A postcard from São Paulo, Brazil: thank goodness for the NHS

sao paulo traffic mediumI recently had the opportunity to spend a week in São Paulo, Brazil, to meet with some infection control and infectious diseases folks. I came away feeling pretty disturbed and very grateful for the NHS.

Brazil is a massive country, with almost 200m inhabitants. São Paulo is Brazil’s largest city, with more than 20m inhabitants making it the 7th largest city in the world. I have lived in London and close to New York, and spent quite some time in Tokyo but nothing comes close to the traffic in São Paulo. It took me 3 hours to travel the 30km from the airport to the hotel, not because it was the middle of the rush hour or because there was a problem, just because the volume of traffic is too big for the infrastructure to handle.

Brazil has around 7000 hospitals; 70% are private with a healthcare insurance system for those who can afford it. The public hospitals are the only option for those who cannot afford healthcare insurance. I visited a number of public and private hospitals and was struck by the following:

  • Rates of antibiotic resistance are eye-wateringly high. Around 40% of healthcare-associated Klebsiella pneuomoniae are carbapenem-resistant and of these, around 20% are colistin-resistant. More than 50% of K. pneumoniae produce ESBLs. The situation with Acinetobacter baumannii is even worse, with >80% resistant to carbapenems. Whilst there is usually some treatment option left, pan-drug resistant Gram-negative bacteria are a daily reality on the ICUs. To top it off, around 60% of S. aureus are MRSA, 80% of E. faecium are VRE and C. difficile is chronically under-reported due to lack of testing infrastructure and limited awareness about sending specimens. There’s an excellent 2011 review on antibiotic resistance in Brazil here, although a lot has happened since 2011.
  • The public hospitals are chronically overcrowded. This is best illustrated by a quick visit to the Emergency Department, where patients on stretchers line the corridors as far as the eye can see. These patients usually stay for days, not hours. The problem is so endemic that ICUs have been established in the ED. The wards are crowded too, with very small distances between beds. Plus, there are not enough staff to cover their beds, especially during nights and weekends. Following one meeting at a very large public hospital (2000 beds), we literally could not leave the building due to the sheer volume of patients trying to get in. Just like the roads, the volume of patients is too high for the infrastructure to handle.
  • The contrast between public and private hospitals is stark. Instead of being met by patients on stretchers when you arrive at public hospitals, you’re met by glass fronted healthcare insurance offices.

So, what can be done? The various strategies to curb the growing threat of antibiotic resistance are as relevant in Brazil as elsewhere: prevention is better than cure; reduce antibiotic use; improve accurate and timely diagnosis; perform surveillance for action; embrace novel solutions; highlight the financial burden; and develop new antibiotics. Some progress has been made, for example, antibiotics are no longer available without prescription over-the-counter. The commitment and enthusiasm of the infection control and infectious diseases folks that I have met here is inspiring. However, they are limited by poor healthcare infrastructure, virtually no investment in microbiology laboratory facilities, lack of national reporting, the widespread availability of poor-quality antibiotics and extensive use of antibiotics in the veterinary sector, which makes progress difficult.

Next time you have the misfortune of visiting an Accident & Emergency Department in an NHS hospital, rather than moan if you have to wait a few hours to access world-leading healthcare free at the point of care, instead be thankful for the NHS.

Photo credit: Fred Inklaar.

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6 thoughts on “A postcard from São Paulo, Brazil: thank goodness for the NHS

  1. Dear Jon, this reality can be seen in many of the Latin American public hospitals, and medical ID, we achieve a constant challenge to adapt the guidelines for infection control in this scenario where resources are scarce.

    Fernando Riera MD
    Infectious Diseases
    Córdoba – Argentina

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    • Dear Fernando, thanks for your comment. Do you have a similar mix between insurance funded private hospitals and government funded public hospitals as in Brazil (70% private, 30% public?

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      • Jon
        The Argentine health system is mixed and is comprised of three subsystems.
        1. The public subsystem that provides care to nearly 40% of the population that has no other social coverage. This system has a wide geographical distribution, is responsible for primary care and is free.
        2. Social Security subsystem (Social Work) 50% of the population. Administered by unions, provincial governments and the autonomous agency in charge of retirees. It is a mixed system which in some cases have their delivery systems, or pay a third party to provide these basic services.
        3. 10% Provides volunteers greet insurance affiliates. The objective of this system is fundamentally healthy population that voluntarily join more for safety and quality of delivery.

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  2. Hi Jon,

    Gary Thurner from the USA. Carmen, my wife is from Rio, and we travel often to Brazil. Sao Paulo is traffic madness, but a really great city once you get to know her. Carmen’s family has had the misfortune of having to use Brazil’s healthcare system, some are affluent enough to afford private insurance, most rely on the public system. I have sent the link to your blog to several Brazilian professionals we know here in the US, hopefully they will comment as well.

    Being a “Gringo” I want to be careful in how I respond here as Brazilians are a proud bunch. But you have hit upon a very sensitive topic in Brazil right now. With Public healthcare and education in such dire straights, the middle and lower classes of Brazil are practicing civil disobedience over the billions of US dollars spent on stadiums for the World Cup, indeed, some of it ending up in the pockets of corrupt officials. My hope is that Brazil continues to grow and develop into a first world nation, but the problems you mentioned are systemic and will be difficult to resolve.

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  3. Same condition of health care institutions all over third world due lack of finances, miss-management, corruption & sheer ignorance of rulers. These problem will not be solved in our life time because no body willing to solve them.

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