Climate crisis and new challenges for health systems: the case of floods in Rio Grande do Sul/Brazil

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measures had been announced by technicians from related areas, but little or nothing was done.The most obvious example was the warning, announced in 2018, and now made public, that the pumping system in the city of Porto Alegre required urgent maintenance, without which it could fail in a likely flood -that is exactly what happened.The floodgate system also failed, which had visible maintenance weaknesses.The city mayor ignored all the warnings from municipal employees.In the face of that, journalist Leandro Demori called the capital Porto Alegre "the case-city of the minimum state" 4 .The state governor, Eduardo Leite, also a well-known defender of the minimum state, when asked about the warnings repeatedly announced about the heavy rains to come, stated that he did not invest in prevention because the state had "other agendas".
In fact, the agendas were different.There were more than 489 measures taken by the administration of the state of Rio Grande do Sul, starting in 2019, the first year of the current governor Eduardo Leite's term, which caused the dismantling of environmental legislation, such as the relaxation of environmental rules for the construction of dams for irrigation in Permanent Preservation Areas (APP) 5 and, more recently, the failure to invest in infrastructure to protect slopes and in the recovery of the flood protection system in Porto Alegre (state capital), which, in the September flood of 2023, had already shown the need for recovery and has now "failed miserably", laments Walter Collischonn, professor of environmental engineering and water engineering at the Federal University of Rio Grande do Sul (UFRGS) 6 .
Climate denialism disregards scientists' warnings and repeats the narrative that extreme events happen from time to time, and are therefore a natural occurrence.Furthermore, they do not admit that such events are happening at a much highway rate and at a much greater intensity, a consequence of global warming caused by human action.Rio Grande do Sul itself suffered two floods within less than a year: one in September 2023, which left 47 dead and dozens homeless, and the current one, in addition to warnings for others in a short space of time.
Fighting climate change implies, in addition to reducing deforestation, carbon dioxide emissions, reducing the use of fossil fuels, mining etc., rethinking the process of urbanization and protecting populations, especially the most vulnerable, whether urban or rural.
In parallel with the population's demonstration of solidarity, many used the tragedy for self-promotion or political dispute, using fake news that hindered the rescue work and even donations, which shows that the regulation of social networks is an urgent issue.

Health systems and climate change
Much has been analyzed about the demands on health systems in the COVID-19 pandemic, the importance of universal systems, the capacity for resilience, and preparation for future pandemics, but we know little about the health demands in cases of environmental tragedies.
The devastation caused by the floods has an obvious impact on the mental health of the more than 160,000 displaced people, as the rains immediately affect people who have lost loved ones, their homes, their way of life, and their livelihood.In these situations, there is a risk of an increase in cases of domestic violence and the consumption of alcohol and other substances.Mental suffering, combined with respiratory illnesses facilitated by collective shelters, is the first concern in terms of health.At the moment the waters begin to recede, leaving trails of sewage, putrefaction and mud in the cities, new cases of leptospirosis appear daily (one month after the start of the flood, we already have 7 deaths, 141 confirmed cases, and more than a thousand in investigation), increase in acute diarrheal diseases, parasitic diseases, tetanus, dengue fever, hepatitis A, and bites from venomous animals, which add to the problems related to mental health, respiratory diseases, and chronic diseases of the affected population.
The complexity of the health situation and the factors that determine it mobilize different sectors in responses and emergencies that range from guaranteeing food security drastically altered by the tragedy, to the safety of girls and women exposed to the risk of sexual violence.There have been reports of sexual violence committed against women and girls in shelters, indicating that strategies for confronting climate crises require taking care of aspects associated with gender relations and vulnerability, requiring specific plans and strategies 7 .It is estimated that two thirds of Primary Care units are compromised and that many of the health professionals who work in health services (including pharmacies and laboratories) had family members and homes affected.With its hospital and Primary Care units underwater, the Unified Health System (SUS) relocated Primary Care to collective shelters and created field hospitals to operate as assistance support.To achieve this, it counted on teams from the SUS National Force and the Military Forces, in addition to volunteers who mobilized nationally to work remotely in support of the people of Rio Grande do Sul.This scenario demands urgency in reestablishing the SUS's capabilities to respond to the known and the new health problems and needs of the population.
The emergency creates some management chaos in the system that must be addressed by specific contingency plans for each event.At the same time, it is essential that states and municipalities develop disaster risk management plans, involving different sectors and actors in society -and not only on preparedness measures and responses to disasters, but also on the prevention of future risks and the mitigation of existing risks., in addition to rehabilitation and reconstruction policies based on the Sendai Framework principle of rebuilding better and safer 7, 8 .
Rebuilding is necessary!But on what basis?The reasonable consensus is to reevaluate the scenarios and resize the risks since the tendency is to recompose risk minimization after the phase of shock caused by the tragedy.This applies not only to housing, but also to public facilities which, if rebuilt in the same locations, continue to subject populations to living in the same vulnerable conditions as they were before.In that context, it is urgent to move from reactive policies and actions to disasters to prospective and preventive policies and strategies.
The Brazilian Constitution provides for the right to an ecologically balanced environment as a common good for the people and essential "to the quality of life, with public authorities and the community having the duty to defend and preserve it for present and future generations" 9 .On the other hand, it also provides that the right to health must guarantee "social and economic policies that aim to reduce the risk of disease and other health problems and universal and equal access to actions and services for their promotion, protection, and recovery" 9 , which is qualified in the expanded concept of health in Ordinance 8,080, which regulates the SUS, in which [...] health has as determining and conditioning factors, among others, food, housing, basic sanitation, the environment, work, income, education, transport, leisure, and access to essential goods and services; The population's health levels express the country's social and economic organization 10 .These guidelines, established almost four decades ago, are more topical than ever, and it is up to society to demand them from their managers, for the safety and well-being of everyone.