As the rain picked up, the ambulance sped across the largest city in the Amazon. In the back, a 78-year-old man lay disoriented, unable to say who he was, slipping in and out of consciousness. The coronavirus had reached his brain, emergency physician Alessandra Said realized. He was in danger of dying. They didn’t have much time.
But in a city isolated by geography and overwhelmed by disease, Said didn’t know of a single hospital with space left for coronavirus patients. The hunt for a bed could take hours, and some patients didn’t survive to see its conclusion. She looked down at the man — bald and frail, writhing on his stretcher — and hoped that this one would.
“We have no place to take him, and we are going to bang on door after door,” thought Said, 45, who described the scene later. “It’s desperation. You have a terrible pain in your heart. We don’t know what’s going to happen.”
Brazil’s failure to provide enough hospital beds for the surging number of critical coronavirus patients is yielding increasingly grim results across the country, but particularly in Manaus, a city of 2 million people on the Amazon River deep in the rainforest. More than 2,000 people died in Manaus in April, more than four times the monthly average. Now, the city is running out of coffins. Hundreds are dying at home, either because they can’t get treatment at the hospitals or because they fear they won’t. Ambulances race down streets with no clear destination, waiting for someone to die and relinquish a hospital bed.
As the coronavirus has swept the world, wealthy countries have been able to expand their health systems to accommodate surging need. Spain hired 52,000 more health-care workers. Germany added 12,000 intensive care beds. The United States deployed the USS Comfort into waters off New York City. Just when the systems appeared to be on the precipice, more resources were found.
But as the pandemic moves into its next phase, pushing into the poorer nations of Africa and Latin America, the possibility of expansion has been far more limited. In Guayaquil, Ecuador, bodies have been left out in the streets. In Loreto, Peru, corpses have been stacked haphazardly in a small hospital room. And in Brazil, which has registered more than 196,000 coronavirus cases and more than 13,000 deaths — by far the most in the Southern Hemisphere — coronavirus patients are spending their final days waiting in chairs.
A stew of factors — limited resources, long-term neglect of the health system, a global competition for medical supplies — has made what has been achievable elsewhere all but impossible in much of the developing world. Health systems already operating at their limits, analysts say, have neither the tools, the personnel nor the money to expand capacity rapidly enough to meet the skyrocketing need.
“Many of the structural problems that developing countries always had — health system disparities, a lack of personnel — are now exacerbated by a crisis, along with the added challenge of having to compete in markets that are saturated,” said Tatiana Bertolucci, regional director for Latin America and the Caribbean at the humanitarian organization CARE. “It’s sad, and it’s complicated.
“What we saw in Guayaquil, we will see in other Latin American cities. We are already seeing it in Manaus.”
Said was seeing it now. She focused on her elderly patient. His eyes were clenched tight. She directed ambulance driver Edilson Magalhaes to head north. The vehicle turned right, then accelerated down the rain-slicked roads. Another desperate hunt for a hospital bed was underway.
Canceled contracts and a health system overwhelmed
In the early days of the pandemic, while Brazilian President Jair Bolsonaro was dismissing the disease as a case of the sniffles, officials at the state and municipal levels started preparing for the most serious health crisis in a generation.
In the state of Rio de Janeiro, officials announced the construction of field hospitals to dramatically increase the number of beds available for patients. The northern state of Pará would deploy 400 ventilators purchased from China. And in Manaus, an emergency hospital was designated specifically for patients with covid-19, the disease caused by the coronavirus.
Weeks later, the promises remain largely unfulfilled. The Manaus hospital was graded insufficient “in structure and supplies,” according to a government analysis. Many of the ventilators bought by Pará either never arrived or didn’t work. Several hospitals have been built in Rio state, but they’re mostly empty shells, without equipment or personnel. “We are going to delay longer,” Edmar Santos, the state health secretary, said last month. “The number of infected is huge, more than our capacity, and even if we build more [hospitals], there isn’t enough doctors or equipment.”
More than three-quarters of Brazil’s population — nearly 160 million people — rely on the public health system, one of the largest in the world. Known as the SUS, for its initials in Portuguese, it is considered perhaps the strongest system in Latin America. But over the past decade, as the economy stalled and health-care funding dried up, the number of hospital beds has steadily dropped, falling below 2 per 1,000 people — lower than regional neighbors such as Chile and Argentina.
For weeks, there have been signs that Brazil would struggle to expand its capacity. Even before the virus arrived, many of the country’s intensive care beds were occupied. Soon state governors, health officials and hospitals were complaining that Chinese suppliers had canceled their orders after the United States launched a market blitz on medical equipment.
U.S. officials say they had nothing to do with canceled purchases. “The United States government neither bought nor blocked any material or equipment from China destined for Brazil,” tweeted Todd Chapman, the U.S. ambassador to Brazil. “Reports to the contrary are completely false.”
With shortages of equipment and doctors, health systems across Brazil have started to buckle. “We are experiencing two wars,” said Cássio Espírito Santo, an undersecretary of health in Amazonas state. “One is against the covid-19, and another to obtain equipment and supplies.”
As her ambulance shot across Manaus, Said was witnessing that war anew. She grabbed the radio and called Hospital João Lúcio to ask whether it could take another patient. She feared she already knew the answer.
No beds, she was told. Completely full.
She hung up the radio, glanced down at the patient through her goggles and prayed he would hold on a little longer.
‘The day of our great anguish’
The look in their eyes was one of the hardest parts. To see the desperation on their faces when informed that the hospitals were full — that help wasn’t within reach — was almost more than Said could bear. She tried to console them, taking their hands, assuring them that for as long as they held on, she’d keep looking, and together, they would find something.
The job had become so “unbearable” at times that it was difficult to remember that being a doctor was all she’d ever wanted. She knew it wouldn’t be easy, working in a health-care system as fragile as Manaus’s. Isolated, underfunded, plagued by corruption, it is the only system in a state twice the size of Texas that can perform complicated procedures. People travel in from all over the rainforest for care. Its hospitals almost always teeter at the edge of capacity. So when the first reports of covid-19 in the city emerged, Said knew they were in trouble. She just didn’t know how much.
She didn’t know her 78-year-old mother would contract the disease, run a temperature of 104, and that she would end up treating her in her mother’s living room, while wearing a full protective suit.
She didn’t know that her father would then fall sick, too, and that she’d worry that if they had to go to a hospital, there wouldn’t be any that could take him.
She didn’t know burials in Manaus would triple, or that the city’s 35 ambulances would soon be so overwhelmed that some emergency calls would simply go unanswered.
Said began seeing guards posted in front of hospitals, forbidding more ambulances. Family members accompanying her patients would bang on emergency room doors, screaming and crying, begging in vain for help. Some hospitals, desperate for medical supplies, would accept new patients from emergency responders only if they forfeited what little medical equipment they had.
“Today is the day of our great anguish,” said Ruy Abrahim, the director of ambulance services in the city. “Our supplies, our stretchers and tubes of oxygen … are the price we have to pay for a hospital to receive the patients.”
“I don’t have any happiness,” said Alexandre Herculanno Ribera Marciao, another first responder. “It’s terrible.”
“So many people are dying at home,” intensive care physician Pietro Pinheiro Alves said, starting to cry. “Some of them couldn’t get any help.”
Said always wanted to believe she’d find a way, even when hospital after hospital turned her patients away. For one patient, the hunt lasted three hours. For another, it took four.
The hospital admitted one woman only when Said told doctors that the problem was her heart, not covid-19. When the tests showed that she did have the disease — 90 percent of her lungs had been eaten up — Said pleaded with the doctors, pleaded with God: Don’t turn her out. The hospital finally found room. Three hours later, the woman was dead.
Now Said and the 78-year-old man were trying another hospital. This time, she knew better than to radio ahead. But when they pulled up to Platão Araújo Hospital, her hopes fell. The emergency room parking area was swarming with ambulances. No way would they have any openings.
But she went inside anyway and flagged down a doctor.
“This patient has covid,” she began. “But there’s a possibility he has a neurological problem, too.”
His tone came back flat and annoyed.
“Look, you already know we don’t have any beds,” he said.
He said he could make room — if. She had to give up the ambulance’s stretcher.
Said didn’t know what to do. Without her stretcher, she couldn’t take any other emergency calls. It could be hours before she found another. How many calls would she miss? How many people would die?
But here, in this moment, lying before her, was someone who might be saved.
The doctor could take the stretcher. The patient was wheeled away down the long hallway, right arm hanging down.
Said got back into her ambulance, reached for the phone and started making calls, hoping she could find a replacement stretcher soon.
The ambulance pulled back onto the road.
One search was now over, and another was beginning.
McCoy and Traiano reported from Rio de Janeiro.