Cases of covid-19 are rising in Brazil, as the more transmissible P1 variant spreads across the country.
In Brazil, the federal government’s approach to the covid-19 pandemic has been to try to achieve herd immunity through contagion. This has so far led to the avoidable deaths of hundreds of thousands of citizens. On 5 March, we published an article explaining the strategy to allow covid-19 to spread, led by Jair Bolsonaro, the Brazilian president himself.  Since then, as expected, Brazil has plunged into an unprecedented health catastrophe.
Last week, nearly one third of all daily covid-19 fatalities in the world were in Brazil, although Brazil makes up only 2.7% of the world population. On 2 April, there were 12.8 million cases and over 325 thousand deaths. In the week 21-27 March, there was a daily 0.8% rise in cases and 1.9% rise in deaths; lethality has risen from 2% to 3.3% since late 2020.  The new variants circulating in Brazil have become a serious cause of concern to neighbouring countries. 
The catastrophe could be much worse had there not been a national public health system (SUS) in place, based on universal coverage. Yet the system has reached the point of collapse.
On 29 March 2021, 17 out of the 27 federal states reached adult-ICU-bed occupation rates of 90% or more; among the 27 capital cities, 21 displayed the same rates, and seven of them had reached their full capacity or were working above it.  At most points of care, the number of available beds, although insufficient, results from successive expansions due to the high demand. Despite these efforts, by 25 March, 6,371 people were waiting for an ICU-bed.  In March, 496 people lost their lives while on the waiting list for ICU in the state of Sao Paulo alone. 
The stocks of medication used for patient intubation are nearly depleted.  The shortage of oxygen, beginning in January in the state of Amazonas, has affected several other cities and threatens the rest of the country.
The collapse of the healthcare system is resulting in higher mortality rates, both from covid-19 and other diseases, including due to a lack of available care. In 2020, hospital mortality rates were already high: 59% among ICU patients and 80% among those who needed mechanical ventilation support. In 2020, 9,311 Brazilians died unassisted at home from covid-19. [8,9]
Against that backdrop, almost all federal states have adopted restrictive measures to curb the circulation of covid-19. They have faced fierce opposition from the federal government.
Bolsonaro has even filed a lawsuit with the Supreme Federal Court against three governors, who had temporarily suspended commercial activities.  The case was dismissed for basic legal inconsistencies. He still maintains a false opposition between the economy and health and he claims that lockdown measures would cause starvation, unemployment, and social chaos.
Starvation, however, is the result of neglect from the federal government itself. The financial support offered to low-income families, allowing them to stay home during the pandemic, ceased in December 2020, forcing millions to resume work. A new aid programme has been announced, but reduced from 600 to 150 reais (19,25 pounds) and, at the peak of the pandemic, is still to be implemented. The financial aid to small and medium-sized companies is meagre, which has led some of their owners to oppose the temporary closing of business. Employees have been incited to join street demonstrations against governors and mayors who adopt quarantines, often without masks.
Bolsonaro keeps holding public gatherings, promoting scientific denialism, and defending the early use of ineffective drugs against covid-19. The so-called “Covid kit,” promoted by the federal government, includes hydroxychloroquine, azithromycin, ivermectin, and anticoagulants, and may cause haemorrhage, renal failure, and arrhythmias. In Sao Paulo, at least five patients who were prescribed the “early treatment” have entered the liver transplant line and three have died from hepatitis. 
On 23 March 2021, a new health minister took office. General Eduardo Pazzuelo, who left the post, has been accused of several crimes in accordance with the Brazilian penal code, among which are the breach of preventive health measures and misuse of public funds.  The new health minister, Marcelo Queiroga, a doctor, has promised to arrange for vaccination against covid-19. The vaccination rollout remains sluggish, whereas the presidents of the Lower Chamber and the Senate stand for the procurement of vaccines by the private sector to inoculate company owners, their families and employees.  That could undermine the efficiency of the national immunization plan by subverting the priority order and increase health inequalities and divisions. Bolsonaro, who has opposed vaccination for months, has started supporting it, due to the general compliance of the public to the campaign set up by local governments and the escalation of the covid-19 crisis.
The response to the pandemic among the military more rigorously followed WHO recommendations, such as the use of masks and physical distancing, as described by the current Army Commander, General Paulo Sérgio, in a recent interview. 
By late March, an alleged “self-coup” attempt by Bolsonaro failed against the resistance of Armed Forces, which have opposed the President’s intention to militarily intervene in the states adopting quarantine measures.  Nevertheless, the President still engages in an all-out war against governors and mayors, whom he labels as “dictators” who violate citizens’ rights and harm the economy. 
In our opinion, the federal government’s stance may constitute a crime against humanity. According to the international criminal jurisprudence, the massive and systematic use of pressure to induce the public to behave a certain way, according to a preconceived plan, which deploys considerable public and private means, may outline an attack on the civilian population.
The fact remains that, if the decision to try to achieve herd immunity from covid-19 by allowing contagion to spread unchecked remains unpunished, it is likely to become an extraordinary means for future rulers to harm vulnerable populations by means of neglecting public health measures.
Deisy Ventura, Professor, Director of the PhD Program in Global Health and Sustainability at Public Health School, University of Sao Paulo, Brazil
Fernando Aith, Professor, Director of the University of São Paulo Health Law Research Center
Rossana Reis, Associate Professor at the Institute of International Relations, University of São Paulo
Competing interests: none declared.