In November, in a room on the second floor of a historic building surrounded by trees at the Butantan Institute, hematologist Carmino Antonio de Souza, executive secretary of the Department of Healthcare Science, Research, and Development for the State of São Paulo (SCPDS), put the final touches on a vitally important document. Delivered in early December to then-Governor Rodrigo Garcia, the researcher now intends to get it as quickly as possible into the hands of the state’s newly elected governor, Tarcísio de Freitas, who took office in January. It is both a diagnosis and a plan for reorganizing the state’s healthcare system, proposing, among other things, overhauling two drug manufacturing plants run by the Popular Medicine Foundation (FURP). This would allow them to resume production of essential medicines, including antibiotics, which were in short supply when COVID-19 cases surged.
Field of expertise
University of Campinas (UNICAMP)
Undergraduate degree (1975) and PhD (1987) at the School of Medical Sciences (FCM) at UNICAMP
395 scientific articles and 1 book
For almost 40 years, Souza has worked with one foot in public management and the other in the university system. In 1985 he created UNICAMP’s Hematology and Hemotherapy Center (Hemocentro), then coordinated the blood program in the state of São Paulo, ensuring that transfusions were free of viruses such as HIV, and served as the state’s Secretary of Health in 1993 and 1994. As chief administrator of the Campinas municipal healthcare system, he confronted the COVID-19 pandemic head on. In 2021, he published the book Minha vida na saúde pública (My life in public health) (Editora dos Editores, 2021), reporting on the epidemics he’s battled, beginning with the meningitis outbreak in the 1970s.
Born in Santos, in São Paulo State, the grandson of Italian immigrants (his grandfather came from Naples and his grandmother from Genoa), Souza is 71 years old, has two sons and two granddaughters—and says he’s not ready to retire. He wakes up every day at 5 a.m. and travels three times a week from his residence in Campinas to work in the office Butantan has provided the Secretariat. There he teaches, coordinates research, holds office hours, and writes scientific articles and weekly chronicles for the HoraCampinas website.
What have you been doing at SCPDS?
The secretariat was created in April 2022 by Governor Rodrigo Garcia. David Uip took over as secretary and called me in soon after, in May. We don’t have a budget, nor do we procure anything. It’s a secretariat for strategic discussion and planning. In seven months, we created working groups and produced a white paper proposing a reorganization of the healthcare industry in the state of São Paulo. Among other actions, we proposed overhauling FURP, which is almost dead and doing much less than it could do. The factory in Guarulhos is operating at 40% capacity and needs to be modernized, and the 20,000-square-meter plant in Américo Brasiliense, next to Araraquara, is at a standstill. With support from Butantan’s technical teams, FURP could be restored to its important role in producing the drugs we need, primarily to treat neglected diseases such as malaria, tuberculosis, leprosy, and leishmaniasis, which the private pharmaceutical firms aren’t interested in producing. Then we could think about the medical specialties. Cancer drugs for use in chemotherapy are always in short supply, worldwide. The two factories, within two or three years, could be producing drugs of interest to public health, while Butantan would keep making the vaccines, serums, and monoclonal antibodies. Renovating FURP will require commitment, investments, and partnerships; I don’t think the public side must always do everything alone, rather, it should be fostering projects. We must be prepared to face other pandemics. David Uip always says: “We can be surprised once, but not a second time.” The pandemic left us naked.
Why do you say that?
When COVID-19 started to spread, we were producing almost nothing, not even masks, not disposable gowns, no medicines. The pandemic has shown how vulnerable and dependent Brazil is on other countries, especially China and India. In a globalized world, those who have money buy from whoever they want, but when there’s a shortage, we’re the first to run out, because the rich countries can defend themselves much more easily. Remember how the United States confiscated mechanical ventilators that were supposed to come to Brazil at the beginning of the pandemic? Recognizing our vulnerability must serve as motivation for us to start producing active ingredients again. Today, more than 95% of everything consumed in healthcare is either directly or indirectly imported. In normal times, no problem. But when we’re living through a health crisis like COVID-19, it’s tragic, because we ran out of everything. We lived in Dante’s Inferno. Because of what we suffered through we saw how to change the situation, through the secretariat. We formed a scientific council with 52 public and private institutions in the healthcare field and 11 working groups, one for each specific area: vaccines, digital health, rare diseases, etc. And we created a document that can guide—as state policy—the next governor. It’s a diagnosis of the healthcare situation in the state and guidelines for what needs to be done. It is a robust document, produced by the best specialists in each area. In one of the working groups, which brought together professionals from the Ministry of Health and the state and municipal secretariats—PRODESP [Data Processing Company of the State of São Paulo], and PRODAM [São Paulo Municipal Information and Communication Technology Company]—we also observed the gaps in the field of digital health.
More than 95% of everything consumed in healthcare is imported. In normal times, that’s fine. But during a health crisis, it’s tragic
What do you propose in this area?
Telemedicine made a lot of progress during the COVID-19 pandemic, but the national health data network needs to be improved. The single record system, or unified patient records system, needs to be implemented immediately. You don’t need to have all the medical data for each person; to begin with, you could include only what’s necessary for emergency care—what diseases a person has, how they’re being monitored, what drugs they’re using, and if they have any medical allergies. We need to make all the most relevant and accessible data easily transmissible to any healthcare professional who’s attending this patient, wherever they might be.
What was the diagnosis for the São Paulo healthcare system?
Brazil, from the public healthcare standpoint, is three different countries. One is made up of São Paulo and Brasília, with the most developed services; then there’s the South and the other states of the Southeast; and in third place comes the North and Northeast, where there is still much to be done. Visiting hospitals and healthcare centers in São Paulo is like visiting those in France, Italy, or Spain; there are excellent facilities, teams, and organizational systems, but coordination and integration between them could be much better. Mind you, healthcare must have a central command, which comes from the State Health Department. What we’re doing, what the secretariat is responsible for, is creating a transversal system and planning for the future to avoid tragic situations such as the COVID-19 pandemic.
How did the job of bringing the institutions together work out?
Everyone got on board quickly. It’s been impressive how there was an anticipation, an eager willingness to be part of the secretariat’s project. David Uip used his own prestige to great advantage. I had been out of São Paulo’s municipal administration for 30 years, I was State Health Secretary in 1993, while he was Secretary more recently, from 2013 to 2018. Of the 52 entities invited to compose the Scientific Council, 51 accepted. And all participated in the thematic groups or nominated colleagues. The same people who participated in the COVID-19 Contingency Center are part of the Scientific Council, which meets here every Wednesday, some in person, most remotely. And another point: since David and I began evaluating the health system in São Paulo, we’ve been very concerned about the situation for the state’s researchers, who receive unacceptably low salaries for the type of work they perform. For this reason, we’re also going to submit a proposal for career and salary restructuring, which would include hiring new researchers through competitive civil service exams.
How was the UNICAMP Blood Center created in 1985?
It was a political battle because until that time blood in Campinas was all private; there were no public blood banks. But the rector of UNICAMP at the time, José Aristodemo Pinotti [1934–2009], accepted the challenge and believed I would be able to create a public blood center, even with zero donors. I had support from the Ministry of Health, from Luiz Gonzaga dos Santos, the creator and director of HEMOPE, the first blood center in Brazil, in Pernambuco, from Nelson Rodrigues dos Santos, Campinas’s Secretary of Health, and from Rogério de Jesus Pedro, the head of my department at UNICAMP. But the person who actually instituted it was Pinotti. Later, as the state’s Health Secretary, from 1987 to 1991, he said he needed me in São Paulo. One Friday afternoon in October, he asked me to come to the secretariat’s office to talk to him.
What was happening with the AIDS epidemic?
It had exploded. Brazil had lost 2000 hemophiliacs because of transfusions with contaminated blood. We were at the peak of HIV transmission through sexual activity and transfusions and São Paulo still didn’t have any kind of blood quality control program. I told Pinotti what I thought should be done and he didn’t hesitate one bit: we go out—the entire press corps was there—he stood me at his side and said, “I want to introduce the new coordinator of the blood program for the state of Sao Paulo.” Then he presented exactly what I had proposed. In January, we delivered an action plan using funding from the BNDES [Brazilian Development Bank] to build blood centers and funding from the state government to carry out serological blood control. We built and equipped blood centers in Campinas, Ribeirão Preto, Botucatu, Marília, and other cities. We created a program, which still exists today, Hemorrede, and we took every action possible to identify contaminated blood, which provided absolute peace of mind to anyone who needed a transfusion.
Were there protests when it became mandatory to test the blood of everyone who donated?
Yes, but it was my duty to stop the transmission of the virus. I stayed there until 1993, when I was invited to take the position of the state’s Public Health Secretary during the Fleury government [Luiz Antônio Fleury Filho, 1949–2022]. I met Governor Fleury 15 days before he appointed me to the position. He went to Campinas to inaugurate the bone marrow transplant unit, which still exists today, and we struck up a polite conversation. When he asked me who I was, I explained: “I’m the person who designed this transplant unit that you came to inaugurate, I’m the director of Hemocentro.” And he responded: “I’m A negative, I want to donate blood.” It was supposed to be a two-hour meeting and he was there much longer. On Sunday night, the rector of UNICAMP, who at the time was Carlos Vogt, called and asked me to go to the Palácio dos Bandeirantes [the seat of São Paulo State government] the next day, because the governor wanted to talk to me. I went, and the governor confirmed that he was considering my name, but that there were other candidates. The following week, I was questioned before a panel of state representatives and afterward the governor advised me, “You take office on Monday.” I flew back to Campinas and handed over leadership of Hemocentro to Fernando Costa, who later became rector of UNICAMP. I didn’t even have a suit to take office in. I took office in a hideous lilac linen suit, the only one I owned. And I stayed until the end of that administration.
And did a college professor do well in state office?
I learned a lot, primarily in political coexistence as secretary, because in a democratic regime, those who have votes are those who govern. Sometimes, people get confused, they think that a council can govern, but no: it is those who vote. You have to learn how to make your argument and to support the political class. I traveled a lot and went to a lot of meetings. It was a difficult time for the country. When I took the position, inflation was at 45% per month. During my time as secretary, I had to deal with four currencies: the cruzeiro, the cruzeiro real, the URV [real unit of value], and the real, which went into effect during the second half of 1994. Each currency change meant changes in contracts with suppliers. In order to adapt the state of São Paulo to the new SUS laws [Unified Health System] that were beginning to be implemented, we had a huge amount of legal and institutional work to do. We created the State Health Council and the Bipartite Intermanagement Commission, which to this day debates the division of funding between the state and municipalities. With the Legislative Assembly, I created the first health code in Brazil, which was put to a first round of voting during the Fleury government and a second round during the administration of the following governor, Mário Covas (1930–2001). I stayed less than two years, but it was a huge learning period. I didn’t know any of the representatives because I never had a party affiliation. In meetings with politicians, I listened a lot. I learned that many of the demands in the political sphere aren’t about getting money, they’re only about demonstrating that the individual can meet with the secretary, that he has prestige, and that he can take a picture to show to his supporters and say that he was in São Paulo.
It was the era of AIDS.
AIDS continued, but not as intensely as in the 1980s, and antivirals such as AZT [azidothymidine, the first antiviral against HIV/AIDS] were beginning to appear. Blood donor testing and the industrial process for producing blood products had already been greatly improved to prevent contamination. I went to several international congresses; I was interested in learning about new diagnostic tests, but I found a geopolitical and social context that I didn’t find in other scientific meetings. Congresses in this field completely expose the world’s ills, and those of Africa, and of women. Interestingly, two years ago, at the invitation of the Ministry of Health and CONASEMS [National Council of Municipal Health Secretariats], I went to a congress on AIDS in Amsterdam, in the Netherlands, and it seemed like I was still in the 1990s. Thirty years later, Africa’s problems, especially for women, remain enormous. In 1995, I returned to UNICAMP, took the competitive exam to become a professor and in 1997 I left to work at the bone marrow transplant unit at the University of Genoa, in Italy. I was already quite mature when I went, I was 45 years old, and it was great. I participated in almost everything with my colleagues at the university: I took care of the patients, collected exams, went to the operating room, aspirated bone marrow, and wrote studies. My career took off after I came back. In 2001, I competed for full professorship and in 2006 I returned to UNICAMP to head the Hemocentro.
Every epidemic is different and works by its own logic. Every virus or bacteria has its own methods of transmission
Who were your mentors?
Many people have guided me and been at my side so I would make fewer mistakes. I learned a lot from Pinotti and from David, whom I met during the HIV/AIDS epidemic. When I was appointed to the secretariat, one of the first people to come talk to me was Adib Jatene [1929–2014], who was then the director of the School of Medicine at USP [University of São Paulo]. We spent an afternoon talking. Antônio Ermírio de Moraes [1928–2014], a businessman who looked after the [Hospital] Beneficência Portuguesa, now BP, also showed up to chat. He didn’t want anything, just to talk. I learned a lot from him about how to engage with philanthropic hospitals.
What have you learned from the epidemics you’ve had to deal with?
I wrote a book detailing my experiences. First there was meningitis, in the 1970s; I was still a student and then a resident. Then came HIV and cholera, with a few dozen cases in the state; then the arboviruses, dengue, chikungunya, Zika, yellow fever; and finally SARS-CoV-2. Each epidemic is different and operates by its own logic. Each virus or bacteria has its own methods of transmission. So, you need to be a great general, see what you have and what you don’t have, where you’re going to get it from, how you’re going to move things, and get everyone on your side and protect them too.
As Campinas Health Secretary, what were your priorities during the pandemic?
I lived with a situation of absolute deprivation. We’d stopped producing many medicines because it was cheaper to import and in an emergency like the pandemic we were left in the lurch. I asked myself: “How can we buy masks, disposable gowns—basically everything—that we need?” We took advantage of the two months between the global pandemic announcement and the first case in Brazil to buy as many sedatives, muscle relaxants, etc., as possible. The consumption of materials increased dramatically. While before Covid a health professional would use two masks and two gowns per day, during the pandemic they began using 10, 12—changing between each patient they saw. We received a lot of support from Asian countries, especially South Korea. Samsung sent an immense number of masks and gowns to Campinas. Even so, at times we ran out, because the speculating was absurd. And what was I worried about? On the one hand, meeting all the needs of the municipality; on the other hand, avoiding arrest. Because in another five years, it will be easy to convict someone of overbilling for having paid R$10 for a glove that cost five cents. I had a heated discussion with my team one weekend because we were having doubts about whether or not to buy more ventilators. We took a count: there were 750 machines in operation and about 20 broken ones, which the major companies in the city, Toyota and General Motors, had repaired for us. Only it wasn’t enough. In the end, when the pandemic was at its worst, we needed help from both the government of São Paulo and the federal government, which sent 25 respirators. I didn’t buy in, because a respirator that cost US$20,000 was being sold for US$100,000. At that same time, we were shifting our older staff, who were at greater risk of becoming infected, into telemedicine or support activities. Even though I’m in the higher risk group, being over 60 years old, every day I went to the office.
Because I was the commander, and the commander doesn’t run away. You can die, take it without complaint, what you can’t do is run away. I protected myself, of course. And I haven’t caught Covid as of today. Many of my healthcare colleagues died, in Campinas there were about 250. In Brazil, there were thousands, most of them in nursing, because they’re the ones in direct contact with patients.
As part of a global research project, we are collecting cases of T-cell lymphoma in Brazil. We already have 560
How much has your field, hematology, changed since you started out in the 1970s?
My first contact was with hemotherapy, with transfusion. My father lost his job in 1971 and I had to work to help my family; I was in my second year of college, and I got a job as a lab technician at a private blood bank. Hematology was primitive. Blood banks worked with open glass vials, something that would be unthinkable nowadays. I worked night shifts at the blood bank, so I could continue with medical school. I did the blood compatibility tests and infusions into patients’ veins. When I graduated, I took the residency exam for hematology; the first year I was in internal medicine and the other two in hematology. There is no comparison with today. In the 1970s, hospital facilities were generally substandard. I worked in a Santa Casa [charity hospital], on a ward with 33 beds for men and 32 for women, one next to the other and one shared bathroom. It was impossible to properly treat patients with leukemia, who require special care. Diagnosis was exclusively morphological, with direct blood analysis and bone marrow analysis. The attending physician himself collected the blood and made the microscope slides and tests before transfusions. A lot has changed. Today, hematology is a broad, complex, and multidisciplinary specialty. We now work with biologists, biomedical specialists, and specialized nurses, as well as teams from molecular biology, immunology, and many other labs, which have themselves developed dramatically. Genetic diseases, such as sickle cell anemia and hemophilia, are also part of hematology. The scientific production in hematology is also quite large. Our annual congress, held in October in São Paulo, brought together 6,000 participants, and more than 1,200 papers were presented.
What have you been doing recently as a researcher?
I basically have three lines of research. The first is chronic myeloproliferation disorders, mainly chronic myeloid leukemia. We participated with other countries in developing inhibitors for a group of proteins called tyrosine kinase, which control cell proliferation. These drugs have brought a previously deadly disease, with a survival rate of around 40 months after diagnosis, under control. People with leukemia can wake up in the morning, take a pill, and go to work as if they had any other chronic illness. As a researcher and physician, the introduction of tyrosine kinase inhibitors was the most revolutionary thing I’ve ever been a part of. My second line of research is in lymphoproliferation, the aggressive lymphomas and multiple myelomas. One of the aggressive lymphomas is T-cell [a type of blood cell] lymphomas, which are rare in the Western world. In Asia they make up about half of the lymphomas, but here in the West, they’re—at the most—10% of the total. It’s a large group, with more than 20 diseases, although six of them are the most common, and even they are rare. As part of a global project, we’re collecting cases of T-cell lymphoma in Brazil. We were planning to include 500 patients, but we already have 560.
What’s the goal of this study?
To better understand the evolution of this group of lymphomas and plan the treatment. We want to see if, in Brazil, there are epidemiological differences by region and ethnic group. We’ve already found an important difference between Brazil and other countries, which is a type of lymphoma associated with HTLV1, a virus related to HIV that’s transmitted through breast milk. In many cases, the person develops T-cell leukemia or lymphoma decades after birth, and it has a mortality rate of around 5%. We have a high concentration of these lymphomas in the region of Salvador, Bahia. The third line of research is in bone marrow transplantation. Our group from Campinas, together with colleagues from the Federal University of Minas Gerais, was the first in the world to carry out a randomized study comparing stem cells obtained directly from bone marrow aspirate with peripheral blood stem cells. We confirmed that it’s possible to use both, although each has specific applications. Peripheral cells have a more potent antitumor effect, but also react more, what’s known as graft-versus-host disease. If you don’t need a very potent antitumor effect, you can use those from bone marrow. Today, peripheral cells are used much more, but the choice is up to the patient, not the donor.
How do you define blood?
Blood is an extremely complex liquid tissue with two important functions. The first is to take oxygen to all the cells and transport the waste they produce, carbon dioxide, to the lungs, where it’s removed. The second is to monitor and protect the body against pathogens and toxins. Blood carries an army of cells: phagocytes destroy pathogens, B lymphocytes produce antibodies, T lymphocytes are responsible for immune memory—because if we produced antibodies all the time, after a vaccine, for example, the blood would become a minestrone. Blood also has an anti-hemorrhagic function, with clotting factors, platelets, etc. It is because of these proteins and cells that blood can transform from liquid to gel, to fix bleeding from a ruptured vessel, for example, and from gel to liquid, so that it can flow again when the problem is resolved. It’s the only tissue in the body that has this ability. It’s marvelous.