A person places white handkerchiefs symbolizing farewell in homage to 600,000 victims of the coronavirus pandemic in Brazil.

Brazilians have recognized the more than 600,000 people in their country who have died of COVID-19 with a display of white handkerchiefs.Credit: Buda Mendes/Getty

According to official government statistics, more than 685,000 people have died from COVID-19 in Brazil, placing it among the nations with the most fatalities. As infections skyrocketed in Brazil between 2020 and 2021, the country spread the SARS-CoV-2 coronavirus beyond its borders, exporting the virus ten times more often than it imported it, according to a study published in Nature Microbiology last month1. The results suggest that the nation — Latin America’s largest — was a COVID-19 epicentre, and that policies implemented by its government, and its leader Jair Bolsonaro, failed to curb the virus.

The report comes as Brazil gears up to elect its next president in October. Bolsonaro is up for re-election and faces 11 challengers, including former president Luiz Inácio Lula da Silva, who led the nation from 2003 to 2010. It remains to be seen whether Bolsonaro’s questionable pandemic response will work against him during the election. Public-health researchers have decried his refusal to implement lockdown measures, his spreading of misinformation about vaccines and his backing of ineffective drugs such as hydroxychloroquine to combat COVID-19.

“For most of the pandemic, the government did not offer a coordinated response, giving room to a wave of disinformation — at times spurred by leaders in the federal government,” says Otávio Ranzani, an epidemiologist at the University of São Paulo and at the Barcelona Institute for Global Health in Spain.

Many of the presidential candidates, including Bolsonaro, are promising to bolster Brazil’s health system, known as SUS. But the country is also now grappling with other issues, including food security and economic inflation, which could trump pandemic concerns when Brazilians head to the voting booth. According to a recent study from the Getulio Vargas Foundation, a higher-education think tank based in Rio de Janeiro, one in three Brazilians could not afford to eat properly in 2021 — the highest proportion in more than a decade.

Still, it’s exciting that health care is being discussed in this presidential election, says Rosana Onocko Campos, president of the Brazilian Association of Collective Health in Campinas, São Paulo. “It is the first time I’ve seen the great majority of candidates say they agree that an increase in federal funding for SUS is needed,” she says.

Virus exporter

According to the Nature Microbiology study, SARS-CoV-2 was introduced to Brazil mainly from Europe in early 2020, before the country had implemented any response measures. But between then and September 2021, the nation spread the virus to many countries; the highest number of virus exports went to other South American nations, ten of which border Brazil (see ‘Super spreader’).

SUPER SPREADER. Graphic showing the countries where Brazil spread the SARS-CoV-2 coronavirus according to a study.

Source: Ref. 1

To draw these conclusions, the team sequenced 3,800 SARS-CoV-2 genomes from infected people in 8 Brazilian states and one neighbouring country, Paraguay. The researchers also analysed genome sequences in the popular data repository GISAID — more than 13,000 from Brazil and about 100 from Paraguay — to understand which coronavirus variants were prevalent, and at what times, between 2020 and 2021. And they compared their sequences with more than 25,000 global sequences to draw conclusions about viral spread. They found that Brazil had most often exported the Gamma variant, which first emerged within its borders.

The main point of the study, says lead author Marta Giovanetti, a visiting virologist at the Oswaldo Cruz Institute in Rio de Janeiro, “is to discuss the role of populational mobility and the emergence of the first variants of concern” in Brazil.

To Marcelo Gomes, a public-health specialist and computational scientist, the findings make sense, because COVID-19 infections in Brazil remained at a consistently high level from 2020 through September 2021, making transmission to other countries possible. Gomes is based at the Oswaldo Cruz Foundation in Rio de Janeiro, of which the institute is a part.

The SUS was overwhelmed by COVID-19, revealing a resource deficit, Onocko says. “We need to requalify services and personnel to increase technical capacity for faster service [and have] better coordination among the federal, state and local governments. It will take an extraordinary effort,” she says.

Promises, promises

Acknowledging that the SUS was overworked during the pandemic, Bolsonaro has promised a 250% increase in funding for health-care workers if he is re-elected. He and Lula — who are leading the polls — have pledged to bolster Brazil’s post-pandemic response, and Lula wants to improve women’s access to public services for the prevention and treatment of disease.

How these promises would be implemented and paid for isn’t clear to many researchers, however. “The proposals are superficial and don’t go into concrete steps on how they will face the challenges we have,” says physician Gonzalo Vecina Neto, who directed Brazil’s Health Regulatory Agency between 1999 and 2003.

Vecina worries that even though the candidates have acknowledged the impact of the pandemic, and made various pledges in response, public-health concerns are being overshadowed by the economy and other issues during the run-up to the election. “The sensation I have is we are forgetting what happened”, he says, “and we are now facing new outbreaks such as monkeypox without having learned enough from the pandemic.”

Others agree. Ranzani says he wants to see more emphasis on strengthening the SUS and Brazilian research in election discussions. “It is fundamental for us to face what the pandemic has caused and still causes.”

The Brazilian presidential election takes place on 2 October. If none of the candidates gets more than 50% of the vote, the two front-runners will advance to a run-off, which will take place on 30 October.