More than 3.5 million health professionals work for public health care in Brazil today — six times more than when SUS was created in the 1980s. But over recent years, the system has been facing a persistent shortage of doctors and an increase in informal and outsourced health workers. Professionals mention low remuneration, difficulty in accessing quality equipment and materials, and precarious employment relationships as the main barriers to work in the public sector.

During the pandemic, the situation was exacerbated. The lack of protective equipment for professionals in various units left them exposed to coronavirus contamination. In March, at the beginning of the spread of the virus in Brazil, 1,374 nurses filed complaints about a lack or shortage of personal protective equipment to the Federal Nursing Council and 1,500 doctors to the Federal Council of Medicine. In Rio de Janeiro, doctors, nurses, and technicians from several health units have also worked without receiving a salary amid the pandemic.

Nutritionist Rosana Macedo has worked in the public health system throughout her whole career. “The entire population should get good service,” she said.

Macedo works at both CTAC and another public hospital in Rio. Despite financial constraints, she enjoys her work and believes publicly funded clinics can provide quality treatment, a mission she pursues since she became a nutritionist almost three decades ago. “I've always wanted to work with people who are assisted by public health care,” she said. “The entire population should get good service.”

But the COVID-19 outbreak made her daily life more challenging. “I’ve never worked as hard as in this pandemic,” she said. While working long hours to ease families’ anxiety, Macedo and her husband, 62-year-old Ricardo Luiz, also had to take care of the family and chores at home.

Her daughters, Júlia, 17, and Luiza, 8, faced difficulties in adapting to online classes and felt emotional distress. Júlia, soon to start college, demonstrated anxiety stemming from her indecision to choose a career path, and Luiza missed her friends who often visited her at home.

Macedo also struggled. As activities at the hospital continued in person, “my biggest fear was to infect people I love who are at-risk groups,” she said. These include Luiza, who is asthmatic; Júlia, with low immunity due to stomach problems; Luiz, with bronchitis; and her old and sick parents. “I did my best to adhere to the quarantine regulations, and I stayed away from family members who do not live with me,” Macedo said. The workload at home was heavier too, and she had little time to herself.

Pediatrician Sonia Paredes explains how CTAC's multidisciplinary environment provides comprehensive care for cleft patients.

CTAC is a public unit offering surgical and clinical services for free, of which 90% are for low-income patients. “We offer, in public care, what we would have at the best private hospital,” said Henrique Cintra, a plastic surgeon and head of CTAC.

For Cintra, this is a result of a team of dedicated and qualified health professionals, management without political interference, and Smile Train’s support. The clinic serves both Rio residents and those from neighboring cities and states — including the municipalities of Magé, São Gonçalo, Petrópolis, and Teresópolis, and the state of Espírito Santo.

By mid-August, CTAC had restarted its activities, offering fewer appointments to adhere to lockdown regulations. Delayed surgeries have been rescheduled. But health workers are not abandoning telecare.

“Patients are still looking for us to have online consultations,” pediatrician Sonia Paredes said. “They liked it. It is practical. They don't need to leave their homes, don't need to be afraid of the pandemic.” And Smile Train’s Camila Beni Ferreira, program manager in Brazil, expects to keep incorporating telecare in routine appointments. “It could help to close the geographical gap,” she said.

Henrique Luiz de Jesus Sacramento and his parents returned to in-person appointments at CTAC when the clinic reopened in mid-August. Henrique went on to have a successful cleft lip and palate surgery in early September.

Duarte and Moraes were excited to bring Kalebe to his first in-person appointment with Macedo. “My heart is beating fast,” Duarte said. “We will go through surgery, and everything will be alright. And Kalebe will have the mark to show what he has overcome.”

Despite her dedication, Macedo looks forward to a break. “Holidays would be welcome,” she laughed. But she knows she can’t stop now. In the meantime, she has been more cautious during consultations, trying to touch patients as little as possible. She uses gloves and masks and asks the parents to place their babies on the scales themselves, but she admitted it is difficult.

“Brazilians like to touch; we miss that. But we can smile with our eyes, exchange kind words, and say that we miss them,” she said. ■