In defense of the Unified Health System in the context of SARS-CoV-2 pandemic

Objective: To discuss the political and structural conditions for establishing the Unified Health System (UHS – Sistema Único de Saúde, SUS) in coping with the SARS-CoV-2 pandemic. Methods: Theoretical-reflection study. Results: At the first moment named “The global and the local in facing the SARS-CoV-2 pandemic” is presented the health crisis that took place worldwide and the government actions to combat COVID-19. A second moment named “Between dismantling actions and resistance, the UHS is the best way to face the SARS-CoV-2 pandemic”, reflects on the neoliberal attacks on the health system and how it resists, remaining the main pandemic response strategy. Conclusion: The strengthening of democracy and the defense of the UHS are the way out of the crisis. It is believed that this reflection generates - in everyone who deals with caretaking - the political action, the ethical attitude, the desire for valorization and the spirit of struggle in defense of the UHS and human life. Descriptors: Unified Health System; Health Policy; Pandemics; Global Health; SARS Virus. RESUMO Objetivo: Discutir as condições político-estruturais de efetivação do SUS no enfrentamento da pandemia por SARS-CoV-2. Métodos: Estudo teórico-reflexivo. Resultados: No primeiro momento, intitulado, “O global e o local no enfrentamento da pandemia SARS-CoV-2”, apresenta-se a crise sanitária que se no mundo e ações o à COVID-19. segundo momento, ações desmonte resistência, SUS melhor enfrentamento pandemia


INTRODUCTION
The Unified Health System (Sistema Único de Saúde, SUS), seen as a public policy of social character, thought, and idealized by the Brazilian Health Reform, in its 30 years of existence has brought advances regarding the confrontation against population's health problems, despite the constant attacks suffered in the political, ideological and financing arena, which prevent its solvability and operationalization according to its principles and guidelines (1) .
Perhaps, the greatest legacy of advances provided by the SUS has been the idealization of health surveillance as the backbone of the system management. In this case it is noteworthy The National Immunization Program, considered the largest worldwide, for inducing the immunobiological self-sufficiency produced by Brazilian public and private laboratories. In these 30 years, the primary health caretaking has shown robustness and improved access to basic services, provided, primarily, by health municipalization, local health management, transferring federal funds directly to other financial spheres, and training health professionals to work in this niche, since around 60% of the Brazilian population is attended by the Family Health Teams. Through the SUS, we have advanced in the development of health information systems, epidemiology, local health systems planning and planification, important monitoring tool, health policies planning and evaluating, plans and health programs (1) .
It is worth to emphasize the performance of the SUS in implementing confrontation actions, at different care levels, in a coordinated management action, to respond to the International Public Health Emergency in the face of the Zika virus and its relationship with an outbreak of microcephaly. It is also worth mentioning the prevention / control actions for arboviruses (dengue fever, chikungunya virus), influenza, H1N1 influenza and, more recently, measles, among others. Today, the SUS stand facing yet another challenge, combating the global health crisis imposed by SARS-CoV-2, the virus that causes COVID-19. The pandemic forces administrators, health professionals, health training institutions, and the society at large to (re) think the role of the SUS, the right to health and the obstacles imposed for its effectiveness considering the regional differences in the country's territory (12) .
For the health administration, the SARS-CoV-2 pandemic draw our attention in the harshest way, while imposing, in face of uncertainties, the lesson to the national/regional/municipal public health systems. There is an urgent need for responsibility as an ethical principle of management so that, in a shorter period of time, we can implement innovative and resolutive strategies and arrangements; it is up to health administrators to assume their role in making political-economic-health decisions that guarantee the indispensable conditions for the SUS to function properly at all levels of caretaking.
It is in this scenario of crisis, insecurity, uncertainties, shared by the global health, that we ask: How is the SARS-CoV-2 pandemic being addressed in Brazil in terms of following the recommendations of international health organizations? How, amidst the weakening of Brazilian democracy, can the SUS play its role as a public policy, guaranteeing health for all, according to operational principles and guidelines?
In search for answers, even if temporary ones, this theoretical reflection is presented. The topic becomes relevant as it allows (re) thinking about how the rapid economic and social changes, provoked by the global health crisis, will reflect on the SUS response capacity.

OBJECTIVE
Discuss the political and structural conditions for establishing the Unified Health System (Sistema Único de Saúde, SUS) in tackling the SARS-CoV-2 pandemic.

Global and local arenas facing the SARS-CoV-2 pandemic
In December 2019, an outbreak of pneumonia associated with a new coronavirus occurred in China, considered then to be of probable zoonotic origin. The hypothesis was that the "new coronavirus" had crossed animal species to infect humans, just as it happened with SARS-CoV and MERS-CoV. Analyzing samples from seven infected patients were reported the identification and characterization of 2019-nCoV, scientifically named SARS-CoV-2, which causes the COVID-19 disease (3) .
The work relationship presented by the first infected with the Wuhan Seafood Wholesale Market, in the province of Hubei, whose space was also used for sale of live wild animals, associated with the spread to the resident population, raised the alarm to the health authorities, who, on December 31, 2019, reported the situation. On January 1, 2020, as a prophylactic measure, the market was disinfected and closed. On January 9, 2020, the first death by COVID-19 was confirmed. Human-to-human transmission took proportions never seen in previous outbreaks by other types of coronavirus already known. The epidemic, which started on December 12, 2019, caused 2,794 laboratory-confirmed infections, including 80 deaths by January 26, 2020 (3) .
On January 21, 2020, the World Health Organization (WHO) reported its first bulletin to the global community, notifying the occurrence of 282 cases of SARS-CoV-19 in four countries: China (278); Thailand (1); Japan (1) and Republic of Korea (1), unit cases exported from the city of Wuhan (Hubei, China) (4) .
In that same WHO bulletin (01/21/2020), the Chinese national authorities informed the preventive / control measures which had been taken: use of infrared thermometers at the borders; expanded search for additional cases inside and outside the city of Wuhan-Hubei; active/retroactive search for cases in health institutions; inspection of other markets; strengthening public education on disease prevention and environmental hygiene in public places and farmers markets (4) .
Meanwhile, the spread of SARS-CoV-2 to other countries/ territories has become a reality for global health. On January 30, 2020, the WHO declared a Public Health Emergency of International Importance (ESPII). The follow-up of February/2020 and March/2020 proved the high speed of human-human transmissibility; in that period, more than 200 countries and territories, on different continents, reported positive cases of SARS-CoV-2. Mortality has risen in countries like Italy and Spain, causing a humanitarian crisis, as well as commotion and fear across the planet at the news that ran in the West through the media and social networks (4) . On March 11, 2020, the SARS-CoV-2 pandemic was declared by WHO. Its effects spread to the global community, which has since then been immersed in social, economic and health instability. The unpreparedness of globalized societies, highly connected through social networks, has erupted. The feeling of impotence, at first, together with its accentuation by the dissemination of false information about various aspects of the nature of the virus and the disease it produces are examples of the consequences of a new coronavirus, whose illness has no effective drug treatment, nor vaccines. for immunization. Although simple flu prevention measures in general are recommended, such as hand washing and social etiquette, to prevent the human-to-human transmission of SARS-CoV-2, our customs, values, culture and individual and collective behaviors have prevented us from taking a new stance in the face of the pandemic and its risks, placing us in vulnerability (4) .
To contain the pandemic, WHO requested, and several countries adopted, measures of social isolation and mitigation to reduce the spread of SARS-CoV-2. At this time, it would be appropriate to take global health actions to prevent the growth of positive cases, popularly referred to as "flattening the epidemiological curve". The WHO recommendations aim to reduce contagion, the risk of overcrowding in health services, which will allow more time for national health systems to organize themselves to care for sick people and, above all, to activate research and development projects to speed up effective diagnostics, vaccines and therapies (4) .
The pandemic calls for global cooperation and coordination of health management within nations. The lack of knowledge about the nature of the new coronavirus, the lack of rapid diagnostic tests, effective therapies, and vaccines, require the transcendence of transnational borders. Isolationism and exacerbation of the protectionist nationalism of governments or blocs -especially rich countries -will not shed light on this challenge that afflicts humanity (5) .
The moment of global health crisis requires real dialogue, leadership, and humanistic ideals; confidence in accumulated scientific knowledge and in the human capacity to reduce problems and seek solutions. It demands collective and cooperative attitudes among peoples/nations so that lives are preserved. To continue, in the name of the ultimate expression of national state sovereignty, with necropolitics dictating who can live and who should die, usually practiced throughout world history for the purpose of maintaining power, accumulating wealth and capital, is not the right choice -"Save the economy or save lives?" shouldn't be the central issue to be raised at this point (5) .
The context of the SARS-CoV-2 pandemic required the federal government of Brazil to respond through concrete actions to the global health agenda conducted by WHO. As a first response, it determined the repatriation of Brazilians residing in Wuhan-Hubei, epicenter of the origin of the outbreak. In a coordinated action, which required diplomacy, expertise in epidemic control, Brazilian Air Force (FAB) planes left on February 7, 2020 to transport 58 Brazilians (between residents and crew) back to Brazil. The repatriation required the imposition of quarantine until February 26, 2020 and the follow up of contingency protocols for travelers (2,4) .
The notification of the first positive case by SARS-CoV-2 in Brazil (although recently the thesis of the first case appeared in January) referred to a 61-year-old man, living in São Paulo with a history of traveling to Italy, in the Lombardy region, on February 25, 2020. At first, the fact did not trigger a climate of economic instability or social concern. On March 7, 2020, WHO changed the pandemic status in Brazil from "only reported cases" to "community transmission", with 13 confirmed cases being reported, 6 positive cases in a single day. Later on, the first case of death due to COVID-19 occurred on March 17, 2020: a 62-year-old man with hypertension and diabetes mellitus, living in São Paulo, with no history of traveling abroad (2) .
As a result of the new epidemiological panorama, and in order to contain the spread of SARS-CoV-2, several Brazilian states and municipalities have enacted measures of social isolation/distancing; suspension of classes in public/private schools and universities; maintenance of essential commercial services (food, medicine, health, among others); intensification of health education/communication actions; issued guidelines regarding travel restrictions, among other measures. The actions of state and municipal governments followed WHO's technical-scientific guidelines, but initially there was a lack of coordination, dialogue and confrontation between President Jair Messias Bolsonaro (2018-2022) and several allied governors and government opponents (6) .
In Brazil, the presidential speech reflected the importance of saving the economy and protecting the self-employed, small entrepreneurs and informal workers, reinforcing that vertical isolation of "risk groups" (the elderly, people with comorbidities and immunosuppressed people) would be sufficient. In other official speeches addressed to the population, the president minimized the effects of the pandemic, treating it as a "little flu" and a "little cold", despite more than 20 members of his entourage presenting positive results for SARS-CoV-2 after a trip to the U.S.A. (March 7-10, 2020); and maintained a posture based on discussions/ ideological confrontations without scientific basis to address the issue, a discourse full of sensationalism and post-truth, populism, and marketing. The Brazilian president's opinion continues in the opposite direction of other international leaders' speeches (6) .
In times of pandemic caused by the new coronavirus, nations/ leaders/societies of different ideological nuances treat the moment as a "war against an invisible enemy", with negative repercussions greater than those experienced after the Second World War. It is a worldwide consensus that we live in times of war, and it is up to the leader of each nation to take the leading role to overcome the health crisis (7) .
Brazilian economists state that the strategies adopted by the federal government are incipient to reduce the negative effects of the pandemic on the national economy; and public health specialists consider timid the actions of the Ministry of Health to improve/operate the SUS (7) .
Faced with this slowness in responding actively to the new demands arising from the health crisis, localized/joint initiatives of governors and mayors are emerging to contain the spread of SARS-CoV-2. Such actions follow the WHO's technical-scientific recommendations aimed at "flattening the epidemiological curve", which would not overload local health systems. Other efforts are aimed at equipping public/private health services, either by setting up field hospitals to screen for suspected cases, isolation, and treatment, or by opening new ICU beds exclusively for critically ill patients affected by COVID-19. Added to this, the quest for the acquisition of respirators, Individual Protection Equipment and diagnostic tests so that notifications can be faster and more accurate; as well as stimulating the production of development researches and network innovation with the participation of Brazilian researchers, universities, hospitals, centers and research networks (7) .
Among the state governance initiatives, stands out the Northeast Consortium, an administration tool created at the Governors' Management Forum, with a view to regional strengthening, improving the provision of public services, and protecting and promoting the rights of the population living in the Northeast Region. The political alignment between the nine states and their governors place the role, the understanding and the criticism of Northeastern leaders in the national context, particularly with regard to proposals under debate in the country and which result in major changes in public policies (8) .

Among dismantling actions and resistance, the Unified Health System (SUS) is the best way to confront the SARS-CoV-2 pandemic
Amid actions of neoliberal policies to implement the minimum state and the privatization processes and withdrawals of social rights imposed over the years, the SUS resists as Brazilian main public health policy to guarantee the universal right to health. Despite criticism and attacks by the government, politicians and part of the population given the lack of knowledge about the true role of the SUS, at this moment of health crisis, it is the main strategy to combat the SARS-CoV-2 pandemic (9) .
It should be emphasized that, in 2019, there were about 48 thousand Family Health Teams, 31 thousand Oral Health Teams and almost 290 thousand Community Health Agents providing health caretaking in primary care. They are doctors, nurses, nursing technicians, dentists and community health agents/endemic diseases; thousands of workers acting on the SUS frontline, providing daily multiprofessional assistance to the population and referring them to different levels of assistance (1,9) .
In the current global health crisis, the SUS workforce is mobilized to receive individuals in the health services for screening of suspicious cases, guiding them on home isolation measures, proceeding with collection of exams for laboratory confirmation and managing beds available for hospitalization. The Unified Health System workforce is also composed of workers who work in the streets carrying out home visits or health education actions, allowing the true information to reach the population (9) .
These are individuals involved in local health management, who plan, decide, and coordinate determinations considered a priori to be carry on by the family health teams. They are managers at hospitals, basic health units and emergency care units. At any assistance level, they act in the execution of COVID-19 Contingency Plans, manage attending flows and referrals; they control the material stock, pointing out, for example, the need to purchase individual protection equipment (IPEs), respirators, among other equipment and supplies. Such management organizes the workflow of health professionals, balancing the need to provide overtime assistance and the physical and mental health of these professionals; ensures the compliance with technical standards for hospital infection control; coordinates the sectors of cleaning, nutrition, nursing, etc. (2,9) . Furthermore, those responsible for management work on the policy formulation, at the state and municipal health secretariats, at the ministerial level, establishing attendance protocols, guaranteeing the purchase of medicines and supplies, and the import of equipment to prevent shortages. In direct contact with the head of the offices -the state and municipal secretaries, the minister, and his secretaries -are responsible for planning, evaluating, and implementing the solutions required by the pandemic. The moment requires responsibility, ethics, and dialogue to face the demands that will come, avoiding political friction so that the concrete actions take place following epidemiological criteria established worldwide, according to validated technical-scientific knowledge (2) .
Despite its leading role, the SUS suffers from a lack of priority and neoliberal attacks aim at its dismantling, reinforced by the economic crisis, by fiscal austerity policies and, especially, by Constitutional Amendment 95 (EC-95/2016), which freezes the public budget for 20 years, causing the chronic underfunding of the SUS (1, 10) .
By prioritizing the payment of interest on the domestic debt, reducing social spending and public investments, the EC-95/2016 deteriorates the population's health conditions with the increase in infant and maternal mortality, return of preventable diseases such as measles, low vaccination coverage, dismantling of the mental health policy, sabotage of Farmanguinhos and wrecking of the Family Health Strategy (FHS), end of the More Doctors Program, Popular Pharmacy Program and the Basic Health Units (UPAs) (1,9) .
Moreover, the situation was aggravated with the approval of a labor and social security reform that removes the acquired social rights. In view of the State weakening and its regulatory capacity, the neoliberal ideals, on one hand, strengthen the health insurance market; and, on the other hand, they expand the outsourcing of company's main activity, the mercantilization of the SUS, increasingly penalizing the budget of workers, families and, especially, the elderly and disabled (1,10) .
The SUS suffers resistance from part of the categories of health professionals, for reasons related to medical corporatism, particularly, whose interests were not contemplated by the policies of work management and health education. In addition to the systematic criticism and opposition by the media, it faces major economic and financial interests linked to health insurance companies, advertising companies and the pharmaceutical and medical-hospital equipment industry. Added to this, we have obstacles in the management to be overcome due to the lack of professionalization, crony capitalism and partisan use of public health establishments, excessive number of positions of trust, bureaucratization of decisions and administrative discontinuity, devaluation and precariousness of health workers (1) .
With insufficient resources, the SUS faces difficulties to maintain the service network and remunerate its professionals, and investments to expand the public infrastructure are limited. Given this reality, the decision to purchase services in the private sector is bolstered, and the ideology of privatization is reinforced (1) .
Thus, in view of the established crisis, it is urgent to defend the constitutional SUS and the SUS proposed by the Brazilian Sanitary Reform. The public universal health system in fact existing, with all its difficulties and fragilities, has produced significant achievements and results in these three decades. Its institutionality can be highlighted by its administrators, the Brazilian Prosecution Office, health councils and workers, favoring resistance against its dismantling (1, [9][10] . It becomes fundamental to constitute individuals of praxis (individuals of resistance, new public workers, transforming individuals), particular and collective, capable of defending the SUS; individuals of antithesis capable of unbalancing the binomial of conservation-change in favor of transformations, radicalizing democracy and the Brazilian Sanitary Reform (1, [9][10] .
The context of the pandemic shows, in Brazil and worldwide, that everyone is affected by the crisis, but its impact will be felt more by some than by others. As SARS-CoV-2 spreads, it will continue to expose existing inequalities in global health systems. It exposes the exclusion of groups from access to health care, either because of their legal status or other factors that make them the target of the State. It exposes insufficient investment in free public health for all, which means that access to quality medical care will only be available to a few, based on purchasing power and not medical need. It exposes the failure of governments and world leaders to plan and deliver services that meet everyone's needs, not only in health, but also from an economic and social perspective.
The SARS-CoV-2 pandemic, the thousands of deaths caused by COVID-19, contributed to highlight how political decisions of social exclusion, necropolitics, reduced access to health care and increasing social inequality will now be felt by all of us. These policies are enemies of our collective health, today, global health.

FINAL CONSIDERATIONS
We believe that the strengthening of democracy and the defense of the SUS are one (perhaps the only) way out of the health crisis we are experiencing. The SARS CoV-2 pandemic calls into question global economic-social-health systems; the role of the national state in defense of its sovereignty in a globalized world; capitalist models of production, consumption, wealth accumulation and relations of production between holders of capital and the labor force, especially the understanding of the right to health as a human right. It is, therefore, a systemic problem that challenges nations, their leaders and society to join efforts to respond quickly and resolutely by implementing universal public policies to preserve human lives.
In Brazil, we need to align political-government actions in the three spheres of governance, dialogue with the established powers and civil society. We must urgently defend the SUS, which is our best way out. The moment is to strengthen the democratic rule of law. The old strategies of devaluing the SUS, privatizing the right to health, maximizing profits in the medical-hospital market, valuing private to the detriment of the public fall apart, because, in reality, they show a cruel, disrespectful discourse against life, a false illusion of security for the most favored classes. May this moment bring as a result the lesson that we need to defend universal, free, and an equitable SUS. The mission is for all professionals who work in the health administration, training, and attendance, so that we can be more prepared for global health emergencies.
The limitations of the study include the still scarce and constantly changing scientific production on SARS-CoV-2 and COVID-19. It is believed that this reflection generates in all of us who deal with health caretaking, such as administrators, trainers/teachers and health workers, the political action, the ethical attitude, the wish for appreciation and the spirit of struggle in defense of the SUS and human life.