When Pamela Serrao’s six-month-old baby Arthur broke out in bright red hives, the last thing on her mind was the measles.
That’s because their rural northern Brazilian town, like much of the Americas, had officially wiped out the disease. In Brazil, that 2016 milestone was the product of a world-renowned government vaccination programme stretching back decades.
Yet, six years later, the country is one of many across the world seeing a resurgence of such preventable diseases.
Serrao’s Amazonian state of Amapa now has become the epicentre of measles outbreaks in the South American country - outbreaks that local health authorities are struggling to control amid insufficient health resources, turmoil in President Jair Bolsonaro’s government and anti-vax sentiments spurred on by coronavirus disinformation.
Late into that terrifying night in March, Serrao and her mother cradled the feverish baby, hoping to calm him down or get him to eat.
Serrao, 15, had no memories of the outbreaks of measles, diphtheria, and polio of decades past, and she frantically wondered what could be ailing the infant when her mother remembered her own measles infection as a child.
“I knew what measles was,” Serrao recalls. “But I never imagined that it would enter the house, because we hadn't heard about it for so long. We end up forgetting about these diseases.”
They rushed Arthur to a hospital a few hours away, worried that the virus could cause his throat to close up. “It’s something that needs to be treated or else he could die,” she remembers thinking. “I felt so desperate about his throat, thinking ‘My God, if we don’t take care of him, the hospital here doesn’t have mechanical ventilators.’”
Across the world, childhood immunisations have significantly dipped during the COVID-19 pandemic.
In 2020 alone, the global health crisis left at least 23 million children worldwide unvaccinated, according to World Health Organization figures. And in Latin America and the Caribbean, one in four children has been exposed to a disease that can be prevented by vaccination.
It’s a backslide that health experts say could take decades to undo.
"The decline in vaccination rates in the region is alarming and puts millions of children and adolescents at risk of dangerous diseases that could be prevented," Jean Gough, UNICEF's regional director for Latin America and the Caribbean, said in a statement.
Gough said the solution lies in a strong vaccination programme, yet in Brazil, that may be easier said than done.
The Brazilian childhood immunisation programme was created in the mid-1970s as a means of knocking out some of the country’s worst endemic diseases.
Over decades, the government threw funding at expanding vaccine access across the massive country, from densely populated urban centres such as Sao Paulo to remote Indigenous communities in the far reaches of the Amazon.
Health authorities opened more than 50,000 clinics to distribute free vaccines, explained epidemiologist Carla Domingues, coordinator of Brazil’s National Immunisation Programme (PNI) from 2011 to 2019, the period in which measles was declared eradicated.
They also incentivised childhood vaccinations by making them a requirement for low-income families to receive cash payments in Brazil’s poverty reduction programme, known as Bolsa Familia.
Health officials would often go door to door to vaccinate children in at-risk communities. Authorities even created a vaccine mascot in the 1980s called Ze Gotinha, or “Droplet Joe”, shaped like a droplet because that’s how the country first administered the polio vaccine.
“The vaccination programme, up until very recently, was very strong,” Domingues told Al Jazeera. “It was known, not just nationally, but internationally, as one of the best programmes freely distributing vaccines to the entire population.”
That began to shift in 2018, when new measles cases first popped up again in northern states, something health authorities initially attributed to a health crisis in neighbouring Venezuela.
While the government responded with a vaccination campaign, that push ended the next year, and vaccination levels in the country began to drop, government data shows.
The situation came to a head in March 2020, when Brazil captured the world’s attention for the devastation wrought by COVID-19. The country has reported more than 665,000 deaths and 30.7 million cases since the pandemic began, according to Johns Hopkins University data.
Much of that has been connected to President Bolsonaro, who has repeatedly undermined the severity of the coronavirus. The far-right leader, often described as the “Trump of the Tropics”, declined to be vaccinated and has spread disinformation about COVID-19 vaccines, including declaring that jabs turn people into “crocodiles”.
Bolsonaro also has repeatedly called into question the safety of the COVID-19 vaccine for children, falsely claiming that “young people are dying from Pfizer” and continuing to stir that disinformation as recently as mid-May.
While Bolsonaro’s anti-vax views are mainly attached to COVID-19, Domingues said they have had a ripple effect on vaccines for other illnesses, and a lack of educational campaigns has allowed disinformation to flourish.
Many Brazilians also have avoided medical facilities out of fear of coronavirus infections, “so people have stopped going to medical facilities to get vaccines, especially kids”, Domingues told Al Jazeera.
At the same time, funding for PNI was slashed in half last year, according to an investigation by local news organisation Reporter Brasil. In July, Francieli Fantinato, the programme’s coordinator and Domingues’s successor, stepped down, saying the role had been politicised. The position was vacant for more than six months.
“I worked tirelessly 24 hours a day, seven days a week, to vaccinate the Brazilian population,” Fantinato told local media, noting that she needed sufficient vaccines and an advertising campaign to make an impact. “Unfortunately, I had neither."
Meanwhile, vaccine requirements to access Brazil’s benefits programme for low-income families were dropped in 2020, eliminating a major incentive for vaccination, and childhood vaccination rates plummeted to the lowest level the country has seen in decades.
Between 2018 and 2021, vaccine coverage among the general population for tuberculosis, polio, measles, mumps and rubella dropped between 20 and 30 percent across Brazil, data received from the health ministry shows.
In the most extreme dip, vaccine coverage against tuberculosis went from 99.72 percent in 2018 to 67.25 percent in 2021.
Brazil’s Health Ministry failed to respond to many of Al Jazeera’s questions - including why vaccination rates have dropped off, and why Fantinato’s position was left vacant for an extended period of time - and has not always addressed criticism from health experts.
But the ministry said it “has been developing and intensifying strategies necessary to face the challenges and to reverse the low coverage”. It said it has launched national vaccination campaigns against influenza and polio, alongside local governments, and that it distributes an average of 300 million vaccines annually across the country.
But in Amapa – the Amazonian state at the heart of the measles outbreaks – Juan Mendes, the state health secretary, said if the Bolsonaro government is making such a push, he hasn’t seen it.
Instead, in a region where half the population lives in poverty and where large families live in small households, boosting spread, with poor access to vaccines and treatment, Mendes said measles infections have surged. “It’s the perfect environment for large-scale spread of the disease,” he told Al Jazeera.
The 143,000sq km region sits wedged between the Amazon River, Brazil’s border with French Guiana and the Atlantic Ocean. It is incredibly difficult to control the disease due to the transitory nature of life in the area, which is travelled largely by boat.
Every time Mendes would tackle an outbreak, he said new cases would come roaring back.
Mendes said those numbers are almost certainly undercounted, however.
“Our reality is a lot different from the centre or south of Brazil. We have these logistical difficulties. Here, we measure distances in a different way,” he said. “If you stop responding to cases, it keeps coming back.”
He said Amapa was not given sufficient resources by the federal government to transport vaccines, or to go out to rural areas where outbreaks are at their worst. “What do we receive? The vaccine dose, the needles,” he said. “I don’t even get one cent more to take the vaccine 36 hours by boat.”
Dr Carla Carvalho strolls the crowded halls of the only children’s hospital in Macapa, the capital of Amapa state, her shoes clicking on green and brown tiles that are worn through to expose patches of concrete.
The narrow hallways are lined with 24 rusted beds pressed up against the wall. Mothers cradle children swaddled in blankets and spoon pink yogurt into their mouths. Thin babies are hooked up to ventilators, and fathers play cartoons on their phones for sick children.
Carvalho, a paediatrician, says the facility has run out of bed space, while she and her colleagues lack basic resources - antibiotics, syringes, lab exams and more.
“These are the realities of this hospital,” she says, walking from patient to patient, brushing their arms gently and pressing her black stethoscope to their chests. Over the roar of crying children and construction on the floor above, she asks, “Are you eating? Drinking?”
Before the outbreaks, Carvalho said she had only seen measles in books. But in recent years, she has seen waves of parents – often young mothers like Serrao – bringing their kids in with cases of the illness, which is largely known for its red hive-like skin rash, but also produces COVID-like symptoms, such as a cough, sore throat, fever and inflammation.
Parents will bring their children in not knowing they have the measles - a highly contagious illness that can be transmitted through droplets or in the air - and be packed into a tiny space with other patients, likely spreading it further.
When Serrao and her mother rushed Arthur to the hospital in March, they drove two hours to Macapa Children’s Hospital because it offers a higher level of care than the clinic in their small town.
But when they told doctors they were worried about a potential measles infection, they said doctors argued over how to respond. They eventually were put in a packed room with five other children. “One woman [doctor] even told us, ‘Oh it’s just an allergy,’” Serrao remembers.
“All the children were together. There was one other doctor there who said that they should separate them because there was a risk of other children being infected.”
Days later, Arthur officially tested positive for the measles.
Globally, measles kills up to 200,000 people annually. In the first two months of 2022, cases jumped 79 percent worldwide from the previous year, according to WHO data.
Health experts say the best way to prevent infection is through vaccination, with jabs typically administered in the United States and United Kingdom to children at age one. However, in places with outbreaks or in situations of travel to high-risk zones, the recommended age can be as young as six months, as is the case in Brazil.
But Brazil today is the only measles-endemic country in the Americas where vaccination coverage is lower than the target rate of 95 percent, according to the Pan American Health Organization (PAHO).
Dr Carvalho said some patients who have come to the hospital in Macapa at a late stage of their illness have died. “It's a feeling of powerlessness, of not being able to do anything,” she told Al Jazeera. “It's sad, and really painful to treat a disease that's completely preventable.”
She and other health experts cast blame on the Bolsonaro government, saying that a lack of resources has hampered efforts to control outbreaks and combat vaccine disinformation.
Yet the feeling that takes over Serrao, when she thinks of how her son’s illness could have been avoided, is frustration.
She said that when she took Arthur to a local clinic for a measles jab when he was six months old – shortly before he fell sick – she was incorrectly told by health authorities that she would have to wait until he was one year old, despite new laws dropping the measles vaccination age to six months.
Now, though Arthur was only in the hospital for a short time because the infection was caught early, he still struggles to eat months later. Serrao and her mother also say that when he gets bit by mosquitos or scraped, it takes longer for his wounds to heal.
Some health experts predict transmission of the measles will only jump in the coming months as coronavirus restrictions are lifted and people stop masking. Dr Carvalho said she worries about even longer-term implications. “It could take us another 20 or 30 years to think about eradicating measles again,” she said.
Others worry the backslide could trigger more serious diseases like polio, tuberculosis or diptheria to once again sprout up.
Few know the devastating effects of these infectious diseases like Eliana Goncalves.
Goncalves, 50, was diagnosed with polio when she was only three years old, around the same time the Brazilian government started its campaign to tackle outbreaks.
She remembers her muscles deteriorating to the point that she looked like a rag doll, her mother taking her to a hospital, and doctors putting her in an isolation ward with other polio patients. It felt like an aquarium, she says.
“There would always be children who suddenly disappeared from the ward, just like that,” she tells Al Jazeera, a ventilator pumping at her neck as she sits in an electric wheelchair in her home in Brazil’s largest city, Sao Paulo. “But as I was only three years old, I didn’t understand. Later, my mother said they were children who had died.”
Throughout her life, Goncalves has worked to build up muscle - but has watched as her condition only deteriorated with later forms of the disease. Today, she lives on the fringes of Sao Paulo in a small room of a school, where she works as an administrator.
She often depends on friends to help her with basic tasks, yet has dedicated much of her life to working with public health groups to explain the importance of being vaccinated.
“I’m the example of what could happen - in the flesh,” she says. “You can affect your child's whole life [by not getting vaccinated]. It wasn't my mother's fault that I got polio [when there were no widespread campaigns for vaccines], but my mother blamed herself all her life.”
Her worst fear is that the disease that completely transformed her life will return to Brazil. Already, cases of polio have been reported in Israel, Afghanistan, Ethiopia, Iran, Ukraine, and Pakistan.
Even more recently, global outbreaks of monkeypox have prompted authorities across the world to stock up on vaccines and release doses from emergency stockpiles.
It’s a fear shared by many health experts in Brazil, as well as national and local government officials like Mendes. But he and Dr Carvalho agreed that in order to stop such diseases from re-emerging, the health system has to shift its focus to prevention, as opposed to putting out fires as they ignite.
“What we really need is to reimagine the health system,” he said. “If you have a child in an intensive care unit with measles, one day of that would cost 100 doses of vaccines.”
In April, Bolsonaro’s government launched a media campaign to try to boost measles and influenza vaccines for children, announcing national days for vaccinations.
Yet Mendes said the campaign is purely “symbolic”, stressing that he and colleagues in cities and states like his have so far received no additional resources to actually facilitate vaccinations in the areas worst affected by outbreaks, like Amapa.
The Health Ministry declined to comment or provide details on the campaign when contacted by Al Jazeera, but said it “distributes an average of 300 million doses of vaccines” annually.
But as Goncalves flips through old black-and-white photos of herself before polio, she said she feels a sense of looming dread, thinking about current vaccination levels. “If it continues like this, there’s no doubt that the disease will come back,” she says.
“It’s a matter of time. In my opinion, it’s only a matter of time.”