A territory of continental size, in the throes of a second wave of Covid-19 and with a leader sceptical of vaccines: Brazil is no easy candidate for a rollout of inoculations against coronavirus.
Latin America’s most populous nation started administering the Chinese-made CoronaVac jab days after scenes emerged of patients dying for lack of oxygen supplies in the Amazonian city of Manaus, where the healthcare system has teetered on the brink of collapse. But the week-old inoculation campaign is already facing bottlenecks because of vital pharmaceutical supplies stuck overseas.
As an initial batch of six million imported CoronaVac doses was being administered to priority groups including the elderly, indigenous Brazilians and health workers, another 4.8m units received regulatory approval at the end of last week while an order of two million Oxford/AstraZeneca vaccines, Brazil’s other big bet for resistance, arrived from India following a delay.
But bureaucratic hurdles to the release of key inputs from China threaten to hamper the next phase in the push for immunity. With a plan largely based on domestic production, Brazil will initially be reliant on imported active pharmaceutical ingredients — the essence of a drug — for making both vaccines, until “technology transfers” allow formulation from scratch.
“We have the technological capacity to produce the vaccine, but we depend on the delivery of the active ingredients,” explained José Gomes Temporão, health minister between 2007 and 2010 and now researcher at the Oswaldo Cruz foundation (Fiocruz), a biomedical institute in Rio de Janeiro.
“And this has a very serious impact on the disease situation in Brazil. It will take several months to achieve minimum coverage to have an epidemiological impact, reduce hospitalisations and the number of deaths.”
Brazil’s late start — other countries in the region like Chile and Mexico began vaccinating their populations last month — has exposed some of the weaknesses of low to middle income countries in securing vaccines, as well as a bungled response to the crisis marked by political squabbling and dysfunction between the federal government and state authorities. The country’s death toll of 217,000 is the second-highest in absolute numbers, although per capita it is ranked 21st behind a number of western countries as well as neighbours Argentina and Peru.
The problems have overshadowed some of Brazil’s strengths: The country boasts a public health machinery which since the 1970s has eradicated polio and controlled other diseases. Thanks to more than 35,000 vaccination posts, the country administers 300m vaccines every year, a large proportion of which are manufactured domestically.
“Brazil runs an influenza campaign that vaccinates 80m people in two months,” Carla Domingues, an epidemiologist and former co-ordinator of the national immunisation programme, said. “Brazil has this organisation and the knowhow to do this.”
While Fiocruz and the Butantan Institute in São Paulo are hoping to receive the inputs for the Oxford/AstraZeneca and CoronaVac vaccines they will produce, respectively, this month, the fear is that the vaccination schedule could be pushed back. “We cannot know if this is a problem that will end soon, or if it is a crisis,” said Isabella Ballalai, vice-president of the Brazilian Society for Immunisations.
Some experts even doubt whether enough vaccines have been ordered — 254m of Oxford/AstraZeneca and 100m of CoronaVac, respectively — given that they require two doses and 211m people live in Brazil.
“We don’t have a production or import plan that’s sufficient to take into account the Brazilian population,” said Fernando Aith, a professor of public health at the University of São Paulo. “And the whole world is competing for vaccines.”
Critics have suggested President Jair Bolsonaro is partly responsible for the hold-ups. In addition to the rightwing populist diminishing the severity of Covid-19 and the importance of vaccines, members of his inner circle have disparaged China during the crisis, in a style straight from the playbook of his political soulmate Donald Trump. The antipathy has extended to CoronaVac.
“Bolsonaro has been eroding confidence in the Chinese vaccine for months and not been looking for alternatives,” said Alexandre Kalache, a former senior official at the World Health Organization and president of the International Longevity Centre Brazil.
“By the time the government woke up, the allocation of vaccines was given to other countries. Why should the vaccine-makers give priority to Brazil? Brazil has antagonised virtually everyone.”
Another target of anger is health minister Eduardo Pazuello, an army general drafted into the position at the height of the first wave last year. The military logistics expert has forecast Brazil could reach 1m people vaccinated per day and has said it will even export shots to neighbours.
But on his watch, efforts to secure stocks of vaccines and syringes have stuttered, while hospitals in some regions have been overwhelmed. Mr Pazuello has insisted Brazil fulfilled an objective to deliver all the initial vaccines within five days and last week said there was no delay in the delivery of the pharmaceutical ingredients.
Yet even as medical oxygen supplies were running out in Amazonas, the health ministry was still pushing for the use of chloroquine on the rainforest’s beleaguered communities. The antimalarial has been touted by President Bolsonaro as an “early treatment against Covid-19, despite a lack of evidence over its effectiveness.
“[Mr Pazuello’s] conduct is of someone about to be expelled from the force, not a four-star general. He is an embarrassment,” said Major Olimpio, a senator with the rightwing PSL party and a former ally of Mr Bolsonaro. “He was placed there as a logistics specialist. But look at all these logistical mistakes. Nothing works.”