In praise of SUS: Brazil’s national health system
Today I write in praise of Brazil’s Sistema Unico de Saúde (SUS), Brazil’s national health system, based on a recent personal experience (spoiler: happy ending, I am alive and well). Created in 1989, it is the largest government-run public health system in the world. The primary care-based network serves virtually all of Brazil’s population, both citizens and people like me with residency. SUS’s span is awe-inspiring, covering 214 million people and 3.3 million square miles. Don’t be fooled by the distorted Mercator projection of the globe, Brazil is larger than the continental United States.
The SUS is challenged, just like all national health systems including the UK’s NHS. In the UK the conservative government has inflicted an attempted death by small lacerations, while blaming GPs (primary care doctors) for various perceived shortcomings. In Brazil outgoing president Jair Bolsonaro frequently floated the idea of privatizing SUS, and as I write this his allies in the legislature are playing a game of financial chicken, refusing to raise the debt ceiling and potentially leaving not only SUS but family assistance programs and public universities unable to pay their obligations.
Brazil has a widespread and robust private insurance system, and anyone with means or a desirable job has a health plan. But even the affluent depend on SUS, in the case of emergencies where they need a trauma center, for example. And over the years I have been amazed by the quality of cancer treatment, where the system provides drugs that Americans often have trouble accessing because of cost and their insurance plans’ limitations.
I recently had a front-row seat to a SUS emergency department in Brasília, due to an accident. It was dumb, and as my son said, “Mom, you should have known better.” Correct, unfortunately. It was the evening before I was to fly up to Ilhéus, Bahia to spend beach time with friends, and I was getting organized and doing laundry. The laundromat is in another building from the flat I’m renting, and I needed to get the clothes out of the dryer, but a huge thunderstorm let loose. When it stopped raining, I went to get the laundry. My errors: not paying attention and walking like an American. Striding through the lobby of my building I hit a little lake left by the rainstorm, hydroplaned and went down smack on the back of my skull. I didn’t lose consciousness, but stars were popping out of my eyeballs and little birdies were tweeting around my head. A couple of guys were nearby and helped me up.
I went back upstairs to my flat and sat down to collect my thoughts. I had to get the laundry. And I had to go to the emergency department. I had huge goose eggs on the back of my head, and I could feel what I thought was an indentation. Oh, and I had a wicked headache. No visual disturbances, no other symptoms. But as a clinician I am only too aware that someone my age (ahem) can develop bleeding between the bony cranium and the brain with even less of a blow than I’d sustained.
A trip to the emergency room was not on the list of what I planned to do in Brazil, but it was a necessary evil. Based on my experience in the US, I thought I would be there all night. And I had to be at the airport at five AM to catch my flight, assuming I was cleared medically. So I went (carefully) to get my laundry out of the dryer, organized and packed my carryon bag, closed up the flat and called an Uber.
My destination was Hospital de Base, the major public hospital in Brasília. I walked in and took a ticket and was called promptly. The staff member quickly found me in the computer, as I’d gotten a Covid vaccine booster at a local health center earlier this year. I was given a wristband and asked to take a seat. A triage nurse called me back just a few minutes later. After taking a brief history, she told me to walk down the sidewalk to the next building and check in at the trauma department. Backpack on my back and rolling my carryon, I headed over to trauma.
I was shown where to sit and sat down ready to wait for hours, but to my amazement just minutes later a doctor clad in jeans, T-shirt and athletic shoes came out to see me. He briefly assessed me via conversation and observation (perfectly acceptable and no time wasted) and told me not to worry, they would do a CT scan.
About 20 minutes later a staffer came to transport me to the CT scanner, sitting me in a wheelchair where I perched my carryon and backpack on my lap. It was an interesting ride through long corridors and down elevators, and at CT I waited about 20 minutes. They took me in and did the imaging, and I was transported back to the trauma area.
Back at trauma things had heated up, with several ambulance staffers having brought in more trauma victims who waited on gurneys with their cervical spines secured. They parked me and my wheelchair among the waiting patients and as a public health, health care delivery and policy nerd I settled in to observe the goings on.
As mentioned, the doctors were dressed casually and moved efficiently and calmly. The ambulance technicians were dressed in orange jumpsuits emblazoned on the back “bombeiros” (firefighters and emergency workers) with black boots, knee pads and shin guards. Several wore helmets and visors, and the women had their long hair back in braids. Other staffers wore scrubs in various colors. What struck me most was the remarkable level of camaraderie and respect, with no visible signs of hierarchy. Everyone listened to everyone else, everyone doing their job with friendly banter sprinkled in.
I can imagine some reading this will think, “Well, you are a high-end patient, so you were treated differently.” First, I didn’t flash my credentials at any point. Technicians and nursing staff were respectful and warm to every patient I saw them interact with. A man on the gurney next to me would have not so long ago in the US been uncharitably described in the medical record as “disheveled,” and the yellow liquid in his IV bag indicated a concern about alcohol and the need for thiamine supplementation. I watched the nurse put in his IV, treating him with utmost tenderness and concern and calling him “meu amor,” as she explained what he could expect. “My love” is a phrase Brazilians commonly use with each other, but in this exchange and every other I witnessed, patients were treated with genuine caring, and yes, love.
The hospital itself was shabby and badly in need of a new coat of paint, with damaged furniture and old desktop computers. If I were a typical American I would recoil in horror at the appearance of the facility. Patients and staff alike deserve a nice modern building and all the latest equipment. That makes it all the more remarkable how well they do their jobs, how competent and kind they are, the quality of care they deliver despite the challenges. Maybe it was the bump on my head, but I found myself in tears with admiration for the people that make up SUS, and sadness at how poorly we so often do in the areas of patient experience in the US, despite all our rich resources.
After a wait of about an hour, the doctor came out and told me the CT was clear and I could leave. By that point I was feeling a little guilty for taking up resources, and I asked him if he thought I had been right to come to the trauma department after my injury. “Corretíssima,” he replied. “Very correct.”
Total time spent: two hours, door to door. Back at my flat I slept for a few hours before heading to the airport with a bad headache but reassured that I wasn’t bleeding into my brain.
How much did I have to pay? Nothing. SUS is a public good, like the interstate highway system in the United States. What would I have paid in the US for the same problem? Conservatively, at least $10,000 without insurance, and a hefty copay even with good insurance. Once again, the US could learn a lot from Brazil.