HOW TO RECONCILE THE EPIDEMIOLOGICAL SURVEILLANCE of military origin with the mark of the Cold War with the democracy that we long for regarding the Unified Health System (SUS)? Is this an utopian task, one that is impossible to achieve?
It is January 2020 and we live under the scary image of the ‘new’ coronavirus which emerged in Wuhan, capital of Hubei, China. From the first days of January to the first ten days of February, we amounted 20 thousand – ‘and one’ – cases of infection by Covid-19, with 426 deaths and 623 people recovered apparently without sequelae. This is equivalent to a figure of 2.12% of lethality of confirmed cases. If the rate of reproduction by contact of an infectious person is equal to or greater than 2.6 effective contacts to trigger the infection, we face more than 52 thousand new cases, whose morbidity may be the tip of the iceberg, in which these cases are 15% to 20% of the infections that result in clinically detectable morbidity, with another 70% that are undetectable – another 260 thousand –, whose transmissibility can be initiated before any signals and symptoms similar to those of mumps11 Sheikh K, Watkins D, Wu J, et al. How Bad Will the Coronavirus Outbreak Get? Here Are 6 Key Factors [internet]. The New York Times. 2020 fev 1. [acesso em 2020 fev 1]. Disponível em: https://www.nytimes.com/interactive/2020/world/asia/china-coronavirus-contain.html.
The lethality of the Covid-19 pandemic is not the ‘end of the world’, as it would be if we had a Severe Acute Respiratory Syndrome (Sars) with a 10% lethality equal to that of the ‘Spanish flu’ of the early 20th century. It is merely a different time, in which air traffic from China to other countries has increased tenfold since the time of Sars in 2003. That implies the spreading of the Covid-19 infection much more than what happened in previous pandemics. Nothing comparable to the lethalities of smallpox, ebola, and bird flu pandemics, which surpass the 40% rate.
The problem is that the Covid-19 is a disease that, in 20 days, has reached twice the number in which the SARS pandemic was stabilized at 100 days counting from the initial case; and there is nothing that indicates that it has reached its letup in Chinese territory during this period. If the public health measures adopted in China are able to be effective in curbing transmissibility, the pandemic may not materialize. There lies the knot in which the cord of epidemiological surveillance finds itself tangled. The passage of the rope either stops at the carabiner, or it breaks.
This carabiner is of an ethical, geopolitical, and less virological nature. A disease of low lethality (2.6%), but high transmissibility (2.6 effective transmitting contacts per patient) may rapidly spread across the globe, and even though it is not so lethal, it will kill many people. For that reason, we call a ‘knot’ the embargo on the continuous transit of the conducting thread of health surveillance in the times of such pandemic22 The Center for Systems Science and Engineering (CSSE) at JHU. Coronavirus 2019-nCoV Global Cases by Johns Hopkins CSSE [internet]. 2020. [acesso em 2020 fev 4]. Disponível em: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html?fbclid=IwAR2eUiZF_45JToUoSiWB5xWg5pF_AXXuMJSlw_wpKPmLNQnYiexsIih3So8#/bda7594740fd40299423467b48e9ecf6.
The United States of America (USA) is the country that most militarized its epidemiological surveillance with the creation of the Center for Disease Control (CDC) in Atlanta/Georgia. It developed biological methods based strictly on the detection, harm reduction, immunization, and development of epidemiological containment therapies under military control without a transparent popular participation. Since the CDC’s epidemiological focus was the fear of a viral and bacterial war during the Cold War, it was always detached from any participatory popular mobilization. Literature and cinema are full of real and fictional production about the clash between militarized quarantine and the rights of civil population.
Ironically, that is the accusation of US epidemiologists against the quarantine measures adopted by the Chinese Communist Party. They claim that civil rights are disrespected, information is impossible to validate, and they accuse the conflict between the enclosure of cities with 40 million inhabitants and the right to come and go.
We do not know the extent to which Chinese citizens will be able to actively participate in epidemiological surveillance in neighborhood, workplace, or circulation and trade committees. We do not know the degree of Chinese democratic decision regarding the notification, investigation, aid to those infected, and the resolution of isolation measures. If the measures are militarized and autocratic, they are destined to fail for the immediate reaction of any curtailed human being is to free himself from his bonds.
The idea of civil responsibility combined with the capacity to respond to epidemics is a complete novelty to the world. In Brazil, there is a corporate reaction from public officials that stand against sharing their health mission with citizens considered ‘laymen’. There is also the disbelief of the popular and union leaders in relying on direct popular participation in the Health Surveillance systems. Both the guiding document and the results not yet released from the first National Health Surveillance Conference show the evolution of the concept and, at the same time, the absence of the proposal for direct participation concerning the rights of notification, evaluation, and the right to know for citizens who are not professionals of the health systems33 Conselho Nacional de Saúde. Relatórios do Conselho Nacional de Saúde da 1a Conferência Nacional de Vigilância em Saúde 2018. Brasília, DF: Ministério da Saúde; 2020..
In the practice of the SUS in Brazil, there is a tacit universe of negligence allowed by public health agencies that attributes epidemiological surveillance only to public services, although the legislation allocates equal responsibility to private health services. In that regard, we are an absolute precarious image of the American militarization without having the vertical Party centrality of the Chinese Communist State. We err on the side of excessive bureaucracy coupled with a lack of structure.
Central European countries, besides the US, have taken ineffective epidemiological measures in view of geopolitical interest. They have closed their borders to the entry of citizens and travelers coming from China, as if their nationals with passports and permanent residence visas were blessed by the absence of infections from a ‘Chinese’ virus. The commercial and geopolitical war seeks to take advantage of the epidemic for its own commercial interests and military supremacy.
Countries ruled by governments that are servile to the American empire, such as Brazil, Chile, Ecuador, Bolivia, and Paraguay, will take epidemiological measures mirrored in the worst of geopolitics and in the incompetence to combine civil rights with epidemiological restraint. They will follow determinations of the central models that have already shown to be politically contaminated by the bipolar economic war between China and the US, with subordination to the latter.
If Chinese citizens have the opportunity to organize civilian health surveillance, they will teach the world the best way to democratize direct popular participation in health. They will have two victories to display. The epidemiological victory will come associated with the victory of the politicization of the relations between the State and popular health responsibility, as they did in the elimination of the endemic schistosomiasis in the 1960s.
If the containment of the Covid-19 pandemic shall fail in China and, consequently, throughout Asia, we will witness the advance of the epidemic inexorably in countries with incompetent, weak, privatized, outsourced, exclusionary, and unequaled health systems to deal with the solidarity character of human nature in face of the emergence of diseases.
Can you picture the wealthy or well-to-do middle class rushing massively to their ‘private health insurance hospitals’ with symptoms of respiratory distress? Even worse: Can you picture mayors, city councilors, and congressmen who defend the neoliberal minimum State model with the budget cut of Constitutional Amendment 95 demanding that their voters jump the line of public hospitals? It will be a ‘Holiday’ of indecent clientelistic spectacles, as it was in the 1970’s meningitis epidemic.
Military measures may contain epidemic outbreaks, but they cannot contain a pandemic. Vertical bureaucratic measures without direct popular participation with the right to full information and the right to know about results are partially effective, but are incompatible with States without democracy.
Accusing the Chinese government of hiding information and complaining about the Secretary-General of the World Health Organization (WHO) who has supported Chinese public health actions is easy for those who dominate Western media. Hiding the dimensions of the health fragility of the militarized capitalist West is also easy for those who dominate that same media, as it happens in Brazil.
The Health Surveillance that presently brings together the epidemiological, sanitary, environmental, and workers’ health surveillance has yet a long way to go before granting full right to epidemiological notification to all citizens and not just to health professionals. All notifying citizens should have the right to confidentiality rules, the right to know the results of the investigation, and to share decision-making in times of human, chemical, viral, or bacteriological warfare44 Corrêa Filho HR. As mudanças no mundo do trabalho e suas repercussões sobre a Saúde do Trabalhador: revisão e tendências para o início do século XXI. In: Feliciano GG, Ebert PRL, editores. Direito Ambiental do Trabalho: Apontamentos para uma teoria geral. Direito Ambiental e do Trabalho. São Paulo: LTR Editora; 2018. p. 93-126.. The central guideline of the Brazilian Center for Health Studies (Cebes) that is reflected in the historical publications of the journal ‘Saúde em Debate’ states: without democracy, there is no health. The corollary of the 21st century is: without democracy and participatory popular committees, there is no Health Surveillance.
- *Orcid (Open Researcher and Contributor ID).
- 1Sheikh K, Watkins D, Wu J, et al. How Bad Will the Coronavirus Outbreak Get? Here Are 6 Key Factors [internet]. The New York Times. 2020 fev 1. [acesso em 2020 fev 1]. Disponível em: https://www.nytimes.com/interactive/2020/world/asia/china-coronavirus-contain.html
- 2The Center for Systems Science and Engineering (CSSE) at JHU. Coronavirus 2019-nCoV Global Cases by Johns Hopkins CSSE [internet]. 2020. [acesso em 2020 fev 4]. Disponível em: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html?fbclid=IwAR2eUiZF_45JToUoSiWB5xWg5pF_AXXuMJSlw_wpKPmLNQnYiexsIih3So8#/bda7594740fd40299423467b48e9ecf6
- 3Conselho Nacional de Saúde. Relatórios do Conselho Nacional de Saúde da 1a Conferência Nacional de Vigilância em Saúde 2018. Brasília, DF: Ministério da Saúde; 2020.
- 4Corrêa Filho HR. As mudanças no mundo do trabalho e suas repercussões sobre a Saúde do Trabalhador: revisão e tendências para o início do século XXI. In: Feliciano GG, Ebert PRL, editores. Direito Ambiental do Trabalho: Apontamentos para uma teoria geral. Direito Ambiental e do Trabalho. São Paulo: LTR Editora; 2018. p. 93-126.
- Publication in this collection
09 Mar 2020
- Date of issue