being here with us.
Marcia Castro:
Thanks so much, June. Appreciate it.