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Brazzil
Health Care
May 2003

Waiting, Waiting for a Doctor in Rio

The Brazilian Institute for Social Welfare is relatively serious
about  what it proposes to do: provide health care for all comers,
indiscriminately. So,
if you have a medical emergency in
Brazil don't hesitate to check into a public hospital if
you have no other options on your immediate horizon.

Thaddeus Blanchette

People are always asking about health concerns in Brazil. By and large Brazil's a pretty healthy place. However, last year I caught dengue in downtown Rio de Janeiro. It was totally unexpected. In fact, you could've knocked me over with a spoon. Sort of like picking up tuberculoses in NYC—I mean, it's possible, but what are the odds, right? Little did I know at the time that I was one of the first cases of a dengue epidemic that was to affect millions of Brazilians...

Anyhow, all that's by-the-by. What I really wanted to do here is share some of my observations as to how Brazilian (well, SE Brazilian) public hospitals work for all of you who are interested in health matters. While I was in line at Miguel Couto, I got so bored that I started taking notes, and right now I'd much rather play with this than do any real work.

The big public hospitals dotting Brazil's urban landscapes generate a mixture of fear, loathing and utter frustration among the Brazilians (of any class) who've had to use them. Anyone who halfway tries can easily collect an almanac's worth of horror stories regarding the absolute lack of resources, care and common courtesy on display at any major public hospital in the country.

However, when it comes to Brazil, first impressions are rarely trustworthy. So let me try and give you a fairly dense description of my most recent experience in dealing with the INAMPS (National Institute for Social Welfare) leviathan.

We arrive at Hospital Miguel Couto in the Lagoa district of Rio de Janeiro at 10 minutes to 5:00 PM. I'm already nervous. Five o'clock is the magic hour when doctors turn into pumpkins in public hospitals here. The shift changes and, as is typical in so many areas of Carioca public life, the departing functionaries always leave a "little" early while the incoming attendant's show up a "tad bit" late. All this means that an hour can easily be added to any patient's wait in line if he shows up at shift-changing time.

Public hospitals—like public universities—are free in Brazil. This means that a wise public hospital user also tries to time their medical emergencies for those hours when the usual hordes of supplicants are otherwise engaged—say 2 AM to 7 AM, weekdays. You are not advised to get seriously ill on a weekend afternoon in Brazil. To make matters worse, this is a four-day weekend. Probably at least half the normal medical staff—mostly working for public service credit and unfireable anyhow—have scurried up to holiday retreats in the mountains.

When we pull up in front of the emergency entrance, I really begin to worry. The line for admittance already stretches across the waiting room and out the door, spilling into a fair-sized throng on the sidewalk outside. Two hotdog vendors are working the crowd. A cherry-red paramedic van is parked to the left of the intake doorway, emergency lights languidly flashing. It doesn't go anywhere the whole time I'm there. A pot-bellied medical technician loafs in a lawn-chair set up next to the vehicle's rear. He doesn't go anywhere, either.

Little Gugu, the Terror

Thankfully, the twenty or so people milling around outside are mostly supporters of the folks in line. Again, as is common in Brazil, kids run in and out of everywhere, ricocheting off the walls and into patients. Occasionally a high-pitched voiced screams something like "Gugu, stop that or you're going to get slapped!" Nobody moves to restrain the children, however, even when a four-year-old starts ramming his way through the patient's line in order to drive his matchbox car around the circumference of the admitting room walls.

Patients who are barely able to keep their feet lurch out of little Gugu's way with a benevolent smile. Even on the third trip around the room. Even when Gugu begins to climb the back of one of the only waiting room benches in a valiant but futile attempt to drive across the ceiling... Ain't he cute? I keep waiting for the header to occur, if only to see if that would pull the EMT out of his redneck recliner, but no dice.

Looking at the people in line, one can easily see that, overall, these are not the kind of Cariocas that get put on postcards. Neither are they the kind of people Sebastião Salgado visits with his camera. They're workin' class folks, probably from all over town, down here today because they figured Miguel Couto would be their best shot at some free care for whatever ails them on this cheerful Corpus Christi weekend.

As such, they are the kind of Cariocas who fall off most gringos' radar screens. They are neither middle-class, nor desperately poor, though assuredly there are representatives from both the condominiums and the favelas (especially from the favelas) somewhere in line. Most of the women are, well, zaftig would be the polite way of putting it. My overly generous Canadian aunt would call them "big boned". Certainly, few people who work out in private academies are here today. Few vegetarians, too. This is a crowd that likes their weekly churrasco and beer and prefers TV to jogging after a hard day's work. There are very few obese folks, however, giving the Carioca proletariat at least one leg up over their American brethren in the fitness department.

The line is mostly made up of women, dressed in the Carioca standard of too-tight pants and too-small tube tops. The combination with the above mentioned body morphologies is interesting, to say the least (I didn't know cellulite could show up through denim). There are plenty of mother/daughter teams in evidence, with the sick one warming a spot on a waiting bench while the healthy one grimly secures their place in line.

The woman immediately ahead of me is a chubby 20-something with lank, mousy-brown locks, dressed in a white tube-top and skintight denims with lace cuffs. Her clothes are muddy and ripped. Cariocas are, in general, as finicky as cats about their personal appearance, so I assume that something nasty has happened to her or someone she knows in the very recent past. It turns out that her husband has had a seizure and was rushed directly into the ER. She's checking him in.

Ahead of her is a young middle-class couple. The boy (who has the flu) looks like he's trying out for a part as James Dean in an under-budget Mexican telenovela. His girlfriend chatters away blithely on her cell phone, dressed in shrink-ons and a yellow tube-top. She, from the looks of things, does attend a private academy.

The waiting room is an odd sight for anyone not used to Brazil because, like the patients, it defies description as "first world" or "third world". One can tell that when Governor Leonel Brizola dedicated it years and years ago, it was top of the line. Nothing much seems to have changed since then, however. Well, nothing much except the things that are absolutely vital. It looks pretty much like a lot of U.S. American hospitals, but it doesn't have that freshly steam-cleaned and pressed look to it. Don't get me wrong: the place is antiseptic enough and like all decent hospitals, subtly reeks of disinfectant. But it's—how can I put this?—worn around the edges.

The women's room is out of order. Some of the floor tiles are cracked. The plywood liner around the ER's swinging doors has had its non-staining plastic coating rubbed away by years of hands passing through in a hurry. The intake nurse's station is behind a triple-paned glass window, but the glass isn't safety glass. As I watch, another EMT strolls out of the ER carrying a very top-of-the-line looking backboard over to the paramedic van. Its high-impact, extruded plastic body is scuffed and indelibly stained from long use, however. He pulls a respirator out of the van. Its plastic facemask is an unhealthy shade of yellow.

Where Do You Think You're Going?

This is my first trip to public hospital in Rio, but I already know the drill from São Paulo. When my turn comes at the window (after a 20 minute wait), I show the nurse my I.D. She doesn't bother to even look at it. Care (such as is available at the moment) is free to everyone who can stumble through the door. She asks me my name, age, address and enquires into the generalities of my problem.

"Dengue, I think."

"OK," she says, handing me a half-filled out form and jerking a thumb towards the far wall. "Through there."

I wander over to the indicated door, only to be stopped by a brown-shirted security guard.

"Where are you going?" he asks.

"Well, the nurse said to go through here," I respond, adding helpfully, "I have dengue."

"Get in line."

Sighing, I turn from the door and form up in another line, behind James Dean and Patricinha, this time. I collapse against the wall, scratch my rashes and sweat profusely.

"You got the flu, too?" James asks.

"Naw. I think it's dengue."

James essays a short cough. "I'm sick," he says, rosy-cheeked and bright-eyed, drumming his fingers on the wall. I get the impression that James is actually fishing for a license to extend the four-day weekend for couple of days or so. That's a very smart move, especially if Patricinha's folks are going to be delayed coming down from the mountains.

After another 20-minute wait, Mr. Brownshirt waves James and me through into the inner sanctum of the ER. This room is like any U.S. ER: a head nurse's desk (with the obligatory ex-master sergeant head nurse) and a series of curtained-off gurney-filled bays for treating patients. There are some significant differences, though...

The wall of the center bay has a computer-printed advisory taped to it, covered with a slice of saran-wrap: "Contents of this bay: 4 tables, 8 chairs. UNDER NO CIRCUMSTANCES ARE GURNEYS TO BE PLACED IN THIS BAY!" That's because this is the all-important triage center. Four young interns sit at the tables, interviewing patients about their disorders and deciding where they are to fit in the hierarchy of care. Well, in theory. When I slog into the ER, two of the interns are polishing off a pizza on one of the back tables while another one appears to be flirting with an intern from the neighboring bay. Only one seems to be doing any interviewing. Beneath the hospital whites of the female interns, I catch occasional glimpses of blue, pink and yellow tube-tops and shorts. One of the guys seems to have a flower-pattern shirt under his lab coat, though that might be a hallucination...

Two other interns are taking care of Lace Cuff's old man, now propped up in a wheelchair with a (clean) respirator strapped over his face. One of them is asking the forty-something head nurse how many hypodermics will make up the dose of whatever they've decided to stick into him.

"Five," says Head Nurse, not missing a beat as she snaps open ampoule after ampoule of amber liquid, rapidly and professionally preparing hypos.

Based on my previous experiences in public hospitals in Brazil, I'm obliquely comforted. Everything's very laid back, but shit is getting done. This is good. There's about a dozen patients ahead of me, in varying degrees of distress, but aside from Lace Cuff's hubby, there doesn't seem to be a single major emergency among them. Though nothing extreme happens while I'm there, I know from experiences in São Paulo that a truly serious case wouldn't be left to rot in the ER unless there was absolutely no other option left.

Things are busy enough that the interns have to dial out for dinner. Nevertheless, the cases being dealt with are mostly penny-ante crap—essentially people wanting band-aids on boo-boos and folks (like myself) who are worried about persistent fevers. This is basically the "give-'em an aspirin, some sympathy and send 'em homeward" (except Brazilian public hospitals don't hand out aspirin: care is free, medicine, you generally pay for).

After another 10 minutes or so, I'm finally called into the triage bay and I'm cross-examined by a young male intern. I tell him my symptoms and he raises his eyebrows. "You don't wait three days before you go to the hospital when you're running a fever," he admonishes me. We chat for a bit. It's revealed in predictable order that, yes, I'm a gringo, yes, I'm a citizen. I'm a doctoral candidate at his university, UFRJ. I don't cheer for football teams. Yes, my girlfriend is going to pick me up and take me home. While this chit-chat plays out, the intern checks my pulse, looks at my rashes and hand-checks my temperature.

"Look, you probably have a virus of some kind. Most probably dengue. In fact, I'll bet on it: you have every symptom in the book," he says.

"That's what I thought," I sigh, rubbing my parboiled eyeballs. "How can I find out for sure?"

"Well, we don't do dengue tests here," he responds. "For that, you need to go to your neighborhood health post. Unfortunately, they won't open until the holiday's over."

"I figured. What do I do in the meantime?"

Lots of Fluids and Bed

The intern visibly relaxes when I don't go into hysterics and demand the impossible, like a super-mega instant anti-dengue shot which will cure me, make me richer and irresistible to chicks to boot. "Well, dengue has no vaccine, so, in a word, you suffer. But here's what you do, so you don't kill yourself while you're healing. You drink lots of fluids, as much as you can handle. Take Tylenol to reduce your fever. Do NOT take aspirin, unless you enjoy hemorrhaging. Stay in bed. Six days from when this began, you should be up and about, but it will take you at least another week to get your energy back.

"Therefore, I'm giving you this prescription [scribblescribble, scrawl, scrawl—STAMP!] for bed rest until next Monday. And you're to stay in bed as much as possible, got it? Monday, you're to check in with your local health post and tell them what your situation is. They will check you over and schedule a blood test for you if they feel it's necessary. If the symptoms start to get worse before then, come back here immediately. Any questions?"

I thank the intern and stumble back through the ER, through the waiting room and out to the curb where, 15 minutes later, my girlfriend comes to pick me up.

Now, the above experience could easily be read in a way that would confirm the general conception of Brazilian sloth, corruption and incompetence that many gringos seem to hold. But let's hold up a minute and examine our prejudices. Though there's certainly real sloth to be seen (James, the lazy sod...), and I wouldn't hold Gugu's mom up as the apex of parental competence, there's more to this story than immediately meets the gringo eye.

First of all, as I mentioned above, public health care in Brazil is theoretically free ("Fuckin' pinkos..." grumble all the Yanks in the audience. "So what?" say all of the Europeans). I won't go into Brazil's public funding squeezes and poverty indexes, as even the most uninformed gringo knows all about that stuff, but this basically means that the government has committed itself to a Herculean task while endowed with the musculature of Pee Wee Herman. Nevertheless, INAMPS is relatively serious about what it proposes to do: provide health care for all comers, indiscriminately. And it really does give the task the old college try.

Imagine what this causes. Reflect upon the intern's comment that I shouldn't have waited three days before going to the hospital. Basically, this system encourages everyone who feels the slightest bit under the weather to wait around for a couple of hours to get their tongue looked at by a professional. I myself normally don't go to the hospital until I think that there's a non-trivial chance I might die or lose a part of my body, but most Brazilians treat our system just like the Europeans treat theirs. Got the sniffles? Need an excuse to stay away from work? Go to the hospital.

Unfortunately, Brazil doesn't have the financial resources Europe does. So when the teeming masses show up at the emergency room gates, sporting everything from chipped fingernails to traumatic amputations, some severe triage work needs to be done.

Ninety percent of what goes on in a Brazilian public hospital emergency room is orientation as to what the patient needs to do to ease their suffering themselves. Very few pills are dispensed. Common, over the counter, medications and bed rest are prescribed whenever possible. However, when a really nasty case comes through (like the time my stepson fell on and broke his dad's toilet bowl, ripping himself from shoulder blade to buttock, necessitating 120 stitches), my God...! You'd think MASH had come to life. Or, occasionally, the Three Stooges and all their cronies... Surgeons get called in. Trauma teams fly together. Blood supplies run out. Mostly, things work and miraculous recoveries are pulled off on shoestring budgets. Sometimes, however, the needed specialist is too busy having lunch at Porcão and has turned off his beeper.

I'm incredibly lucky. I've never been wrongly diagnosed or suffered any malpractice, ever, at a Brazilian public hospital. I have been kept waiting in line for hours only to be treated like Patient #765,900 and man-handled like a slab of bacon. And this, I suspect, is what really sticks in the craw of most Brazilians, and founds the factual basis of most of INAMPS unsavory reputation. Brazilians expect to be treated like friends, even by people who they don't know, especially if they're sick.

I once twisted my ankle getting off a bus, fell down in the middle of Avenida Paulista and two people immediately rushed into traffic to lift me up. One of them helped me hobble five blocks home. Insisted on it, in fact. So it is quite a slap in the nuts when one goes to a public hospital with what one thinks is a legitimate health complaint, only to find that the on-duty interns really don't care that much.

The health care professionals of INAMPS are too busy to take things personally. And when they aren't busy, they're keeping their cool for when it will matter, which they know will come soon enough. It's not that they don't care, really, they just don't care about you, personally, unless you happen to be a really buff specimen of the appropriate sex or the Governor's nephew.

And you know what? They're right. "Oh, yeah. Dengue case #765,900. Well, nothing we can do. Go home, sleep and take fluids. Don't gobble aspirin. Don't stick your fingers in any light sockets. Next!"

I really can't argue with that diagnosis, y'know?

In general, neo-liberals complain that free public health care is worth every penny. I beg to disagree. In the case of INAMPS, it's worth far more than nothing and far less than anyone who has to pay income tax would think a good buy. But that, my friends, is what public health care is all about. It gives those folks at the bottom of the barrel at least some recourse to fall back on, a security blanket. And, in my experience, that makes it well worth its Cost to Society.

So I hope that if you're ever in Brazil and have a medical emergency, you'll not hesitate to check into a public hospital if you have no other options on your immediate horizon. And I also hope, that if that day—God forbid—ever comes, your particular specialist won't be eating at the Porcão with his beeper off.

Thaddeus Blanchette is a 35 year old immigrant to Brazil who has been living in and studying the country most of his adult life. He can be reached at poboxthad@yahoo.com.br 

 

 

 

 



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