Brazil's Main COVID Strategy Is A Cocktail Of Unproven Drugs
In January, Thalita Rocha stood by her mother-in-law, Maria da Cruz Lima, at a public health clinic in Manaus, Brazil. Lima, a 67-year-old retired nurse, had caught the highly contagious COVID-19 gamma variant (formerly called P.1) assailing the Amazon's largest city. She was waiting for a spot to open up at an intensive care unit but was feeling optimistic — a nurse had started her on oxygen, and she seemed to be improving. An oximeter clipped onto Lima's index finger measured her blood oxygen saturation and was finally showing healthy levels, around 98%.
That afternoon, though, Rocha noticed her mother-in-law's skin turning purple. Lima also broke out in a cold sweat and was feeling breathless. A sense of panic filled the room. Lima was not the only one: The oxygen at the unit had run out.
An hour later, a police car showed up at the door with two extra tanks. A team of young men hauled the heavy 5-foot tanks into the clinic. Patients took turns breathing in the lifesaving gas.
For Lima, it wasn't enough. She died that day, along with 31 others. "The oxygen ran out so unexpectedly," Rocha said. "We had no warning."
But Brazil's government did. Just a week earlier, the oxygen supplier in Manaus had sent government officials an urgent letter warning that the company's oxygen would soon run out due to the sudden surge in critical COVID-19 cases caused by the gamma variant.
Despite the letter, the Ministry of Health failed to secure sufficient oxygen in time or encourage a lockdown in Manaus to limit the virus's spread. Instead, the federal government decided to combat the rising COVID-19 cases by launching a public health campaign advertising the alleged benefits of treating early-stage coronavirus with a loosely defined cocktail of unproven drugs, commonly called tratamento precoce since mid-2020, Portuguese for "early treatment."
Although other early COVID-19 interventions with existing drugs have shown promise, proponents of tratamento precoce — which include Brazilian President Jair Bolsonaro — lean on discredited or skewed experiments to trumpet the regimen's effectiveness, even after several of the pills were proven not to work against COVID-19 in conclusive clinical trials last year. Some of the more concerning — albeit rare — side effects include rapid heartbeat, or tachycardia, and liver toxicity.
In Brazil, where more than 488,000 people have already died due to COVID-19 — second only to the United States — pseudoscience has become government policy. Bolsonaro regularly promotes repurposing unproven and cheap drugs to his nearly 40 million social media followers as he continues to minimize the gravity of the pandemic and dismiss its victims. Meanwhile, his administration has spent millions of dollars to produce, purchase and promote pills such as the lice medication ivermectin, the antimalarial chloroquine and popular antibiotic azithromycin as well as anticoagulants, painkillers and a set of vitamins. The Ministry of Health and numerous doctors endorsed using a combination of these medications to treat COVID-19, even though there is no solid evidence that it works.
"It's not because they believe it works, but because it is a way for them to escape their responsibility for controlling the pandemic," said Jesem Orellana, a Manaus-based epidemiologist at Fiocruz Amazônia, one of 16 units of the public health research center Oswaldo Cruz Foundation. For at least a month last fall, Orellana urged local authorities to implement a lockdown.
David Nemer, a Brazil political analyst and assistant professor at the University of Virginia, agrees. "Bolsonaro is doubling down on his bet on early treatment to give people a sense of security to keep going to work," said Nemer, adding that Bolsonaro's strategy appears to favor an open economy over health and to distract citizens from his vaccine failures. "He needs something to contain his rising rejection rates."
With recorded daily deaths breaking national records earlier this year — 4,249 deaths on April 8 — the dangers of the Bolsonaro administration's method are becoming clearer. Just in the city of Manaus, 4,430 people died within the first two months of the year, raising the death rate to among the highest in the world.
Lima had not taken any "early treatment" pills but still fell victim to the government's focus away from real measures — securing more vaccines and oxygen, tracing and testing, lockdowns, advocating mask use, social distancing — in favor of pseudoscience.
A false sense of protection
As COVID-19 spread over the past year, reports of possible off-label uses of existing medications started to pop up. In March 2020, a French scientist published a now-discredited study purporting to show that hydroxychloroquine taken with the antibiotic azithromycin reduced mortality. Later, an Australian study found that the anti-parasite drug ivermectin reduced the viral load of the coronavirus in cells in a dish, even though the concentrations used in the lab were not viable in a human body. For zinc and vitamins C and D — said to improve immunity — and a flood of other medications, the story is the same: small, biased or false studies rather than solid scientific support. Researchers continue to look more deeply at some of these treatments, including ivermectin, although it is still unclear whether the drugs will show promise.
Over the course of the pandemic, the politicized approach has gained a footing in almost every sector of Brazilian society. Medical professionals are prescribing unstandardized drug cocktails to their patients. Mayors of small and large cities have built their COVID-19 response around it, stockpiling the drugs for public consumption. Bolsonaro-allied doctors and influencers are using effective social media to tout it. This has led to individual Brazilians desperate to save themselves with a $30 kit of unproven drugs and vitamins.
When Enilson Mesquita, 52, and his family in Manaus fell sick with the coronavirus in April 2020, he treated himself and his wife and son with traditional teas and herbs that he referred to as "jungle medicine." The COVID-19 drug kit still wasn't popular then. But as cases began to rise again in the Amazonian city in the last quarter of 2020, he said he was determined to prevent reinfection and protect his mother, 76, and father, 70.
So, prompted by news reports promoting ivermectin, he decided that both he and his parents would take the pills. "I explained to my mother that until the vaccination comes through, we could at least use it to prevent coronavirus," Mesquita said. In the months leading up to January's oxygen crisis, Mesquita said residents swapped stories of which drugs helped them prevent or survive the coronavirus. After the family took ivermectin, Mesquita said he felt relieved. Neither of his parents caught the coronavirus. "I felt protected," he added.
But the drugs may have provided people in Manaus a false sense of protection. The best evidence for this comes from a longitudinal study of 3,046 Manaus residents developed by scientists from Fiocruz Amazônia and the Federal University of Amazonas and published as a non-peer-reviewed preprint. Participants who admitted in August they were self-medicating to prevent the coronavirus were more likely to have contracted it.
"That person feels protected, and therefore they lower their guard," said Jaila Borges, an infectious disease expert at the Federal University of Amazonas and an author of the study. Borges added that proven interventions such as mask-wearing and physical distancing lose value with people who think the drugs will prevent the coronavirus.
The study examines risk factors associated with a positive coronavirus test result. Participants took a coronavirus blood test and answered relevant questions — on sociodemographic characteristics, presence of symptoms, testing, and whether they were self-medicating or taking prescribed medications — every eight to 12 weeks.
Alexandre Naime Barbosa, the head of infectious diseases at São Paulo State University, has been working on the front lines since the beginning of the pandemic and says he has seen more than 1,000 COVID-19 patients. For him, the claim that the drugs constitute an early treatment of COVID-19 is misleading, using a catchy term to give people false hope.
"It's pseudoscience to even call this 'early treatment' because it's a term that seeks to legitimize a strategy that doesn't have scientific validity," he said. "No sane person would be against a real early treatment with drugs that were capable of preventing the progression of mild COVID-19 to a severe case."
Millions for pills with no proof of effectiveness
Despite the lack of evidence for the early treatment, Bolsonaro's government has taken at least $6 million out of public coffers to buy and produce the pills and advertise the approach, which is supported by Brazil's Ministry of Health and Federal Medical Council.
Three days before Manaus' oxygen supply ran out, the Health Ministry launched TrateCOV in the city, an app that was supposed to help guide doctors in treating COVID-19 cases. But in every case, the app recommended prescribing chloroquine, ivermectin and five other medications, Brazilian media reported. The app, available for use nationwide, was eventually taken down on Jan. 21.
For the Ministry of Health's secretary of labor management and health education, Mayra Pinheiro, the main official behind Manaus' January "early treatment" campaign and the TrateCOV app, the regular rules of medical practice can be suspended in an emergency. "In a pandemic situation, ideal scientific evidence on pharmacological and non-pharmacological measures can take time, which has a high cost in human lives," she said. "It is necessary to not interfere in the autonomy of patients and their doctors in promoting this solution even if it is a temporary one."
With drawn-out lockdowns falling out of favor among Brazilian constituents, there are political advantages to touting an easy fix. Numerous cities and states aligned with Bolsonaro had already implemented the "early treatment" as standard in their health systems in 2020. Several mayoral candidates adopted the treatment as a campaign platform in the November 2020 elections.
Bolsonaro openly declared he would not be taking the vaccine, claiming he was immune after having contracted the virus. From August to December, his administration ignored repeated offers from Pfizer, even with the pharmaceutical company offering doses for half the price of those sold to the U.S. and Europe. Brazil only launched its vaccination campaign because the São Paulo state governor had made a deal to secure a Chinese-made shot. Today, 14% of the population is fully vaccinated, and the Ministry of Health has projected an additional 563 million doses by the end of 2021.
As Brazil's health care system collapsed in several cities in April, resulting in thousands of people waiting for an intensive care bed, politicians continued insisting on the treatment. The mayor of Sorocaba, a city of 600,000 people in the state of São Paulo, authorized the "early treatment" to confront its COVID-19 crisis as recently as mid-March.
Bolsonaro supporters have taken to the streets of large cities to protest new lockdowns — and advocate for the unproven pills. "We don't want the vaccine. We have chloroquine!" one sign read in Curitiba, the capital of the state of Paraná in southern Brazil. Another, held by a woman wearing a Brazil flag shirt, read: "Prophylactic treatment. Ivermectin NOW!"
Doctors endorse unproven pills
In May 2020, a group of Brazilian doctors united to promote the use of chloroquine and their right to prescribe whatever medications they feel are appropriate, naming themselves Doctors for Life. Later in the year, the group met with Bolsonaro in person, along with former Minister of Citizenship Osmar Terra, the parliamentarian who has tweeted the most fake news about the pandemic, according to Brazilian fact-checking agency Aos Fatos.
Even though a Brazilian Medical Association survey shows that around two-thirds of doctors in Brazil don't believe the drugs work, many have embraced the treatment. In February, Doctors for Life paid to publish a half-page manifesto — signed by more than 4,800 doctors and counting — in eight of the country's largest newspapers.
Carolina Muniz Ferreira is one of 70 doctors on the group's website. Ferreira said that she sees it as her obligation to do everything in her power to help her patients. After weighing the potential benefits and harm of the early treatment medications, she opted toward administering unproven pills such as ivermectin, and today is convinced that they work. "We are human beings," she said. "We can't sit idly by waiting for someone to die nor hearing their family members pleading, 'Save my family,' or 'Save my husband,' and do nothing."
Some doctors are even choosing to take the unproven drugs themselves. When urologist Márcio Nóbrega, 48, contracted COVID-19, he delayed his trip to the hospital, even after several days of breathing difficulties. According to Barbosa, the infectious disease doctor, who treated him in the hospital, the medications he was taking at home gave him a false sense of security.
But Nóbrega said he would do it all over again. "It's agonizing to have an unknown disease and do nothing to treat it. Maybe the early treatment with hydroxychloroquine and ivermectin isn't effective, but from the psychological point of view, at least you are trying to do something," he said. "Just for this reason, I think it is worth it. The scientific guidelines say it doesn't work. But I don't know if I didn't die or not because of it. It's hard to know whether it helped."
Prescribed by social media
Last December, Fabio Malini, a social scientist at the Federal University of Espirito Santo who regularly collects social media data on online movements, noticed an explosion in the amount of online content posted by Bolsonaro supporters on the early treatment. Just as Manaus' gamma variant gained steam and deaths mounted between late December and early January, the number of Twitter profiles promoting the treatment doubled.
Fake news and conspiracies about masks, vaccines and lockdown spread like wildfire on social media, dominating the conversation on these topics. Similar to this, information on the so-called early treatment overwhelmed its naysayers, Malini wrote in a Jan. 15 tweet.
According to CrowdTangle, a social media monitoring platform owned by Facebook, Bolsonaro published the most popular Facebook post on the early treatment on Nov. 19, encouraging Brazilians to start the drug regimen with the arrival of the first COVID-19 symptoms. Twitter, YouTube and Facebook are where Bolsonaro, right-wing influencers and even doctors hawk the benefits of unproven drug cocktails. Agência Pública, a nonprofit publication focused on investigative journalism, recently revealed that Brazil's Ministry of Health contracted social media influencers to post about early treatment in January.
Bolsonaro supporters gathered to protest lockdown measures in Rio de Janeiro in March amid surging COVID-19 cases. Signs read "No lockdown" and "I just want to work."
While Twitter and Facebook have repeatedly removed and added warnings to some of the more prominent tweets, including those by Bolsonaro and the Ministry of Health, this has inadvertently added to the Brazilian president's anti-establishment rhetoric, according to a 2020 paper on medical populism published by the Getulio Vargas Foundation.
To understand the phenomenon better, Malini mapped out the keyword tratamento precoce and found that in early January, its supporters vastly outnumbered those critical of the treatment, overwhelming the internet with voices that, at first glance, seem reliable, authoritative and science-based. Malini's mapping reveals that nearly all of these voices are intimately interlinked with pro-Bolsonaro online communities, which have previously been called "digital militias."
"This 'magic cure' has its scientific connotation upheld by doctors, the same doctors that are making YouTube tutorials on how to self-medicate using these drugs," Malini said, adding that doctors hold an outsize influence in Brazilian culture. Doctors in these videos, many of whom don't specialize in pandemics or infectious diseases, explain why they support the treatment and even recommend specific dosages.
With their encouragement, Carla Ferreira Ramos, 48, has been taking ivermectin since July. "I saw some doctors talking about tratamento precoce on YouTube. Television rarely shows this," said the Rio de Janeiro state government employee and enthusiastic Bolsonaro supporter. Ramos started taking ivermectin once a month and then increased it to every two weeks, based on independent online research on these platforms. After she tested positive for the coronavirus in January, she credited ivermectin for limiting her symptoms. Now, she gives the drugs to all five family members in her house, including her three kids.
Raymundo Paraná, an expert in drug-induced liver injury and head of gastro-hepatology at the Federal University of Bahia in northeast Brazil, said the craze can cause liver damage. "One patient came in with clear symptoms of liver toxicity, with high levels of liver enzymes, yellowed eyes and dark urine," he said. "They were taking ivermectin, nitazoxanide and hydroxychloroquine. That was an easy case to diagnose."
While the drugs are generally considered safe for their intended uses, the sheer number of people and amounts being taken have sparked reports of negative side effects. Ivermectin sales increased more than 550% in 2020 over 2019 (from 8 million individual pills to over 53 million), and there was more than a 100% increase in hydroxychloroquine sales (from 963,000 in 2019 to 2 million in 2020), according to Brazil's Federal Pharmaceutical Council with data from IQVIA.
Because valid scientific studies on the use of ivermectin for COVID-19 have not yet been completed, the prescriptions have no standardization or pattern, Paraná said. "I've seen people taking pills once a week, three times a week, every day, three times a day," Paraná added. "Today, I saw a prescription recommending a dose 12 times higher than the dose that has been studied in humans."
But a four-pack of ivermectin costs around $5 and is available at most pharmacies, some of which have announced deals under $30 for a complete drug cocktail. Even in states that now require prescriptions, most pharmacies will sell the drugs without one.
As the COVID-19 death count continues to rise, the federal government is showing no sign of reversing its unfounded approach but has warmed up to vaccines. On April 27, the Brazilian Senate opened a formal investigation into the government's contentious handling of the pandemic. In recent hearings, key figures of the early treatment movement and pro-Bolsonaro politicians reaffirmed their support for the use of chloroquine and ivermectin in the fight against COVID-19 amid fiery debate.
But Bolsonaro's minister of health, Marcelo Queiroga, recently admitted at the hearings that there is no evidence proving hydroxychloroquine, chloroquine or ivermectin work against COVID-19.
"If these drugs work, then why is it that after one year, the situation is getting worse in the country?" asked Orellana, the Fiocruz epidemiologist. "We are in a moment of deconstructing this wrong notion that this early treatment works. It's fairly clear already. It's one thing to do that in science, but it's another thing to do that in the social imaginary. That takes months or even years."
This story originally appeared in Undark, a nonprofit, editorially independent digital magazine exploring the intersection of science and society.
Shanna Hanbury is a Brazil-based journalist and social scientist covering science, society and the climate crisis. Her extensive reporting from Latin America has been published in The Guardian, BBC, Mongabay, Time and more.
Kiratiana Freelon is an independent journalist based in Rio de Janeiro. Her reporting focuses on social injustice, Afro-Brazilian communities and Brazil's dynamic economic and political landscape. The Harvard graduate has worked for The New York Times, and her work has appeared in The Washington Post, Essence magazine, New York magazine and other publications.