Six March 2020. Aula Magna was full like never before. All rows of chairs were taken, the stairs were blocked by those who arrived later and sat down on the floor.
Since December, people had heard about SARS-CoV-2, but the truth is that there were still no clear signs of propagation in Portugal.
The first announcement came from Filipe Froes, Pulmonologist and member of the National Contingency Plan for COVID–19, which showed how the virus had already travelled around the world, in each plane that left China.
The Local Contingency Plan that would be implemented at CHULN announced the strategic work of the GCL-PPCIRA Coordinator and Director of the entire Infectious Diseases Service at Santa Maria Hospital, Álvaro Ayres Pereira.
With a sharp sense of humour, even in the face of the subtle uncomfortable mumbling coming from the room, his tall, slender figure, called my attention, as he faced the future of something that could hardly be measured with extra lightness and spirit.
What followed everyone knows. The pandemic set in and brought fatigue to the teams. It wiped out lives, isolated populations, cleared out the noise of cities.
Almost two years later, and with almost 90% of the Portuguese adult population vaccinated, I dare to look for him, believing that now there will be time to look back.
Álvaro Ayres Pereira has been an Infectologist for almost 22 years, a specialty that he accumulates with Intensive Care Medicine. After graduating in Medicine from the Faculty of Porto (1978 – 1984), he did his general internship in Gaia. He then went to Braga, where he began his paediatric internship, a specialty he chose and thought of following. But he interrupted it to work as a volunteer for a French and Italian NGO in Kinshasa. The 4 years he spent there, the experience of being in almost a civil war, with the sound of gunfire all night, dead people on the ground, gave him a new vision of life and reality. It also prevented him from doing other things, such as continuing the paediatrics internship. Upon returning to Portugal, he needed to take the exams to access the specialty again, as too much time had passed to enable resuming the path he had left halfway through.
Born into a large and reputable family from the north, his father's lineage alone is currently more than 70 family members. Álvaro knew that being one of 12 children required him to be responsible for finding solutions for independence. It was still not common to justify all the steps that were taken, he tells me, he even found it strange that his Faculty friends excessively justified to their parents every exam they took. The ability of each one to be more for himself, did not take away, however, the solidity of a united and conservative family. Today, the father of three boys, the youngest of whom is 7 years old, admits to being an owl. His eldest son is 17 years old, and the couple waited almost 8 years for the next child, now 10 years old.
A Catholic man who gives room to his own faith, he continues to believe that the path is determined by each one's will and not destiny. Yet it is still curious that it was an INEM (Emergency and Reanimation Medical Vehicle-VMER) car that led him to the definitive professional path, even to his destiny. The meaning is real and not figurative. The moment he realized that it was not possible to go back to Paediatrics, he was lost in thoughts about what he would do next. It was when the VMER car passed him by that he decided to follow it, as if he were chasing his own inner response. He followed the ambulance to Rua D. Pedro V, where the INEM headquarters were located. He walked in and asked if there would be any opportunity to work as a medical officer. "How did you know we were looking for a doctor? You will start on Monday". He stayed for a year.
Having completed a course in Tropical Diseases, taken with Professor Champalimaud, and between a postgraduate course in the same area and the experience in Africa, the result was his specialty in Infectious Diseases. “It set me back 10 years in my career, but it was really worth it”, he concluded, showing little pressure in the face of society's own pressure for us to always meet the globally established deadlines.
Álvaro Ayres Pereira worked at Pulido Valente Hospital for 4 years, where he was part of a team specialized in Intensive Care. He took over the Directorate of Infectious Diseases in September 2019 and coordinates the GCL-PPCIRA (former Infection Control Commission). He has been at the Northern Lisbon University Hospital Centre since 1995.
I sent him a message hesitantly, considering that in the middle of a pandemic, even in calmer times, there is no time for what is not the most important. He didn't answer me and so I persisted even more hesitantly, with the feeling that there was a bit too much thinking that there would be time for us to talk. He called me back. Gentle and empathetic, he apologized for the delay in returning the contact. With a bad cold and coughing, he hastened to confirm that he did not have Covid and so we could meet a few days later. And so it was. I asked for half an hour out of his busy schedule, but two hours passed when we realized that, after all, we talked a lot more than what I write here. A privilege that I insist on maintaining, being with people face to face, like two seemingly strange parts that quickly come to trust each other.
Interestingly, his constant humour was kept for a more public moment, where he should always foster the collective spirit. Despite the wit always implicit in the dozens of stories he told me, he allowed himself to be more reflective and gentle, not because of the cold, but because a frontline man who faces fierce clinical wars also needs to rest.
“Is it Álvaro Ayres or Aires?”, I ask after trying to find out myself. The name became comfortable over the generations who wrote it, originally Ayres, in the family registers. Not everyone seemed to be familiar with the Y. He started to use the I so he wouldn't have to prove his origin in each celebration.
Where does your ability to be able to laugh and play in the face of adversity come from?
Álvaro Pereira: At least for me it works better if I'm like that, but not everyone interprets it well, they consider that there is a certain cynicism in the way I try to take things. But I don't know if it's fair that they judge me like that.
It's not easy to lead a Service like yours. When you spoke to all those teams (at Aula Magna) did you already know what was really awaiting us in terms of pandemics?
Álvaro Pereira: No, I didn't know. At that time I was already in charge of GCL-PPCIRA, as coordinator. I had already gone through the experience of SARS-CoV, the threat of avian flu and Ebola and the pandemic caused by influenza A. So it was another situation that could have similar contours. But this did not happen. This experience, associated with my own way of being in life, made me take things lightly, without excessive alarm. As I always am. In fact, I've been like this all my life.
Does this mean that despite your long experience, you were still caught off guard by the pandemic?
Álvaro Pereira: We had already experienced threats from what could be epidemics that would vause havoc, and Influenza A still did it. Covid-19, on the other hand, due to its setbacks and advances, has always made us live with many questions. Even today, and almost two years later, we are still not sure of what will happen, because there are still retreats and advances. Infectious diseases have a very funny law, not everyone will die, because nature, humanity, is always able to turn around adversity and as such these diseases are not easily predictable when they arise. Of course, there is great damage, just remember that we have lived with Leprosy, the Plague, the Flu Epidemics, HIV/AIDS, but human resistance will always manage to overcome it. This is the great optimism of those who work with the reality of Infectious Diseases, it is the struggle of human nature. This fight exists since we have been here on Earth, us and the microorganisms. And it was with them that we were always creating a certain balance, a certain symbiosis. It is not in the interest of these viruses to kill the human species, otherwise they too would become extinct. Viruses look for the human species to adapt to them and they to it, so that they can progress and do more damage, multiplying. Ultimately, it can be said that the virus does not mean to harm us, it just wants to spread.
Is that what fascinated you about Infectiology? Because obtaining a grade of 19.6 at the end of their specialty is not for everyone...
Álvaro Pereira: It was precisely because I liked to study this relationship between human beings and microbes and the adaptation of people to them.
Do you think humanity continues to know how to get the better of it?
Álvaro Pereira: (He is silent) I think there are reasons for having learned things. But I'm afraid people quickly forget. I'm afraid that after Covid-19, we haven't learned enough to prepare for the future. Because this was not the first and will not be the last major pandemic, there are several pressing threats, just look at the threat of a strong return of malaria, or other flu and other viruses. I'm afraid we won't prepare enough, because even now people are asking such inexperienced questions as if the virus had just arrived and the fact is that almost two years have passed. We should already know how to draw the consequences, for the patients, but also for the hospitals in particular.
I am very concerned about the architectural part of our hospitals, which would require major renovation and that doesn't happen. We cannot continue to have wards with more than 20 beds and a single bathroom. Or even the question of the dimensions of space we have, that is, we should have fewer beds for the space we have, or with the beds we have, increase the space between them. The architectural part is essential to contain the infectious area and we are not just talking about this pandemic now. In a Hospital with these dimensions, we have many patients, many immunocompromised, many pathologies, very different ages, but the structure is the same as it was 40 years ago, and the population's expectation is also bigger.
He spoke about the issue of space and the extreme need for disinfection and the precaution regarding keeping distances, precisely in that meeting at the Aula Magna.
I am very insistent with the proposals for plans and renovation of the Hospital, because it is necessary to change structurally.
Will there not be more and more spread of pandemics as the environment also deteriorates?
Álvaro Pereira: Yes, most likely yes. With global warming, for example, the probability of having malaria again increases. Here in Portugal, there has been no malaria for many decades, but with the rise in temperature, the vectors adapt and immigrate. People's lifestyles also provide these aggravations. Large trips, large-scale displacements, are all new forms of contact that bring us closer to greater risks. Possibly, we should reconsider returning to a more regulated life.
But we can further reduce the scale. If we reduce the distance from the place where the person lives to the place where he/she works, we could also conclude that it is much more risky to work 100 km away from the area of residence. For example, telework is one of the good options, precisely because it can minimize risks. Have you seen how the residential centre of Lisbon is deserted? This is because people cannot afford to live in cities, but they need to travel to them every day to work and they all come together in public transport.
Can I interpret from here that major political decisions are more at the mercy of party trends than of major social causes for the good of the country, or of health?
Álvaro Pereira: Very likely. Because it seems to me that there is a lack of strategy, for a common good, in the medium term. It's the medium term that worries me, you know? I don't even consider talking about the long term. I believe that maybe there is a vision of the common good, but with the power shifts, continuity is lost. There is no follow-up plan.
As Director of Service, you take on a more strategic job and doesn't walk around seeing patients as much. Do you miss that side?
Álvaro Pereira: Sometimes I do. But I also like managing people. It demands more patience, more personality management skills. More strategy. But it also allows us to have more contacts with the entire Hospital. It is very enriching to talk to the various medical areas of this Hospital and participate in meetings with them, because it means communicating with all the hospital areas.
Let me go back to the moment you followed INEM's VMER car. Are we the ones making our way or is it somehow destined for each of us?
Álvaro Pereira: I'm a Catholic man and I believe in divine providence in some ways, but I think it's us who make our own way. Still, I don't know, if everything has a scientific explanation, I can't say...
When you told me about your 4 years in Kinshasa and that there was almost a civil war, you reminded me of an expression of war often attributed to the commandos and which goes "a commando is neither hungry nor thirsty". Does a doctor in the middle of a real war stage, or in front of a pandemic scenario, also feel that way?
Álvaro Pereira: It's still different. In this pandemic, I was no longer in the front line, I was in a more strategic and general place, which obviously does not prevent me from having a global vision of what is happening on the ground. But I think there is a big difference to the war scenario. This is a virus war against us. A war between men can no longer be described... In our pandemic war, we give people time to withdraw and adapt to the virus. That is, in practice this is the spirit of lockdown, strategically retreating to better recognize the enemy. We give time and delay things to prepare, in a figurative sense, it is like a courtship between parties, but in which the humankind strategically gains time.
The wars of people divide them into distinct fields, they do not unite them all for the same side of the battle. We live a war, yes, against the virus, but it is a war against third parties and not people against people.
In this process of war against third parties, has humanity come out more united?
Álvaro Pereira: I don't know... In terms of family, we didn't always see this, many families were completely broken, the pandemic was the precipitating factor of something that was no longer right. What is noticeable is a generalized tiredness and there are problems that were latent and have become more prominent, such as the tiredness of doctors, nursing teams and other health professionals. That tiredness is causing people to be less tolerant and to become more demanding and aggressive. This spirit will continue and I only see any inversion if the National Health Service undergoes profound changes in its way of existing.
I know we can't do futurology, but the cold is coming and proportionally the numbers of those infected and killed by Covid are increasing in Europe, more than anywhere else in the world. Some European countries have already taken the first containment measures. And in Portugal, if no lockdown is done until Christmas, calculations point to 6,000 infected per day. What is your view regarding what awaits us? What awaits your team?
Álvaro Pereira: My team is always adapting to the new DGS guidelines, but also always attentive to international guidelines. Difficult times await us, but nothing like January this year (2021). The Portuguese are in fact a docile people, because they accept new adaptations, in this case they adhered to vaccination. If the flu vaccination goes well and the third dose is received by all age groups, then I will say that we can greatly minimize the damage.
There is even talk of vaccinating younger children and I see it in a very pragmatic and positive way.
Will it be as safe to vaccinate adults as young children? What is your view?
Álvaro Pereira: When I was at school, I saw cases of Polio, because parents did not vaccinate their children, fearing the vaccine. I lived closely with this reality of stigma in relation to the vaccine. I am therefore a staunch advocate of vaccination, because it reduces the risk of disease and its own infection and spread. We must have some confidence in science and in the decisions made. Now, there are other questions I ask about vaccination these days. Is it worth getting vaccinated with the third dose, or are we going to give it to the third world?
The third world will never be entirely vaccinated...
Álvaro Pereira: No it will not, it will immunize by itself, you know how? By getting infected, then the most fragile will die and the youngest will keep on with it and this will be its form of “vaccination”.
And then what next? A pandemic stronger than the last?
Álvaro Pereira: I don't know, but not knowing what awaits me doesn't scare me.
Even as a father?
Álvaro Pereira: Even though. I am an optimist and a follower of the norms, I believe in institutions such as the WHO and I see them realistically. And just look at my grandparents' generation and realize that there are big changes in health. At the time of grandparents, how many children survived in a large family? Several young ones died. We reached a level of civilization that distanced us from this precariousness in life, which now remains only in the third world. Now, even based on this scenario, I don't know what awaits us, or what is in store for life, or for death, even though many people don't like to look at death. Doctors don't know how to talk about death, they don’t like to talk about it.
Don't you like to talk about death either?
Álvaro Pereira: I talk about it and I am frank with my patients. I feel there is always a conversation I need to have with them, about the treatments we can do, how far we can go.
And whoever is sick accepts talking about death?
Álvaro Pereira: If we talk closer to the end, it's more complicated, it's not well received. It is easier when we talk in advance and patients value their time and options more. People think and are confronted with thoughts, no one is forgetting the topic. I think about it myself… some of my friends have already passed away and were precisely my age. I think about it.
Do you think about your own end?
Álvaro Pereira: Yes, but it doesn't upset me. I think about it with some peace of mind, but I don't do it regularly.
It has always been the balance between the divine and the realism of things as a doctor that made him always face life head on. He doesn't wait for divine providence so that something happens in the world. He puts encouragement and intention and speeds up the process of his will. As a doctor, he works and lives on the basis of several possible scenarios, knowing that in each scenario there will always be multiple other possible outcomes.
On the path he has been following, he could perhaps have changed course and gone to the private sector, where he would have done much more for his own investment. However, he has a sense of duty that he does not talk about, but which is clear from the roots he comes from, from the role he accepted to play in front of others, from himself.
A family man, a natural leader, he took on the mission of something that, not being able to change alone, he commands wisely, even knowing that there are boats that do not survive storms. But ironically or not, it's precisely because of the storm that he's made of fibre, it's in the perfect storm that he knows that the best he has to give will come out of him.
People like him also save the heavy and worn boat called the National Health Service.