Brazil was the first Latin American country with covid-19 cases on 26 February 2020. At that time, reports from China, Italy, and other Asian and European countries were already abundant and worrisome, and the Brazilian population expected a robust action plan. Instead, the ensuing global health crisis was minimised at the highest political level and covid-19 was referred to as a “little flu.” Wearing face masks was not recommended, quarantine and lockdown measures were ignored, and the population were encouraged to use unproved medicines to prevent and treat covid-19, which the public health system (SUS) was instructed to purchase. [1,2,3] The repercussions were global and, in the first half of 2020, Brazil quickly became the country with the second highest number of covid-19 cases in the world.
People with chronic non-communicable diseases were extremely concerned about the potential consequences of the pandemic on their care. As a first measure to protect this high risk group, the minister of health announced that they would receive medical supplies for a three month period.  This was intended to help these individuals avoid their monthly return visits to public health centres and pharmacies, and instead adhere to stay-at-home recommendations. Regrettably, it was shown to have benefited only 21% of individuals with diabetes.  A few weeks after this announcement, the minister was replaced by another, who also resigned less than a month after assuming office. An army officer took over as interim minister until he was confirmed as minister of health.  Thereafter, a good number of politicians tested positive for the coronavirus, including the president and most ministers including the minister of health. Despite the Brazilian Supreme Court act to guarantee autonomy of states and municipalities, misaligned adoption of emergency measures yielded limited outcomes. 
Health services were reorganised as a result of the pandemic with healthcare professionals and workers redirected to provide urgent covid-19 response. Access to care and medicines for many people with non-communicable diseases was affected. [4,5,6,7] As a consequence, some observed their biomarkers getting off target, their quality of life deteriorating, and new diseases or complications of previous diseases developing. [5,6,7,8] Some not-for-profit organisations proactively mobilised help to provide to those who needed it most, but many preferred to stay silent or did not have resources to adapt their routine.  Subsequent studies described how people with non-communicable diseases were subjected to the consequences of limited measures more severely than other individuals. Malta et al. showed that physical activity and consumption of vegetables were severely reduced in these individuals, while screen time increased substantially amongst them (60%, 10.8%, 196.5% without non-communicable diseases and 58%, 12.7%, 302% with such health conditions, respectively).  Mental health was dramatically affected, 40.4% of Brazilian adults frequently felt sad or depressed and 52.6% anxious or nervous.  In a later publication, Goularte et al. reported psychiatric symptoms in most of the population: anxiety (81.9%), depression (68%), anger (64.5%), somatic symptoms (62.6%), and sleep problems (55.3%).  In common, both groups found that younger individuals, women and people with a history of psychiatric illness were prone to developing more severe symptoms. For cancer, dramatic reductions in appointments, screening, diagnosis and surgeries were reported.  The proportion of people in high-risk groups for covid-19 severity and mortality in Brazil was rapidly increasing, setting the scene for a national health and economic crisis. 
Immunisation provided a clear exit option. However, delays in approving, purchasing, and investing in the development of vaccines were experienced. On 17 January 2021, vaccination slowly started in the country as more infectious new variants of SARS-CoV-2 were emerging in the United Kingdom, South Africa, and Brazil. Two of the new lineages were detected and spread throughout Brazil: B.1.17, with local date of transmission as 18 January 2021, and P.1., with three variants of biological significance with a local date of transmission of 15 December 2020. Consequently, the speed at which the virus spread was higher than that at which vaccination was rolled out. The collapse which erupted in Manaus in January spread across the country, with reports of beds in public and private hospitals fully occupied and people dying while awaiting vacancy in ICUs. [1,3] During the second week of March 2021, Brazil became the country with the highest number of daily deaths from covid-19, more than 2000. [1,3] On 15 March the president announced a change to the government and appointed the fourth minister of health since the start of the pandemic, who saw on 23 March the daily covid-19 deaths exceeding 3000.
Prioritisation of vaccines for high-risk groups became decentralized, with each municipality making its own protocols. Most included in their plans healthcare professionals and elderly people, leaving out people with non-communicable diseases.  The lack of vaccination and high exposure resulting from little preventive behaviours and measures led to higher infection rates of younger age groups in the second wave, especially underprivileged people and those with comorbidities. [3,12,13,14] The fact that young people were infected, in conjunction with treatment improvements, led to an increase in the average length of hospital stays, from 10 to 14 days, according to the Brazilian Association of Intensive Care Medicine.
The collapse was forecasted.  Lack of thorough measures, controversy, and denialism prompted national and international alerts. It was hoped that this would encourage a change in course, with prompt implementation of measures to protect and save Brazilian lives. According to Hallal, almost three quarters of deaths could have been avoided.  However, during the peak of the second wave, not all high political authorities supported measures proposed by the scientific community and adopted in different regions of the country (including partial lockdown) to halt escalating deaths and collapse of the health system. [1,3]
Alarming is the fact that new cases and deaths continue to rise. For this reason, several medical, scientific, academic, public, private and civil-society organisations and alliances have published manifestos in March, demanding urgent actions from the government and offering themselves to partner in multisectoral and multi-stakeholder efforts to rescue Brazil from the collapse.  Meanwhile, the population pray that models predicting a long lasting worsening of the current scenario are proved wrong, and that the new minister of health makes better decisions aligned with scientific recommendations, so that at least by the end of 2021 the pandemic is under control in Brazil.
Mark Thomaz Ugliara Barone is a Member of the BMJ Patient Advisory Panel, and Founder and General Manager at the Intersectoral Forum to Fight NCDs in Brazil (ForumDCNTs).
Nayanjeet Chaudhury is Founder and Director at the Ramaiah International Centre for Public Health Innovations (RICPHI).
Lucas Xavier de Oliveira is a Young Leader in Diabetes at the International Diabetes Federation (IDF).
Matheus Chaluppe is Student at the Escola de Saúde da Universidade Municipal de São Caetano do Sul (USCS).
Bruno Helman is Founder and President at the Instituto Correndo pelo Diabetes.
Bruna Talita Patricio is an Independent Psychologist.
Ronaldo José Pineda Wieselberg is a resident physician in Endocrinology at the Santa Casa de São Paulo, and Global Master of Public Health student at Imperial College London.
Belinda Ngongo is the Founder of Pan African Women in Health (PAWH).
Viviana Giampaoli is Statistician and Professor at the Instituto de Matemática e Estatística, Departamento de Estatística of the Universidade de São Paulo (IME-USP).
- Biller D, Álvares D. Brazil’s Hospitals Are Buckling in the Absence of a National Virus Plan. Time [Internet]. 2021 Mar 11. https://time.com/5945644/brazil-hospitals-coronavirus/
- Hallal PC. SOS Brazil: science under attack. Lancet. 2021 Jan 30;397(10272):373-374. doi:10.1016/S0140-6736(21)00141-0. pmid: 33493436
- Phillips T. ‘Covid is taking over’: Brazil plunges into deadliest chapter of its epidemic. The Guardian [Internet]. 2021, Mar 13. Available from: https://www.theguardian.com/world/2021/mar/13/brazil-covid-coronavirus-deaths-cases-bolsonaro-lula
- Barone MTU, Harnik SB, de Luca PV, et al. The impact of COVID-19 on people with diabetes in Brazil. Diabetes Res Clin Pract. 2020 Aug;166:108304. doi:10.1016/j.diabres.2020.108304. pmid:32623040
- Brant LCC, Nascimento BR, Teixeira RA, et al. Excess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital cities. Heart. 2020 Dec;106(24):1898-1905. 2020;106(24):1898-1905. doi:10.1136/heartjnl-2020-317663 . Epub 2020 Oct 15. pmid: 33060261
- Barone MTU, Ngongo B, Harnik SB, et al . COVID-19 associated with diabetes and other noncommunicable diseases led to a global health crisis. Diabetes research and clinical practice. 2021 Jan;171:108587. doi:10.1016/j.diabres.2020.108587. pmid: 33307134
- Leite JS, Feter N, Caputo EL, et al. Managing noncommunicable diseases during the COVID-19 pandemic in Brazil: findings from the PAMPA cohort. Ciência & Saúde Coletiva, 2021 Mar 15;26(3), 987-1000.doi:10.1590/1413-81232021263.39232020
- Goularte JF, Serafim SD, Colombo R, et al. COVID-19 and mental health in Brazil: Psychiatric symptoms in the general population. J Psychiatr Res. 2021 Jan;132:32-37. doi:10.1016/j.jpsychires.2020.09.021. pmid:33038563
- Malta DC, Gomes CS, Barros MBDA, et al. Chronic non-communicable diseases and changes in lifestyles during the COVID-19 pandemic in Brazil. Scielo Preprints, 2020 Dec. doi:10.1590/1980-549720210009
- Barros MBA, Lima MG, Malta DC, et al. Report on sadness/depression, nervousness/anxiety and sleep problems in the Brazilian adult population during the COVID-19 pandemic. Epidemiol Serv Saúde. 2020;29(4):e2020427. doi:10.1590/s1679-49742020000400018. pmid: 32844918
- Fórum Intersetorial para Combate às DCNTs no Brasil [Internet]. TJCC, FórumDCNTs e 217 entidades enviam carta solicitando ações emergenciais ao governo. 2021 Mar 24. https://www.forumdcnts.org/post/217-entidades-manifesto-pandemia
- Faria de Moura Villela E, López RVM, Sato APS, et al. COVID-19 outbreak in Brazil: adherence to national preventive measures and impact on people’s lives, an online survey. BMC Public Health.2021 Jan 18;21(1):152. doi:10.1186/s12889-021-10222-z . pmid: 33461508
- Brazilian Ministry of Health. 52 Special epidemiological bulletin: COVID-19 coronavirus disease – Epidemiological week 8; 2021. https://www.gov.br/saude/pt-br/media/pdf/2021/marco/05/boletim_epidemiologico_covid_52_final2.pdf
- Ribeiro KB, Ribeiro AF, de Sousa Mascena Veras MA, et al. Social inequalities and COVID-19 mortality in the city of São Paulo, Brazil [published online ahead of print, 2021 Feb 28]. Int J Epidemiol. 2021 Feb 28:dyab022. doi:10.1093/ije/dyab022. pmid: 33657223
- Neiva MB, Carvalho I, Costa Filho EDS, et al. Brazil: the emerging epicenter of COVID-19 pandemic. Rev Soc Bras Med Trop. 2020 Oct 21;53:e20200550. doi:10.1590/0037-8682-0550-2020. pmid: 33111917