Rio de Janeiro, Brazil – When Rosa Dos Anjos was admitted to a COVID-19 intensive care unit in the Amazonian capital of Manaus for 15 days in January, she thought her fortunes could not possibly get any worse.
The 50 year old had already lost her father to the virus during a deadly first wave of the pandemic last year – and Dos Anjos was fighting for her life as oxygen supplies ran out and the healthcare system collapsed all around her.
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While she narrowly survived, her family’s struggle is far from over, as her 41-year-old brother also contracted the disease and saw his oxygen saturation levels plunge to 80 percent in April, the deadliest month in Brazil since the pandemic began.
“Before I was concerned for myself. Now it’s my brother,” Dos Anjos told Al Jazeera.
The Dos Anjos family has lived through two brutal waves of the coronavirus pandemic, which have claimed more than 400,000 lives across the country – the second highest death rate in the world after the United States.
While public health data shows 11 of Brazil’s 27 states registered stable infection and death figures last week, in Amazonas state COVID-19 cases have begun to accelerate. Data from health research institute Fiocruz’s InfoGripe and the Amazonas health secretary showed infection rates increased by 42.3 percent in the last week of April after cases climbed for two consecutive weeks.
Health experts now warn that complacency and a slow vaccine roll-out may spell disaster – and that another surge could be imminent. That would be especially devastating in Amazonas state, which is at the height of its respiratory disease season and where the highly contagious P.1 coronavirus variant was first detected before it became the country’s dominant strain.
“We’re bracing for the worst possible scenario,” Amazonas state Governor Wilson Lima said last month. “[Previously] Amazonas was the first state to have been hit, followed by the rest of the country.”
Lucas Ferrante, a biologist and researcher at the National Institute for Research in the Amazon, told Al Jazeera that Amazonas could be hit by a third wave in a month and a half.
“A third wave is a big concern. It may not be as explosive as the second but it could last longer. It depends if it breeds new variants,” said Ferrante, who warned of an impending second wave months before it ravaged the region.
Intensive care units in Amazonas state were at 63 percent capacity on May 7, according to Fiocruz data, and health experts have said that if coronavirus infections climb, the healthcare system could collapse.
The Amazonas health secretary’s office, which is in charge of the healthcare network in the state, told Al Jazeera the department was working with the Pan-American Health Organization (PAHO) to prepare for a third wave.
“We plan to increase the number of COVID beds and to ensure medicine stocks are sufficient,” the office said in an email, among other measures to bolster the regional health network.
But while these steps are positive, some front-line health workers fear it may not be enough.
“We’re very worried,” Dr Tamires Imed, who works at SPA Hospital in Manaus, told Al Jazeera. “We’re extremely exhausted and understaffed. We lost a lot of colleagues to the disease and others resigned after the health system collapsed again this year.”
‘We’ve lost governance’
Far-right President Jair Bolsonaro’s government is increasingly being blamed for Brazil’s healthcare crisis, as a Senate commission on April 27 opened an investigation into his handling of the pandemic.
The former army captain has rejected lockdowns, encouraged mass gatherings, dismissed the virus as a “little flu” and failed to treat the purchase of COVID-19 vaccines as a matter of urgency.
“A crucial pillar in public health security is governance. But in Brazil, we’ve lost governance,” said Eliseu Alves Waldman, an epidemiologist and professor at the public University of Sao Paulo (USP). “This is vital not just internally but also externally in order to guarantee sufficient medical imports.”
Brazil’s health ministry has ordered 281 million COVID-19 vaccines for 2021, but just over seven percent of the Brazilian population has been fully vaccinated and under 15 percent of Brazilians have received their first dose to date, according to Our World in Data, a data research website.
Despite the growing criticism and continuing parliamentary probe, Bolsonaro has remained defiant and defended his policies. Last week, he implied that China may have created the coronavirus as part of a “chemical war”.
The Butantan Institute that is producing the Chinese-made CoronaVac jab in Brazil warned on May 6 that it could run out of the vaccines as early as this week due to a shortage of key ingredients from China.
Back in Amazonas state, health experts say vaccines offer the most hope but delays in shipments of ready-made jabs and ingredients have meant applications of the first dose have been put on hold.
More than 38 percent of Amazonas residents have been fully inoculated, according to the Amazonas Health Surveillance Foundation (FVS-AM). But health workers in the sprawling state, home to more than two million people across 1.571 million square kilometres (607,000 square miles) enclosed almost entirely by rainforest, face a serious challenge of vaccinating residents of remote, riverside communities.
“If it’s a rainy day, it can take up to three days to travel down the river. Other shorter trips take around 12 hours,” said Bruno Correa, a nurse coordinator from the National Immunisation Program (PNI) who works in Presidente de Figueiredo, a small tourist municipality in Amazonas.
Correa, who is coordinating the vaccination campaigns in more than 11 of Manaus’ rural communities, said health workers must trek on foot for several kilometres through forests to reach 70 percent of the communities they serve, while the remainder of the journeys are done via boats. He said about 1,500 people live in these hard-to-reach areas.
The long trips make administering a second dose of COVID-19 vaccines a challenge. So far, 28.4 percent of residents from the rural communities have received their first dose and 0.2 percent are fully inoculated, according to data from FVS-AM.
“We could arrive and they’re not there. They could have moved, taken a trip to Manaus or rejected the shot. This means that our team has to return multiple times to ensure all second doses have been applied,” Correa told Al Jazeera.
As vaccination efforts continue in hopes of softening the blow of a third wave, Correa said more public health measures are needed to stem the potential spread of the virus.
“We need a lockdown. But governors have allowed schools and commerce to reopen,” he said. “If transmission rates climb, we can breed more lethal variants. Brazil doesn’t have adequate monitoring systems to identify new strains.”
Waldman, the epidemiologist, also said reopening is a risk. “Manaus remains at the centre of international tourism; if the virus spreads in great quantities, this could be dangerous,” he said.
Meanwhile, Inloco, a tech startup using GPS data to monitor social distancing, found that less than 40 percent of the Amazonian population was respecting social distancing, one of the lowest rates in northern Brazil – a reality Manaus resident Dos Anjos knows too well.
“COVID feels like a ghost here. It pains me to see people out on the streets acting as if the virus doesn’t exist. We COVID survivors live with what we suffered and take precautions,” she said, adding that she is bracing for the worst.
“I’m preparing to support myself and survive. We all are. Our aim now is to avoid losing any more lives.”