The good thing about reunions is the fluidity of a conversation that can be picked up from where it was left the last time, as if it had never stopped. There is a sense of continuity that happens without prior introductions or the formality that we are all socially obliged to. There is a dialogue and ritual that restart without a beginning and will finish without a real end.
In a marathon that he describes as a sprint, Válter Fonseca heads the Health Quality Department of the Directorate-General of Health (DGS). He has been in this position for three years now. He arrived in November 2018 and spent 2019 with common functions. In December 2019, the pandemic began and from then on he would take on not only the paths of Health Quality, which he had proposed, but now also various work and action strategies in the prevention of the health of Portuguese people faced with SARS-CoV-2. A few months later, he took on another task, the coordination of the Technical Commission for Vaccination against Covid-19 (CTVC).
The pandemic appeared not only in health, but also as a social phenomenon. Still before I started to record our conversation, he sat in the meeting room, perhaps taking the same seat he had taken in the last meeting. "I read a phrase that describes well what I have felt in these two years, we carry the country on our shoulders every day," he was telling me with a smiley face, after we had postponed our interview due to the sudden unavailability in his schedule. The original holder of the phrase is Anthony Fauci (the White House chief epidemiologist), currently protected 24/7 by the security forces due to numerous death threats for being one of the great defenders of vaccination against Covid-19.
Further on in the conversation, Válter Fonseca would explain to me with extreme simplicity what made so many people elaborate solid conspiracy theories, moving several campaigns of negationism, or just moved by fear, attacking Science and its researchers, when it was always to Science that everyone turned to when looking for solutions.
"Do you mean to say that you've been living as if there were several emergency rooms?", this was my rhetorical question to the Professor of the Faculty of Medicine, internist, who is used to spend so many hours in the aforementioned. But no, the comparison doesn't fit because in the emergency room someone always comes to replace us at a certain hour. And in the DGS, and with the position he holds, there is no substitute for the emergency room, which is kept on permanently.
I had met him almost two years ago in the same room, in that DGS building that rises up overlooking Técnico and the gardens of the Alameda da Fonte Luminosa. On our first conversation, both of us were very far from imagining how Válter Fonseca's life would turn into a blender of time, decisions and emotions.
Can the pandemic already show us if it has left any impact on our lives?
Válter Fonseca: We still don't have enough time and distance to understand what will happen to the world after this pandemic. As for our intervention, I have no doubt that it was sensible and balanced. The way we look today at Covid-19 is already the result of a set of actions that were taken. There is a learning process through the knowledge generated that makes us look at this disease, no longer as something totally unknown, but "eye to eye", one to one. This "look in the eye" is something that can only be built with vaccination and with the evolution of the infection itself and of knowledge. The pandemic itself has exposed a set of needs and challenges, both from a social and human point of view. For example, it exposed this concept of the digital, this overwhelming exposure to data and information. How are we going to deal from now on with a society that has the greatest knowledge in history? This is a point of great reflection. Several times the things we took for granted presented themselves as a shake-up of our convictions, of the institutions and of society in general. So we need some time and distance to see if it was just a turbulence during the pandemic and that it has passed, or if it will leave marks forever.
Personally I think they will leave a mark. Now, the big challenge is that these are opportunities for us to do better and not to complain about what happened. For the Health area we have lots of opportunities, the health service, its professionals and patients, everyone can look at the pandemic as a turning point, and for the better. But we must seize it.
Allow me to draw a parallel with what you describe and what I imagined as an picture.
Is it as if after a big hit, the body gets so hot that it doesn't feel the real damage? Are we still in this process of a collective hot body that has not yet felt the real cold crash?
Válter Fonseca: It was precisely because of this notion that I mentioned earlier that we need some time and distance. We want to believe that we are coming out of the turbulence. The truth is that while we are going through it, we don't have much capacity, or time, to think about what is happening. We are just working with great intensity. Let's go back to the analogy of the emergency room. In those 12 hours, when the work was very intense, it was only the following day that I realised two things: what I had done and learned, and how tired I was. It was never during the working hours. Now, if we apply those 12 hours to a 2-year scale, the recovery won't be done in 24 hours either, and so it's going to take longer for that awareness. We are at a stage where data suggest that we are starting to come out of what I call a marathon run at sprint speed and with no finish line in sight. We are now starting to see that finish line, but we don't yet have enough time or distance to see what is left and how tired we are.
Therefore, for institutions in the Health area, it is time to renew teams. I have no doubt that there are people who will want to start working at this time of enormous opportunities, it’s the turning point. But, at the same time, not abandoning the people who have worked intensely these two years, and who will be of great value to share a unique experience.
And do we have those people to embrace the opportunity?
Válter Fonseca: (Thinks for a few seconds) We do. The world is full of people. Is it easy to find them? No, but I think that being able to come and work to create change is one of the things that motivates people the most. From my perspective, people in general don't like to work in a routine, they like to embrace projects and interact with new people.
It's curious you say that, because people at the moment of change are generally very averse to it...
Válter Fonseca: But they embrace this change. They are afraid, but they embrace change. I understand what you are saying, people don't like to get out of their comfort zone sometimes, but at the same time, if the comfort zone is too long, they also get discouraged. As always in life, it is in the balance that we will find the way. You know I think people, and most especially the younger generation, need challenges and we are living them right now. The pandemic is a catalyst for change.
Still, we have here another interesting perspective that reminds me of an opinion article by the doctor Eduardo Freire Rodrigues, written for the Observador newspaper and which reads: "I recall the message left by the Director of the DGS Health Quality Department: "Scientific conclusions are the result of a process that is not black or white, but has several shades of grey, with advances and setbacks, thesis and antithesis, proofs and counterproofs, sometimes with diverging opinions and doubts". Pandemic management is dynamic; information changes as scientific knowledge advances; science answers some questions and others immediately and inevitably arise. A process like this, with back and forth, inevitably generates fear, insecurity and doubt." Funny how when we are all desperate for answers, we go to Science and Medicine for help, but then when we hear from this class that there are not always absolute certainties, we attack and doubt. What is this duality? How have you dealt with this whole scenario?
Válter Fonseca: This is perhaps The Question: "What happened to the credibility of Science?” I think that this reflection will still give us many more essayistic pieces. The answer for me is clear, the current generations, from the oldest to the youngest, lived in a world after the scientific revolutions. What they know of science is solidity, with highly robust and proven certainties. They have always associated Science with its results and not with its process, they know the results but they don't know the process to reach those conclusions that are presented before them. There is a book I read some time ago that says that "Science is built by proving that what you believed in was wrong". In other words, Science evolves by undoing what comes from the past and building a new truth. But there is always a judgement, an interpretation and a process, where Science evolves by hypothesis, thesis, antithesis... What Covid-19 demonstrated is that Science had no immediate certainty, nor could it have, because when facing something new, what we had was only the extrapolation of what was known and we were not sure about the best model to use to extrapolate. What would be the best model to use? That of the pandemic flu? That of another coronavirus? And then people were confronted with the process of science. They came face to face with the live scientific process: the doubts, the grey areas. As you know, my PhD was in a laboratory, an experiment that involves obtaining results, putting forward a subsequent hypothesis and trying to reach a conclusion. Science usually presents a sequence of possible spectrums, revealing, in the face of every problem of every need, the vast array of hypotheses. This is dealing with uncertainty. Because, you see, in a situation where people's lives are at stake, we cannot wait for all the experimental and scientific conditions of observation to be verified before deciding. But we know that Science continues to provide the important answers. Looking back, we know that the answers we got, based on Science, were the ones that had the biggest impact on how we dealt with the pandemic. But you have to explain to people that they are witnessing not the end, but the building of Science. The point is that they've never been confronted with this scenario before. So, what is happening to the process of Science is normal, that's the way it is. The zigzags portrayed by the press show only that sometimes, in just two weeks, there is new information and decisions have to be adjusted.
When we say that people need literacy, perhaps it cannot only be for the results, but also to understand the process and the way Science is built. On the other hand, for me, who have always been and still am a defender of Evidence-Based Medicine, I was faced with the need to decide even in uncertainty, not because there was this or that practice, but because it was people's lives that were at stake.
Can you explain me how?
Válter Fonseca: This is a big challenge for Science and Health decisions. I read an article recently that says that Science should base all decisions on Health, but the absence of Science cannot justify an absence of decision. Fortunately I think we have passed through the pandemic in a time, with a great advance in immediate access to information that we would not have had many years ago. Years ago, a Professor at the Faculty of Medicine told me that, in order to do a PhD, I needed to ask by mail for access to a certain document to be studied. Now, all this took much longer. Have you seen how nowadays we are working on a global scale? We access everything in a few seconds. It's remarkable how mankind has managed to organise itself. The issue of time has become imperative and decision making increasingly pressured to be fast. We need to look at the methods of generating evidence, with the perspective of decision-making, for the sake of life and the protection of people in society. It is no coincidence that someone once said, "Pandemic is a disease and a social disease". It is necessary to find methods that do not undermine scientific rigour, but that allow for faster decision-making.
And is there also in that quicker decision a greater amount of risk?
Válter Fonseca: (Thinks for a few seconds). Life is a risk every day. We are the ones who know the risks and learn to deal with them, thinking that we control them. But this is not true. When we leave home every day, we have no idea how many risks we are taking and yet we move and live. As to your question I don't think it's a question of risk, but accepting more risk is in itself a decision.
Can we say that we are taking the first steps towards living in an endemic? Or is it still early?
Válter Fonseca: The technically correct answer is that it is early. We still don't have the epidemiological knowledge nor the knowledge of the seasonal behaviour of the virus, to be able to definitively establish if we are in a pandemic, or if we are in an endemic. In fact, many scientific terms are applied retrospectively. It is only after some time has passed that we look back and are able to establish a date for certain transitions that have occurred. For example, so many times it has been asked, "but are we already at the peak? Have we passed the peak of this wave?" The truth is that only looking back can we say that we are past it. Pandemic and endemic concepts are also similar to these. The need to be alert is not over yet. There is still a great level of uncertainty that should force us to be vigilant, but we don't have to continue to consider that it is a disease that we don't know about. We don’t have to continue to believe that we do not have a set of powerful weapons to look this disease "in the eye". Hence, the big question is not whether we are facing a pandemic or endemic, but that we can now live with a disease much more safely and without fear than we did in the beginning.
And that statement is due to the fact that we have vaccines that give us that safety?
Válter Fonseca: We have vaccines and knowledge about the disease itself. And we are in the advent of the arrival of new therapies for Covid-19, which make us face this disease as we face many others. Now, it doesn't mean that we don't have to be vigilant and that we don't have to be very serious and cautious, and never arrogant. Please note that we don't do that with any disease, medicine is like that, it is not arrogant with any disease. I remember, in my life as a doctor, people would come to me because they had a heart attack despite having a healthy lifestyle. They'd ask me, "Why, Doctor? If I don't even smoke, or am overweight? Why me?” It's simply because we don't control everything. We are biological beings and this is part of a risk inherent to our life.
Is it this notion of the need for information that made the DGS launch, with the Professor as the representative, a strong communication campaign explaining in a simplified way the prevention and action measures for Covid-19? Is it information versus fighting fear?
Válter Fonseca: If you allow me, I need to say that nobody does anything alone. The people who work with us are the most important thing in any organisation. And here I reinforce, they work with us and not for us. Having said this, I would add that the reason why I am here today in this interview is because there is a group of people who have taught me a lot over the years. As for explaining and demystifying fear, without a doubt, the best way to face fear is with information. Explaining to people is, as such, an act of citizenship. If I know, there is no use in knowing if I cannot explain it to others. This is why I like teaching so much. It doesn't do me much good if I know something and don't share it. I must share and spread the word, so that others can also know and that will make us progress. Even when you have to make more assertive decisions, the best way for people to accept it is to tell them "this is decision, because...". And we can even say, "this is the decision because I don't know much about it yet, but as soon as I know I'll go through it again".
Should we always assume that we don't know?
Válter Fonseca: We must! There is then a fine line between assuming that we don't know, and "it can't end there". That is, the fact of not knowing yet, cannot make us stop there. We have to continue, "I don't know yet, but I'll know what to do and we'll assume this...". Someone once said that "nature hates emptiness", and as such, it will always fill itself up. So, by saying that I don't know what to do, we are creating a void that will be filled in an unpredictable way, generating misinformation, confusion and fear. That is the big question, effectively we know little at first, but we will know more!
It reminds me of our first conversation. That principle of yours comes from your scouting days, doesn't it? You always need a solution to follow a map and the final destination.
Válter Fonseca: True. I remember so well a situation where we were doing a long hike –a raid – that is guided only by rules of orientation. There are times when the data we have (maps, compasses) are not enough. And there is a moment when someone needs to tell us whether we are going right or left. I remember an activity in Serra da Arrábida when this happened. We came to a forked path, one of them drifting slightly to the left and the other slightly to the right. At the time the instruments we had did not allow us to make the decision with certainty. There were two things to do: either decide, or stand still. And from those times I remember learning that a bad decision is better than no decision at all. Standing still gets you nowhere. So we have to decide, even assuming that we are not sure of the best solution to the problem. Whatever path we choose to follow, we need to explain it, this is a basic rule for dealing with people. If we explain the decision, even if it was not the best one afterwards, people know that we made a decision and they follow us. Now, if we do not explain decisions, then we cannot expect them to understand and move with us.
You were always associated with the issue of technical recommendations through the Health Quality Department, which follows the standards. Of the several ones published, there are four that still stand as true pillars today: Standard 004/2020, which establishes the recommendations for the person with clinical suspicion of Covid-19; Standard 015/2020 that explains how to do the contact tracing of confirmed cases; Standard 019/2020 that defines the testing strategy for Covid-19. In January 2021, Standard 002/2021 defines the Vaccination Campaign against Covid-19. These norms show the very evolution of the pandemic in a short period of time. At the moment we recorded this interview, we are already facing the 18th update of Standard 002/2021.
Could one conclude, as has happened in the past, that people will all need a fourth dose of vaccine?
Valter Fonseca: It is too early to talk about that. But it is equally important to demystify that we had several types of initial vaccination plans. We always considered the impact of the previous SARS-CoV-2 infection from a vaccination perspective. That is why these people had adjusted plans, which shows the capacity we had to adjust the evidence as much as possible to each situation. There was not just one general measure, we personalised it a bit along some lines. That reveals a country with a very organised health system. Therefore, it is early to be asking if there will be a new plan of vaccination because we are in an epidemiological transition, which still requires reflection on the best vaccination strategies adapted to a transitional phase. The objectives are also adjusted to reality. It is different to have vaccination strategies that seek to contribute to transmission control, or vaccination strategies that aim primarily to prevent severe disease, hospitalisation and death.
We were talking at the beginning of our conversation about your marathon as a permanent sprint with no finish line in sight. For you, in your career, is there already a finish line in sight? What will happen?
Válter Fonseca: I still haven't managed to distance myself enough from the pandemic to have this reflection. But there are things that I can already say, it was a privilege... it is! I don't like to talk about the past. What I was able to experience, participate in and get to know would take many years in another context to have the experiences that I have achieved here in two years. It is a kind of compact life (the phrase is not mine, but it is a concept of someone I respect a lot). There are absolutely hard and tense days, complicated days, but when we manage to distance ourselves, we think it was important and fundamental. So much can happen in one day: a meeting about Covid-19 vaccination, then it's the group drafting the contact tracing standard, then the new tests, whether or not they should go into the testing strategy, and little emergencies and questions from journalists that need to be answered quickly. You have to go on a TV channel in the evening, explain the recommendations to people.... And I was not only dealing with pandemic issues, the Health Quality Department continued its activities. At the same time, we managed to elaborate the new National Plan for Patient Safety, something totally separate from Covid-19, but that all together reflects the multiplicity of arenas. But I say this now from a quiet distance, because there are days when I think "but why? why me?". (laughs) But you know? As I mentioned in another interview, I think that each person is in the right place at the right time...
And this is where you should be?
Válter Fonseca: I like working in a place where I am heard, where I can make a contribution that adds value. From that perspective, I am comfortable where I am and I know that after this pandemic I am more capable of facing new challenges. And there is much to do in the area of Quality. The great secret for the new vision of Health, after the pandemic, is through the combination of digital and the principles of Quality. That is what will give the tone that we want and need in the health system.
And now the question which should have been my first: What do you understand by Health Quality?
Válter Fonseca: It is a difficult concept to define, but there are two ways of looking at it and they are not mutually exclusive. The more classical one, in which Quality is a set of instruments and processes which are very standardised, because of the way they are constructed, based on rigour and consensus among peers and which are translated into standards, certification, audits... There is also a more conceptual vision in which Quality transcends the process and is not just a set of instruments to achieve goals. But it is a culture and a spirit that involves a set of principles. And what are these? Evidence-based health care that is safe, appropriate to each circumstance and each person, for greater efficiency of the system as a whole. I identify with this vision of Quality, which is more strategic in order to give us principles to progress, without ceasing to use the classic instruments. Because "vision without execution is a hallucination", as someone has also realistically described it.
I end our conversation with an image associated with you that I don't forget. There is an image of your daughter (approximately 4 years old now, maybe 3 at the time) and she is watching you on a TV channel and goes to the monitor to touch you. This sense of responsibility for the country made you make a choice also for your family?
Válter Fonseca: Now the family has grown, because there is also a son, a 9-month-old baby.
The relationship with the family is a sensitive point. I know that despite the many moments of distance from my family, I was also only able to progress in this marathon because I had a safe haven, the family. In this family I include, of course, mother, grandparents, but especially my wife, my daughter and my son. For my daughter I had to adapt the language and simplify. She learned and understood. Now I know that in these two years there have been many stages in her development that I have not witnessed. But it's funny because she often says "Dad is taking care of Covid". I think my daughter certainly doesn't understand what it's like to take care of the people of the country, but life has choices and for me there is always a spirit of mission for the sake of something greater for all of us. I think I have also contributed to the world where my children will live. I think that for us, countries of the Western world, who have never lived as well as we do now, to experience a threat to that way of life is also a reason for us all to strive to maintain the good things that we have. So the option is wanting to give them a world that we believe in and that can make them happier.