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Margareth Dalcolmo: Pandemic scars

The physician-researcher discusses the difficulties faced by health professionals dealing with Covid-19, the dramatic struggles of patients she attended, and the likelihood of an increase in tuberculosis cases in the coming years

Léo Ramos Chaves / Revista Pesquisa FAPESP

On April 13, O Globo published an essay by physician Margareth Pretti Dalcolmo, recounting the two years since she started writing for the newspaper and detailing once again the reasons she is concerned that other strains of the coronavirus may still cause localized epidemics. “We must continue to pay heed to containment measures, in addition to vaccinating extensively and applying the fourth dose to the entire adult population,” she stressed in the piece.

Since the beginning of the pandemic, Dalcolmo has not hesitated to play the role she calls the “total shrew,” even recommending the cancelation of family Christmas parties in 2020, when there were still no vaccines against Covid-19 in Brazil. Her ability to communicate with the general public in a simple and cordial way has made her one of the main spokespersons for science during the pandemic.

In this interview, given via online video on April 12 from her office at the Oswaldo Cruz Foundation (FIOCRUZ), Dalcolmo talks about her experiences during the pandemic and warns of a likely increase in tuberculosis cases in Brazil (her area of research) over the coming years, as a result of the reduced number of people who sought medical care to receive diagnoses and continue treatments during 2020 and 2021.

Age 67
Field Of Expertise
Respiratory Medicine
Oswaldo Cruz Foundation (FIOCRUZ) and Pontifical Catholic University of Rio de Janeiro (PUC-RJ)
Educational Background
Degree in medicine from the Medical School of Santa Casa de Misericórdia de Vitória (1978), doctorate in pulmonology from the Federal University of São Paulo (UNIFESP, 1999)
Published Works
77 articles, 2 technical books (coauthored)

During the pandemic, in addition to working on Covid-19 studies, you didn’t neglect your line of research on tuberculosis.
I just continued the research that was already under way; I didn’t begin any new studies. Tuberculosis is still a highly prevalent disease in Brazil. We are ranked nineteenth among countries with the most cases in the world, with approximately 75,000 new cases each year. Mortality is also high, with nearly 5,000 people still dying annually from tuberculosis in Brazil.

How did Covid-19 interfere with the treatment of tuberculosis?
The impact was devastating, particularly in Brazil. According to the Ministry of Health, there was a 40% reduction in the number of molecular diagnostic tests done in Brazil, because services stopped working during the pandemic. This means that people with symptoms went undiagnosed and others, those undergoing treatment, weren’t monitored. Therefore, many likely abandoned the treatment, which is long, lasting at least six months. More serious still: people with resistant forms of tuberculosis requiring longer treatments probably went undiagnosed and transmitted the disease. The WHO [World Health Organization] assumes that tuberculosis control around the world has been set back eight to ten years due to Covid-19. The WHO has already changed its language and no longer talks about eradicating the disease worldwide over the next 30 years, despite the progress in treatments and diagnostic methods today. This includes Brazil, where molecular diagnostics have been implemented in the SUS [Unified Health System] network, which allows a person with respiratory symptoms to go to a clinic and receive a diagnosis within 24 hours, or even—like here at FIOCRUZ—within three hours.

In what way is the healthcare network failing?
The treatment is free and includes making available high-cost drugs. The problem is that diagnoses aren’t being made in a timely manner. People arrive too late and aren’t warned about transmission risks. The media and government agencies haven’t made people aware of the fact that anyone who has a cough—with or without discharge—for more than two weeks must seek medical attention. Tuberculosis is a respiratory disease that’s transmitted by coughing or sneezing, like Covid-19, so there has been an interaction between the two diseases, although one is bacterial and the other viral. They have some of the same symptoms, so these days everyone should be tested for Covid-19—but also for tuberculosis—if they have persistent symptoms, accompanied by fever, weight loss, or fatigue.

Which groups are at highest risk for tuberculosis?
This was once a disease that was associated with bohemians and poets, but it lost that romanticism. The AIDS epidemic stole its spotlight. Today most cases occur between the second and fourth decades of life, so young people, in their productive years. This is why it has such huge social and economic impacts. The WHO uses the expression “catastrophic expenditures of the disease,” which consumes a high proportion of household income, close to 20% in the case of tuberculosis. Many people stop working altogether. Children and the elderly are the most vulnerable. We vaccinate children at birth with BCG [Bacillus Calmette-Guérin], even in the maternity ward, and we had an exemplary coverage rate of 100%. However, due to deterioration of the SUS, BCG vaccinations have fallen, which is a scandal [the vaccination rate for newborns in 2020 was 75%, lower than the minimum expected of 90%].

What do you expect over the next few years?
I expect an increase in cases over the next two years, because tuberculosis is a slow disease, it’s not like Covid-19, which makes a person sick within a few days. People infected with this bacterium take months to show the first symptoms. Over the next few years we will be diagnosing those who are being infected now, during the pandemic period.

I don’t think we’ll have another devastating wave, but we’re going to have epidemics caused by Omicron-2 or newer variants

How can this situation be alleviated?
Alerting the population through the media is very important. We have to make people aware that they should get to a doctor early; it’s no use waiting until you’re really sick and losing weight. Each patient diagnosed with tuberculosis generates at least four close contacts who must also be examined. Among these four, usually one is sick. It’s a very easily transmitted respiratory disease, the bacillus stays in the air for hours. Tuberculosis has a large social component because transmission is directly linked to the environment. The risk of contagion is higher for someone who lives in a shack with five other people than it is for a person living in a large house with high ceilings. Tuberculosis has also ascended the social ladder and no longer affects only the underprivileged. Today, those with immunodeficiency, and those who can afford medicines and have health insurance, are also part of an important risk group. Diabetics too. They are prone to becoming infected because diabetes is a disease resulting from failures in cellular immunity. They currently represent about 15% of tuberculosis patients. People who have rheumatoid arthritis, lupus erythematosus, psoriasis, Crohn’s disease, and those who use immunosuppressive drugs, are also more likely to acquire tuberculosis.

You were one of the coordinators of a BCG trial in Brazil to treat people with Covid-19. How is that study going?
We’ve already finished the study and are now in the follow-up phase [following-up with patients]. It is an international multicenter study, with five countries: England, Holland, Australia, Brazil, and Spain. Julio Croda—who’s also from FIOCRUZ—and I are the principal investigators in Brazil, the country that enrolled the most volunteers, with 2,700 health professionals. We’re now finishing the analysis for publication. We wanted to test whether BCG, because it provokes a highly varied immunological reaction, could promote immunity against the virus, especially in the older population. Personally, I don’t believe that BCG can prevent Covid-19, but perhaps it will be useful in mitigating the severity of cases. It’s a hypothesis. The final analysis should be out by the end of the year.

What did the pandemic teach you about the country, about human beings, and about yourself?
I wrote an article that comes out tomorrow [April 13] in O Globo with the title “More than two years, many scars,” because it’s been two years since I started writing weekly articles for the newspaper, and the pandemic has left a lot of scars, for everyone. I am well acquainted with epidemics; I participated in the Ministry of Health group that dealt with the H1N1 virus 17 years ago and I’ve seen other epidemics up close, such as Ebola in sub-Saharan Africa. But when the Covid-19 pandemic began, it became clear that because it’s a disease spread by respiratory transmission, the impact in Brazil would be dramatic and would emulate what was being observed in the countries that preceded us in the pandemic. In my first interview, on March 13, 2020, I said, “We have two weapons: SUS and social distancing.” But we didn’t know, at that time, that we’d be facing what I would call a misguided and unnecessary tension, and that was the clash between the political rhetoric and our own discourse based on scientific evidence. We’ve been dealing with this tension from the beginning.

Are you referring to the defense of drugs without proven efficacy?
In May 2020, when phase three studies for chloroquine were starting, a group of researchers developed a paper showing, through drug repositioning studies, that chloroquine wouldn’t work for Covid-19. After one year, we revised the document and included the data from the phase three studies [clinical trials done with large numbers of people to evaluate the efficacy of a drug]. Even so, we had to continue dealing with this misconception and with the expectations of patients and their families. Many times I was treating a patient and the families confronted me saying, “Aren’t you going to give chloroquine to my son—to my husband?” And I said no, that I didn’t use that medicine, because I knew it didn’t work. This tension was harmful, I would even say perverse, and based on the spread of disinformation not just about chloroquine, but ivermectin as well. Several mayors bought millions of pills and used it as a political flag, and now it’s become abundantly clear that what ivermectin is really good at is treating lice and worms, but not Covid-19. Brazil was the stage for phase three studies of spectacular vaccines, such as CoronaVac and those from Janssen, AstraZeneca, and Pfizer. Why didn’t we also order vaccines at the time the studies were being conducted? For political reasons. We didn’t buy vaccines in advance and when we did get around to buying them, there weren’t any left. Our salvation was our two national public agencies, Butantan with the CoronaVac and FIOCRUZ with its technology transfer to produce AstraZeneca’s vaccine in Brazil. The rest of the world started vaccinating in December 2020 and Brazil only at the end of January 2021. We started late, despite having been the country that placed the most volunteers in phase three studies. In addition to these paradoxes, the idea went around that it wasn’t necessary to distance yourself or wear a mask.

Could other waves of Covid-19 be coming?
I don’t think we will have any more devastating waves, but we will have epidemics caused by Omicron-2 or new variants. Each of them will behave differently in each location. In Brazil, 100 to 200 people still die every day from Covid-19. That’s a lot of people for a vaccine-preventable disease. Cases of the SARS-CoV-1 virus, which causes Severe Acute Respiratory Syndrome, and MERS-CoV, the virus responsible for the Middle East Respiratory Syndrome—the two coronaviruses that preceded the current one—have practically disappeared. Today, there’s only a case here or there in China and the Middle East, where these diseases initially emerged, but SARS-CoV-2, which causes Covid-19, is not going to simply vanish from our lives, cases are going to appear everywhere in the world, in an endemic way. These days this virus has already been incorporated into the viral panel that we use to test patients suspected of having a viral disease, along with H1N1, H3N2, influenza, adenovirus, and rhinovirus.

We had to learn another way to communicate with the patient. We were pairs of eyes only, with minimal contact

What makes it possible to say that a pandemic is over?
We say it’s ended when it disappears or becomes endemic, as will be the case with Covid-19, when the number of deaths is very close to zero and when the number of cases has dropped off almost vertically. We can’t yet say that Covid-19 is endemic, because it continues to kill a lot of people. We will only achieve a good level of protection and prevent outbreaks when the entire population over the age of 18 is vaccinated with four doses. Today in Brazil we have what’s called hybrid immunity, with many people who survived the disease and then were vaccinated. Unfortunately, the anti-vax discourse has contaminated our families, because the rate of children’s vaccination is still negligible, far from what’s desirable. It’s a shame, because Brazilians love vaccines. Brazil had received the measles eradication certificate in 2016, then lost it in 2019, because we started to have measles cases in adults. Measles vaccination has dropped a lot in Brazil, for several reasons, the main one being our headless PNI [National Immunization Program, which the current government has left without a chief executive]. Theoretically, we would have had better conditions to face the pandemic, but that wasn’t the case in practice.

In a presentation in July 2020 at the Institute of Advanced Studies at the University of São Paulo, the IEA-USP, you commented that the pandemic challenged the omnipotence of doctors, who thought they could save all their patients.
Right, because we started losing patients. We had to be humbler in the face of a new disease. We also lost many doctors and nurses. Meanwhile, we had to treat critically ill patients, deal with grief, comfort families, and live with our own fear. The first patients we hospitalized, and eventually lost, were those with pneumonia that progressed to severe acute respiratory syndrome or thrombosis and embolism, conditions about which we had little clarity; we didn’t know exactly what they were. In short order, we—both the more experienced and the younger doctors dedicated to intensive care—entered a compulsory, intense, and permanent learning curve, which continues to today.

What did you all learn?
We needed to understand how a patient could come into an emergency room walking and talking with only 85% blood oxygen levels, which was almost incompatible with life. He didn’t have pneumonia, he had thrombosis. Soon after, Covid-19 was named by the journal Nature as a storm disease, because it compromised the body’s entire microcirculatory system. Then the pathologists defined it as an endotheliitis, a disease of the endothelium, which affects the innermost layer of microcirculation. The virus launches a brutal viremia [viral load] at first and then decreases. This is enough to affect circulation and even the central nervous system, which explains the encephalitis and neurological sequelae of long Covid. We saw that we needed to treat the sick differently. It’s a systemic disease, for which there were no specific remedies. We saved critically ill patients based on what are called best practices for intensive care. Germany had a low Covid-19 mortality rate because it has a lot of intensive care infrastructure and had younger patients at the beginning of the epidemic, coming from the ski resorts. In the United States, where there is no public health system, people died at home. For the first six months, many of us stayed in the hospital or slept in hotels, afraid to go home and spread the virus to family members.

At what point were you afraid?
When I got sick in April 2020. You just keep waiting for the eighth or ninth day, because you know that’s when it’s going to get worse. It’s not a disease where you’re waiting for it to pass because it will get better, no, you’re just waiting for it to keep getting worse. Those who had Covid-19 or saw those who had it up close felt this fear, of the ultimate rupture, as a result of isolation. When a patient sees the door close in the emergency room or intensive care unit, they don’t know if they’ll see the people they love ever again, and it plunges them into a profound loneliness. Few people enter the ward, and they’re always wearing protective equipment, to avoid contagion. We had to learn another way to communicate with the patient. We were just eyes, nothing else, and eyes behind prescription glasses and transparent face shields, with minimal contact, and always with gloves. Many who went through this and stayed awake hooked up on a high-flow oxygen machine, lucid the entire time, lived with the terror of seeing that all the people who approached them were also afraid.

How have you dealt with your own personal losses during the pandemic?
It’s been hard. My sister became seriously ill with Covid-19 and almost died. I lost four classmates and close friends, my very dear stepdaughter died in November, and my husband [Candido Antônio José Francisco Mendes de Almeida, 1928–2022] died suddenly a month and a half ago, but not from Covid-19. I was reading a book called L’avenir de la vie [Future Life, by Michel Salomon, 1927–2020]. He had what Simone de Beauvoir [1908–1986] would call a gentle death. This is a time of mourning and reorganizing our lives. I’ve received demonstrations of affection and solidarity from people I’ve never seen, I was very moved. It’s a very new experience, because I’m used to this with my friends, my family, my patients, but not from people I don’t even know, but who talk to me intimately, as if they had met me the day before. I’m very touched by all this affection.

I love to read a good novel, but I’ve been reading a lot about the history of epidemics, which is the history of humanity itself, particularly in the West

You’ve become a media figure. How did you end up on television?
It was another learning experience; I didn’t understand any of it. At the beginning of March 2020, I participated in the group that advised Luiz Henrique Mandetta [Minister of Health from January 2019 to April 2020]. Júlio Croda was still in the ministry [as director of the Department of Immunizations and Communicable Diseases of the Secretariat of Health Surveillance]. We spent three days reviewing the projections for flu and severe acute respiratory syndrome, in order to predict the direction the pandemic would take in Brazil. From there I went to a meeting of the Pulmonology Society in São Paulo and recorded a video summarizing the first preventive measures recommended by the Brasília group. It was the first time I used the word tsunami: “Look, the sea is retreating, which are the countries that preceded us, and the waves will come in very heavy, it will be a catastrophe in Brazil.” Seven hours later, as I was going to sleep, my pulmonologist colleague Mauro Gomes, who recorded the video with me, sent a message saying that our interview already had 200,000 views. Completely innocent, I asked, “Is that a lot or a little?” He burst out laughing, “You have no idea what this means.” The next day, I’m at Congonhas [airport], returning to Rio, and Camila Bonfim, a reporter for TV Globo, calls me. “Doctor Margareth, you recorded an interview that has 400,000 views. Can you come to the station and go live?” I accepted. It was the first big interview about Covid-19, March 14th. The next day those special six-hour programs would begin. They continued to call me and virologist Amilcar Tanuri, from UFRJ [Federal University of Rio de Janeiro], until, in April, I told the program’s staff that I couldn’t go to the studio anymore, because the Covid-19 transmission rate was too high, and we should start doing things online. At the end of April I got sick with Covid-19. Afterwards, I went back on television, but online.

How did you deal with this visibility?
It’s a major pain. In 2020, I ended up giving eight interviews on the same day, for newspapers and television in Brazil and abroad. Sometimes I lost my patience a little and told them that I’d already said the same thing four times that day. And they replied: “But, Dr. Dalcolmo, you haven’t spoken to me yet.” I’ve always worked hard, and I tend to be quite reserved. Going into the supermarket to shop and having people recognize me and ask to take a selfie is pretty unusual, but very nice. Every time I was interviewed, I told the truth. At the end of 2020, I remember a journalist asking me, “Are you really going to say families can’t get together for Christmas?” I replied, “I’m going to say it much more forcefully than I’m telling you.” And I did say, publicly: “You can’t have a Christmas party, you can’t meet your family, and you can’t gather in groups of more than five people. Even if you have taken the test, you have to wear a mask, if you have a grandfather and grandmother, keep your distance, if you have a child, distance.” I was a total shrew, but I knew how to say it in a way that people complied, many said to me: “Doctor, I had everything ready and I canceled because you asked. I only had my children over, and kept a distance.” At that time there was still no vaccine. In 2021 I didn’t say any more about it, but until it got better, several colleagues and I went public to say that the situation was getting worse, the number of cases was increasing, and the transmission rate was very high.

This stance is unusual among doctors, who are generally more reticent…
I wasn’t the only one. Júlio Croda, Rosana Richtmann [from the Emílio Ribas Institute of Infectious Diseases], Renato Kfouri [from the Brazilian Society of Immunization], Alexandre Naime Barbosa [from São Paulo State University, UNESP] and Marco Sáfadi [from the School of Medical Sciences at Santa Casa de São Paulo] are also quite outspoken. We made a good team, even sidelining colleagues who defended positions we could never agree with, because they didn’t have consistent evidence. I was equally tough as part of the group here in Rio de Janeiro, appointed by former governor Wilson Witzel in 2020 to deal with Covid-19. Also part of this group were Paulo Buss, who was once president of FIOCRUZ, José Temporão, who was once Minister of Health, and Roberto Medronho and Amilcar Tanuri, both from UFRJ. We worked hard and prepared the document, which at the end of April we delivered to the then Secretary of Health, not knowing that he was involved in those horrible things [corruption]. Unlike with the governor of São Paulo, who met every day with the group of doctors who advised him, in Rio we were never received by the governor. Even so, we prepared a document and said: “The situation is much worse, let’s do a serious lockdown in this city.” Finally, we decided to dissolve the group and two days later news broke about the scandal involving the Secretary of Health, Edmar Santos. I continued as part of the Com Ciência [With Science] group only, which is coordinated by Jerson Lima, president of FAPERJ [Rio de Janeiro Research Foundation]. It was a tough experience. That’s why I talk about so many scars.

Why did you leave Rio when you were a teenager?
My ancestors and grandparents are from northern Italy, immigrants who moved to Espírito Santo. My parents were born in the Canaã valley and Colatina, where they got married and where I was born, but we came to Rio de Janeiro when I was two years old. I studied at a school run by nuns, Divina Providência, and later at Colégio Bennett, an upper-middle-class high school; I was a very good student and also quite engaged, at a time of intense student activism. My parents were afraid of me staying in Rio de Janeiro when they moved back to Vitória [in the state of Espírito Santo]. I was 17 years old and I moved with them quite unwillingly; besides my family I didn’t know anyone, my friends were in Rio. In fact, they’re my friends to this day, cultivated like the best “sap of life.” It was the year of the college entrance exams. I’d spent a lot of my teenage years saying I wanted to be a diplomat, but I changed my mind the year of the entrance exam. It was during the era of military government, and very difficult. I’ve always had a knack for taking care of people; taking care of my grandparents was a pleasure for me. I told my parents I was going to take the mid-year entrance exams for medicine, which confused them, because I had been more involved in the humanities. I made a deal with my school colleagues: I tutored English, history, geography, and Portuguese and they taught me physics and chemistry. College was an extraordinary experience, I never had any hesitation, I always liked everything, but it didn’t make me lose the love I always had for literature. I carried The Magic Mountain in my bag on duty, and during breaks I would read Hans Castorp climbing the Magic Mountain.

Which teachers most influenced your choices?
In college, the head of the pulmonology department was great, and later became my friend until his death—José Luís Loureiro Martins [1943–1998]. I also learned a lot from Jayme dos Santos Neves [1909–1998], who was a wise, learned man. During my residency, back in Rio, I had unforgettable supervisors, Haroldo Meyer, Germano Gerhardt, and Newton Bethlen [1916–1998]. Someone who also inspired me, although I never met her personally, was Rita Levi-Montalcini [Italian neurologist, 1909–2012, Nobel Prize winner in Physiology or Medicine in 1986], for her ability to reconcile the life of a woman and a researcher during much more difficult times than ours.

What were you reading during the pandemic?
I read far fewer things than I would have liked, due to the need to keep up to date with so many medical articles, but the books kept coming in, from friends and academics. I love reading a good novel, I do, but I ended up reading a lot about the history of epidemics, which is actually the history of humanity itself, especially in the West. I’ve always read a lot. Right now I’m reading Leçons d’un siècle de vie [Lessons from a century of life], by Edgar Morin, and Um dia chegarei a Sagres [One day I’ll get to Sagres], by Nélida Piñon, and I’ve already set aside The Great Influenza, by John Barry, and D’un siècle à l’autre [From one century to another], by Regis Debray, to read next. In my house there are books everywhere, even in the bathroom. If a visitor takes a while in there, I know they’ve picked up something to read.