TWO YEARS HAVE PASSED SINCE THE BEGINNING OF THE PANDEMIC and after a year of vaccination of segments of the population, the global situation of Covid-19 still shows no concrete prospects that this disease will be controlled shortly. The expectation that vaccination would change the courses of the infection was confronted with the emergence of a new variant, with vaccine hesitancy in richer countries due to denialism and nationalism of vaccines, and with unequal access to immunizations in poorer countries. After 12 months, the use of different vaccine types and strategies, the presence of variable rates of infection, recovery, coverage, and vaccine efficacy transformed the current immunological scenario, making it more diverse than that of the beginning of the pandemic.

Covid-19 has taken millions of lives around the world, leaving the bitter realization of the inequalities and perversity of the capitalist order and the relations between countries. These situations determine the disparate possibilities of governments to mobilize to timely mitigate the social, economic, and health impacts of the pandemic. This shows the complexity of the global environment when it comes to facts from the ethics of solidarity between countries, especially knowing that there is no control of the disease if efficient interventions are not adopted jointly and indistinctly among all of them.

On the other hand, if the innovations in the system for disseminating scientific knowledge allowed the velocity of sharing the knowledge produced, there was not only competition for equipment and inputs, but also purchases that exceed the needs of those inputs, as occurred with respirators, Personal Protection Equipment (PPE) and vaccines, greatly compromising the access of populations in the poorest countries.

The mitigation initiatives adopted by governments resulted from a variety of tensions and trade-offs that can be identified and located between national and global health needs, private interests in profits and market share expansion, the need for efficiency in manufacturing and distribution of ‘Covid-19 products’, including equitable availability and public or collective interests in relation to universal access to diagnosis, appropriate treatment, and vaccines. In this field of forces, collective interests and health commitments have not always prevail.

The fact is that, after 24 months of duration, the pandemic is still not over. The sum of deaths resulting from it is no longer a factor that causes greater shock in the news and on social networks, either because of the naturalization of genocidal barbarism in countries ruled by authoritarian leaders, or because of the feeling of fatality and abandonment, especially in peripheral countries that live with high rates of violence in populations marginalized by society.

The victorious race of science for vaccines has made it possible for several countries to reach satisfactory levels of coverage, reducing the occurrence of severe cases, hospitalizations, and deaths. However, both because of denialism and the concrete difficulties in accessing immunizations, only 62.3% of the world population received at least one dose of the vaccine against Covid-19. Even more worryingly, only 11.4% of the population living in low-income countries received at least one dose of the immunizer¹1 Ritchie H, Mathieu E, Rodés-Guirao L, et al. Coronavirus Pandemic (Covid-19). [Local desconhecido]: Our World in Data; 2020. [acesso em 2022 fev 22]. Disponível em: https://ourworldindata.org/coronavirus .
https://ourworldindata.org/coronavirus... . In this scenario marked by inequalities, the coronavirus, which is recombinant, continues its course, with the potential to produce new variants, which are increasingly infectious. As long as this pattern of inequity persists, there will be no health security.

In Brazil, the debate about vaccinating children was another element to stir up tempers in a context fraught with the federal government’s negligence in communicating the risk of the pandemic and high levels of misinformation that characterize the infodemic and the semiotic war waged on social networks.

Public and universal health systems proved to be more resilient and better prepared to deal with a public health emergency. This is the case of the Unified Health System (SUS), which has shown high resilience despite policies of privatization and lack of funding for health that, in Brazil, have been accentuated since the 2016 coup. The fight against Covid-19 exposed the strengths and weaknesses of the SUS that will require changes in the health care model, strengthening the central role of primary care in surveillance and health care, increasing of the hospital network, surveillance systems and health information, integration of actions and strengthening of inter-federative coordination, among others²2 Massuda A, Malik AM, Vecina Neto G, et al. A resiliência do Sistema Único de Saúde frente à Covid-19. Cad. EBAPE.BR. 2021 [acesso em 2022 fev 25]; 19(esp):735-744. Disponível em: https://bibliotecadigital.fgv.br/ojs/index.php/cadernosebape/article/view/84344/79919
https://bibliotecadigital.fgv.br/ojs/ind... .

In opposition to the federal government’s attempts to make access to vaccines difficult, states and municipalities, based on past experiences coordinated by the National Immunization Program (PNI) and on investments made by the SUS in public laboratories (Instituto Butantã and Fiocruz), managed to implement strategies of vaccination that allowed increasing rates of vaccine coverage.

Thus, despite the high degree of adherence of the Brazilian population to vaccines, considered exemplary by international organizations, built on almost half a century of investments in a robust and successful PNI, in the last week of February/2022, only 71.8% of the population has a complete vaccination protocol (single dose or two doses) and 10.6% of them received one dose of the vaccine³3 Conselho Nacional de Secretários de Saúde. Painel Nacional: Covid-19. Brasília, DF: CONASS; [2022]. [acesso em 2022 fev 22]. Disponível em: https://www.conass.org.br/painelconasscovid19/
https://www.conass.org.br/painelconassco... . This means that more than 61 million Brazilians, which is equivalent to the total population of Argentina and Chile, are still vulnerable. This group of unvaccinated or incomplete doses is formed, in part, by denialists, but is mostly composed of children and the elderly, poor and with low education, many with comorbidities, victims of fake news or the absence of a communication policy and health education.

After a few months of relative calm, with stabilization of the incidence and mortality coefficients, from the last week of December 2021 an explosion of a new wave of cases was observed in Brazil, credited to the Omicron variant, which was already present in other countries since November.

Its entry in the country was marked again by the unpreparedness of the federal authorities. It was not possible to rely on the health information system of the Ministry of Health, victimized by an attack attributed to hackers in early December, which imposed the challenge of managing the new wave in the dark, without secure information, and which is still operating in a precarious way after two months. Tests and supplies were once again insufficient, as the Ministry of Health was not able to prepare in advance and provide them in a timely manner, despite the alert caused by the stratospheric increase in cases in the Northern Hemisphere. The health network, once again unprepared, operated overloaded and the beds of the Intensive Care Unit (ICU) for Covid, which were deactivated, took a long time to be put back into operation.

The Omicron variant produced records of daily cases and, given the high number of sick leaves, compromised the functioning of the health network and essential services. Young people and, in particular, the youngest children, hitherto spared, were significantly affected. Due to the vaccination coverage achieved, the curve of deaths did not follow the explosive trend of the curve of cases - as observed in the previous waves produced by other variants -, and more than 90% of the severe cases, which resulted in hospitalizations and deaths, occurred among the unvaccinated. The effectiveness of the vaccine was proven, in Brazil and in other countries, from the high degree of protection it conferred to the ones who were immunized.

Irresponsibly, the country missed the opportunity to further intensify vaccine coverage and adequately protect the population against the new variant, including children between 5 and 11 years old. At the beginning of December last year, the Minister of Health launched a ‘public consultation’ to delay the start of vaccination for children, already endorsed by committees of experts, scientific societies, and approved by the National Health Surveillance Agency (Anvisa).

The main objective of mass immunization is to provide collective prevention, which only occurs when high levels of vaccination coverage are obtained in the population. This should constitute a national obsession, but it continues to be treated under the aegis of the negationist logic and the submission of the Ministry of Health to the containment of expenses imposed by the economic field and the New Fiscal Regime.

The availability of vaccines for the Brazilian population was only possible thanks to political pressure movements and strategic action carried out by various actors, among which state and municipal managers, the National Congress, the intervention of the Supreme Court in several issues, the strong positions of the National Health Council, the denunciation made by a significant part of the media, but, above all, by the movement of the Brazilian society, which forced the federal government, albeit belatedly, to act and make the immunizing agent available for the SUS.

The Parliamentary Commission of Inquiry (CPI) of Covid-19 in the Federal Senate - CPI da Pandemia - played a relevant role in fighting the disease, laying bare the real dimension of the tragedy that affected the Brazilian population by demonstrating that the federal government adopted the thesis of ‘herd immunity’, guiding its conduct to, deliberately and inconsequently, expose the population to the virus, resulting in thousands of preventable deaths. It revealed that incompetent public agents joined doctors, businessmen, private health insurance operators, bloggers, politicians, and the military in a parallel cabinet, to articulate and finance this criminal thesis. The CPI forced the federal government, albeit belatedly, to acquire vaccines and to hinder measures that were obstructing the action of subnational managers. It helped to abort ongoing shady deals, such as the acquisition of overpriced vaccines and tests. It proved the responsibility of the Bolsonaro administration in the genocide of indigenous peoples, in the collapse of the Amazonian health system, in the deals involving ‘early treatment’ and the use of medicines proven to be without efficacy and safety. In addition, it opened up the modus operandi by which health insurance entrepreneurs mixed business, denialism, and political reactionaryism to support the president’s fascist theses, generating stratospheric profits, without regulatory agencies and other state bodies fulfilling their primary role of defending the public interest⁴4 Brasil. Senado Federal. Relatório da Comissão Parlamentar de Inquérito sobre a Pandemia. Brasília, DF: Senado Federal; 2021. [acesso em 2022 fev 22]. Disponível em: https://legis.senado.leg.br/comissoes/mnas?codcol=2441&tp=4
https://legis.senado.leg.br/comissoes/mn... .

Brazil will never be the same again in the face of the mourning and tragic legacy of about 30 million reported cases and more than 650 thousand deaths from Covid-19. The omissions of government authorities and their fascist denialist, which unequally impacted the lives of women, black people, indigenous, quilombolas, riverine, and LGBTQIA+ communities drew indelible marks that cannot be forgotten. The combination of future health, climate, environmental, and social crises will require a change in political actions that expand and strengthen public social security systems, the SUS and, consequently, the State model itself. Without it, we will be condemned to barbarism, necropolitics, and the hopelessness of the markets.

In this context, a broad national debate is required, one that is capable of politicizing society, political parties, workers, and social movements on the importance of a pact that guarantees health as a social right and the defense of the universal system. The challenges for the Brazilian health system are complex, for which five structuring guidelines are presented here, such as objective-images, as a contribution to the national debate on the future of health and the SUS in our country:

1. Health is the right to live well

In order for health to be a common good, the population must have decent living conditions, with housing, food security, basic sanitation, income, employment, social security, leisure, education, public security, and peace. These depend on the adoption of various public policies and government action to reduce inequalities with social inclusion and preservation of the environment. Popular needs include protection and support by the State for all who live in situations of vulnerability.

2. Investing in health is essential to national sovereignty and economic development

For that, it is necessary to increase investments and strengthen science, research, and technological innovation, guaranteeing the country’s autonomy in meeting its needs and, at the same time, increasing the sector’s participation in job creation and national development.

3. The SUS is indispensable to care for people and promote citizenship

The SUS needs to become the best health insurance for the Brazilian people, including those who currently spend a lot on the health market. It is very important to increase awareness that health is a right, and the SUS, a heritage in defense of the lives of Brazilians. The SUS is a State social policy, but there is a huge difference when governments give it priority and importance, guaranteeing its public, universal, and quality nature.

4. It is necessary to ensure adequate funding for the SUS

With more resources, the government has to commit to guaranteeing access and quality of services for the population. With more resources, it will also be possible to expand the SUS workforce, open new positions, and create professional careers that dignify and encourage health workers. In addition, to guarantee equipment, medicines and other supplies necessary for the quality of services. On the other hand, it is also necessary to improve the management of the system and services, improving the mechanisms of control, inspection, and social participation.

5. Health is democracy, and there is no health without the facing of inequities and social justice

Any form of discrimination (social class, race, color, religion, ideology, gender, and sexual orientation) cannot be tolerated. It is unacceptable that, when a person needs attention and care, there is any restriction of access. Therefore, the government must commit to combating prejudice and discrimination, as well as guaranteeing that the doors will be open, that efforts will be made to end the long lines for treatment, surgeries and consultations, and that everyone will be treated in health with promptness, respect, and dignity.

Within the framework of a society that considers health a social right, guided by the observance of fundamental rights, democracy, justice, and solidarity, it is imperative that the health-disease process be faced from its social, economic, and cultural determination process, transforming health as a central element in the development of the country.

It is essential that the debate on the future of health involves all segments of society, in addition to the formulations and contributions that historically the entities and activists of the Health Reform movement have been able to produce. The Covid-19 pandemic opened up the possibility of placing the right to health and the SUS at the center of the political debate. The time is now. There is still a pandemic, but there is hope!

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