Since early 2020, rheumatologist Eloisa Silva Dutra de Oliveira Bonfá has been at the forefront of the fight against the pandemic at the University of São Paulo School of Medicine Hospital das Clínicas (HC-FM-USP), the largest medical center in Latin America and a beacon of COVID-19 treatment in São Paulo. As clinical director of the HC since 2011, Bonfá and her staff activated a disaster plan a month before the first COVID-19 case was diagnosed in Brazil, and pre-purchased the gloves, masks, and other equipment needed. In March, the crisis committee of which she was a member turned the Central Institute into an area dedicated exclusively to COVID-19 patients, moving the emergency room and 35 specialized clinics to other units of the HC. At the beginning of the pandemic, one of the major challenges was insufficient ICU (Intensive Care Unit) beds—which in two months had been expanded from 85 to 300—and staff—which grew from 4,000 to 6,000 workers.
Bonfá had to motivate the staff, manage their fear of catching an unknown disease, handle protests from resident doctors, and learn to ask for donations, since the hospital could not afford to hire extra staff. In this interview, granted by video, she shares how some of her colleagues stood out as creative leaders, or even at the point of exhaustion, asked to work longer hours.
Born in Ribeirão Preto, São Paulo, married to an economist, and mother of three adult children, she has recently returned to something akin to a normal pace, including trips to restaurants and evening walks with her husband three times a week.
field of expertise
Rheumatology
institution
University of São Paulo (USP)
educational background
Undergraduate degree in Medicine from the USP Ribeirão Preto School of Medicine (1981), PhD from the USP School of Medicine (1991)
published works
377 scientific articles; 6 coauthored books
Nearly two years after the start of the pandemic, what does your life look like?
I still avoid enclosed and crowded places, but I do go to open, well-ventilated restaurants. In Brazil, we boast a very large vaccination capacity, without the resistance seen in other countries. The result is a steady decline in the number of cases. This opens up the prospect of, in the medium term, rethinking a new post-COVID way of living. That said, COVID-19 has not been eradicated, even if the number of beds occupied by COVID patients is currently quite low. Our hospital is a beacon for serious cases, which have decreased significantly with vaccination. Currently, 30% of beds are in use.
How did the HC prepare to face the pandemic in early 2020?
We have been facing crises for a long time at HC. One of the members of our clinical board, Dr. Bia [Maria Beatriz de Moliterno Perondi], is an expert on disasters. In 2010, she volunteered to help those affected by the earthquake in Haiti. In 2013, we set up a crisis committee, which is activated whenever we predict there will be greater demand than we can meet. In addition to yellow fever and COVID-19, the committee was activated after a fire at the Latin America Memorial [in 2014], during the World Cup [in 2014, in São Paulo], and during the truck drivers’ strike [in 2018], because we have 2,400 beds and the strike could have halted food delivery for our patients. We reactivated the committee on January 29, 2020. Brazil hadn’t seen any COVID-19 cases yet, but we began purchasing caps, gloves—all the equipment we would need. Many did not believe it could reach our nation, but when analyzing how the contagion took place, we realized we needed to prepare. The crisis committee’s first proposal was the most logical. The HC has eight specialized institutes: for cardiology, oncology, pediatrics, orthopedics, and other areas. We decided that each should designated their own COVID-19 isolation area and wait for patients. We had accepted this idea; however, Bia heard that a hospital in Israel had designated an entire institute to exclusively treat patients with this disease and suggested we consider doing the same. In March, we circled back to the idea.
Why in March?
That was when we realized the pandemic was more serious than it initially appeared. I discussed with Bia the possibility of designating the Central Institute, but it still seemed far off into the future. Over the weekend, I informed the director of the School of Medicine and the members of the HC Board that we were considering directing all COVID patients to the Central Institute. On Sunday afternoon, the governor of São Paulo, João Doria, came to the hospital to inaugurate new ICU beds, unrelated to COVID-19. But, upon arriving at the ICU that was to be inaugurated, the governor announced that we were going to designate the Central Institute for COVID-19 care. I later learned that he had shared an elevator ride with the School of Medicine director, who had mentioned the possibility. It nearly gave me a heart attack, but there was no turning back; it was out into the world.
How did you adapt the space?
We moved equipment and people from the largest tertiary emergency room in Latin America, which covers multiple specialties, to INCOR [Heart Institute], turning it into a general emergency room overnight. We relocated 35 specialized clinics to the other institutes, which meant they would have a low rate of exposure to COVID-19 and would be able to care for patients with other diseases. The medical clinics were moved to the Institute of Orthopedics, the surgical department to the ICESP [São Paulo Cancer Institute], and the high-risk nursery to the HU [University Hospital]. In 15 days, we turned the Central Institute into an exclusive space for the care of COVID-19 patients.
Was there any resistance to these changes?
Yes, definitely. The first point of resistance was justified, in my opinion, since I had called the members of the HC Board and told them we would present the project to them first. Suddenly, the whole plan fast forwarded. The Board members had a hard time believing I hadn’t been the one to tell the governor. In any case, this measure allowed us to assign any employees that were at risk for COVID-19, such as those that had high blood pressure or diabetes, to the low-exposure institutes, keeping the others at the Central Institute. People were very scared of being infected with the coronavirus or giving it to a family member. At the Central Institute, we implemented a strict protocol: only those who had undergone training could enter, and we forbade staff from moving around from one institute to another at first. We used the amphitheaters to train staff in the use of PPE, ventilators, and all the necessary precautions; the professors’ lounges were converted into accommodation for the COVID-19 staff. The professors’ table was pushed to a corner to make room for two bunk beds for front-line workers.
Agnaldo Dias Correia / HC-FM-USPThe HC leaders during the pandemic (from left to right): Leila Letaif, Amanda Montal, Edivaldo Utiyama, Eloisa Bonfá, Aluísio Segurado, Maria Perondi, and Anna MoraisAgnaldo Dias Correia / HC-FM-USP
Did you have to hire more staff?
At one point, we had around 6,000 employees at the Central Institute. We used to have around 3,500 to 4,000. We had to hire more people since the number of ICU beds was greatly increased. We had 84 beds at the Central Institute, a number that grew to 300 from April to May. All elective procedures were suspended during the pandemic, so we turned 35 operating rooms into ICU beds. But then, we encountered a problem: there were no intensive care or pulmonology experts available to hire, and we also lacked mechanical ventilators for the patients. The anesthesiologists came to our rescue by using the anesthesia equipment to ventilate the patients. Many were out of work since there were no elective procedures, but we also could not afford to hire them. I had never engaged in fundraising, not even selling raffle tickets or letting my children do so; I always bought everything myself, because I was too embarrassed. At that point, however, I overcame my trepidations and set out to ask for everything we needed. The superintendent and I asked the BTG Pactual bank for a donation, which we used to hire anesthesiologists. However, because they were not intensive care experts, they were unable to work on their own. So, we deployed an intensive care expert to work alongside an anesthesiologist in each operating room. This allowed us to support 300 ICU beds for two months. Doctors from other areas, such as orthopedists and ophthalmologists, were also recruited, and did an amazing job. They would work in the ward, caring for less serious cases. We offered support teams to help them with intubation, finding blood vessels, or performing tracheostomies [inserting a cannula in the trachea to facilitate the delivery of air to the lungs]. All they had to do was call, and a member of the team would quickly come to help. In addition to setting up ICUs, we established specialized wards to adequately care for COVID-19 patients—a pediatric ward, a psychiatric ward, and an obstetric ward. But it was not enough. The BTG funds were not enough to support the 300 beds. We needed more.
What did you do?
I called all the hospitals in São Paulo we were friendly with and asked them to lend us equipment and multidisciplinary teams. It worked. The Sírio-Libanês set up a 10-bed ICU to add to the 300. The [Hospital Israelita Albert] Einstein sent people to train HC employees, since the number of dialysis patients increased sevenfold. The Rede D’Or set up an ICU and a ward for patients that had COVID-19 and cancer. The HCOR brought in a full multidisciplinary team, which we greatly needed. No one told me ‘no.’ Even the SAMU [Mobile Emergency Care Service] team came to me, since they were idle due to a decrease in the number of accidents; they set up an ICU here at the Central Institute. At the same time, I had to juggle many other things. If we anticipated a shortage of a type of medication, we would replace it with another one and ask the doctors and nurses to ration it. The procurement and supplies department was responsible for managing the supply, as well as for rapidly expanding our energy and oxygen capacity.
How did you overcome that?
We had to build a station to increase our oxygen supply. We didn’t have the capacity for so many beds. In its 70-year history, the Hospital das Clínicas had never seen 300 ICU beds with such high oxygen needs. We also built a power station, since the Central Institute did not have the energy capacity we needed. The procurement team worked to ensure there was no shortage of PPE [personal protective equipment]. In one day, we went from having 4,000 to 40,000 masks. We had to organize. We began educating the staff about which masks to use in one area or another in the hospital. It was truly like a war effort. More than war—it was a life effort. Local residents and businesses would send us clothing, pizza, ice cream, and flowers. Now, how do you distribute such gifts without forming a crowd? Procurement did their best to make sure the gifts reached the COVID-19 staff at the hospital, who needed recognition.
How did you decide on which treatments to use for COVID-19?
Early on, the disease seemed to affect organs other than the lungs, such as the heart. We boasted very experienced intensive care experts and ICU committees. The committees would set up a protocol, and staff were instructed to follow it. Every day at 7 a.m., we had an outside meeting with the leaders from each area, [patient] care workers, physical therapists, and so on. In a circle in front of the hospital, respecting social distancing protocols, we discussed any adjustments to procedures or new papers that had just been published. In the early evening, a smaller committee would meet to define the next day’s measures. Our initial protocol included the use of hydroxychloroquine, since the Ministry of Health had approved it and there was no research indicating we shouldn’t. But we suspended its use as soon as the first pieces of evidence came out showing it didn’t help with the treatment. And we communicated to all our staff that it was no longer part of our protocol. Doctors are, of course, free to test out new treatments, but this type of work should be carried out in the context of research. Thus, based on studies done both elsewhere and here at the HC, we learned the best time to administer corticosteroids and other medications to COVID-19 patients. We would communicate any changes and all staff members were supposed to follow them. It wasn’t easy; people became tired and disillusioned. There was even a threat of a strike by the resident doctors, who, while fundamental on the front lines, saw their training being negatively affected.
How was research organized?
We established a committee for rapid approval of clinical trial and research proposals, but our greatest challenge was the competition for patients. I would receive such complaints as: “So-and-so is stealing all the patients; you must establish a rule.” So, we established that the assignment of patients would take place through a rotation. First one doctor calls in a patient, then another doctor calls in another. We added ICU patient data into a computer system. So far, we have cared for more than 10,000 patients with suspected or confirmed COVID-19.
I called all the hospitals in São Paulo we were friendly with and asked them for equipment and staff. It worked
What was it like working at the hospital during the pandemic?
I’ve seen amazing things. I once found one of the doctors crying. She said, “I just sang for a patient.” I replied: “That’s so beautiful.” She then shared: “He was in a terrible state when he was admitted and kept asking me not to let him die. I told him, ‘You are not going to die, and I will sing for you on the day you are discharged.’ I’m returning from the ward; he has just been discharged.” A professor who works in the emergency room, who must be about 85 years old, Almir Ferreira de Andrade, wanted to help in the COVID emergency room. I would not let him. One day, I caught him sneaking in. I warned him: “Professor Almir, you cannot be here.” He replied: “But I don’t care if I die working; that’s what I love doing.” The next day, I caught him again. “You must be keeping tabs on me!” he complained. I warned him that I’d place a security guard to stop him from getting in, but he stopped coming and remained in the non-COVID ER only. Our head of procurement, Antônio José Rodrigues, whom we call Tom Zé, was amazing. I have no idea how he managed to keep stock of all medications. His team gave it their all and got everything done. He would attend the meetings and knew what was going on. But we also had many lawsuits from staff members who did not want to work out of fear of getting infected. We had to confront them; if we let anyone stay home, others would also want that.
How did you make sure these employees kept working?
With help from the HC Legal Department, we became half lawyers ourselves. The three professors in charge of the crisis committee were: Edivaldo Massazo Utiyama, deputy clinical director of the HC; Aluísio Segurado, chairman of the Central Institute Board; and myself. We took turns responding to the lawsuits and explaining to the judges why the individual in question had to keep working. If they were scared of catching COVID-19, they could work in a laboratory doing blood tests, away from patients, or in an administrative department. There was always somewhere they could work. Thanks to all the measures we implemented, the Central Institute had one of the lowest rates of contagion among employees of all the HC institutes. Of the 22,000 employees, we had 117 hospitalizations due to COVID-19 and, unfortunately, eight deaths. No one from the crisis committee has caught COVID. But we had to set the example of how to use the PPE and sit at the table. We all ate together, but with the windows wide open and never facing each other. We were lucky because we did have meetings with people who later found out they had COVID-19.
How do you put together a good team for this kind of emergency?
It is challenging. Medical professionals often handle emergencies, but our greatest leaders, who coordinated the ICUs, emerged of their own accord. Many simply came to us, saying, “I am available for whatever you need me to do.”
Who were the ones that stood out?
First, the clinical board managers—Bia, Leila Suemi Harima Letaif, Anna Miethke Morais, and Amanda Cardoso Montal. They were the great orchestrators of the whole process. Professor Carlos Carvalho was also brilliant. Mortality rates in the ICUs of the HC were much lower than in other hospitals in the city of São Paulo. He would make remote visits to the ICUs of other hospitals in São Paulo and other states. The doctor in question would present the situation, and he would suggest changes that helped reduce hospitalization time and mortality rates. It was great work, later implemented in obstetrics—as Brazil was, at one time, the country with the highest COVID-19 death rates for pregnant women. Professor Rossana Maria dos Reis would remotely help hospitals in São Paulo and other states improve the care of pregnant COVID-19 patients, whose treatment is very specific. The humanized care department put together a veritable army to help communicate with patients and support family members at times of both discharge and death. We also saw gains, such as the biorepository [blood serum samples] and the patient database, which were set up during the pandemic. We saw how important a multidisciplinary team really is. Because COVID-19 is a respiratory disease, physical therapists and physiatrists were, at times, more important than the medical team.
What is it like to work in such a masculine space?
In HC’s 70-year history, I am its first female clinical director. The School of Medicine has never had a female director. In any case, it was easier for me to become director here than it would have been elsewhere, since we work based on merit here. If I were a man, perhaps I would have gotten this job sooner. When the pandemic started, I had been on the board for 10 years, which sort of empowered me in my work. The clinical board is located in the administration building, but we moved to the Central Institute to improve our performance. We converted an amphitheater into offices and worked there from 7 a.m. to 9 p.m., every day. Our leading team was also made up of the other two tenured professors and the four managing physicians. We were one unit, and people saw us that way. If any conflict arose, we would face it together. Whenever an employee was admitted into the hospital, that would be part of the agenda of our daily meeting, and we would see what we could do for them. In a catastrophe, we must prioritize those that can help save the most lives once they are healed.
Our leadership team was also made up of two other professors and the four managing physicians. We were one unit, and people saw us that way
Were you able to work on any research during the pandemic?
Our rheumatology team conducted some work with immunosuppressed patients [those with a low natural defense against pathogens], which was used as a reference when prioritizing vaccines for this group of patients. This work was funded by both FAPESP and the private sector through the B3stock exchange. The first study, which involved 910 patients, was published in Nature Medicine and helped us understand the effects of drugs on COVID-19 vaccines. The patients had a moderate response of 70% in antibodies produced after being administered the CoronaVac vaccine. But 30% did not respond, and we had to understand why. We found that it was due to the use of certain drugs. We studied 10 different rheumatologic medications. Following a recommendation from the American College of Rheumatology, we temporarily withheld immunosuppressant medication from patients with rheumatoid arthritis, and their immune response increased. The number of COVID-19 cases fell by 81% after vaccination, while the opposite occurred in the city of São Paulo: an increase of 45%.
One of the drugs studied was hydroxychloroquine. What did you find?
Hydroxychloroquine is an immunomodulator drug, widely used for lupus patients, but it requires several steps to enter the body. Once taken, it penetrates the bloodstream and reaches tissues, then cells, then the lysosome [a cell compartment]. It takes around three months before any effect can be observed. We concluded it made no sense that an acute disease like COVID-19 could benefit from a drug that requires such a long time to act.
What concerns you now?
Post-COVID health care, for one. A survey led by Professor Geraldo Busatto included about 800 patients who had had severe COVID symptoms and who now have mental and physical issues that have lasted many months, longer than the disease itself. Another concern is how to resume pre-pandemic life. We believed our lives would return to normal after three months at most, and it still hasn’t. There is a huge number of patients who avoided coming to the hospital during the pandemic, because we told them not to, and they need care. Every doctor believes their patients are a priority and will die if not seen. But we must scale and reorganize the system to get back to normal as soon as possible.
What strategies would you recommend for anyone who might be in your shoes in a few years, having to face another pandemic?
The first thing to do is prepare in advance. It’s better to have the resources on hand and not need them, than to not have them at all. Every institution should have a crisis committee and change their strategies as the crisis progresses. It is also key to focus on communication. Our external communication is really poor, since we cannot keep up with fake news. Many individuals put on scrubs and act as if they know all about vaccines, but often aren’t even health professionals. They filled a void that was left open because we are focused on our work. We would gain a lot from having a communication channel with the population; the media have gradually built this as they began choosing better professionals to interview. But that took a long time. Internal communication is also a challenge, especially in a hospital with 22,000 employees and around 3,000 contractors. They would get angry that we had to open more ICUs. If we had taken the time to explain what was going on, they might not have felt that way. To them, it must have seemed like creating more ICUs was a frivolous thing. The residents would hold a meeting and we had to explain to them that this was not the case. We had to constantly put out fires. Internal communication was not enough to reach everyone, support them, and justify our actions. We celebrated and thanked the staff every thousand patients discharged, but those on the front lines might have needed and deserved more. We started to take preventive action, asking a psychiatrist to hold a weekly meeting with the ICU leaders, where they could speak out and complain. Just being heard, even if there is nothing that can be done about it, helped them feel supported. The Institute of Psychiatry, particularly Professor Euripídes Constantino Miguel Filho, conducted several psychiatric support activities for employees and assigned a therapist for each of us on the crisis committee. It was very helpful. During the first wave, my husband would come and pick me up from work. It was good for me, as I would leave work extremely stressed. By the time I got home, I was more relaxed. The hospital had never faced such a challenge, but its roots are deep, and we have endured.
