“I'm sorry to cause you so much trouble”

MSF’s Dr Raquel Simakawa, working in an emergency shelter in the Brazilian city of São Paulo, asks who the real villains are in the fight against coronavirus.

"I'm sorry to cause you so much trouble." I lean over the table to be sure of what I just heard in that timid voice coming from behind the mask: "I'm sorry to cause you so much trouble." I  breathe in sharply as I look at the man in his 60s, with the wheezing of someone whose oxygen saturation levels are below 90%. He has been in this condition for three days between comings and goings from the emergency room. Time and again he was treated without dignity: a man who clearly needed inpatient care—who needed at the very least to receive oxygen—was discharged from hospital.

The man is one of more than 50 patients in one of the emergency shelters in São Paulo where I work as an MSF doctor. These are spaces created so that people with suspected COVID-19, experiencing mild symptoms, can isolate themselves from others.

Patients with mild symptoms are instructed to remain isolated at home and to seek medical care at any sign of their symptoms worsening, just as they did for my patient. But such these recommendations are difficult to follow when you are homeless, when you sleep in the street or in a reception centre, as is the case for more than 24,000 people in the city of São Paulo.

The latest census, conducted in 2019, reveals that 85% of the city’s homeless are men; more than 65% are black; and 46% are between 31 and 49 years old; while 386 people identified themselves as trans. Chemical dependence and a high prevalence of tuberculosis are just two of the many difficulties faced by this population group.

The recommendations are difficult to follow for various reasons, including the impossibility of self-isolation when you sleep on the street, or in a shelter, or in a room with four or five others or more. There is also the cruel neglect and prejudice with which this group of people—already invisible before the pandemic—are often served by the health system.

It is not the virus alone that has caused all this suffering; the virus is not the only enemy to be fought on the frontline, in those questionable analogies to war and superheroes. The man I am looking at is living proof that there are other villains here, including social and economic inequalities. How is it possible that an elderly black man, sick and homeless, feels that he is causing "trouble" to health professionals who are only doing their jobs?

The scene makes me realise that we, as health professionals, should not be the only ones on the so-called frontline. The real frontline should be made up of the whole global community, which needs to create a fairer and more egalitarian society for all, without excluding anyone.

I breathe out again and try to make it clear to the man—perhaps more for me than for him—that this care is his right.

In response to the COVID-19 outbreak in Brazil, teams from Médecins Sans Frontières/ Doctors Without Borders (MSF) are supporting vulnerable people in the city of São Paulo, including the homeless, elderly people in care homes, residents of impoverished neighbourhoods, drug users and teenagers in detention. MSF teams are involved in health promotion activities, performing screening and medical consultations to detect people infected with the virus and transferring patients with severe symptoms to hospital.