Interview: “Covid-19 has revealed structural problems”

Covid-19 has shown Brazil’s fragility in promoting an industrial policy in the health area: facing the pandemic involves prevention, services preparation, drugs, equipment, diagnostic tests, and the future vaccine. When one of these parts fails the entire strategy to contain the disease’s expansion will be jeopardized. This is Carlos Gadelha’s evaluation, a researcher and coordinator of Prospection Actions at Fiocruz. “From the beginning we have been saying that if these dimensions are not articulated, then SUS [the Brazilian Public Health System] would be vulnerable and fragile, with no health sovereignty”, says.

Photo: Zô Guimarães

Gadelha evaluates the enormous technological and productive dependence in the health area as “alarming”. The researcher states that the uncomfortable position in which the country is now could have been different if there had been an innovation policy for the Economic and Industrial Complex of Health (CEIS, in the Portuguese Acronym). In an interview to Radis he reaffirms the need to surpass the view that opposes economy and health. He points that “we will not achieve a universal SUS if we continue to present productive fragility”.

What is the Economic and Industrial Complex of Health?

This concept was developed in the first decade of the 21st century and sees health as part of a development strategy. It was implemented in 2007 when the Minister of Health was José Gomes Temporão. We already had a research line on the subject at Fiocruz. I always say that the Complex of Health is the other side of the Social Determinants of Health (SDH). While SDH look into the situation of health in all policies, the Complex of Health studies in which way development is reproduced within health. It should be understood that if there is inequity in the development pattern, in the technological and innovation capacity, there will also be inequity in health. In a way, Brazil was a world protagonist when looking into this articulation of social and economic politics of development. Hence, the economic and productive system is subordinated to the social aspects and linked to a strategy of development. And from the start we have said that if these dimensions were not articulated we would have a vulnerable and unsustainable SUS, with no health sovereignty.

Why does the pandemic highlight the interdependence of the health area?

Because one can no longer look into health with separate lenses for each sector. The picture brought by Covid-19 is a complex one and there is no more space for a disciplinary action carried by a fragmented vision of the world. This is a disease that involves prevention, services preparation, drugs, equipment, diagnostic tests, the future vaccine, treatments being tested and other therapeutics for problems caused by it. This is why the social policy for coronavirus breaks down when one of these pieces does not work. In such a way that if there is basic care capacity, the response will be better; if high-complexity ventilators are used, hospitalized patients will receive better treatment. But if Brazil does not produce the vaccine we will see developed countries immunizing their populations and ours will be dying. It is the local production capacity that ensures the chance that our population will not be drifting regarding new technologies. A product can be studied but there must be the perspective of its insertion in a productive system.

In which health areas is it possible to implement technological processes?

In all of them. For instance, epidemiologic surveillance requires intelligent basic care, testing and frequent analysis of epidemiological and demographic data, regionalized in the smallest possible level of territorialization. This certainly involves high technology of artificial intelligence and big data, which are crucial and are leaders in the fourth technological revolution. No one performs basic care and epidemiologic surveillance without these technologies of the future. Data have no knowledge. Knowledge is produced by people using these new technologies. Today, a modern laboratory conducting Zika research utilizes artificial intelligence to map children’s health for the anticipation of convulsions they could have. Without convulsions they do not waste two years of physiotherapy and have a better development, causing less impact on services delivered by the health system.

Are health and economy in close or opposed fields?

The logic of public and collective wellbeing and the logic of the market are not situated in opposed fields. We will not achieve a universal SUS if we continue to present productive fragility, including of private companies in Brazil. But the State must provide guidance and direction to integration policies drawing on public interest, not the other way around. We have always advocated that the production and innovation system is an indissociable part of a development pattern, rather than simply an accessory and exogenous factor. This other public policy standard articulates industries such as pharmaceutical and biotechnological, equipment, and medical material with health services. I believe the country faces supply shortage problems due to not having understood health as part of a development strategy that aggregates the economic, social and environmental dimensions. This development agenda must be embraced by all, including the collective health field.

Having a structured health policy, why is health not yet seen as development?

I always say that it is necessary to put on other glasses. Health is not expenditure and problems, but rather development and opportunity. This productive system mobilizes 9% of GDP [Gross Domestic Product]. The public part spends 4% of it and we have the only universal system in the world in which the government spends less than 7% of GDP. This is almost the total GDP value of the entire Brazilian manufacture industry. Health creates seven million direct jobs, equally distributed among public and private sectors. If one adds indirect jobs, the estimate can reach 14 million jobs. But in fact, there are approximately 20 million jobs because health professionals go beyond traditional occupations such as physicians, nurses, physiotherapists, and psychologists. It involves all health professionals: sociologists, anthropologists, economists, like me. In a laboratory there are mathematicians, engineers, information technology professionals, social scientists. Health is a job multiplier: one job within this area generates another job outside.

Do you consider health as a way to overcome the crisis?

Yes, because it is a fallacy that universal health does not fit in GDP. Health is the answer to have GDP increase again. If we invest the R$ 20 billion that health lost in the last three years [due to a law that established an Expenditure Ceiling] and allocate this amount in the system, we will generate jobs and income of high impact and we will trraise this country from the floor. There is immediate return, it means having jobs and income directly in the vein. Because care must be provided, there is no other way. We can, for instance, expand basic care, which currently covers 60% of the population, aiming at 70% coverage. Basic care is an important productive arrangement because it mobilizes health professionals from various backgrounds, involves families, generates jobs and income, mobilizes local economies. In some municipalities retirement and basic care incomes are decisive factors to local economy dynamics. Rather than being a burden to the country, it is a privilege to have this strategy of care.

What is the current situation of Economic and Industrial Complex of Health [CEIS]?

The institutional model that shaped the complex started to be dismantled in 2016 when Michel Temer became president of the country, with the implementation of neoliberal policies that reduced resources of social programs, such as health. But what is happening now reflects years of neglect with the developmental agenda of health. In the economic field a distorted mentality did not see health as development; and in the health field there was no vision that it could be not only the promoter of economic development but also that it would needed it. The National Council of Health played an important role in strengthening the theme of health’s economic development by accepting that it was not a wicked capital’s agenda, but rather a strategy capable of subordinating capital to social needs. There was an understanding that the country could not have the entrepreneurial vulnerability that we have in the health field. In a capitalist context, we must do something so that Brazil does not continue to be despised as it is today, on its knees, begging for ventilators, new drugs, as to have equipment and drugs for Covid-19 treatment and other problems.

Is China our greatest problem because of the dependence on materials and supplies?

It is a problem, but not the only one, given that 60% of the commercial deficit in the complex of health lies in Europe and the United States; their products have greater technology content, for the most part of high cost and patent protected supplies. This dependence is alarming, because 88% of current health patents originate in only 10 countries, which means that the future of Brazil’s health depends on 10 countries. This is why CEIS is a great opportunity to transform health in leverage for the next stage of national development. It creates jobs, innovation, and can be the motor that will enable the country to enter the fourth technological revolution. Brazil is insignificant in terms of artificial intelligence patents, despite its universities’ high qualification. It is regrettable that the knowledge produced is not being transformed into social wealth. Policies must have continuity because no ventilator is made overnight, nor are vaccines. The length of time for the development of a vaccine is at least 10 years; of a simple drug, 5 years; of a biotechnological, 10 years. 

What is the size of the commercial deficit in health in Brazil?

When we started to study the subject there was no trade balance of health [import and export of products]. There was of drugs, vaccines, reagents, hospital material. That was when we realized the tremendous trade deficit. It makes evident the dependence size and the discrepancy between the proposal of universal access and the outcomes of the national productive basis. Today the country imports the equivalent to the entire budget of the Ministry of Health to provide universal access with no generation of internal wealth. In the last 25 years Brazilian imports on health raised from US$ 4 billion to US$ 20 billion, in current prices; it aggregates the final health goods, captured in the statistics of international electronic commerce, the intermediary goods and the payment of services such as royalties, licenses, assistance, just to mention a few. It is a lot. In the case of ventilators, dependence reaches 80% when considering finished products in the box including more sophisticated components. In 2019 we had 60% of dependence degree only in the ventilator box. In more critical and sophisticated consumption goods, such as surgical gloves and masks with higher technological content, Brazil’s dependence is virtually total, with 95%, according to data from organizations that monitor these markets.

Is SUS capable of enduring this dependence?

No health system can endure this degree of dependence. Now we are paying ten times more and still do not have the products. It is vital to have national capital and enterprises because the companies are abroad, and we have no influence over them. Besides, as SUS is a system that provides care to almost 80% of the population, it is a robust internal market with capacity to absorb all the national industry’s production. We must rebuild the developmentalist state in health. This is our mission. And we must rebuild the vision of health that includes the innovation and production basis, the relation between the State and the productive sector. In the capitalist world there is no country in which the State and the market are not strong. The complex was created aiming to simultaneously improve the country’s productive basis with the right to life, with social rights of the universal systems pointing to a more equitable society and a country with more sovereignty in the world. 

What are the inequities revealed by the pandemic?

No one can question if health expenditure is necessary because it is. And the pandemic occurs at a moment when the bases of health’s industrial policies show fragility with the diminishing of the Brazilian State and the national system of science and technology; besides SUS expenditure decrease, especially due to the Constitutional Amendment 95, that instituted the Expenditure Ceiling, which cut the federal government budgets in health and education. The pandemic clearly exposes Brazilian inequities in the health productive system. In Maré [a favela in Rio de Janeiro] lethality is 13 times higher than in a middle-class neighborhood. This is why I reject the idea of new normal. It is a current normal, undesirable and repaginated, one that does not face inequity, the society’s huge problems, it is a normal that maintains racism and exclusion. We must enter a new transformation time since these issues brought by the coronavirus show the need to change the inherited pattern. Our problems are not from 2020; our problems have accumulated in the past 40 years. But the coronavirus reveals structural problems of Brazil and the world.