‘Pandemic will only come to an end if we have active surveillance’

Paraphrasing the writer and playwright from Paraíba Ariano Suassuna (1927-2014), the Pernambuco doctor Jarbas Barbosa da Silva Júnior, 65, elected the new director general of PAHO (Pan American Health Organization), calls himself a “hopeful realist” when asked about the direction of Brazilian health after the presidential elections this Sunday (2).

“I hope that the visibility that the health sector has achieved during the Covid-19 pandemic will be reflected in policies to strengthen the health system,” he says in an interview with Sheet. Barbosa occupies the position of assistant director of the organization and takes up his new position on February 1, 2023.

For the doctor, it is necessary that the country increase health financing, have a strengthened and well-trained primary health care and improve the legal framework so that good regional agreements of municipalities for the financing of medium and high complexity health services do not end with each management change.

In his opinion, the health crisis has shown that, in order to face the numerous health inequalities, countries need to use the “equity lens” in all programs in the area, identifying and breaking down barriers. “The poorest were more at risk of getting sick and dying because they have uncontrolled chronic diseases, they arrive later to the health services”, says Barbosa.

There was a lack of concrete proposals from the candidates for the numerous challenges of health, the area that most concerns the population. In your opinion, what are the key issues to be faced? I am a hopeful realist, as my countryman at heart would say. [Ariano Suassuna, que nasceu na Paraíba, mas viveu em Pernambuco a maior parte da vida]. I hope that the visibility that the health sector has achieved during the Covid-19 pandemic will be reflected in policies to strengthen the health system.

We have funding that needs to improve. Federated systems, such as Brazil and other countries in the Americas, need to have a good definition of roles and good negotiation about responsibility at the three levels [União, estados e municípios].

In Brazil, some services of medium and high complexity are only effective if they are regional. There is a permanent lack of a legal framework for the good negotiations carried out by the municipalities to persist. Sometimes you have a group of municipalities that make a good agreement to jointly finance a cancer service, for example, but they change the management and everything starts from scratch.

Strengthened primary care and trained human resources are essential. It’s a big challenge. We do not have strong training for doctors and nurses to do this work. Despite the challenges, people have come to recognize and value SUS in the pandemic.

Even so, the Health budget for 2023 is expected to be the lowest in the last ten years, with cuts planned in several programs. How to reconcile this reduction of resources within a scenario of so many demands? I hope that changes. The budget piece is still going to be debated in Parliament, and we hope that the lessons left by the pandemic will be taken into account, including that we need to respond to the current situation and future challenges.

Recently, the WHO declared that we are close to the end of the pandemic. Are there specific indicators to end this global state of emergency? The WHO is still debating what would be the indicators to consider it finished. The point is that the pandemic is not over yet. To complete this last step, we need to keep a very attentive surveillance, including genomic surveillance. As the virus circulates, new variants may emerge.

We also need to reinforce vaccination, especially in those groups that need it the most, such as the elderly, people with immune system problems, chronic diseases. And third, we need to ensure access to antivirals. We already have effective antivirals, but the price is too high. We are looking to make a collective bargaining to lower the price.

If we get those three things done and a new game-changing variant doesn’t emerge, we could be a few months away from turning the pandemic into an endemic one.

There seems to be no doubt that new epidemics will come. Have countries learned a lesson from Covid-19 in terms of preventing close? We don’t know when or with what severity, but we know it will happen. Preparation has to walk on two pillars. First, in strengthening better global governance, for example, a mechanism for equitable access to vaccines. There has to be a rule to divide the production of vaccines. Rich countries, as we saw in the pandemic, had very fast access [aos imunizantes] and in a much larger amount.

The second pillar is the preparation of each country to quickly identify new viruses and contain them. The pandemic has shown that, in addition to having laboratories with basic testing capacity, for example, we need a mechanism capable of rapidly expanding that capacity. The same for hospital beds, ICU beds, production of vaccines, medicines and strategic inputs.

The pandemic has exacerbated many of the health inequalities. How to face them? In the pandemic, the poorest were at greater risk of getting sick and dying because they have uncontrolled chronic diseases and arrive later to health services. We need to have an equity lens in all the health programs that we develop.

Even in health systems with universal and free access, such as the Brazilian SUS, economic, social and cultural barriers prevent some groups from having effective access to health. We have to have strategies to identify and overcome these barriers. For example: what makes the poorest populations not vaccinated? Is it because the gas station is too far away, doesn’t open on the weekend?

What is the way to alleviate the growing burden of chronic noncommunicable diseases on public health, which is expected to worsen with population aging? Of every 100 people with hypertension in Latin America and the Caribbean, only 50 know they have the problem and only 25 of them are under control. If we do not have a strengthened and prepared primary care to diagnose and treat hypertension, diabetes, make an early diagnosis of cancer, we will continue to have this unacceptable situation: 30% of deaths from non-communicable diseases are preventable deaths.

40 years ago, primary care was very focused on the health of children and women. It’s important to keep this up, but if you don’t incorporate chronic noncommunicable diseases, some hypertensive people are not going to discover the condition when they have a stroke. [acidentes vascular cerebral]. Some people with diabetes won’t find out until they start to have kidney failure.

There is a dramatic drop in childhood vaccination rates in Brazil and fears that the country will record polio cases again. How to face this challenge? Vaccination programs need to be modernized. In several countries, we do not know, for example, what the vaccination coverage is for each neighborhood in a metropolis, such as São Paulo. Having the average coverage of the municipality doesn’t mean anything. It can be good, 90%, 95%, but the unvaccinated can be concentrated in certain poorer or more violent areas. We have to have information on people vaccinated and not on doses administered.

We also need to identify barriers. When we take the poor population in Brazil and Latin America, 50% of households only have one adult with income and that adult is a woman. This means that this woman needs to miss 10 to 12 days of work [por ano para vacinar o filho] if the post does not open on the weekend, at night. We can’t keep that old strategy, from the time when women didn’t work.

We also need to improve communication strategies that involve health professionals, inform them how a vaccine is registered, how the certification, safety and quality process is carried out. We did research in the Caribbean during the pandemic. And 30% of nurses did not want to be vaccinated for Covid.

And, last but not least, there must be engagement of political, religious and community leaders. We have to reposition the immunization program [PNI]. It is a program that has been very successful, but sometimes, for this very reason, it has a certain difficulty in adapting, innovating and incorporating new strategies.

Is it just that health professionals lack information or is it also an ideological issue? It’s both. There are anti-vaccines, but all estimate that this is a small group, at most 1.5% of the population. But there is another group that can vary from 15% to 20% that want more information. So, those past communication campaigns, which were more to warn the moment to vaccinate, no longer work.

What is within our reach is to work on the topic of information. It is very important that specialist societies participate, that medical and nursing schools have the necessary information on scientific evidence and that training is continued. Every professional needs to be updated according to what we are observing at the moment.

Mental health has been one of the most neglected areas of public health. What needs to be done to change this scenario? PAHO has established a high-level commission, with experts from several countries, which will present a diagnosis of the situation and a set of recommendations in January 2023.

These are broad recommendations, starting in the community, with a focus on prevention. They also go through primary care, which has to be prepared to identify a case of depression, drug abuse, and offer specialized, emergency services when needed. Brazil has community agents, there are already interesting experiences, but this transformed into a strategy within the SUS, the country can have an extremely positive model of mental health care.

Jarbas Barbosa, 65

Graduated in medicine from the Federal University of Pernambuco and specialized in public health and epidemiology at the National School of Public Health of the Oswaldo Cruz Foundation (Fiocruz), he has a master’s degree in medical sciences and a doctorate in public health from Unicamp (State University of Campinas).

He was the CEO of Anvisa (National Health Surveillance Agency) from July 2015 to July 2018. Before that, he worked at the Ministry of Health as Secretary of Health Surveillance and, later, as Secretary of Science, Technology and Strategic Supplies. He currently holds the position of Assistant Director of PAHO