We need to get out of this dark night
A medical doctor with a doctorate at Harvard University, Carlos Nery has been a reference name when it comes to covid-19 in Piauí
With the continuous apprehension in the minds of millions of people around the world, it is inevitable not to have a feeling of long and slow waiting. The past six months have not been easy to get through. The infectious disease (ID) physician Carlos Nery's analogy about a dark night makes more sense than we can imagine. After all, nowadays we know that the darkness of the night is not merely caused because we are on the side of the Earth not reached by the Sun light, but because the Universe had a beginning. Without stars, this dark period of the Universe leaves its mark on the night until today. But the patient and continuous action of the universal forces guaranteed not only the light and possible dawn on our planet but also life.
The struggle for survival during the pandemic we face has required effort from each person, for a new dawn. Carlos Nery says that “we have to do a lockdown so that it dawns” and guarantees that this measure needs to be taken in a set of forces and decisions thought in the collective. The doctor mentions history, politics, and makes us understand a much larger and interdependent dimension of the current situation.
His reflections take into account a vast experience in the fight against emerging diseases. His sincere way of saying things gives us a warning of how we can act more precisely.
The interview was given by videoconference on June 26, 2020. take a look.
Sapience – Tell us a little about infectiology and your experience in this area that is so important nowadays.
Dr. Carlos Nery – Infectiology is not one of the oldest specialties, it appeared in the 80s – I had already graduated, by the way. There was no medical residency in infectious diseases at that time, so I studied clinic residency. Soon after, I did a master's degree in tropical diseases, it was this master's degree that was recognized by the RCM (Regional Council of Medicine) as a title in the infectious diseases field. The beginning of my career was in medical practice and when I came to Piauí, in 1984, I took over the Hospital for Infectious Diseases, where I really learned infectiology. And I added the research activity to it since my main intention in coming to Teresina was this. We did not have much space in Brasilia. I was dedicated to Chagas' disease in the states of Goiás and Bahia, in the research area, and when I came here, I have faced a new disease, a recent epidemic, which was visceral leishmaniasis, calazar, which was spreading here. Then I changed my area and started to dedicate myself to this new disease. But as time went by, several diseases were happening in Piauí, each with its own time.
I saw cases of diphtheria, which no longer exists today, protected by vaccination. I saw a lot of malnutrition, but thanks to the food support programs, that disappeared. I have seen many cases of tetanus, until recently, and even today, due to vaccination failures. At that time, mortality was very high, since we did not have an ICU (Intensive Care Unit). We had a lot of malaria at the time of the Transamazônica¹ and gold mining in Carajás and Serra Pelada, there were multitudes of patients who came here. Even Piauí had many cases of autochthonous malaria, many patients with severe malaria from those regions. Then, when artisanal mining was banned, they migrated to French Guiana, Guiana, Suriname and the cases in Teresina decreased considerably. We have had many cases of hepatitis B as well, which has greatly reduced with vaccination. Then there were other impacting diseases, HIV, AIDS, in the eighties. I was there at the beginning of the epidemic, which was a tragic thing, patients arrived and life expectancy was six months. Many died in the first hospitalization, young people, very intelligent people who died. Then came the cholera epidemic, the dengue epidemic, we discovered hepatitis C, and others emerged over time.
More recently we had two epidemics of Corona, which fortunately did not arrive here, but we were prepared for that: Sars and Mers. There was the avian flu, which was a huge scare, much of the equipment at Natan Portela Hospital was acquired at that time. I was director of this hospital from 1999 until 2010, when I decided to dedicate myself more to research, to what I really like to do, which is Science and teaching medicine, seeing patients daily.
Infectiology is one of the richest areas of medical practice because it involves all other specialties. But, to finish the emerging ones, later came Zika, chikungunya, West Nile encephalitis and now it has reached covid-19. During the 1970s, an American researcher went so far as to say that the end of infectious diseases had come, but the series of retaliations began. This shows how infectious diseases are a very dynamic specialty. People started to get older, transplant became a reality, the treatment of cancer evolved, more longevity, and more fragility for people, and infectious diseases started to take advantage of these people. Then, new diseases for immunosuppressed patients emerged and new treatments needed to be invented. It is a rich and dynamic specialty that requires a lot of professional updating.
Sapience – Covid-19 has already infected millions of people. Quarantines are being extended as a possible solution. Do you think there will come a time when governments will no longer extend these quarantines, mainly due to the discourse on the resumption of the economy?
Dr. Carlos Nery – Brazil has given an example of failure to control the covid-19 pandemic. The right-wing countries, liberal countries, all with fragile public health, had a disastrous action, more or less the stance of England and the United States, which is one of the richest countries in the world, but which the president acted by boycotting the control program. And our Federal Government is also the main boycott of attempts to control the epidemic, which are still very inexpressive.
Even considering the governors of the Northeast, the attempts are very fragile, given that we do not do our homework. We are trying to isolate in a very limited way, with little collaboration from the population, isolation levels always low. This reflects, on one hand, disinformation, anti-science, the speech of businessmen, and the speech of the Presidency of the Republic, which carries with it a substantial percentage of very influential people. We have the cultural unpreparedness of the population to understand the scientific message. We are moving towards an out of control situation, with micro epidemics populating Brazil abroad, cycles and cycles with no prospect of control. The situation is more worrying because the history of the peak, the plateau, all of this took two blames, first that the conditions of control were reduced, and also that there was, hidden, something called collective immunity.
When a microbial agent that generates immunity arrives in a population, people are no longer susceptible to that infection and become immune. As a result, the population of resistant people is accumulating and the proportion of susceptible people is decreasing. This is what we can call a plateau for diseases that cause collective immunity. That's when scientists started to estimate when that peak would be. And they have been systematically wrong because it does not depend only on the estimate, since it fails a lot since it incorporates exponential concepts; so, any change in this basic reproduction number, in this exponent, generates a huge repercussion on the predicted values. The same thing as playing pool, a minimum deviation when hitting the ball can cause it to hit others and others. And unless you're an expert, you won't know where the ball will reach. The models have this, they incorporate parameters that are very vague. That varies a lot over time. If we operate with measures with social distance, especially the lockdown, then this whole forecast is changed.
We have the parameters and control actions. As Brazilian measures are based only on social distance, we do not make the other part as or more powerful, which is mass testing, not fast testing, which does not serve except for estimates of the serological population. And the most worrying thing is that we are finding that the fast test does not measure immunity. We don't know if there is immunity. Apparently, yes. Because people rarely get infected again. We know that they are no longer susceptible to become immune, but the measurement of that immunity is unknown. We know that the antibody is just one of the components.
There is a work published about a month in the scientific journal Cell showing that there is another type of immunity more appropriate for viruses, called cellular immunity, which controls most of this resistance. As the other, older, coronaviruses circulate in the general population, causing flu, so this cellular immunity seems to already exist and would be responsible for part of the resistance of the current population. So, we have several scenarios. First, weakness in control numbers, with relative political neglect; the doubt about lasting immunity, and the fragility of the parameters. All of this leads to a scenario of a lot of ignorance that will come in the future. We cannot say today when we are going to reach this plateau.
On the other hand, there is this enormous pressure from society as a whole to end isolation, which terribly affects people's productivity, employment, and survival. We have an economy entirely focused on banks, on the market, so it is difficult for the government to accept helping the poorest. The Brazilian tradition is that the poor are not important.
There is also enormous pressure on the mayor and the governor; absurd pressure for them to relent. And they are in a very fragile structure, they are no longer based on making the economy more flexible with parameters. If you ask for the Piauí parameter, we will have some indicators, but when is the point of giving the signal? It does not exist. There is this committee in which, the businessmen and the technical staff are listened to, and from there a political decision is made, which is the government's internal decision. This is very bad in my opinion because it creates opposition forces. On one side, People who value social well-being, the lives of their relatives and friends and their own, and those on the other side, who depend on commerce.
I have the impression that if these parameters were determined in advance - "we will only open when the number of new cases has dropped by half" - I am sure that everyone would work to reach this goal, as several countries in the world have already done. And there is the last lesson for those countries that have already succeeded in controlling transmission, but that have outbreaks. Countries with strong restrictive measures, and a collaborating population, China, Germany, Korea, Singapore, and others; as soon as they have a rebound, they can continue with the isolation and control. It is imponderable to say when. It will depend a lot on the intimate of the government. It depends a lot on the weaknesses, it depends on the parameters to reach the horizon of the end of that long night. As things are set, the scenario will be the worst, we will end the isolation in the middle of the epidemic and it will be a lost job. And whoever had to die, who has no immunity, will die, since there is no way for people to survive without isolation here in our country. The scenario is quite bleak in the face of these forces at stake.
Sapience – What situation can we expect for Brazil and Piauí this year? Is it possible to estimate numbers?
Dr. Carlos Nery – Covid-19 depends a lot on social phenomena, on poverty, but it also depends on political issues. The world has shown that it is possible to end the disease with distance measures. I cannot be fatalistic and say that it will be very bad, because there is room for action by government management to curb transmission. An effort would have to be made that has not been tried before, a much greater effort, we would have to go for a lockdown of at least two or three weeks in length, with border closings and massive testing. I believe that today we do not have the capacity to test in the dimension that would be necessary. In order not to be entirely pessimistic, I say that there is hope, but that it is in the hands of the government.
Sapience – How to improve social distance in regions where there is cultural resistance?
Dr. Carlos Nery – It is a political and cultural struggle. We have to act by making massive educational enlightenment of the populations, making the media reach the most peripheral population, through the formation of data, using the example that this is possible. Behind all of this, is hopelessness and fatality - "oh, there's no way and we can't do anything". There is also the situation of Mayor Mão Santa, who is, like the President of the Republic, opposed to measures to contain the epidemic. But it is possible with hard actions. Even the judiciary has shown itself to be on the side of control measures.
It is necessary to have a very decisive and very strong attitude from the government. We have to be 100% health and 0% savings for a while. Why do I say that? Because if we do that, the horizon at the end of the epidemic is possible, if we don't do that the scenario is this: we will stay forever in that dark night, with the disease becoming more and more endemic. And I am not the only one who is saying this, it is being widely discussed in the world about what is the future perspective of covid-19.
Despite this fatalism, this bad perspective from the point of view of public policies established here, there is enough space for incisive and legal political action. So it depends on the decision, a little on the personality, on the support of the enlightened people: universities have tried to pressure the governor in the opposite direction, taking the message of science so that he stays on that, but we have to show him that if we don't do the difficult thing that we should have done a long time ago, the scenario is the one I told you about: disarm everything, go back to normal in the middle of the epidemic, throw away all the effort that has been done, whoever has to die will die and the market supposedly return to normal. And it won’t happen.
The experience in other countries is that when they return, the economy in a situation of transmission does not return to normal, the recession continues. And then we will have a long, endless night of disease, transmission, recession, and this whole cycle tends to perpetuate itself with the disease that has become evident and endemic.
And people will start to shrink back; remember that many businessmen are people at risk age. Elderly people will all be involved in this. Let us remember that many families live on the income of their elderly relatives and once they are lost, the family income falls, which signals a nefarious social scenario. Poor people will have to survive in whatever way is available if it is through violence, whatever.
We enter then, as if it were a perspective of post-barbarism Rome, of darkness if there are no such measures. Or let's hope that science asserts itself and that in two, three, or four months the vaccine is ready, so the night will be shorter. Even if it is not very effective, even if not everyone gets vaccinated, it is capable of generating group immunity to the point of inducing the end of the epidemic.
These cards are on the table, a lot of biology, epidemiology, a lot of politics involved with social components, and a lot of hope in science, technology, and what is to come. But I don't have a crystal ball, I have to say this clearly: the existing models currently are not able to answer that. If we make a forecast on the conditional, the answer would be one. If we make a conditioned response to the public health policy measures that will be taken later, the answer would be different. Same thing with global warming and climate change. It essentially depends on what we do in a few days.
Sapience – There was a research published in China that investigated 37 symptomatic and 37 asymptomatic patients and found out that the presence of antibodies, specifically the IgG antibody, showed a decline of more than 90% within two to three months. How do you see this publication?
Dr. Carlos Nery – Science always has to go further, but it is not like that either. See, as I tried to outline for you, there are two main immune responses: each of them is suitable for a type of aggressive agent or type of infection. There is the so-called humoral immunity, which are the antibodies, and the cellular immunity, which are the cells themselves that act against these pathogens. For some types of pathogens such as tuberculosis, calazar, cancer, it is the main immunity, the cellular type.
How do we find out? Do people who have tuberculosis have antibodies after some time? They do not, but they are immune. People who have had leishmaniasis have antibodies during the disease, after spending a few months, a year or two, they lose antibodies but have strong cellular immunity, and the disease is unlikely to return. But humoral immunity is made for some types of illness. For example, measles, which is a virus, depends a lot on humoral type immunity, antibodies. Hepatitis B basically depends on humoral immunity. What about coronavirus? We do not know, as I said, the article in the scientific journal, Cell, which came out about a month ago, shows the opposite: that lasting immunity seems to be cellular immunity, which is not measured by antibodies. So, these antibodies (from China's research), which we are seeing are evolving, the more or less expected would be a cell-type deficit, which does not mean any tragedy. It is worrying because it showed a certain opposite reaction between the number of viruses and the number of antibodies. People who have more antibodies have fewer viral particles and the virus is eliminated faster. The opposite also happens.
Do you mean that antibodies are killing viruses? Nor does it, because humoral immunity depends a lot on cellular immunity, it is cellular immunity that holds strong humoral immunity, because it stimulates cells called B cells, plasmacytes, to produce antibodies. So, I think that despite this scare there, these positions and information that show viremia, implying that the amount of virus eliminated be longer than we are expecting, which would imply quarantine time. I think it’s not that much, at least in my thinking and impression, obviously dependent on future research, that it is cell-type immunity that controls viral replication, and I think so, people become immune, facts have shown this. The literature is extremely scarce to show relapses of patients with covid-19.
We will find one or another report, an absolutely minimal thing in view of the cases that have already happened. My impression is that this work, although it is important, is a disastrous work to think about building a collective immunity from the current immunity. I think it is forming, there is some evidence that we notice that it is forming, and we hope it will be complemented by a vaccine, which can be released in a short time. Even Brazil, as it is a country that is currently contributing about 20% of new cases in the world, is the main target of the study of these vaccines. Brazil is participating, as you saw, in the trial of this Oxford vaccine and others will come to be tested here as well.
Sapience – Still regarding this controversy between medicine and the economic recovery discourse, how can we adopt measures or create a collective conscience between these two groups?
Dr. Carlos Nery – I think it is possible, but we have to do a lot of work to clarify the ideas of the population and the leaders. Then FAPEPI's role comes in. If we can convince - speaking in the name of science - the government and business that we need to contain the pandemic to return to a normal life, a new normal without worse damage, we will have the battle won. Now it is necessary, first, that these people believe in this information and that they really have trust. These leaders who are taking containment measures are immensely popular, they have the approval of the vast majority of the population. I do not know of any survey that has yet been evaluated by the population of government officials with the measures they take, but my impression is that it is very favorable to containment measures.
Of course, there are people who suffer most from this: those who need jobs, some who depend on those jobs that will return with economic activity, for example, construction, an important source of jobs, and we need entrepreneurs. And there is this line of people who are against anything that is social investment. But I think that most of the population supports the control measures, and if they are taught by the governors themselves, and if they themselves are aware that we have to end this long night, we have to do a lockdown now, hard, so that tomorrow day dawns. If we can do this, if they are convinced of it, the day will dawn and we will return to the new normal. But as long as things are being done half-assed, with 40% social isolation, without massive testing, the day will not dawn.
Sapience – So we really need a lockdown, and also that the supporters of the economic recovery, for now, accept the scientific discourse. Do we move forward together like this?
Dr. Carlos Nery – Exactly. Notice that behind this there is an anti-science speech, so defamation of science is part of the strategy of the extreme right-wing groups. The sale of products, such as chloroquine, is part of this immense attempt, which goes from getting people back to normal activity anyhow until the delegitimization of science is done. And the consequences will be enormous because one of the consequences of discredit in science is not to vaccinate. Remember that the anti-science,
flat-earth belief, and anti-vaccine movements are all associated. And what is the result of that? When the vaccine is made, nobody will get vaccinated because nobody believes in science.
So, the fight for the credibility of science is fundamental, essential. All entities that work with science, from academic institutions to development institutions like FAPEPI and others, have to help us sell this fish, to make this convincing to the authorities. We have everything to believe in science; penicillin exists thanks to science, cancer treatment exists thanks to science, your well-being, without infections at that moment, having air conditioning to go through hot seasons, talking through video, all of it is science. So, we have to bring back the conviction that science is fundamental and that there is a deliberate political action by sectors financed by very wealthy people, in order to delegitimize science, to allow the status quo to continue.
The two main governors in Piauí are clearheaded people, the governor, and the mayor of Teresina. But more needs to be done. It was unfortunate that the mayor signed a medical protocol, as happened last week. This is extremely serious, he has no scientific knowledge to do this. The mayor signed a medical protocol that resumed the indication entirely out of science, for the use of medications that have as much effect as a spider web or bat wing.
It is necessary for people to be immensely clearheaded and to be honest with the population. This honesty is essential, no one is there to push fake drugs into people's throats. They leave the house to look for a doctor in the hope that they will be prescribed an effective medicine, not that they will be deceived with drugs that are false promises. So, I think that the governors are clarified, the mayor has made an immense effort in view of his possibilities, in the face of so many interests. I think he messed up on this one now, I do not even understand why and what political factors led to it. I fear the governor will fail into the same thing, I feel the governor under even more pressure.
I have a brother who is a businessman and I realized that they speak the language of businessmen, the thing is very powerful, and the mayor needs the loyalty of people, his voters. But we must believe this: if he does the lockdown, if we can contain the epidemic as China contained it, being tough, tomorrow we can gradually return to normal life with economic productivity, that's why I have been willing whenever I am called to these various forums, I have no personal benefit from this, my benefit is to translate the science language so that people, with this technical knowledge, can reach the end of the trip.
Imagine if an airplane pilot taking any trip decided to listen to what passengers say - “are we going this way or that way? Increase or decrease speed? Where are we going to land?”. This cannot happen, and it is the same thing that is happening today. The pilots are scientists and health professionals. Let us leave the advice to them and we will not make improvisations based on the opinion of business owners.
Sapience – You estimated between two and three weeks of necessary rigidity in the measurements. But how long would this lockdown really take to control the pandemic in Piauí?
Dr. Carlos Nery – The answer was given by many countries that managed to get there, so we need to investigate the dynamics of reducing transmission with extreme lockdown measures and, for example, follow the Chinese curve. This may take a few weeks. I think we will notice a sharp drop in the transmission of the disease within a few weeks after the start of extreme measures, why? Because the disease is transmitted for a short time, it is transmitted in the first two days of incubation and then for a maximum of 5 to 7 days.
The strategy is to be able to block the transmission of people through strict social containment measures and a lot of education and if possible, buy the machines to do massive testing here in the state of Piauí. It is the component that it had in other countries, that have been rejected here in Brazil. So, depending on the strength with which we apply these measures, I think we can achieve this in a scenario of two or three weeks. To the extent that we realize that there is a substantial reduction in transmission, this feeds back into the control measures, the desire to end this soon - "it's working, I want to end it soon, we're getting there" - this creates a climate, almost a collective climax in the sense that everyone would join hands to end this story soon.
But this will be noticed quickly as the measures are taken and we start to monitor the number of cases. I would not even join much in the proportion of serology tested, my biggest concern is the number of cases being diagnosed with the severe acute respiratory syndrome, with or without a positive test. This is a picture of disease transmission; this is easy to diagnose. We begin to map the regions of the most intense transmission, where the measures have to be redoubled, then we can strictly monitor each situation in the sense that if we relax, the disease will return. It is a very dynamic thing, but I think the first results would be achieved after a week.
With a week we would see that it is being controlled, I think that there would be positive feedback in the sense of continuing the measures to end this long night, all together, before more people die and people starve because of it. You have to be very energetic now for that, that's my perspective. I think that with three weeks the results would be noticeable, and then it would be a time for everyone to evaluate from a technical point of view, with mathematical models, trying to assist together with the political perception of the population, and then we would have a very favorable scenario and totally opposite to the current one.
Piauí has some advantages, it is necessary to give credit to the government. Remember that the situation in Piauí is very different from our neighbors, Ceará and Maranhão, which are suffering much more than we are. In a way, we slowed down the epidemic curve, but unfortunately, we started to fall in temptation to relax ahead of time. People are giving in, of course: now this week people started saying - “look, I lost a relative, I lost a friend” - so this pain is being felt now, we are learning the hard way now.
If we had understood this before, the population as a whole, through much more powerful educational measures, maybe we were already in another scenario and with enough time to do this, but we have to go through the lockdown, there is no prospect of having any short-term horizon without lockdown.
Sapience – How has the occupation and the number of beds in the Intensive Care Unit (ICU) been in the small towns?
Dr. Carlos Nery – If the state and cities had not increased the number of beds, we would have already filled up the units, people would be dying without ventilation assistance by now. But as the pandemic increased, municipal and state governments were able to establish the creation of ICU beds in order to meet this demand. So, it was a more or less parallel growth, in a way of 20% to 30%. But if we do not manage to contain the epidemic, it may be that this vague amount of beds will be extinguished and then we will have a situation similar to Guayaquil in Ecuador, where people began to die at home without assistance, which is the chaos that we all feared at the beginning of the epidemic.
Sapience – What do you think of the radicalization of medication use to combat covid-19? How do you see political action in decisions about medical treatment?
Dr. Carlos Nery – It is difficult for us to understand why we are moving between science and politics, but we have to make a historical retrospective of that. It started with Didier Raoult, that controversial French researcher, unorthodox in following the scientific method. He was in favor of chloroquine, which has antiviral action in vitro, but several compounds also have antiviral action, and that was replicated by President Trump, of the United States, as the magic drug - “take it! The epidemic is over, no one dies”. What happened here in Brazil is that everything that was said there, was repeated in here, and the same thing was done. This led to deep political partisanship by the extreme right-wing political propaganda machine, largely through fake news. It worked wonderfully well in regard to that. People were repeating the same thing because people are very limited. Against scientific research, some said - “There is no time! There is no time to do science!” - as if to say - “We cannot venture. We do not really know where we are going. We are here lost in the forest, this is it and we are going this way!” - based on very fragile information, only with information of antiviral utility in vitro.
It started to have a strong political connotation in which people who were favorable to employment, to companies, mobilized by very specific sectors of society, started then to try to sell this agenda. Doctors are more or less uniformly accepting the chloroquine thing, for several reasons, in my point of view. First, the political thinking of doctors is erroneously on the right-wing, I mean, the majority; and has always been, like many sectors of the elite. Doctors are only more exploited than the judicial staff because, in order to make as much money as them, they need to sacrifice their personal lives a lot. But from one side or the other, it is a dilemma that has pushed itself on doctors' minds. In difficult access to pure scientific knowledge.
In fact, medical knowledge spreads horizontally, from ear to ear. We have the annual medical book, and also the “ear book” which is a doctor talking to another - “did you see that! Did you see that!" - and this horizontal dissemination among doctors, without checking, without consultation, which was once done through medical congresses, textbooks or messages, periodic visits to the main websites and research institutions such as the Brazilian Society of Infectious Diseases or the Association of Intensive Care Medicine, this was thrown aside, and the “ear book” started to predominate among doctors.
The medical culture, which was already inclined to take these measures due to political conditioning, also came to believe that that new book called WhatsApp, which equates laypeople and doctors, was spreading real news, and it looks like they see it in a very convincing and emotional way. Second, in my point of view, there is a decision dilemma. The doctor imagines that: if the medicine is being researched somewhere in the world, it is because it makes sense, it has an in vitro study, maybe it will work.
Third, the drugs have no side effects, so I will prescribe them for my patient. This thinking structure of medical colleagues, I imagine that this is how it works, causes something to be prescribed in a crucial time that is not guaranteed by science, taking a non-scientific recommendation. Where is the fault? It is in the third premise. Because when it is said that chloroquine has no side effects or that it has few side effects, they are referring to young people who have malaria or who have some rheumatic diseases. They are not referring to very serious disease with inflammation of the heart and even other organs, with conditions totally different from the others, which has the enormous potential of sudden death. This relativization of side effects is the weak point of the argument.
When chloroquine left the scene and was banned in the United States, ivermectin remained. - Where does ivermectin come from? It is a vermifuge. used in tick treatment, widely used in veterinary medicine, widely used for this, we prescribe it a lot to treat worm-related diseases. - She also had in vitro studies showing that it had antiviral action. Hence, there was a publication, a single publication, a pre-publication that was going to be made in an important scientific journal, but also a work coordinated by the same company that did that study that was taken from The Lancet. It was a company that was using artificial intelligence to allocate patients for studies through methods that they could no longer replicate. And we don't know if there were bad intentions behind it.
The key to science to control this knowledge that does not follow the rules is that you know how the data was collected and how the population was studied. This study, also pre-published when the company scandal happened, was also withdrawn and is no longer available for download. I have it on my computer. All the knowledge you have is this and the notion that clinical studies are being done with this medicine. And yes, they are, it is even possible that studies in Piauí can also be carried out. But doing a study is different than using it in practice. Especially to make a recommendation - a recommendation - for doctors who have little time to be studying, to be reading these articles. Their tendency is to quickly incorporate it into their prescriptions. They have already incorporated chloroquine, now ivermectin and heparin have emerged.
Heparin is an anticoagulant, and it has a logic in the use of heparin. People who have severe covid experience a state of hypercoagulability in the blood, with an enormous tendency to form thrombi both in the lung tissue and in large vessels, with cases of stroke, infarction, etc. People think that if you use an anticoagulant, you will stop the process, which is also false. First, because there is no study on this. And according to that, this coagulation process is already known for other diseases that also present a state of coagulability, such as meningococcal meningitis, for example. And the use of heparin is very contested, much discussed, in these scenarios.
There is no recommendation by international hematology and hemotherapy societies to use heparin for these conditions. But, people in this scenario of a lot of anguish, a lot of emotion, a lot of politicization, end up prescribing. And that was what the municipality's protocol adopted without any demonstration, with enormous risks that people bleed profusely, be at risk of death with the inappropriate use of heparin, by a study that has not been demonstrated.
This fallacy that - “since there is nothing to do, there is a small chance that it will work, and I presume that there are no effects, so I will try that there” - contributed to the fact that the municipality launched that protocol, which I am very critical. And the next day the study came out showing that prednisone was slightly advantageous for moderately ill to seriously ill patients and what did the municipality do? The following day a protocol was issued extending the use of corticosteroids, dexamethasone, to patients with mild disease. Remember that dexamethasone can reduce the body's defenses, with the risk of transforming a disease that would be mild, through the reduction of cellular immunity, into a devastatingly serious disease, which is why clinical trials are necessary.
We have a principle that is important, that all doctors take into account, which is the principle of not doing harm. And every medicine is bad, the doctor is only authorized to prescribe when it does more good than bad in that specific condition, and if he does not do well in that specific condition, he will surely only do the bad. That is what has to be spread. And it is important to understand that when protocols arise that do not specify exactly where that information comes from, where that advantageous effect comes from, we are selling ignorance.
When I make a statement to my students which medicine he is going to use, I say: "you are going to use this medicine because this happened, the literature says this, and that is published in such a place". This is particularly mandatory in all recommendations from official agencies, this recommendation even escaped the recommendation of the Brazilian Society of Infectious Diseases. When there is an institutional recommendation, the error that would be of a doctor, with the only patient to whom he is prescribing that, or the few patients, will be multiplied by all those who will read that diagnosis.
These protocols have a devastating effect. Remember that in the beginning, here in Piauí, there was a protocol, without any reasoning, only in professor WhatsApp, and it had an effect that has not yet arrived. We are yet to discover the devastating effect this has had. Here comes a prestigious institution, the size of the Municipality of Teresina, composed of people I have the highest esteem, who are colleagues, and I don't know why the mayor was the first to sign. He's not a doctor. Could it be that these colleagues were coerced, by authorities, by their employer, to take these measures?
It is very worrying. I think it is a very serious matter because it defies science, and no doctor is authorized by any medical council to use a drug superfluously, lightly, as it is happening now. He has to have a solid foundation. Let's imagine that we are all patients in the doctor's office, no one is going there to receive an unsubstantiated prescription, we are not going there to receive a batwing and spider web. We are going to trust a doctor who will bring benefits and not a doctor who will bring harm. All of this creates a lot of gravity in this fact, in this recommendation, and challenges institutions.
We are a country in which institutions are very fragile, they have to strengthen and speak out now. It is time for the medical councils to comment on this, on this fact by the Teresina City Hall. But there is this culture of making fun of science, of not giving importance to science, it is necessary, then, that institutions, the Council of Medicine, the Public Ministry, the Judiciary, and people are mobilized.
If you go to the doctor and he prescribes a remedy that is superfluous and has the potential to harm you without his authorization, all patients have the right to sue that doctor and to be compensated for it. We create a rule of law, based not only on institutional actions but also on individual actions. It is necessary for society to react to this because it is a tremendous threat, we are opening the dike of a huge valley, with an institutional stamp, of a very respectable institution. So, there needs to be an action for this protocol to be withdrawn as soon as possible and for us to do it in scientific language, which generates confidence in the population, in the users of the system, and not in illusions.
Sapience – The big problem with anti-science speech is that it comes out of the mouth of people who are in a position of power. How to scale it? Is it possible to have more space for popularizing scientific knowledge? How do you see the Ministry of Health in Brazil?
Dr. Carlos Nery – Science is neutral, it has no political party, in fact, it is violated, it is attacked, by any authoritarian sector. To the right-wing or to the left-wing, wherever there is a dictatorship, science will be the first target of these interests. And now, for economic interests, which are not necessarily authoritarian, it is being violated.
If science says something that is against the interests of A or B, then it will be on the opposite side. We begin to politicize a system in which it is not possible to take a clear position, and it is necessary to remain neutral. Becoming susceptible to all external influences. Science does not live inside a convent, it is susceptible to the influences of society, financing, political modes, etc. But it is still the best system out there. The Ministry of Health does not act technically. As there is a military hierarchy, the ministry gives an order to the military, who prefer to cede their military hierarchy to the violation of the truth than to pass on scientific knowledge to the population. It happened with the previous ministers. When a minister who imposed his military hierarchy on medical advice appeared, which reverberated here in Piauí, the ministry's determination to release chloroquine happened. what they did there, we will do it here, regardless of any type of confirmation or scientific truth.
There is, of course, an anomaly surrounding science and taking it off its axis because of political interests. I would say that chloroquine in its symbology, which comes with all these drugs that come in addition to it, is a scorpion that poisoned science, which is the best system we have today. Capitalism came, which would not have been possible without science, and it has been all these innovations, so much good life. But we are going back to the Middle Ages, to a big setback, due to these interests that are part of a set of economic actions. And then the large-scale philosophers and economists know that we are experiencing a crisis of capitalism, huge, very dangerous, which reduces its replication, and they will not lose replication, the tendency of capitalism, as a system, is to replicate despite people.
Human beings are today secondary individuals in the interests of this great system called capitalism. then comes this use of governments, countries, full control of countries that are part of the capitalist system. What we are experiencing with covid-19, with this whole discussion here, is a small reflection of the aggressiveness of the struggle between capital and human beings. I would say so trying to be a little more philosophical.
Sapience – In a common sense the disease remains a mystery. Why does it manifest itself in so different ways? To what extent has medicine, science, made progress in terms of knowledge about covid-19?
Dr. Carlos Nery – Not so, not so little. Medicine, in these six months of the pandemic, has made extraordinary diagnoses. There has been an admirable advance. In addition, we are able to apply knowledge from another disease. The basis of covid is not unique, it did not appear suddenly, - what we call pathogenesis -, although it has its unique, peculiar characteristics.
For example, this great capacity for thrombosis also occurs in other diseases. Thrombosis in the lung is very much related to covid, but also to severe flu, severe influenza, something very similar to it. This phenomenon of hyper inflammation, of an exaggerated and localized inflammatory response, was known before. Entering a field of a lot, a lot of imagination, I would say that a large part of the inflammatory response is due to immunity, to previous immune experiences, that is, experiences with similar coronaviruses. That cross-immunity seems to exist and that's what the Cell study showed.
We are all used to hearing people say they have bad flu, a headache, a high fever, and either their spouse or children have symptoms of skin marks. So, there is an individual response from each person. This response is linked to several mutations, several proteins that are part of the immune antibody, but it also resides in the main histocompatibility complex. To have an immune response, the attacking microorganism must be swallowed up by the immunity cells, such as phagocytic cells, and it is then digested into small protein fragments, the peptides, which are placed inside the molecule of the larger compatibility system, MHC and then it makes a kind of a valley and a cell called T lymphocyte is presented, which will recognize only that peptide based on the similarity of the genetic identity associated with the response. So, each individual has his MHC, which is peculiar to him. Recognizing that peptide is able to mount a specific response to it. That's how immunity is done.
As each peptide depends on each presentation of antigen, if the presentation is well done, that is, if the physical force of interaction between the CD4 lymphocyte and the cell is high, the response is efficient. Therefore, there is a possibility that the response of the coronavirus is not mediated only by the experience of previous immunities, but also by the genetic peculiarity of each individual. We still don't have the answers to every question about the behavior of the virus, but compared to other diseases, the thing is more or less repeated, like influenza, for example, the same people who are at risk for covid are at risk for influenza. There is something that is in common with these diseases that we do not know yet, we are still learning and we will certainly learn. Science is fascinating!
Sapience – How are the virus mutations? Can you explain a little about that?
Dr. carlos Nery – It is a very interesting question and the subject of very intense studies to try to clarify the virus genome, the nucleotide RNA sequence, and the host response or transmission, but there is no conclusive answer yet. Several studies have suggested that they have different variants. In Brazil, they have many variants, but there is no conclusive study to say which variant has the highest transmissibility or which has the greatest severity of the disease.
Sapience – Is there a possibility that pandemics will become more common in the future?
Dr. Carlos Nery – Well, this is the period of emerging and reemerging diseases. As we saw in the 1970s, scientists said that infectious diseases were going to end, and then there is the first and a set of diseases that came forward. What is that due to? Diseases have always emerged, this is not new, they are often acquired from animals that are in the environment or from people through mutations or through other origins that are not necessarily microbial.
For example, an emerging, very serious disease that we pay little attention to is motorcycle accidents. It is a clearly emerging, lethal disease that, as it is not caused or transmitted by a mosquito, we do not attach much importance.
And others will come. Global warming will come with all its diseases, diseases due to physical causes, landslides, floods, new mosquitoes appearing, new microorganisms. All of this is inevitable and will happen in the short term.
But we have important milestones, one that we can underline was the fall of the Soviet Union. Despite all the problems they had, of developing a dictatorship on account of the communist regime, there was a barrier to the deranged liberalism that we are experiencing today. The fall of the Soviet Union was very serious, all public health was dismantled, all over the world, it was not only there in those countries that had really serious economic crises, but the whole world relaxed public health measures, making it easier for these controls to have been diminished.
And we also have the mass destruction of the environment, destruction of trees, invasion of natural spaces, populations growing and migrating with a lack of regulation and all this added to immense mobility of the population, causing disease to quickly spread across the globe, as we saw now with the covid-19.
Covid-19 will not be the last lethal disease that humanity is experiencing. We went through the bubonic plague in the 14th century, when millions of people died. We have never had anything of this magnitude again, but nothing prevents another pathogen from appearing for which we do not have treatment at a skillful speed and humanity can suffer these situations again. It is necessary to re-discuss the return to public health, the means of prevention, to confront the giant, this monster that swallows us up, which is wild capitalism and which is taking the place of human beings. We need to have a macro, global, social, and defensive measure of human beings, regardless of ideology, and to monitor borders, reduce aggression to the environment. We need to learn from this moment of cooling the economy when the land is cleaner, and the deterioration in the environment has decreased a lot, that the mobility of the population has decreased a lot, is it possible to live with such a scenario?
We have to reinvent the future with this new normal, not just being a new normal, using masks or a certain distance, but really reducing this monster that threatens our entire planet.
¹The Transamazônica, or BR-230 highway, was built during the government of Emílio Garrastazu Médici, between the years 1969 and 1974. A work of great proportion that became known as a “pharaonic work”.