Doria's Gambit

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By PAULO CAPEL NARVAI*

Caught up in his beliefs and fantasies created by his media area, Bolsonaro, who has always disdained the pandemic, has also made light of vaccines

O 'epidemiological earthplanism' that has been marking the policy adopted by the federal government to face the COVID-19 pandemic only finds defenders in Bolsonaro's acolytes. Already in mid-March, many (me too) warned of the very serious risk of denialism and neglect with the disease, which should not be played with. I mentioned at the time that one should not manipulate illness and death, commodifying them, nor ideologize and partisan the epidemiological phenomenon, undermining its confrontation based on scientific evidence.

Since then, the federal government has been doing exactly the opposite and, against all recommendations, adopted the “So what? I'm not a gravedigger, okay?!" said by Bolsonaro in response to inquiries from journalists about the increase in cases and deaths, at the end of April. While statistics, although underestimated according to experts, indicate that the country recorded more than 6,6 million cases and 178 deaths in December, Bolsonaro never admitted the mistake of having considered the pandemic “just a flu”. Arrogant in his ignorance, he seems to rejoice that his government was unable, in the long period from March to December 2020, to outline a national plan to control the pandemic, coordinating the actions of States and Municipalities.

Without this indispensable articulation, the federative entities were left to fend for themselves, which led them to try everything and spend public money on actions that, many times, violated the bioethical principle of non-maleficence. Supported only by beliefs, the use of chloroquine, hydroxychloroquine, ivermectin, anal application of ozone, nitazoxanide and recommendations of faith and prayers, among other infallible “solutions”, proliferated across the country. The Ministry of Health has been recommending the adoption of “preventive measures”, without identifying them – no one there knows, strictly speaking, what they would be, since even the recommendation to use masks is frequently disqualified by Bolsonaro, who either does not use it or uses it in a deliberately clumsy way.

I looked for, but did not find, photos of Bolsonaro washing his hands or using gel alcohol. He seems to insist on not issuing positive signals or these simple preventive measures. Technicians from the Ministry of Health admit that the mention of such “preventive measures” seems to be a way of “pleasing” Bolsonaro, who recommends (he thinks he can and should recommend something…) the use of hydroxychloroquine “from the onset of symptoms” .

In recent months, however, the prospect of one or more vaccines being viable in the very short term has intensified. The world was immediately in the running for a vaccine. The world, understand it well, except Bolsonaro, certainly, who seems to live in another world.

However, appreciative of a good spotlight, the governor of São Paulo, João Dória, soon also tried to get on the scene. He, by the way, had been looking for proscenium since the arrival of the pandemic in Brazil.

But the scene in which both dispute the spotlight is more than the COVID-19 stage, as Bolsonaro anticipated the 2022 election race. So, pieces put on the board, the chess game began. It's not official yet, but Bolsonaro took the initiative to open the game. His tactic to “occupy the center of the board” was to attack, in advance, the main possibility of preventing the disease: the vaccine.

Caught up in his beliefs and fantasies created by his area of ​​social communication, the President of the Republic, who has always disdained the pandemic, also ignored the vaccine(s). First, it took the initiative of a sterile debate about the supposed “obligation to undergo the vaccine”, while announcers announced in the 'Voz do Brasil', in an optimistic and grandiloquent tone, that the country “leads in the world the recovery of patients from COVID-19". Afterwards, he ideologized the vaccine developed by China, CoronaVac, whose phase 3 tests are underway in Brazil, Indonesia and Turkey. “Communist vaccine!” he roared.

Open the game, Doria made her move, performing a kind of "Queen's gambit".

Before proceeding, a clarification: “The Queen's Gambit” is the title of a hugely successful miniseries on Netflix, based on the book by Walter Tevis. The story begins in an orphanage in the interior of the United States, in the 1950s, and tells the story of Beth Harmon (Anya Taylor-Joy), a chess prodigy girl, introduced to the game by the janitor, in the basement of the establishment, at nine years. He begins to teach her by applying the strategy called “Mate do Pastor”, with which she quickly defeats her opponent, performing only four piece movements. Beth is enchanted with chess and soon learns the strategy known as the “queen's gambit”, known to any well-educated chess player.

The Queen's gambit consists of sacrificing the pawn, one of the pieces in front of the Queen, to trigger other moves and set the course of the game. It can be accepted or not by the opponent and the game continues. Gambit, in this context, corresponds in popular language to rasteira, or passa-moleque, in which one seeks to “overthrow the opponent” by hitting him in the legs or, metaphorically, inducing him to make a mistake. Chess players say that the gambit is a way to “show your teeth” at the opening of the game, gauge the opponent's reaction, and then line up your pieces for battle.

With the announcement of an anti-COVID-19 vaccine “for all” in January, Dória postponed for a month what he had promised for mid-December. With this maneuver, she emptied Bolsonaro's movement to formalize changes in mental health and AIDS programs, among others implemented nationally by the SUS, with which she hoped to create a smokescreen for the start of vaccination in São Paulo. In January, Dória will celebrate more than the anniversary of the capital of São Paulo, on January 25th.

It remains to be seen whether Bolsonaro will have other possibilities in January to ensure a presence in the media while the Paulista is speaking about the progress of vaccination in the state. Judging by the December spectacle involving his and the first lady's own attire at the inauguration ceremony, his team doesn't have many aces up its sleeve. They will have to look for something relevant to compete for the space in the media, occupied by Dória.

Anyway, chess aside, it is evident that the governor of São Paulo is playing for the crowd. There are well-founded reasons for admitting that the state of São Paulo is not in a position to vaccinate even all the people from São Paulo who go in search of the vaccine. His call that everyone who wants the vaccine will have it in São Paulo is nothing but health populism.

Furthermore, the practice of the São Paulo government has not been to defend the SUS, much less to act to maintain the financial resources that our universal system needs. Dória never said a word against the freezing of SUS resources over the next 20 years and politically supported the approval of Constitutional Amendment 95, in 2016, today the main threat to SUS funding.

São Paulo has not been prioritizing the basic services network for a long time. The outsourcing of SUS management reinforces and deepens the “hospital-centric” model that guides state health policy. Indicators for the development of basic care, or primary health care, for the state of São Paulo are disappointing according to the evaluation of specialists.

The deliberate scrapping and disorganization of this base of the structure of the SUS, represented by the basic health network and its multidisciplinary teams, both in the capital and in the interior, is expressed in health indicators, in the performance of services and, also, in the reports of counselors of health and SUS professionals. With this deficiency in the public health system, the state of São Paulo was unable to adequately organize effective health surveillance strategies to face COVID-19. Currently, the São Paulo government focuses its control strategy on the vaccine.

But the problem is precisely this: putting all the chips in the vaccine, because, although they put the possibilities of success in facing the pandemic on another level, sanitary control measures based on health surveillance, with territorial actions, house to house, participation family health teams and broad community participation are indispensable. Specialists say and reiterate that today, more than ever, the participation of communities is essential. Without this participation, there is no possibility of controlling the pandemic, other than waiting for its spontaneous remission, recognizing the health failure. This, by the way, is the strategy of the federal government, which postpones all decisions, does not use budgetary resources, commits administrative negligence.

It is certainly not a question of opposing vaccine and surveillance, but, on the contrary, of understanding that they are complementary possibilities of action, both necessary and that require organizing their use in an articulated way. As wrong as refusing the vaccine-surveillance binomial, as Bolsonaro does, is to emphasize the vaccine to the detriment of surveillance, that is, without testing suspects, without tracing contacts and without isolating patients. This goes for any vaccine, as there is no doubt that all of them will be necessary in Brazil, given our territorial, cultural and institutional characteristics.

What is most worrying, therefore, about “Dória's gambit”, is that his move is only intended to place him in the center of the political-electoral chessboard. His actions at the head of the state government have not effectively qualified him as a firm defender of the right to health, nor in the recognition of the SUS as the best instrument for the Brazilian State to ensure this right to all - as, by the way, is inscribed in the Constitution of the Republic.

But what is, after all, the "Dória's gambit"? It is a political strategy that consists of placing responsibility for what will not be achieved in São Paulo, in the lap of ANVISA. Surprisingly, for a federal government that has invested in creating an image that it is supported by notable political strategists, Bolsonaro and his team have accepted the gambit. In doing so, they acted like the beginner Beth, surprised by the “Mate do Pastor”, because, in a continuous act, Anvisa “issued a receipt” and sent word that the vaccine would only be given in February, if all goes well. The Minister of Health communicated the decision to Dória and other governors and health secretaries a day after Dória made the São Paulo vaccination plan public.

Anvisa's denial of the vaccine, as it turned out, corresponding to a ′′ no ′′ by the federal government, was what Doria needed at this point, to pursue her strategy and reorganize her game.

Check. Easier than “Mate do Pastor”.

But the checkmate will be given, by all indications, in 2022. Until then, however, there is 2021 and there is no shortage of players willing to prevent both Bolsonaro and Dória from continuing to move pieces on that board. The preferred target is Bolsonaro. All who seek access to the board, without exception, are willing to do whatever they can to keep it far, far away from the board.

With the new year will come much more than the expansion of the second wave of COVID-19 which, which started at the end of 2020, has been showing signs, in the capitals of southern Brazil, of having epidemiological characteristics similar to the first wave. Very urgent actions are necessary, in addition to checks, mates and gambits.

*Paulo Capel Narvai is senior professor of Public Health at USP.

 

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