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EF: If 2020 was the year of diagnosis and prevention and 2021 a year of vaccines, what do you think 2022 will be the year of?
NT: The year of preparation for possible new health emergencies. This should be a year of recovery. I was recently in Portugal, and I spoke with many ministers of health, science, and technology. I could see that in the European Union and Portugal, people are focused on economic recovery and crucially attribute this to health, especially to science and technology for healthcare. So, I imagine 2022 will be the year to think about recovery and repair.
EF: If you were sending a message to world leaders about the importance of health in the recovery of the world’s economy, what would your message be?
The countries, especially the low-and-middle-income countries, need to develop health science and technology capabilities. This is not just an element of social spending, but an economic factor as well. In Brazil, we deal with this. At Fiocruz, we have an economist named Carlos Gadelha who created the concept of the Health Economic-Industrial Complex (HEIC), so the idea is not just to view healthcare as a social expense. Of course, it is, but at the same time, health is a development component.
I think that would be my main message. As I was at the WHO, the World Health Assembly, I mentioned that local production of health devices such as vaccines, diagnostics, medicines, and so on, is very important. I would also like to mention that technology should be seen as part of the healthcare system, we should not isolate technology because the idea is to promote equity in access to healthcare.
For technology to help improve access, we need to have a strong health system and we need to develop it in the direction of equity. This is not done, as it is not natural. This process is the result of political choices.
EF: What were the lessons learned since the pandemic from your point of view as a leader of Fiocruz?
In my case, due to the role I played and the decisions that I had to take as President and as part of the institution, it is challenging to think about lessons. History has shown that traumatic experiences and great disasters, or great pandemics, did not always generate consistent learning.
If we think in terms of a historical perspective, we had the plagues in the Middle Ages that generated more consistent health effects. For example, health councils were created in many European cities because of the bubonic plague, but this did not lead to better treatment of people or better prevention. If we think back to the beginning of the 20th century, we had the big Spanish Flu Pandemic. Today, there is even a whole piece of literature being published because of the Covid pandemic, but it seems that societies quickly forget. So, remembering and forgetting is a processes, and we have to study this from a historic perspective because there are no automatic lessons.
Klaus Eder, a German Sociologist, says that societies learn. He talks about collective learning, but that the world is very difficult to change. This phrase is very appropriate for this moment. While we are going through this catastrophe, we are also facing wars, such as the war in Ukraine. So, during the process of overcoming a crisis caused by the pandemic, we still have a war to increase the difficulty of recovery. For there to be a change in the world, it requires a series of political consultations and new agendas, between the public and private sectors and civil society. So, efforts are required to make changes happen.
From Fiocruz's point of view, I believe that some learnings come with challenges. The first is the need to have a permanent investment in science and technology. This applies to us and the whole world.
One of the representatives of the British government commented that nothing new has worked in this pandemic. We might think that vaccines were developed in record time, it's true, but there was a basis. Since other emergencies like Ebola, there was a whole research process, a continuous investment in science and technology research for innovation. So, the first lesson is the need for constant investment in science and technology, which should not be seen as an expense, but as an investment.
A second lesson is a need to reduce social inequalities between countries, including in terms of scientific and technological capacity. There has been a strong emphasis on the need for local production, and even developed countries have shown themselves to be very vulnerable with the concentration of production in the health industry in very few countries. The third mission would be the need to strengthen health systems without discouraging innovation. Finally, the need to think about health from an interdisciplinary perspective, which includes social and environmental factors in the construction of health and disease.
In 2002 I wrote a chapter of a book about the history of the Pan-American Health Organization (PAHO) and I resorted to a concept created by a Brazilian Political Scientist named Wanderley Guilherme dos Santos. He spoke about the “public evil”, where some disasters and communicable diseases on large scale have a negative impact, as is the case of a pandemic. It is different from the “public good”. For example, the vaccine in Brazil is a “public good”. People may not take it, so a “public good” can cause public harm. From a “public evil”, no one can escape, just like with this pandemic. You may have better response conditions, but you will not be immune to its effects. This is a very important learning experience, to think about the collective dimension of illness and response. This learning needs to be collective, which leads to actions of preparation, response, and recovery, which are objectives that must be present in all societies.
At Fiocruz, there was less visible learning, and we will need to publish about this, in relation to civil society. Brazil is a country where there is not, in a very marked way, philanthropy participation in research, science, and technology, and this was intensified during this pandemic. At Fiocruz, we launched a platform, “United against Covid”, and there were investments and philanthropic assistance from the private sector for the diagnostic support unit, for the entire vaccine quality control area, and for actions with populations in their health and vulnerability. Another point was working together with social movements and different civil society organizations in a very intense way. We launched a public notice for these actions based on projects presented by groups, leaders, and movements in these communities. We had a very rich experience at the headquarters in Rio de Janeiro, with very intense action in the “favelas”, in Complexo da Maré, of vaccination, testing, digital health, and telehealth in partnership with the private sector, which was important. Initiatives such as “All for Health”, which was also vital for the construction of the units for diagnosis and good data. So, there is also learning in this form of relationship with civil society. Sometimes we need public policies to make these actions more widespread on a larger scale, but these were important experiences.
EF: Do you think that in all these lessons there is something that can be converted into public policies?
NT: Yes, I believe that Brazil needs reinforcement in all its policies and data integration. It is also important that, during the pandemic, information and communication proved to be components of the pandemic process itself. So, these whole areas of data information, data policy, and digital health require strengthening with public policy and expanding digital access. The other fundamental policy is the strengthening of the Unified Health System, as the pandemic revealed the capacity to respond. Systems like the one in Brazil, which is a universal system based on the principle of integrality with all levels of care, primary and specialized, make all the difference. However, we know that there are also many weaknesses, in terms of funding, and the strengthening of primary care, in thinking about the unequal distribution of the apparatus of this health system, the northern region of Brazil has indicators of this. In short, I think they are important policies. The policies in the field of mobility, both in urban and rural areas, were another very important factor in the transmission process because the virus can be seen as a biological fact, but transmission is not. Transmission is both biological and social, it depends on people. That's why information and communication are so strategic. You quickly see information, some are true, and some aren’t, and that impacts behaviour.
What priorities do you have today for the future of healthcare?
Priorities, in general, are focused on strengthening the science and technology capacity and health surveillance capacity. We have a strong interaction with the Pan American Health Organization and with the World Health Organization to reinforce what has been called epidemiological intelligence. In the case of Fiocruz, we also have the strengthening of a systemic view of health and of the institution itself, because we have this characteristic of dealing with all areas of knowledge that apply to health, with the entire spectrum of the health chain, from research to technological development in all regions of Brazil. Finally, to strengthen Fiocruz's role in the global health scenario because the institution has a role in international cooperation and must have a part in several leading actions in global health, ranging from what I have already mentioned, such as epidemiological surveillance, science, and technology capacity, in the field of local production of vaccines, medicines, and diagnostic tests. Also, tomorrow I will take part in a meeting of the Pan American Health Organization to coordinate actions in the field of vaccine production. So, there are many initiatives in the international field that the pandemic demonstrates the need for, that countries like Brazil, which are in development or middle-income, play a more active role in this process.
I would like to mention an important article, of which I was one of the authors, along with Dr. Suman Sharazan of the WHO and Dr. Bernard of DNDI, and many other authors. It's important because it's about rebooting investments and developing research.
EF: Fast forward 10 years from now, what would you like to remember from this period of your career?
NT: In the future, I think this moment will be seen as a moment of importance for institutions, coordination, and collective actions. So, for me, it's the coordination of the collective. Having a united intention, work, and effort.
Communication often tends to look for leaders, this is a characteristic. When the main is taken decisions, for example, in the field of scientific health, I trust much more when they are the result of someone’s advice, with different points of view and not the result, however excellent a researcher, of individuals. In this sense, institutions really play an important role. I'm talking about Fiocruz, but the same applies to the Butantan Institute which is another great laboratory, the university that developed fans, and helmets, and often with great difficulty in mobilizing resources. Finally, institutions with ballast because an institution implies time, implies accumulated knowledge, and trained people. We talk a lot about technology, but technology is inseparable from human capacity in the sense that I speak of institutions and not of individual actors with great prominence. I received several recognitions and several awards, and of course, I am happy with that, but I believe that in fact, my role was much more of coordination and mobilization of institutional capacity, because in a disaggregated way this knowledge is dispersed and becomes very ineffective. The point is to make it something effective and that requires this integration.