Sunday, October 26, 2014. 7:15 AM, Brasilia Time. In the United States most people are resting before making preparations for Halloween over the weekend. After reviewing and editing three articles for our joint Union for International Cancer Control/ASCO/European Society of Medical Oncology World Health Organization Essential Medicines List for Cancer project, as I run the three-mile track that separates my place from my voting station, I course through 500 years of Brazilian history and wonder what’s wrong and right about our country. Sao Paulo’s population exploded in the late 19th and early 20th centuries as the coffee boom led to industrialization. Our own Great Migration (southwards and forced as the slave trade was prohibited internationally, rather than northwards and free as in the U.S.) and later immigration of huddled masses from Europe and Japan increased it from 31,000 in 1872 to 2,200,000 in the 1950s and more than 11 million today (in the metro area, the number reaches 22 million). The city of Sao Paulo has a gross domestic product (GDP) in excess of $200 billion (US$), about the same as countries such as Israel and Portugal.
Around Paulista Avenue, one of the financial hearts of the city, not only do I pass by gleaming glass towers but also at least three private hospitals, including the one I work in, which bolster multidisciplinary teams with physicians trained in the U.S. and Europe. At these and other similar institutions around the country, we cater to the 50 million or so Brazilians, out of a population of 200 million, who have private health insurance. Here, those we treat for cancer have as good medical care as one can get in high-income settings, with the exception of a few drugs that we would consider standard of care which have not been approved by our national regulator, ANVISA. More on that in upcoming posts and an article we will prepare for next year’s ASCO Annual Meeting.
As I pace downhill, through Augusta and then Consolacao streets, leaving the 2,600-foot-high area where rich Coffee Barons and Captains of Industry built their estates at the dawn of the 20th century (one of the few remaining, Casa das Rosas, is open to visitors—stop by if you’re ever in town), I edge closer to the then–mosquito infested older urban core. This is where the city began in 1554 with a humble rammed-earth Jesuit building, Patio do Colegio, also worth a visit. I have now left the wealthy areas behind and start glancing at decrepit, poorly kept, and often illegally occupied buildings from the 30s, 40s and 50s, which stubbornly try to keep their old charm amid the hordes of homeless people, drug addicts, and men and women struggling to make ends meet by selling their bodies. Even in this decadence we can see the Brazilian spirit of making the best of what life throws at us and our joie de vivre. It was in settings like this that graffiti became a true national art form and people living in such areas still dance, sing, and smile this early in the morning, making their days that little bit better so they can keep moving on.
Before I reach downtown, I also see a beautifully well-kept, imposing Victorian-style building from the same epoch; it houses a hospital, the Santa Casa. One of the first health safety nets in a sprawling city, a couple of months ago it had to close the doors to its emergency department, as it ran out of money. It is in publicly funded places like this that Brazilian oncologists spend most of our work week. Brazil has expenditures of nearly 9% of GDP in health, but the public purse, which covers the whole population but is the only source of care for the 75% of us who do not have private insurance, accounts for less than 45% of the total. In Sao Paulo, state government supplements federal transfers to the city and most patients have access to what one would consider essential care and medicines, in overcrowded settings and after waiting longer than anyone with cancer would like to do, for sure, but in remote parts of the country the difficulties rise exponentially with a lack of trained personnel and equipment. A welcome announcement last year of the purchase of 80 radiation machines by the federal government has recently morphed into a rumor of a botched process due to corruption.
7:50 AM. I arrive at the subway station in Republica Square, the name given after the 1889 military coup that ended Brazil’s parliamentary republic, its original form of government after independence in 1822, to the area where Paulistanos, the inhabitants of Sao Paulo, watched rodeos and bull fights a little bit longer than 100 years ago. This is where I vote. It is also here that I see the future of Brazil. This is how we will make things change. People are already lining up to cast our votes, participating in the fourth largest democratic process in the world. Outside, at the square, scores of Brazilians from all over the country are setting the stalls where they sell their fare—food and crafts.
The Bandeirantes state, nicknamed for the pioneers who braved the Brazilian countryside and who gave us our current borders, starting in the period the Portuguese and Spanish crowns were joined in the 1680s, has always been more liberal (in the European sense of the word, right-leaning in the American parlance) than the rest of the country. It is here that we hope to start the movement that will change our statist model into a more individual liberty-based and less collectivist system that spends our tax money on what matters: health and education. As I wrote in this venue last year commenting on the protests that overtook Brazil:
“It is only through public participation and the strengthening of health care systems funding and care provision that low- and middle-income countries can truly improve cancer control in the long run. Countries with less-developed health infrastructure have worse cancer outcomes as patients struggle to have access to preventive, diagnostic, therapeutic, and rehabilitative services. Increasing health care worker training, the creation of cancer centers of excellence, virtual teaching, international support, and other initiatives can help, but a well-funded system with universal coverage is of fundamental importance for conquering cancer in low- and middle-income countries.”
The change starts with this vote. As I leave the station, even if I sleep through noon when I get to my place, this has been a very productive day. My way back home is an uphill struggle. So is our country’s.