Pandemic – behind the mask

Pandemic – behind the mask

Su-ming Khoo and Mayara Floss 

March 23rd, 2020, a very hot day. The sun was coming in through the window and the air-conditioner had to stay off as a preventive measure so Mayara was already sweating in her clothes. She moved through the steps of putting on the personal protective equipment slowly and methodically. Tap on, two pumps of handscrub, twenty seconds, paying attention to the spaces between the fingers, the backs of her hands, the base of her thumb. Hand dryer, gloves, (just regular procedure gloves), and apron over scrubs and then mask and special glasses , uncomfortable and muffling her voice, but a protective barrier. Only then could she approach any patient showing respiratory symptoms, like a cough, a fever, or a runny nose.

Mayara works as a Family Medicine resident, in the Brazilian Health Public System (SUS), in a community that bears the name of a dictator who oversaw the most oppressive period of the 1960s, “Costa e Silva”, in Porto Alegre, state capital of the Brazilian state of Rio Grande do Sul. She is training with a Primary Care team, at the diagnostic frontline. It is this community frontline that knows who has what needs and who are likely to be unnoticed, and whose needs are going to be failed. They care for around 4,700 people, an uneven mix of some people who live relatively well and are able to protect themselves, and others –  migrants, people in irregular occupations, and vulnerable people with extreme needs.

Her back was sore because she had spent the previous day moving refrigerators and other equipment to create a separate space to see patients with respiratory symptoms. She was trying to pay attention to all the instructions to be careful, to avoid touching things, other people, her own face but she still had to try to communicate well with her patient. She was distracted by the lower back pain caused by urgently hauling furniture – benches, chairs, refrigerators to set up a temporary clinic. There was Mayara and three colleagues on the day of the move working on preparing the unit for the coronavirus. A fourth colleague was sick with coronavirus symptoms.

The coronavirus was just at its beginning in Brazil on 23 March. The situation was changing every day, and very confusing what with the federal instructions, state instructions, municipal instructions and instructions circulating around our hospital. We ended up mainly relying on the information that comes informally by WhatsApp, but with this reliance comes so many new responsibilities – to monitor the media and quickly understand and advise others about what is fake news and what is not, a stressful responsibility since misinformation outpaces good information.

A month later, April 23 and infections are starting to peak, but are still under control. We are not testing enough (in fact, we are testing far too few). Worst of all, we have a new Health Minister, and are facing a terrible political crisis. The new minister wants to re-open everything and local governments are in agreement. As they are rescinding the quarantine restrictions, we are seeing the cases increase.

Mayara worries about her family. She is 500 km away from her parents and sister.  She cannot visit them now. Distance and time pressure aside, she could carry the virus to them, or from them. They are understandably worried about her work.  She and her partner have adapted their home routines as best as they can. She goes straight into the shower when she arrives home and immediately washes her work clothes. This is not enough, but it is the best that she can do under the circumstances. Her partner is studying at home as classes at the federal university remain suspended.

The federal government seems only preoccupied with the economy and does not seem to be taking the question of the people’s health and survival seriously. Bolsonaro has denied that there is a pandemic crisis, saying that it is a media fantasy. He has insisted that ‘lives must go on’ and ‘jobs must be kept’, even as citizens have publicly protested at his pronouncements by banging pots and pans in the street. He has sown discord, doubt and care-lessness by questioning the statistics, dismissing the virus as ‘just a little flu’ and implicitly accepting a course of too-little action by saying how sorry he is that many will die. Even Facebook has decided to delete his misleading announcements, downplaying the severity of the pandemic, or the importance of social distancing measures. He claimed that hydroxychloroquinine was an effective treatment, leading people to deplete the pharmacies of this medicine in a panic, leaving those who actually need the medicine without access to it.

The primary care team is working from 8am to 6pm, with half of the team on in the morning and the other half on in the afternoon. In total, 2 nurses, 6 nurse assistants, 4 medical residents work in a multidisciplinary team with community workers, social assistants, and a psychologist. Mayara’s team is  a ‘remnant health team’, surviving amidst a mass dismissal of health workers across a large city, that has affected 1,847 SUS (Unified Health System) primary care professionals and, impacted more than 140 basic health units. They are acutely aware that community health workers might lose their jobs at any time.

The patients have been pre-triaged, masked and separated. The man in front of her had a cough, but no other noticeable symptoms. He was not looking for a sick note for an employer. In the past year, Mayara has noticed many more unemployed people asking for such notes and regretted that she does not have a pill she can prescribe for unemployment. More and more people are depressed and mental health is a big and growing issue.

As these were not her regular patients in normal times, Mayara had no way of knowing that the woman who was next in line was the man’s wife, her consultation had ended. From behind masks, she saw that she had the same frightened and sad expression in her eyes as he did. Mayara hadn’t understood at first why they had risked coming to the clinic.

As the consultation came to an end, she said, with downcast eyes,

“It’s good to eat fruit for the coronavirus, right?”

Mayara looked at her, agreed, and waited, as it seemed like there was something else. The line behind her was growing longer. She nodded to her to continue:

“But I don’t have any money for fruit, we only live on the Bolsa”.

The Bolsa Familia is a monthly basic social protection payment. Throughout Brazil, over 13.9 million families are on the Bolsa Familia programme that supports the ‘extreme poor’ and ‘poor’ –  with monthly incomes below R$ 89.00 per person (USD 16.65) and R$178.00 per person (USD 33.30). A family qualifies for the support if there are pregnant women, children or adolescents up to the age of 17 in the household. Beneficiaries must be enrolled in the Federal Government’s Single Registry for Social Programmes, and each family can register for up to 5 benefits per month, to a maximum of R$ 205.00, or about USD 38 a month, in total.

Mayara had a patient guidance leaflet on home isolation and quarantine procedures to give to patients. Whenever she gives these out, she asks if the patient knows how to read. They usually can, but only her husband was literate. She was supporting a family of four on the Bolsa payment. Mayara stood in front of her with her cap, protective glasses, apron, gloves, everything. From behind her mask, she finally asked the question that had actually brought them there:

“Doctor, does having the coronavirus qualify you for a cesta básica?”

A cesta básica is a basic food basket – beans, rice and some provisions, given by charities and/or local government to families struggling with hunger. A doctor cannot write a prescription for hunger, either, but we can discuss it with the social workers and the community health workers in the multidisciplinary primary care and community health teams. Within the local community, the community health workers have organised food donations for families that are struggling with hunger.

We are still many months, maybe one or even two years away from a vaccine or other treatments to cure the coronavirus. But for that other plague, the plague of hunger which is unfortunately not novel, but that determines so much ill-health – if we could write a prescription for basic food, that would be at least be an effective prescription.

 

Mayara Floss is a Family Medicine Resident in a Primary Health Care Unit of SUS in Brazil, she is also involved in the access and care of rural people and Planetary Health. Su-ming Khoo is a lecturer in the School of Political Science and Sociology at the National University of Ireland, Galway. She leads the Governance and Sustainable Development Research Cluster of the Whitaker Institute and the Economic and Social Impact Cluster of the Ryan Institute at NUI Galway. Mayara and Su-ming are working together on a project on ‘survival activism’.

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