We arrived late.
Antonio Flores was the Medical Coordinator for the Médecins Sans Frontières (MSF) team that arrived in April 2020 in Manaus, the capital of Amazonas State. “We had COVID-19 response teams in Rio de Janeiro and Sao Paulo, and then the bad news started coming from the interior. When I arrived in Manaus, the grave diggers were working beyond capacity, all the hospital Intensive Care Units were overflowing with dying patients, and there were lists with hundreds of severely sick patients waiting in health centres for an intensive care hospital bed to become free. It was worse than we had feared. We were able to get an ICU ward up and running, relatively fast. It was initially operating at full bed capacity, but we felt that the worst had probably already happened.”
The limited COVID-19 testing deployed by Brazil’s central authorities made tracking the pandemic’s spread across the vast country difficult, all the more so in the Amazon basin where transport is limited, distances vast and population centres widely spread out. What’s more, the limited testing is mostly done with the antibody test – the one that tells you if you have had COVID-19 in the past – and not the test that lets you know if you have the disease now. This means that the epidemiological data in Brazil gives a rough snapshot of what the situation was like about three weeks ago, not a current view of the state of the pandemic.
By early May there were a range of MSF activities deployed in the city. Manaus has a vulnerable population of refugees and homeless people. Mostly they are accommodated in organised shelters, with families living in very close proximity and where the possibility of physical distancing is almost non-existent. The situation of the Warao indigenous people, who have come from Venezuela to Brazil, caused particular concern because of their crowded living conditions. MSF set up an isolation centre for this community for anyone showing symptoms of COVID-19.
The Warao indigenous people have their blood pressure checked in an isolation center run by MSF in Manaus. Most of the Warao indigenous people who live in the capital of the state of Amazonas live mostly in shelters, where social distance is almost impossible. © Euzivaldo Queiroz/MSF
The Intensive Care Unit
The central part of MSF’s Manaus response was the medical support in one of the main hospitals, called 28 de Agosto Hospital. MSF took over the running of the fifth floor, with a 12-bed Intensive Care Unit (ICU) for critically ill patients and a 36-bed ward for severe patients. Although the overwhelming pressure of the initial peak of COVID-19 had passed, the wards were all full and MSF’s emergency experience helped the rest of the hospital to improve the flow of patients and increase the quality of care.
(Left) Nurse Rebecca Alethéia provides training to the team at the regional hospital in Tefé explaining the process for disinfecting hospital materials. © Diego Baravelli/MSF (Right) Our team is training the staff of the regional hospital on IPC measures, as well as general emergency training linked to COVID-19 response. © MSF
Doctor Pedro Cury Moyses remembers this as a high-pressured environment: "Arriving at the hospital, we faced a scenario familiar to anyone who has worked in Brazil’s national health system: a precarious structure that’s working at its limit.”
“But I have good memories of the discharge of a patient who was admitted to the ICU. When I first met her, she was obviously scared, mainly because she had a slow and complicated recovery. She had underlying medical conditions as well as COVID-19, and that complicated her case. The team was afraid that it would get worse. Finally, when she was well enough to leave the hospital, we organised her departure. In a wheelchair, she was surprised by the ICU and ward staff applauding her in the corridor and, at the end of it, by the sight of her husband who was waiting for her with a bouquet of flowers. She was the greatest symbol of our work in this Manaus hospital. Restoring her to life helped to restore hope to the doctors there, who had witnessed devastatingly high mortality rates throughout the pandemic."
Into the Amazon Forest
In Manaus, the waters of the Negro and Solimões rivers meet, forming the colossal Amazon river. As the epidemic peaked and then stabilised in the state’s capital, the disease had already been silently spreading upriver and into the rainforest.
“At first there were infrequent one-off calls of alarm about COVID-19 cases coming from remote and riverside communities in the Amazon basin,” explains Dounia Dekhili, MSF head of mission in Brazil. “For many years there has been a significant underinvestment in health and welfare infrastructure and resources in this region. The vast distances and lack of transport options result in major challenges to follow the epidemiological spread, and also ensure timely referrals for patients in need of more complex medical care. We knew we needed to better understand the epidemic situation in the forest, but this is a very vulnerable and sensitive area, where the ‘do no harm’ principle applies in a rather unique way. There was a need to ensure COVID-19 treatment capacity accessibly close to the riverside and indigenous communities, but there was also a need to avoid bringing the disease right into the heart of these communities.”
The teams leave the vessel of the primary healthcare boat to carry out routine screening and vaccination from house to house. © Diego Baravelli/MSF
A two- or three-day boat journey up the Solimões river brings you to one of its tributaries, the Tefé River, which gives its name to the municipality of 60,000 inhabitants on its banks. This was one of the towns most affected by the pandemic in the region. Tayana Oliveira Miranda, director of the regional hospital in Tefé, tells how the disease appeared:
“When the first case with hospitalisation was confirmed, the whole team was already alert and afraid. We started to withdraw the elderly, pregnant and chronically ill staff from the team. Then, it started to overwhelm those who stayed to work. The number of hospitalised patients began to increase. Then we had the first death. The staff on that shift were devastated. And the pressure was increasing. The cases in May were growing, the number of hospitalised patients increasing - and the deaths too - hospital staff becoming ill. We changed the flow, we brought the COVID-19 ward into the hospital because there was no more space due to the number of patients. Chaos was beginning to take over. The peak was on the day that we had 41 people hospitalised, six intubated, and the demand for air ambulances for the entire state was very high.
"That day there were nine deaths. The team suffered a lot. The doctor on duty broke down in tears, the team did not eat, it was a horrible day and I dare to say that no one could eat and sleep that night. At least I couldn't. Next day we would have to go through the hospital door and move on. We had no other option.”
When MSF arrived in the city, the number of patients had stabilised to a more manageable level. The hospital team were clear that what they wanted was some training to be prepared for the possibility of a new wave of infections or for another situation of mass arrival of patients. More than 200 medical and paramedical staff attended the MSF training at the regional hospital in Tefé.
The Boat Clinic
Tefé has a primary healthcare boat that brings a basic medical service to communities living along the river; a two-week return voyage includes several stops to assist the riverside residents. Nova Sião, one of the last communities served by the boat before returning to Tefé, is on the shore of lake Mirini. Here, the health team travels in smaller boats from house to house, giving medical consultations.
“We knew we were getting closer to very vulnerable communities,” explains MSF nurse Nara Duarte. “So it was vitally important to prevent patients and health staff from becoming contaminated during consultations. We asked to help with the infection control on the first boat clinic after lockdown, as we felt this would be an important part of helping to minimise the risk of the disease spreading into the most vulnerable communities.”
The MSF infection-control team spent their time on the boat developing a circuit through which people enter, pass and exit when they arrive for consultations. In the evenings, after the consultations had finished, the team gave the regular boat clinic staff and crew additional trainings on infection prevention and control measures and emergency respiratory care.
"It was great. MSF showed our weaknesses and we are working to improve them”, said Jhonaliton de Freitas da Silva, a nurse on the medical boat. “I learned a lot about communication and knowing how to listen better to the patient. Sometimes we ask the reason for the consultation, but do not go further to find out if there are other problems. I learned to do that.”
Local population arrives at the primary healthcare boat to receive care. A MSF team was present in the first primary healthcare boat voyage from Tefé when the lockdown was eased after the peak period of the pandemic. © Diego Baravelli/MSF
A consultation at the primary healthcare boat upriver from the Amazonian town of Tefé. ©Diego Baravelli/MSF
Adapting to the communities' needs
More than 400 kilometers to the northwest, bathed by the dark waters of the Negro river, is the municipality of São Gabriel da Cachoeira. MSF set up a care centre in the town to receive patients with mild and moderate cases of COVID-19. The facility was specifically adapted to suit local traditions; over 90 percent of the population of São Gabriel da Cachoeira is of indigenous origin.
In the care centre, for example, indigenous patients with COVID-19 can remain for the duration of treatment with a carer, something that is not usually allowed in hospitals. Hammocks are available for patients and companions. In addition, traditional medicines used by many people in the region are accepted at the centre and can be taken together with the treatment offered by MSF, as long as their combination does not cause any adverse effects. Shamans, spiritual leaders of indigenous communities, can visit and perform rituals. The only requirement is that they use personal protective equipment to avoid being contaminated while in contact with the patient.
A health worker wears the personal protective equipment before entering the control area of the MSF care center for mild and moderate cases of COVID-19 in São Gabriel da Cachoeira. © Diego Baravelli/MSF
It was also important that everyone knew where they could look for assistance tailored to their needs. MSF spoke with leaders and organisations linked to indigenous communities and, in order to answer the questions from the communities, MSF staff participated in radio transmissions are periodically broadcasted for the indigenous villages.
In its first two weeks, the facility admitted ten COVID-19 patients; everyone was discharged cured. Antonio Castro, 99 years old, was one of them. Breathing hard and suspected of having contracted COVID-19, he was followed up by the MSF team and could return home a few days after entering the centre.
The MSF team helps 99-year-old patient Antonio Castro at the MSF care center in São Gabriel da Cachoeira. He was under observation for a few days with breathing difficulties. © Diego Baravelli/MSF
Among the many unanswered questions raised by the new coronavirus, the path ahead until the end of the pandemic is still in doubt. One of the few certainties is that preventive measures such as physical distancing, wearing a mask, and hand hygiene remain essential.
“We hear that the pandemic is over in Amazonas state and that it was just a matter of waiting to achieve 'herd immunity',” says Flores, the MSF medical coordinator. “This idea is absurd because it ignores that with a greater number of infected people we are also talking about a greater number of deaths. We saw the health system collapse and the enormous cost for the population of not having a timely response that could control the spread of the disease.”
The numbers of new cases are beginning to decline in the state, but without clear information about what happens in the interior of the country, the fear is that the disease will continue to spread silently to more remote areas that have difficult access to medical care.
Vilmar da Silva Matos is a Yanomami indigenous leader who occasionally travels from his community, Maturacá, to the city of São Gabriel da Cachoeira. He talks about the fear he felt when he heard on the news that the disease was getting closer to his people and was affecting the elderly more severely. “We thought we were lost, we were especially concerned with the elderly. We were afraid of losing our leaders, who are like our dictionaries, our storytellers”, he says in the makeshift settlement where Yanomami indigenous people take shelter when they are in the city.
Keeping COVID-19 from spreading across the Amazon is fundamental to saving lives and to saving the dignity encapsulated in the immeasurable and irreplaceable knowledge of generations.
(Left) Municipal health system's worker talks to family during house-to-house visit in lake Mirini region. ©Diego Baravelli/MSF (Right) Nurse Nara Duarte teaches a child the correct way to perform hand hygiene in a community visited by the MSF and municipal health system's staff in Lake Mirini. © Diego Baravelli/MSF
MSF in Brazil
Elsewhere in Brazil, aside from its work in Amazonas state MSF is also currently responding to an acute peak of COVID-19 in Roraima State, running an ICU unit and developing community outreach in an impoverished suburb in eastern Sao Paulo, and has formed a team dedicated to identifying high-transmission hotspots of the pandemic that need medical assistance elsewhere in the country. MSF has handed over earlier COVID-19 activities to other organisations in Rio de Janeiro and in central Sao Paulo.