President Jair Bolsonaro has in recent months defended hydroxychloroquine as the panacea that would help Brazil win Covid-19 and should be adopted by the population both to treat the disease caused by the new coronavirus and to prevent it.
Now, the president is testing his own beliefs. Since announcing he contracted the new coronavirus, Bolsonaro also said he used hydroxychloroquine, associated with the antibiotic azithromycin, as treatment.
Announcing the positive result in a televised interview on Tuesday, the president also stated that he had already taken two doses of the medicine. Later, posted a video on social media taking the third dose. “I trust hydroxychloroquine, is that you?”, said.
Bolsonaro's contamination is a symbol of the government's failed response to the country's epidemic. More of 1,7 million people in Brazil tested positive for coronavirus and almost 68 thousand died, a number that leaves the country just behind the United States.
Strong critic of social isolation and closing deals, Twitter, of 65 years, did not stop doing events, came to participate in several demonstrations in favor of his government, avoided wearing masks as much as possible and minimized the epidemic several times, even calling Covid-19 a “gripezinha”.
In your manual to fight the epidemic, hydroxychloroquine and chloroquine have been transformed from unproven treatments into a centerpiece.
Both drugs have been used for decades to treat malaria and autoimmune diseases. Some countries have authorized the drugs to be tested on patients with Covid-19, and certain doctors even reported encouraging results.
However, there is growing evidence that these drugs do not benefit hospitalized patients. The US Food and Drug Administration (FDA, in the acronym in english), for example, revoked in June its authorization for emergency use of hydroxychloroquine in the treatment of Covid-19, stating that it was no longer reasonable to believe that hydroxychloroquine would be effective in treating hospitalized Covid-19 patients. Last week, the World Health Organization (WHO) suspended testing with the drug, claiming that there is no evidence of benefits.
Bolsonaro was not affected by the new information, even coming from the United States, who usually follows, and continued to pressure the Ministry of Health to expand access to medicines. The result was the fall of two ministers of health - Luiz Henrique Mandetta and Nelson Teich - who advocated a more cautious approach.
Teich Executive Secretary, General Eduardo Pazuello provisionally assumed the post of minister in 15 May - and remains there today - to carry out the president's wishes, and was much more obedient. Under your watch, in a few days the ministry expanded access to medicines in the Unified Health System (THEIR), publishing a usage guide so that it can be prescribed to almost anyone who has tested positive for coronavirus, including pregnant women and children with certain health conditions.
To understand how and why the Bolsonaro government adopted this unconventional strategy, Reuters interviewed more than two dozen people, including health officials currently involved in the federal response or who have previously been involved, medical, researchers and specialists in public health. What emerged was the image of a leader terrified of the paralyzing effects on the economy of isolation imposed by governors and mayors across Brazil and eager for a quick solution to reopen the economy..
Wanted, the Planalto Palace addressed the questions presented by the report to the Ministry of Health, who hasn't responded yet.
According to a dozen sources heard by Reuters, Bolsonaro was initially inspired by his political idol, the president of the USA, Donald Trump, one of the first proponents of hydroxychloroquine. But Bolsonaro went much further than his American colleague.
Two days after hearing Trump advocate the drug, Bolsonaro ordered the Armed Forces laboratories to increase chloroquine production, that was produced on a small scale for use against malaria. It was the first presidential measure against the epidemic, but the Ministry of Health was not even informed of the decision.
With the first information that chloroquine could be useful, Brazilian public entities, including some state governments and federal departments, went to the market to buy the drugs. So far this year, were spent 2,3 million reais in hydroxychloroquine - an increase of 6.592% compared to the total amount spent on 2019, according to a Reuters analysis of government data. These bodies also spent 1,51 million reais in chloroquine so far in 2020, Comparing to 626.472 reais in 2019.
At the center of all this is Bolsonaro.
Fired in April, Mandetta told Reuters that the president's support for the drug has hampered efforts to impose social isolation measures and stem the spread of the virus.
“It made many people believe that the cure was ready, that already existed, that you didn't need to worry, that you could just take this medicine that would solve the problem ”, Mandetta told Reuters.
Your replacement, Nelson pond, was brought down by chloroquine. The former minister, who quit with less than a month of work, did not respond to Reuters requests for comment, but since he left office, more than once, publicly said he resigned due to disagreements with Bolsonaro, that pressured him to expand access to drugs hydroxychloroquine and chloroquine.
Four sources heard by Reuters who followed the process revealed that Teich hoped to convince Bolsonaro to wait for the results of an accelerated hydroxychloroquine study, but failed.
Marcia Castro, Brazilian professor at Harvard School of Public Health, states that it is a “totally absurd” strategy to prioritize unproven drugs instead of reliable tools, as tests, tracking and social distance.
“It is a deeply regrettable situation and it is no coincidence that we now have more than 60.000 deaths ”, said.
Bolsonaro's interest in hydroxychloroquine and chloroquine began with reports from Asia and Europe about the potential of these drugs to help victims of Covid-19, according to six people who talked to Reuters.
In mid-February, Chinese state media reported that the country's health authorities "confirmed" that chloroquine "has a certain curative effect". At that time, a french microbiologist, Didier raoult, also started to praise drugs.
Raoult's defense of hydroxychloroquine and chloroquine was used by right-wing bloggers and liberal thinkers. So, in 19 March, Trump entered the debate. "I think it could be a game changer", disse Trump, who claims to have taken hydroxychloroquine as a prophylactic measure.
Trump's comments particularly influenced the Brazilian president, that until then had dealt with the epidemic just to say that the country could not stop due to the disease.
Wanted, the White House just gave Reuters a note of 31 May when it reported on the sending of 2 million doses of hydroxychloroquine as a donation to Brazil.
Bolsonaro had met with the U.S. leader in early March at Trump's Mar-a-Lago resort, in Florida, and several members of the Brazilian delegation were diagnosed with Covid-19 on his return.
"It is the idea of a miracle cure", said a former Bolsonaro minister, who recently left office, speaking on condition of anonymity. “(Twitter) believe in these magical solutions. And I also think that, partly, is to copy Trump ”.
The order to increase the production of the medicine in the Armed Forces' laboratories came in 21 March, two days after Trump's comments. Following this directive, the Army Chemical and Pharmaceutical Laboratory, located in Rio de Janeiro, manufactured 2,25 millions of pills 150 milligrams of chloroquine, the army told Reuters.
In the previous three years, total production had been 265.000 tablets, according to data obtained through a request registered by federal deputy Ivan Valente (PSOL-SP) and viewed by Reuters.
The military is no stranger to chloroquine. The reason that military laboratories use the drug is to prevent malaria at stations and operations in the Amazon, where the disease is endemic. currently, it is the military that occupies a considerable part of the Ministry of Health team.
At least 27 active or reserve military personnel recently joined the Ministry of Health, replacing experienced public health officials, according to a Reuters count. Besides that, they are in almost half of 23 ministries of the Bolsonaro government.
Sources explained to Reuters that the military's familiarity with the drug helped to erase any government concerns about the risk of side effects..
“Most of them served in the Amazon. They all used chloroquine for a long time ”, said deputy Osmar Terra, former Minister of Citizenship and who still serves as the President's informal adviser on issues about the epidemic.
The Ministry of Defense did not respond to a request for comment.
The Ministry of Health claims to have distributed 4,4 million chloroquine tablets for the United. It is not clear how widely they are being administered, since doctors in the country are free to prescribe medications as they see fit. The drug is also sold without major restrictions in pharmacies and, after it disappeared from the shelves initially, found again.
Thaysa Drummond, infectologist who treats patients with Covid-19 at Eduardo de Menezes Hospital, in Belo Horizonte, stated that many of the patients coming from primary care clinics or other hospitals had previously been prescribed medication, and that colleagues at other institutions said they were giving drugs to patients.
"In practice, many doctors are prescribing ”, said the infectologist. The hospital where she works is not doing this, “Because there is no robust and quality scientific evidence to support the use of these drugs”, said.
Possible side effects of hydroxychloroquine and chloroquine include loss of vision and heart rate problems.
At the Ministry of Health, initially caution was the keynote. Sources told Reuters there was resistance to adopting the drug even in cases of critically ill patients.
Science and Technology Secretary of the ministry at the time of Mandetta, Denizar Vianna was totally opposed to the use, but, under pressure, accepted to adopt for serious cases, told a source, as a “last case” measure, when nothing else worked out ”.
Unable to change the position of its technicians, Bolsonaro turned to external medical professionals who shared his enthusiasm.
Among these people were oncologist Nise Yamaguchi. Virtually unknown in the epidemiology and public health sectors, Yamaguchi said he became interested in hydroxychloroquine early due to Raoult's work and Chinese studies. She appeared on radio and television publicizing the potential promise of these treatments. Bolsonaro took notice and, in 3 of April, sent a Brazilian Air Force plane to take her to Brasilia for a conversation, Yamaguchi told Reuters. The president's office declined to comment on the doctor's report.
At the meeting, Yamaguchi said Bolsonaro showed the press reports with her about the Raoult hydroxychloroquine study. He wanted to know “why it couldn't be used more widely” in Brazil, according to her.
Yamaguchi said that he told the president that he was concerned about the lack of supplies, partly because India, one of the world's largest suppliers of generic drugs, in March imposed an export ban on hydroxychloroquine to meet its own domestic demand.
The next day, Bolsonaro publicly announced that he had asked the Indian Prime Minister, Narendra Modi, to loosen restrictions. Two days later, amid growing international pressure, India lifted export ban. Modi's office did not immediately respond to a request for comment.
Bolsonaro instructed Yamaguchi to develop guidelines for the use of the medicine, in spite of then Minister Mandetta and his technicians, said three sources who belonged to the Ministry of Health.
In 16 of April, Bolsonaro fired Mandetta. The two had been arguing publicly for weeks because of Bolsonaro's aversion to containment measures and support for hydroxychloroquine.
That same day, the Federal Council of Medicine (CFM) agreed with guidelines on how and when doctors should prescribe drugs.
In 17 of April, Bolsonaro replaced Mandetta with Nelson Teich, oncologist without public health experience. In mid-May, Bolsonaro publicly pressured the new minister to deliver a new protocol to allow doctors to prescribe hydroxychloroquine and chloroquine for early-stage Covid-19 patients.
Without further evidence that the drug was effective and safe for this use, Teich was reluctant to do so, according to four people familiar with the situation. So, his team devised a plan to win over the president: a Brazilian study on hydroxychloroquine that would provide partial results in a few weeks.
They contacted Álvaro Avezum, a cardiologist from São Paulo who was part of a team conducting robust clinical trials on possible treatments for Covid-19, the sources said. One study investigated whether patients with less severe symptoms could use hydroxychloroquine to potentially avoid hospitalization.
Under the condition of support from the Ministry of Health, Avezum agreed to speed up the study, claimed two sources. Avezum declined to comment on the negotiations, but said the goal was to be as efficient as possible.
In public, Bolsonaro increased pressure on his health minister.
“All ministers are my political nominations and when I talk to ministers I want effectiveness at the end. In this case, is not like or dislike Minister Teich, that's what's going on ”, Bolsonaro said in 13 of May. “We are having hundreds of deaths a day. If there is a possibility of decreasing that number with chloroquine, why not use it?”
The next day, Teich met with Bolsonaro to discuss the clinical trial. Ready to present the idea of accelerating the study, Teich was silenced by the president. Bolsonaro told Teich he wanted hydroxychloroquine, and wanted at the time.
“I'm the one who makes the decisions”, stated the president, according to two sources with knowledge of this meeting.
Teich resigned the next day.
Hydroxychloroquine and chloroquine are, at this time, conflict focus in Brazilian politics. People's opinions on drugs have become a kind of referendum on the president.
One of the first to put a study on chloroquine on the street, the Brazilian doctor Marcus Lacerda was in the middle of the turbulence. At the end of March, Lacerda, one of the leading specialists in infectious and parasitic diseases in the country, initiated a randomized study in the city of Manaus to investigate the safety of two different doses of chloroquine - one high and one low - in hospitalized patients with severe Covid-19. The study did not refer to the response of the medication, but which dose was safe to use.
When monitoring noted an increase in the lethality rate in the high-dose group, recommended that part of the study be archived. At the time the results were published, 16 people in the high-dose group had died, compared to six in the low-dose group.
The results were quickly rejected by supporters of the drug. In 17 of April, one of Bolsonaro's sons, Congressman Eduardo Bolsonaro (PSL-SP), tweeted that the study had been designed to “disqualify chloroquine” and accused the researchers of being supporters of the left. "This absurdity must be investigated immediately", wrote.
It was the password for Lacerda to become a target on social networks.
Lacerda told Reuters that his life turned into hell. President supporters, angry at the result of a study that seemed to show Bolsonaro's favorite drug as lethal, flooded his social networks with messages calling him a “killer”, “Monster” and “pseudo-scientist”.
"Your turn will come", said one of the haters.
The researcher was under armed escort for weeks and even today he eventually receives threats. Gradually life returned to normal, but he remains shaken by online hatred. "It has an incalculable effect on people's lives", he told Reuters.
Bolsonaro's age and the fact that he almost died in a stab in 2018 put you at risk with Covid-19. Even so, considering that the current mortality rate in the country is less than 5%, and Bolsonaro, as president, you will have access to high quality medical care, he has a good chance of recovering smoothly. So far, the president himself says he only felt mild symptoms.
Since now, Bolsonaro already credits his well-being to hydroxychloroquine.
Wildo Araújo, former Ministry of Health employee who co-authored one of the first major Covid-19 studies in Brazil, said that claim will help further politicize the drug. It would also be unfounded, he added, since the effectiveness of the drugs can only be proven with large randomized clinical trials, placebo-controlled.
“An individual's statement does not prove anything”, he said. “(Twitter) will use that narrative. But, from a scientific point of view, it has no value ”.