Many visitors to Rio de Janeiro recognize the Oswaldo Cruz Foundation (Fiocruz) by its Moorish Pavilion-style headquarters, which pops up from a patch of forest on the edge of Manghinhos favela along the road in from the international airport. More than just a pretty building, though, it is one of the world’s foremost public health institutions which has been an important actor in the scientific community in identifying and fighting tropical disease pandemics from Chagas disease, which was originally discovered at Fiocruz in 1908, to Zika. Fully integrated into Brazil’s public health system with an annual operating budget of nearly $1 billion, Fiocruz has evolved over the years into a national network of research institutions and labs, vaccine and medicine production facilities, the nation’s foremost public health university and patient treatment centers. Today, it represents the Brazilian public health system’s front line against the spread of the coronavirus.
In the following interview, conducted by Agência Fiocruz de Notícias (AFN) and translated by Brian Mier, Fiocruz director Dr. Nísia Trindade Lima talks about the Covid-19 pandemic and the challenges caused by its arrival in Brazil.
AFN: How do you see the context of the Covid-19 pandemic in the World today?
Nísia Trindade Lima: I look at my institutional role on the one hand and, on the other, look at the perspectives of the people who are working to build a socio-historical reflection on public health and the relationship between epidemics / endemics and society. We are in a unique situation in the World, which of course has experienced other pandemics. This pandemic poses enormous complexity because we are in the 21st century. Today we live in a world that is extremely connected from the point of view of population, people and goods. We also have a large capacity to generate information and analysis and intense levels of knowledge production in different fields of science like molecular biology, immunology and epidemiology, which are very important at the moment.
We are dealing with a context of more intense spread of viruses, the reemergence of old diseases and the emergence of new ones. This is a very important fact to think about. We will have more and more cases of viruses in the coming years, primarily respiratory viruses. This is a trend that is being shown by research and it is linked to our development model, through environmental variables and the relationship between humans and non-humans, as is the case with this virus which came from animals. Of course there is a very great deal of complexity in this and there are still a lot of questions.
Our daily lives are being totally altered. There is a lot of insecurity, restlessness and fear, which is normal during the spread of a new and unknown disease. On the other hand, today we have information and communication resources and technology that help us face such a serious situation and perhaps enable us to live through this period of isolation more in a state of physical distance than social distance.
We also need to look at the social and demographic realities in each country and in each territory where the epidemic is spreading because it does not reach everyone at the same time and containment strategies will play a role in this. So, there is human, political and scientific interference all happening at once. This is a big responsibility for all public authorities and for society as a whole. This is a huge challenge that was unimaginable until very recently.
AFN: What are some of of the characteristics of the pandemic’s arrival in Brazil?
Lima: Since I am a sociologist I will talk about social impacts. It is very important to think about the socio-spatial dimension, which is an essential factor in an epidemic. Each epidemic has to be viewed through its peculiarities. Covid-19 is intensifying in Brazil, starting in two major urban centers. This is natural because it arrived through air travel. It arrived in business class but is spreading in a context of high population density and vulnerable housing conditions prevalent in the peripheral neighborhoods and favelas in all of Brazil’s urban areas. Furthermore, we have urban mobility problems, crowded public transportation systems and a series of other issues that will affect the course of the epidemic. There are also specific population groups that concern us a lot, such the Brazilian prison population. Attention also has to be given to older age groups. These factors have to be recognized and the research and public policies will have to look at this complex reality, which can be summed up in one word: inequality. We need to look at these factors to think about strategies for solidarity.
AFN: What is Fiocruz doing to respond to this emergency?
Nísia Trindade Lima: From the start, since before it was defined as a pandemic when the cases of the new coronavirus in China and the identification of severe forms of pneumonia began, we have been tracking the evolution of the disease in partnership with the Ministry of Health’s surveillance department and through the development of our own research and actions. We are clear that the top priority now is to save lives.
For this reason one of our main actions from the beginning has been working to develop, produce and analyze diagnostic tools. A second priority, which we also defined together with the Ministry of Health, is to provide specialized care for critically ill patients. A third line of action is holding clinical trials to define elective therapies. We are also developing research in various fields to help advance knowledge about the virus and to fight the epidemic. I would also like to highlight our work training professionals and maintaining information platforms – this is something that is fundamental today and will be throughout the course of this pandemic, so that not only Fiocruz but the Health Ministry and Brazilian society will have data and evidence to orient institutional policy. Last but not least, we have our communications actions.
Fiocruz is commemorating it’s 120 year anniversary in May and it will be marked by our response to this pandemic, just as our institution was founded as a response to the epidemics that were sweeping through Rio de Janeiro at the time. This is why our anniversary will be observed by all of our institutes and centers in all of the states where Fiocruz operates. Each one of these institutes and centers is working to strengthen the state government’s health departments so that we can respond to this challenge in the best way possible.
AFN: What are the main diagnostic actions you are taking?
Lima: Fiocruz has a long tradition in developing diagnoses and the entire Brazilian health system depends on Fiocruz’s diagnostic tests. We do this by combining technological development and production. Right now we are dedicating all of our energy to this.
We started developing test kits in our Respiratory Virus and Measles Laboratory, which is a reference in Brazil. The laboratory engaged in the important task of training staff in our other laboratories and setting up a working network. Our first training was for the Adolfo Lutz (São Paulo) and Evandro Chagas (Pará) laboratories, and for the Goaís State Central Laboratory (LACEN), which was where the Brazilians who were in China first arrived. Based on this work, we conducted training in partnership with the Pan American Health Organization [PAHO] for public health officials in other Latin American countries and we developed training for all of the state testing laboratories so that exams can be processed in every state in the union.
We have a production facility for test kits in our our Immuno-biological Technology Institute [Bio-Manguinhos]. The Ministry of Health ordered us to increase production of these tests as quickly as possible. We are working hard and we have set a target of 1.3 million test kits. This is being done in a very integrated way. Bio-Manguinhos has been relentless in increasing its pace of production. We are also working with the Paraná Institute of Molecular Biology, which is an institute that was created in partnership between Fiocruz and the state government to try to increase production of testing kits.
Finally, the National Institute of Health Quality Control (INCQS) has assigned us the important role of analyzing coronavirus test quality.
AFN: What about treatment?
Lima: The Evandro Chagas National Institute of Infectious Diseases [INI / Fiocruz] is Fiocruz’s primary unit for the clinical research of and specialized care for patients with infectious diseases. It is already a national reference for the care of critically ill patients with Covid-19, but it has a very small operational structure to meet this level of emergency. Therefore we are mobilizing our entire team in a great effort to increase our support for critically ill patients. We are increasing the number of beds at our Fiocruz Hospital Center for the Covid 19 Pandemic, at our headquarters in Manguinhos in Rio de Janeiro.
We are also setting up an additional 200 ICU and semi-intensive treatment beds in the football field in Manghuinhos. We created a dedicated monitoring committee so that these beds can be offered under conditions of quality and patient safety, which is only possible due to the excellence of our team and from the boldness which I think our institution has to have right now. This is a boldness that comes from our commitment to public health.
We also have our Fernandes Figueira National Institute of Women’s, Children’s and Adolescent’s Health (IFF), which is monitoring what is happening to pregnant women and newborns in Brazil. I think this work is fundamental since there are still many doubts about the disease’s transmission and and possible effects.
AFN: What kind of research on coronavirus is being done at Fiocruz?
Lima: We are building mathematical models and conducting research on the impact of the pandemic on the health system along with its social impacts and economic impacts. I would like to establish a Researchers’ Forum for Covid-19 and to use Fiocruz’s Technical Research Congress to contribute to this. With this structure in place will be able to use our Inova program to describe this dramatic situation and help our our institution and our nation to better prepare for possible new emergencies, as we responded to the Zika emergency a few years ago. I think at this moment we have important research challenges in all fields.
AFN: What is Fiocruz doing in terms of conducting clinical studies on possible drug treatments?
Lima: We are working, together with the Department of Science and Technology, the Ministry of Health and the World Health Organization as part of an international set of clinical trials and research to help define the best therapies. This work is being coordinated by the Evandro Chagas National Institute of Infectology [INI / Fiocruz], with support from the Vice-Presidency of Production and Innovation in Health [VPPIS / Fiocruz]. Our Pharmaceutical Technology Institute [Farmanguinhos / Fiocruz] will fabricate and supply part of the drugs used in the clinical trials.
Without a doubt, this is a very sensitive issue where I believe we can make a very important contribution. I have been very careful talking about the therapeutic issue because a lot of information has come out. We can say that there are promising drugs, but we will only make an official statement about them after the Ministry of Health and the appropriate governmental bodies approves these drugs for use by patients. One of the problems that has occurred now is scarcity of some of these drugs for patients who who already use them continuously. The population is insecure and we have to work to ensure effectiveness and safety so that there are no problems with side effects. We are working hard towards this goal.
AFN: What are some of the communications activities you are doing to help fight the pandemic?
Lima: Communications plays a fundamental role, due in part to the fact that our specialists are answering questions from the media now. We have set up a communications network coordinated by Fiocruz’s presidential press department, which plays a fundamental role, as well Fiocruz’s own communications medium, the Portal, which is our center for information; social networks; Radis; the Health Channel; etc.
But I think we need to think about language and audience. We need to communicate to the youth and this has to be done together with the population. We cannot direct messages, they have to be built together with the population. How do we make communications that resonate with everyone, not just the middle class? It is very important to constantly review our discourse because communication tends to be directed towards a middle class public and is often based on the idea that people can isolate themselves in individual rooms inside their houses, avoid crowds, afford to purchase hand sanitizer and things like that. But we know that these guidelines are not realistic for a lot of people. This is one of our challenges.
One interesting initiative of ours is Se liga no corona, a public health communication campaign that Fiocruz is doing together with community organizations from Maré and Manguinhos favelas, to prevent coronavirus from spreading into the population living in favelas and periphery neighborhoods. All of the materials are prepared based on questions from favela residents that are collected by our partner organizations in the communities.
AFN: What kinds of training activities is Fiocruz operating for the pandemic?
Lima: Right now we are giving very special attention to the laboratory professionals who are processing the coronavirus tests. We are also providing training to public health officials on the pandemic together with the Joaquim Venâncio Polytechnic School of Health [EPSJV].
These first weeks will be very hard for everyone and this creates challenges for this whole set of activities because we are looking at the models and predictions. We were planning a distance learning course on sustainable development with Professor Jeffrey Sachs, but it would be alienating to talk about any subject other than this pandemic, so the focus of the course was immediately changed. We are also preparing distance learning courses for health professionals focused on combating Covid-19. These courses are very important for the care coping strategy. Our graduate programs are adapting and preparing online activities, as are all of our educational projects due to self-isolation requirements.
AFN: How is coronavirus effecting the Fiocruz workers in their daily lives?
Lima: The impact on our workers’ daily lives is huge. For this reason, we have established a contingency plan to protect our workers and our essential activities, since Fiocruz is part of the solution to the problems that we are dealing with. Right now, health professionals are feeling a strong impact due to the pandemic’s effect on their work and the very strong psychological impact that this is causing in them. They have to deal with very difficult and very dramatic situations. So, we are worried about all Fiocruz workers, especially those who are working with patients. We are working to provide an additional salary supplement for our health care workers, which we believe is important to guarantee that they can take better care of people.
We do not want to demobilize our institution. On the contrary, we want to provide secure conditions for our workers and students, within the guidelines that health authorities have defined. We want to protect our workers as much as possible but at the same time keep Fiocruz operating. Afterall this is also what will enable us to be more cheerful, not to get sick and to give meaning to this difficult period of isolation in which many are stuck at home. It is what will enable us to remain connected to one of the most important things, which is our pride in being part of Fiocruz and being able to respond to such a serious health emergency. This is a crisis that impacts not only that people who develop the most severe form of the disease, but the entire health system. We have other health problems impacting our Unified Health System [SUS], which is a universal system that we believe in, that we contribute to the construction of. Even with its weaknesses I think that it is one of Brazil’s strengths at the moment.