Surging in remote and poor areas, Brazil's COVID-19 death toll is 2nd highest in the world

It was late at night and a chaotic crowd hadgathered in front of a hospital in Manaus,the biggest city in Brazil's vast Amazon and the last hope for medical care for tens of thousands of COVID-19 patients in the region.

Doctors shouted patients' names, working their way down an impossibly long listwhile the sick and their families jostled through the jammed emergency entrance.

"Where is the help?" yelledPriscila Carvalho, whose mother layon a respirator inside, in Portuguese to a cluster of TV cameras.

"People are dying here! It's not a game!"

The scene was captured on video earlier this month by Reuters as cases continued to surge in the city of 2.2 million people.

Indeed, the death rate in thatpart of Brazil is more than 170 per 100,000 residents, three and a half times Canada's. Nationally, deaths have topped 215,000, putting Brazil's toll second only to the United States. It has the third-highest number of coronavirus cases after the U.S. and India, at more than nine million.

Freshly dug graves fill new cemeteries in Manaus and beyond, stretching to the horizon and growing quickly.

"Over the past two weeks, we've seen a sharp increase," said Pierre Van Heddegem, the head of a mission run by Doctors Without Borders in the region, in a Skype interview with CBC News.

"Fifty to 60per cent of the people we test, test positive. That's a huge amount."

New, more contagious variant hits hard

That's partially the result of a new strain of COVID-19 first detected in Brazil, a more contagious and possibly more deadly variant of the virus, known as P1. Research done by immunologist Ester Sabino at the University of Sao Paolo suggests that P1 accounted for 42 per cent of new cases in the Amazon's biggest centre since last month.

"Everything points to this variant being behind the way the pandemic is evolving in Manaus," Sabinotold Reuters.

Experts on the ground say the spread is so rapid and the government's response so inadequate it's overwhelming doctors, nurses and hospitals.

Doctors Without Borders is struggling to find places for severe cases that need to be sent from the two smaller communities they are helping, So Gabriel da Cachoeira and Tef, both several days' boat journey from Manaus.

"If the system collapses in Manaus, this whole population of the interior of the Amazon will not have access to necessary higher levels of care, with potentially grave consequences," said Van Heddegem.

Scenes of desperation

Local factors make conditions there ripe for the virus' spread. Indigenous communities have large households, poor access to health care and little reliable information. And even in large centres like Manaus with more substantial medical facilities, huge distances and inadequate roads make it hard to bring in supplies or experts.

All 650 of the region's ICU beds have been full, and airlifts of critical patients to other Brazilian centres are slow no more than a handful of people fit on transport planes brought in by the air force.

Oxygen supplies for the sick have all but run out as scenes of desperation spread online: five patients sharing a single tank in a hospital room, the infected suffocating to death and distraught nurses crying after losing patients. Long lines have beenforming in Manaus and other centres, with families desperate to fill empty oxygen tanks for sick relatives at home.

Meanwhile, teams of mortuary workers in hazmat suits have been patrollingthe city to pick up bodies of those who die in their own beds, after being turned away from hospitals.

'The risk is yours'

Brazil started a vaccination campaign in the past two weeks with fanfare, photo-ops and a declaration from Health Minister Eduardo Pazuello that "Brazil has made it" and promising "the largest vaccination campaign in the world!"

In fact though, the country is struggling to get even a tiny fraction of the vaccines it needs, with delays from suppliers in China and India. Initial doses were only enough for about 6 million people out of a population of 213 million.

Many in the hardest hit areas including the Amazon and Rio de Janeiro have been eagerly awaiting the vaccine to stop the spread of COVID-19. But Brazilian President Jair Bolsonaro has not only declared he won't be getting the shot, he's cast doubt on its safety.

"The risk is yours," he said earlier this month. "If you turn into an alligator, that's your problem."

Two tiers of care

In the favelas of Rio, the densely packed slums on the outskirts of Brazil's second-largest city, the crisis grows.

"It's getting very much worse every day," Dr. Gustavo Treistmantold CBC News over Skype from Rio.

He works in the Souza Marques Family Clinic in Madureira, a poor neighbourhood where some 200 people die daily.

Treistman says he sees 30 to 40 patients who have COVID-19 during every six-hour shift, sending the serious ones to hospital by ambulance when he can and seeing some die when he can't. Most are sent home.

"We don't have the equipment to treat patients," he said, with frustration in his voice.

At the same time, the government has refused to take other needed steps, he said, such asordering lock-downs or giving financial support for the sick to stay home from work.

"I feel very sad, very angry sometimes. And very tired every day. It's just too much for all of us," he said.

Treistman blames Brazil's high death rate on living conditions that make it hard for the poor to avoid COVID-19 and a two-tier health care system that favours the rich.

Brazilians who can afford ICU beds in private hospitals are almost twice as likely to survive COVID-19 infections than those who end up in the public hospital system, according to data from the Brazil Society of Intensive Care. Since last March, mortality rates in public hospitals were 51 per cent of ICU patients, compared to 28 per cent in private hospitals.

But with infections spreading so rapidly, Treistmansays now everyone in Brazil is at risk.