Brazil: the riches and the risks
Brazil is the largest country in South America attracts around five million international visitors each year. David Kernek reveals the nature of assistance services in the country and how well equipped the hospitals are for dealing with international patients
First published in ITIJ 126, July 2011
Brazil is the largest country in South America attracts around five million international visitors each year. David Kernek reveals the nature of assistance services in the country and how well equipped the hospitals are for dealing with international patients
Brazil offers unmatched natural beauty, thousands of miles of to-die-for beaches and some of the world's most exciting cities; and as an emerging economic superpower, it will soon be hosting two of the planet's biggest sports events – the 2014 football World Cup and the 2016 Olympics. But a struggling public health sector and the high cost of private emergency services makes medical and repatriation insurance essential.
Safety first
Holiday and business travellers preparing for their first visit to Brazil – and assessing the scope of the insurance cover they might need – would do well to avoid relying entirely on the encouraging overview offered by the Brazilian embassy in London. While conceding that ‘just like in London, Paris, New York or any other major metropolitan and tourist centre, petty crime in Brazil is an unfortunate fact of life’, the embassy’s information website attributes security fears to ‘urban myth’. It says that this vast country – the world’s fifth largest by both population and geographical area – ‘including the main cities of Rio, Salvador and Sao Paulo, is no more dangerous than anywhere in Europe or North America and violent crimes against tourists or foreign visitors are extremely rare, hence the headlines if they do happen’.
Extremely rare? The US government’s Bureau of Consular Affairs takes a somewhat less sanguine view. “Crime throughout Brazil,” it says, “has reached very high levels. Brazilian police and media report that the crime rate continues to rise, especially in the major urban centres, though it is also spreading in rural areas. Brazil’s murder rate is more than four times higher than that of the US. Rates for other crimes are similarly high.”
Tourists for whom we are responsible are always directed to private hospitals and clinics, where the standards of care, hygiene and technology are comparable to the best hospitals in the USA and Europe
The UK’s Foreign and Commonwealth Office’s (FCO) travel advice strikes a similar tone: “Levels of violence and crime are high. Shanty-towns – favelas – exist in all major Brazilian cities; they are characterised by poverty and extremely high levels of violent crime. Do not venture into a favela even with well-organised tours, as favelas can be unpredictably dangerous areas. Outbreaks of violence, particularly aimed at police and officials, can occur at any time and may be widespread and unpredictable.”
The ‘be very cautious’ theme is echoed in the advice given by the Canadian Foreign Affairs department. “Travellers should exercise a high degree of caution in Brazil due to high crime rates and regular incidents of gang-related and other violence.” Canadians are advised that drug and other illegal trafficking make remote and largely uninhabited border areas dangerous, and that ‘robberies involving tourists occur regularly, even during the day, and are sometimes violent’. They are urged to avoid unsupervised beaches and to ensure that their hotel is ‘totally secure’. “Foreigners,” they are warned, “have been victims of sexual assault.”
Tourists are not immune from the increased risk of mugging at festivals, carnivals and big sports events, and visitors who think they would be safe on four wheels should take the car-jacking into account. A 19-year-old Brazilian soccer star was murdered while resisting a car-jacking attempt this year, and in 2010, an attack on a car taking England’s Formula 1 ace Jensen Button to his Sao Paulo hotel highlighted a crime wave that is said to be twice as high as South Africa’s.
Car-jacking aside, the FCO says that ‘Brazil has a high road accident rate’, while the US State Department’s assessment is somewhat blunter: “Brazil's inter-city roads are widely recognised as among the most dangerous in the world.” The UK’s road death toll of 3.8 per 100,000 people compares with estimates ranging from 18.3 to 21.3 – approximately 35,000 each year – in Brazil.
Furthermore, health and safety considerations for plucky, nature-loving holidaymakers heading for the Amazon Basin River and the Panatal – the planet’s largest freshwater wetland accessed only by small planes, motor-boats or a raised dirt road – include malaria, dengue fever and yellow fever, all caught from mosquito bites. Experienced tour guides can be relied upon to keep tourists at a respectful distance from jaguars and anacondas, if not poison arrow frogs, some species of which pack enough venom to kill ten to 20 humans. So, what kind of medical facilities are available to those in need?
Medicine matters
The emergency health services that sick and injured foreigners might need mirror the severely lop-sided nature of the Brazilian economy. It’s a familiar Third World-story of public scarcity and private abundance.
“We are the world’s seventh-largest economy,” says Cristovam Buarque, a professor at the University of Brazilia and a former minister of education, “but 22 per cent of our population lives without running water and more than half without sewers. Forty-three per cent of Brazilian homes – 25 million – are not considered adequate for habitation.”
Brazil’s state-run hospitals – which provide emergency treatment for foreigners free of charge, but only up to the point of stabilisation – have been studied in depth by Dr Christina Bloem, founder member and vice president of EMEDEX International, a New York-based organisation that promotes emergency medicine, disaster management and public health. Brazilian governments, she says, have attempted to improve emergency care to cater for an increasing number of victims of road traffic accidents and violence, as well as the overcrowding of emergency departments. “But emergency services still lack a consistent standard of care. Since 50 per cent of medical school graduates in Brazil do not get residency positions, these new physicians with minimal clinical training look for work in emergency departments. In non-tertiary care centres – the majority of hospitals in the country – emergency department physicians are largely under-trained, underpaid and over-stressed by their working conditions. This has compromised patient care and created an incredible need for improvement in the emergency care system,” said Dr Bloem.
In addition, long waiting times, a lack of medical equipment – and often air conditioning – and few, if any, English-speaking staff are features of many of Brazil’s public hospitals, even though they account for more than two-thirds of the government’s entire health budget. The country’s best private hospitals and clinics, however, are world-class, helping to make Brazil a major medical tourism destination: high quality cosmetic surgery – everything from nose jobs and tummy tucks to thigh lifts and sex changes is available – is a booming industry in Sao Paulo and Rio, with approximately 400,000 procedures a year at costs 30 to 70 per cent lower than those in the US.
“Despite the existence of some very good public hospitals, most of them suffer from overcrowding and lack of governmental investment, which reduces medical assistance and hygiene to a low quality level,” says Dr José Sallovitz, medical co-ordinator for Mondial Assistance Brazil (MAB). “Tourists for whom MAB are responsible are always directed to private hospitals and clinics, where the standards of care, hygiene and technology are comparable to the best hospitals in the US and Europe. The only exceptions are in areas where there are only public hospitals. In those cases, if it is necessary after the first evaluation, MAB provides transport to a private hospital."
At the same time, while Ruy Vasconcellos of MAPFRE Asistencia says care standards in public and private sector hospitals are ‘very similar’, Dr W. Jorge Kalil, medical director of AXA Assistance in Sao Paulo, points to the private health sector as being ‘one of the best in the world, with hospitals of an international standard of excellence’. State hospitals of a similar standard can be found in some states, he says, ‘but tourists are usually taken to private hospitals, except when none are available in the area’.
International SOS has audited multiple healthcare facilities in Brazil, says its Americas region medical director, Dr Robert Quigley. “There is a wide range of standard of care, dependent primarily on location. In remote areas, facilities are often primitive, or there are none at all. In major cities, they can be equivalent to those in developed Western regions,” he says.
All of Brazil’s major cities have private hospitals capable of handling trauma cases. The two that appear on all three of the ‘best’ lists provided by MAPFRE Asistencia, Mondial and AXA are in Sao Paulo – Sirio Libanes and Hospital Israelita Albert Einstein. Mondial’s Dr Sallovitz describes them as ‘the best in the country’. The Albert Einstein is the hospital of choice of expatriates who have sufficient health insurance cover. Currently being expanded from 485 to 700 beds, it has pioneered minimally invasive and robotic surgery in Latin America.
Private hospitals of note in the Amazon region are Porto Dias in Belem on the Atlantic coast, and the 81-bed Santa Julia 1,064 miles distant at the very heart of the Amazon Basin in Manaus. The Santa Julia has 12 emergency and six intensive care units, and one team of English-speaking doctors. It also stocks – perhaps unusually for a private hospital – anti-venom for snake bites. The ‘must-know’ information given to field staff on a biosphere project in Amazonia cautions: “Public hospitals are usually the only hospitals that have anti-venom for poisonous snakes and other venomous animal bites. The Secretary of Health for each state furnishes anti-venom for public hospitals first. Since the supply is limited, they often cannot furnish anti-venom for private hospitals.”
Brazilian governments, she says, have attempted to improve emergency care to cater for an increasing number of victims of road traffic accidents and violence, as well as the overcrowding of emergency departments
Language barriers are likely to be insurmountably steep in most public hospitals and in remote areas. The FCO says that tourists who are attended by local emergency services are usually are taken to public hospitals, where they are entitled to emergency assistance. The main issue raised in these cases is the communication problem, as most of the medical staff do not speak English. Only large private hospitals have English-speaking staff, says Dr Kalil. Dr Sallovitz says hospitals that also cater for foreign patients seeking elective surgery will certainly have multi-lingual staff from the attendant to the treating doctors.
Money matters
None of the major assistance organisations that ITIJ spoke to report significant problems with payment – either over-charging or asking for cash up front – for the treatment of insured patients, although Dr Quigley warns: “Individual practitioners can charge whatever fee they want to a sick tourist. There are no regulations in Brazil that dictate fees. As is the practice in most developing countries, medical services in Brazil must be paid up front,” he says. “Corruption is limited when services are procured and paid for by an organisation such as International SOS which has established a relationship with the provider.”
“When there are such problems,” says Dr Kalil, “AXA Assistance has staff members who specialise in resolving the issues.” Mr Vasconcellos reports that hospitals used by MAPFRE Asistencia are ‘professional and reliable at all times’.
Dr Sallovitz explains his network’s payment procedure: “When Mondial sends a patient to a hospital, there is always a guarantee letter that goes with him or her. The letter specifies the services that are covered at that time. If there is a need for admittance and additional treatment, the hospital sends a report to Mondial and the guarantee amount is raised as necessary. Sometimes, depending of the severity and the patient’s limit coverage, there may be problems over payment.”
So, what sort of treatment costs are uninsured foreign patients in private hospitals looking at? Dr Kalil estimates them at ‘somewhere between those charged in France and the US, and similar to the cost of the private sector in Germany’. Mondial’s Dr Sallovitz says: “The cost in the best hospitals is often more expensive than for the same service in Europe, but is normally much lower than American levels. The total bill for treating a non-complicated acute appendicitis in a good hospital would be approximately US$10,000 (GB£6,160).
When in need…
Depending on where uninsured foreigners are in Brazil when misfortune strikes, getting to a hospital – or back to Britain on a repatriation flight – is likely to be even more expensive than medical treatment: a 1,000-mile private air ambulance flight will cost around US$23,000 (GB£14,166), and a stretcher repatriation with a medical escort on a scheduled flight to the UK, approximately US$22,00 (£13,550).
The Serviço de Atendimento Móvel de Urgência (SAMU) is the country’s state-funded medical emergency response service, equipped with land and air ambulances carrying, if needed, intensive care equipment and crewed by doctors and nurses. It is, however, free only to Brazilian citizens, it takes patients only to public hospitals, and it is not known for speed or reliability.
What help can foreigners in trouble on the country’s 4,600-mile coast, in the Panatal or the 2.7 million square miles of Brazil’s share of the Amazon rain forest – in which the Amazon itself is the main road – expect? “The more remote the area, the more challenging the evacuation is likely to be,” says Dr Quigley at International SOS. “Deep in the Amazon region, near the Peruvian and Bolivia borders, there are neither airstrips nor roads. Rescues may be possible only via water craft.”
“Tourists tend to like places such as the Amazon – where access can be extremely difficult – and empty beaches,” says Dr Kalil. “This can sometimes hinder an emergency evacuation.” Mondial’s Dr Sallovitz adds: “There are no government services to rescue or transport injured tourists from remote areas, unless there is a calamity situation such as floods, in which case the army will provide that service. But there are many private air ambulance companies who do that kind of job with great expertise.”
Furthermore, clear, warm water and an estimated 3,000 wrecks make Brazil's 4,600-mile Atlantic coast a powerful magnet for serious scuba divers and snorkellers, the most favoured spot being Fernando de Noronha, a group of islands north of Recife. It is a marine life sanctuary, and recommended for year-round diving. There are also good sites within short drives of Rio and Sao Paulo.
Deep in the Amazon region … there are neither airstrips nor roads. Rescues may be possible only via water craft
The more remote the dive site, the further away are medical centres with hyperbaric chambers. A report from the US-based Undersea and Hyperbaric Medical Society identifies 65 coastal centres with mono- and multi-place chambers, 56 of which are privately-owned, with nine run by the Brazilian navy. "There are many hyperbaric chambers spread around the country – Sao Paulo, Rio de Janeiro, Salvador, Recife and many other cities," says Dr Jose Sallovitz of Mondial Assistance. "But they are not really close to most of the diving regions. Brazil has more than 4,000 miles of coast, which makes it impossible to be close to a specific place all the time."