By MARCELO EDUARDO BIGAL*
Anosognosia is the inability of a person to be aware of their own disease. Brazil suffers from self-imposed anosognosia
Anosognosia is the inability of a person to be aware of their own disease. It is not denial or psychological inability to accept a situation, a defense mechanism. It is the pure lack of awareness of being sick. This condition represents a sequel to a neurological disease. Brazil suffers from self-imposed anosognosia.
As I write, we have surpassed the mark of 2.1 million cases and 80 deaths. It is worth reflecting on national anosognosia.
we deny the destructive potential of COVID. The 80 deaths, which increase every day, were treated as statistics. The Brumadinho tragedy claimed the lives of 254 Brazilians. Today, however, four brumadinhos happen a day. Day after day. We mourn the death of 2700 people when the twin towers fell on September 11, 2001 in the United States. Two twin towers collapse in Brazil every week. Week after week. We continue to deny the disease and seek normality.
we deny the need for testing. In March, I recorded a video warning that, while other countries equally affected by covid were carrying out around 3000 tests per million inhabitants, Brazil was carrying out 256. Today, with 23 thousand tests per million inhabitants, Brazil remains miserably short of what is needed. United States, Russia and United Kingdom have about 220 thousand per million. Countries such as Kuwait (107), Lativia (95) and Kazakhstan (94) have exposed the nauseating neglect in force. But why test what is tried to be trivial? When we denied the epidemic, other denials had to follow.
we deny the need to use the few tests rationally. First, the test that really matters for epidemiological control is the PCR. It shows who is infected at the present time, therefore infectious. I have advocated since the beginning of the crisis that, while the tests were insufficient, they should be used to test individuals at risk, contacts of symptomatic individuals and contacts of those who tested positive. The goal is to identify contaminants, symptomatic or not, and quarantine them. Epidemic is like wildfire. Either the source of the fire is removed or the fire does not go out. Either we identify the contaminants and quarantine them so they don't contaminate others, or the epidemic doesn't end. What did Brazil do? Federal authorities were unable to regulate testing, indicating who should be tested. Wealthy individuals were and are tested multiple times, unnecessarily. Tests that measure antibodies (which show who has had the disease, not who has it) have been used indiscriminately. We test insufficiently and incorrectly, without discipline or method. Brazil tests three people for each infected person, when the international recommendation is thirty.
we deny common sense as we continue to insist on chloroquine, ivermectin, dewormers and the like, which have been repeatedly tested and failed to demonstrate efficacy. This denial is typical of Brazil. Not even in the United States did this persist. As I wrote in previous articles, Brazil thinks it has discovered the squaring of the wheel, the solution that no one else has been able to discover. We continue to behave like court jesters on the international stage. We belch ignorance and do it with pride.
we refuse to understand that flattening the curve is different from epidemic control. Flatness indicates stability, which can be good (few cases) or bad (many cases). By the way, in Brazil stability has not yet been reached. But even if we had flattened the curve, this flattening happens with an unsustainable 40 thousand cases and 1200 daily deaths. We still deny the fact that we are in the first wave of the epidemic. Not the second, as some say. There will be a second wave of the epidemic, in the world and in Brazil. Our denial will cause the second wave to start on top of the first. Back to the fire analogy. In many countries a bonfire in ash will threaten to catch fire again, and efforts will try to put it out. Here, second-wave gasoline will arrive in an Amazon fire.
we deny the cost of herd or barrier immunity. This concept needs to be well understood. It is based on the fact that if around 70% of the population catches a certain transmissible disease (for example, COVID), the disease diminishes until it becomes extinct, for the simple fact that there is a barrier of people with immunity around each new contaminated. Barrier immunity appears to be unattainable for COVID, which may generate only transient immunity in many. Very affected countries, such as Spain, have not reached more than 15% of immune people. Still, to achieve barrier immunity we have to concede that many people will die. If we believe the official statistics, the mortality of COVID in Brazil is 3.5% and we have, in the most affected areas, about 10 to 13% of individuals with immunity. The cost of barrier immunity in Brazil would therefore be at least 800 deaths and many more with sequelae.
we refuse to understand, borrowing the words of Gonzalo Vecina Neto, former president of Anvisa, that the new normal is very different from the old normality. The easing of social isolation, worldwide, is based on three criteria: sustained drop in the number of cases, high level of social isolation and ICU occupancy rate below 60%. Most of the places that are easing isolation in Brazil have not reached any of the three, or have only reached the ICU goal. Still, flexibility does not mean a return to normal. The state where I live, Pennsylvania, has evolved to allow for flexibility. The entire state had 600 cases on Sunday. Ribeirão Preto, in SP, had around 500 on its own last Friday! And flexibility includes wearing masks, encouraging remote work and others. New York has kept indoor bars and restaurants closed. Broadway, museums, remain closed. The new normal is very different from what we knew.
we deny the possibility that an effective vaccine is not guaranteed. And that could take years, not just months, and generate only transient immunity, requiring reinforcements. We deny that, to guarantee immunity, 70% of the population has to be immunized (the famous barrier immunity). This means that, worldwide, around 5 billion vaccines will have to be manufactured. By sabotaging the World Health Organization, we sabotage our own interests, as that organization advocates equitable access to vaccines (most affected countries get it first). Do we really believe that a productive system that has not been able to distribute gloves and masks worldwide will be able to distribute 5 billion doses of vaccines in a reasonable time? Of course. Stronger countries will receive it first, then it will be distributed to the most vulnerable and exposed (elderly, health professionals). It will take a long time for barrier immunity to be achieved with vaccine. In the meantime, barrier immunity has to be guaranteed by masks, which jesters insist on rejecting.
we deny the real cause of the obvious economic effect. The restoration of a minimum of economic normality requires a decrease in the intensity of the epidemic. The countries that controlled the epidemic can now aim for a near economic normality. Brazil pursues a bizarre situation. The denialism of a considerable part of the population forces the reopening of trade, sabotaging some well-intentioned state initiatives. The reopening brings few consumers (many are afraid), but increases the epidemic (more fuel on the fire). Social isolation has to be re-implemented, and the bad guys get more violent and virulent. Instead of the “close until it gets better, open prudently and sustainably, and demand economic support”, we will be in an opening and closing in which fewer and fewer people open, and more and more close for good, victimized by their own denial.
We could go on discussing national anosognosia for a long time. We deny the role of efficiency and accept that tests take weeks because national authorities order an input but not the extractor. We deny the hell of having had three ministerial changes in the area of health in the middle of the epidemic. We deny the ridiculousness of having an active general, without any credentials to occupy a relevant position in the area of health, as a minister in the most acute moment of national public health. We deny the ridiculousness of having two religious fanatics in key roles to mitigate the effects of the epidemic, Education and Human Rights. We deny the embarrassment of having an Olavista leading Itamarati, and sabotaging any possibility of collaboration.
Anosognosia is a neurological disease. In the case of Brazil, it was self-imposed. We elected an abject being, the greatest representation of everything that is bad, cruel. From homophobia, disrespect, misogyny, racism. And now we deny our own responsibility for this tragedy. We must add to our president's enviable curriculum, the sociopath, the one who wakes up every day thinking about how to increase the pain and tragedy of others. But that's up to us. He will not change. The anosognosia was self imposed and we will have to purge it. Well, in the words of Saramago: “I don’t think we are blind, I think we are blind, Blind people who see, Blind people who see but don’t see.” (Ensaio about Cegueira).
*Marcelo Eduardo Bigal, is a neurologist and researcher, with a doctorate in neurosciences from USP. He has 320 articles published in international scientific journals, and has published five medical books. He is CEO of a Boston-based biotechnology company dedicated to medical development in the field of immunology.
