University of São Paulo: Pulmonologist still believes in the victory of science for the treatment of covid-19

In the midst of a pandemic that has lasted two years, the Brazilian government still does not have an official recommendation with a set of procedures on how to treat covid-19 patients. But the knowledge for that exists! The proof of this is in the treatment protocols developed by Professor Carlos Roberto Ribeiro de Carvalho, from the USP School of Medicine (FMUSP), and by a group of specialists he coordinated. “It is a set of recommendations on how health professionals should act in the care of patients with covid-19, from hospitalization to discharge”, describes the doctor, noting that the group brings together professors from the best universities in the country. Last year, Carvalho received an invitation from the Minister of Health, Marcelo Queiroga, to assume a kind of “special secretariat” for the fight against covid-19. “It was on a visit he made to the HC Complex. I didn’t know the minister. I told him that I could not accept the invitation due to several commitments here in São Paulo, but I made myself available to help in the best way possible”, says Carvalho to the USP Journal .

Months later, in July 2021, the then Secretary of Science, Technology, Innovation and Strategic Health Inputs of the Ministry of Health, Hélio Angotti Neto, asked Carvalho for an outpatient treatment protocol for covid-19. The protocol containing the treatment guidelines was approved by the National Commission for the Incorporation of Technologies in the SUS (Conitec).

Even considering this whole situation as “absurd”, Carvalho says: “I don’t consider myself defeated!”

But the turning point came in January of this year, when Angotti released an extensive document that contained a technical note comparing technologies to combat the disease and citing hydroxychloroquine as effective and safe. The same note said the vaccines were “neither effective nor safe”. Days later, still in January (24), Angotti signed a new version of the document, removing the technical note, but citing that the recommendations made by the group coordinated by Carvalho lacked scientific evidence.

The reaction
On February 4th, Carvalho filed an administrative appeal against the ministerial decision not to give official publicity to the guidelines prepared by his team and approved by Conitec. The resource also contains recommendations against prescribing the “covid kit” to patients in the Unified Health System (SUS). In a new twist, since the 16th, Angotti is no longer the Secretary of Science, Technology, Innovation and Strategic Inputs in Health of the Ministry of Health. Saúde, instead of Mayra Pinheiro. To replace Angotti, the director of the Department of Pharmaceutical Assistance and Strategic Inputs, Sandra de Castro Barros, took over. As Carvalho points out, “while Angotti ‘fell to the top’, the decision ‘fell in Queiroga’s lap’”. The FMUSP doctor believes that the Minister of Health will approve the document. “I trust him to honor his commitment. After all, Queiroga has a respectable history”, highlights Carvalho.

We managed to ‘pilot’ 20 ICUs monitoring an average of 500 patients per day

Even considering everything “very exhausting”, Carvalho shows the same disposition he had when he was a resident of the FMUSP Medicine course. “Our team met almost daily, even on weekends. And all this voluntarily and for the benefit of the population”, highlights the doctor. Even considering this whole situation as “absurd”, Carvalho says: “I don’t consider myself defeated!”.

The story
What led Carvalho to be invited by Marcelo Queiroga to collaborate with the Ministry of Health was his respectable history and performance at the head of the Pulmonology Division of the Instituto do Coração (Incor) of the Hospital das Clínicas of FMUSP. There, he commands the Respiratory ICU, created by himself about 40 years ago.

He remembers the first case of covid-19 at Hospital Albert Einstein, in February 2020. In March of that year, preparations began in the ICU of the HC. “That was when we had several dialogues with professionals from almost all over the world about the use of specific protocols containing procedures for the treatment of the disease”, he says. These procedures were then presented to the São Paulo State Health Department and became official in the state. “We even developed a free mobile application that presented the mechanical ventilation protocol for the treatment of the disease”, highlights Carvalho. “We got to ‘pilot’ 20 ICUs monitoring an average of 500 patients per day.”

ICU is for those who like emotions. Imagine having to attend ten beds in emergencies. I was often alone in charge of the shift

Carvalho’s experience in the ICU dates back to his struggle to install an ICU in pulmonology, even in the days of his medical residency. “Pneumology did not have an ICU. In 1979, my colleague Alexandre de Oliveira Ribeiro and I opened a respiratory ICU”, he recalls. In this first attempt, Carvalho was in the second year of his medical residency. However, the unit had problems and was closed a few times, until in 1982 the ICU was reopened and no longer closed. “Alexandre died two years ago”, laments Carvalho.

In all this history, Carvalho survived with the medical residency grant and with earnings obtained in shifts on weekends in private hospitals. “He came in on Saturday night and left the shift on Sunday, also at night. There were about 70 to 80 hours of work per week”, says the doctor. And it was after the sixth year of the Medicine course that Carvalho chose to specialize in Intensive Care. He always found that “adrenaline” interesting. “ICU is for those who like emotions. Imagine having to attend ten beds in emergencies. I was often alone in charge of the shift,” he recalls.

In the 1990s, Carvalho and his colleague Marcelo Amato pioneered a study that won the world over. “In 1995 I was Marcelo’s advisor in his doctoral thesis, which brought innovations in mechanical ventilation applied to patients who needed the procedure”, he says. The title of the research is A new approach to mechanical ventilation in ARDS: effects on lung function and mortality . Carvalho recalls that it was only in 1998 that the scientific article was published in The New England Journal of Medicine.. “It took a while for the reviewers to convince themselves that some ‘crazy’ and unknown people here in Brazil had developed such an efficient ventilation technique”, he recalls. The fact is that the disease known as Acute Respiratory Distress Syndrome (ARDS) has come to have a treatment technique that has been adopted as a standard throughout the world.

Carvalho’s retirement papers are shelved for now. Would it be time? “I intend to retire before reaching compulsory age.” The accounts to retire began to be made in 2019, after, in 2018, he had a health problem, an aortic dissection, which took him out of his activities for four months.

Carvalho has been working since he was 13, when his father João Fernandes de Carvalho got him a job as an office boy. “He thought I needed to learn to get by,” he recalls. From childhood memories, the doctor, who has always lived in the capital of São Paulo, talks about the period when he lived on Avenida Doutor Ricardo Jafet, still unpaved and on the banks of the Ipiranga River, in the neighborhood of the same name. “There were floods and that was fun for us! It broke the routine and I loved helping the neighbors move the furniture.” The boy Carlos Roberto Ribeiro de Carvalho was then between 7 and 8 years old. He couldn’t even imagine a future in medicine.

But he remembers when, at the age of 3 or 4, he saw his mother, Mrs. Dulce Ribeiro de Carvalho, lying on a bed, affected by a serious illness. “I would ‘hang’ on the sheet and joke telling her that I was going to be a doctor to cure her”. Despite this “prophecy” as a child, his real interest in medicine arose when a cousin, Natanael Ribeiro de Melo, coming from Uberaba, stayed at his house to study Medicine at USP. “This happened in the 1960s. Together with Nathanael, I started to attend Atletica da Medicina. In 1971, I took my first entrance exam for the Medicine course. Failing, I tried again the following year, when I passed and went to college.”

Carvalho has a sister named Mirtes. “My mother had seven pregnancies, but only she and I ‘made it’. I am the youngest of the family”, says the husband of Heloisa Andrade Carvalho, also a physician and professor of Radiotherapy at the Institute of Radiology at HCFMUSP. And medicine continues in the family with her daughter Luciana, who is a psychiatrist. Paula, the other daughter, preferred communication. She majored in Journalism and History.

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