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From the file

The Covid Variants | Covid may be losing the vaccine battle. But, as the virus evolves fast to form new variants, the war is most definitely not over.

City of horrors

Thursday 4 March 2021

Last year, Covid-19 took a terrible toll on Manaus in Brazil. And then it came back – in variant form. Has this rainforest city become a tragic test-case for the impact of coronavirus mutations?


When the history of the Covid-19 pandemic is recounted by future generations, the ordeal of Manaus will be recalled with reverence, grief and horror. Once known as the “Paris of the tropics”, this Amazonian rainforest city has, in the last year, become a sweltering necropolis: not once, but twice.

What happened in Manaus, as portrayed in this compelling photo essay edited by Jon Jones, is a terrible warning to the rest of the world of the power of virus variants. It is a parable of evolutionary spite, and the cunning of the pathogen: its vicious capacity to adapt, morph and return to the battlefield of disease and death, newly-strengthened and ready, once more, to wreak havoc.

With more than 255,000 deaths to date, Brazil is second only to the US in the grim league table of Covid-19 fatalities. Manaus, a city of 2.2 million inhabitants, was especially badly hit in the first wave of the pandemic, the first place in Brazil where mass graves had to be dug and mortuaries could not keep pace with the number of dead bodies arriving at their doors. Grave-diggers were overwhelmed, doctors desperate.

From this carnage arose one slender cause for hope. By October, more than 70 per cent of the surviving population appeared to have developed antibodies, making Manaus enormously interesting to the global scientific community as a mass-population area that might have achieved something approaching herd immunity. Yet this was not the case. The Brazilian variant known as P1 – first isolated in Japan, and now detected in at least six people in the UK – tore into the city in December and smashed through the inhabitants’ apparent resistance to the original virus.

In May 2020, about 80 coronavirus deaths a day were being recorded in Manaus. By January 2021, in the grip of the second wave, the figure was closer to 100. On 6 February it was 140. Dismayed municipal leaders and public health officials pleaded for help with oxygen, basic medical supplies, hospital beds. Patients were being manually ventilated, panicked families driving off to buy oxygen from private suppliers.

Jair Bolsonaro, Brazil’s populist rightwing president, had dismissed the virus from the start as a “little flu” – though he tested positive himself in July – and the federal assistance that Manaus desperately needed was haphazard at best. 

Vaccination roll-out – mostly using the Chinese Sinovac jab – only began on 19 January and has been woefully patchy. What happened in Manaus is not going to be replicated in the UK, where the health infrastructure is much stronger, lockdowns have been stricter, vaccine roll-out has been so successful, and levels of immunity against the variants so far isolated remain, to date, encouragingly high (although data on the vaccines’ performance against P1 specifically is still too scant to form a clear judgment). 

Instead, the city’s dreadful experience has been an unforeseen test-case with an unhappy outcome: we now know that virus mutations can cause reinfection, at scale. The evolutionary potential of the pathogen has already proven remarkable (in Kentish, South African and now Brazilian variants). 

So, too, of course, has the ingenuity of the scientists who, at breakneck speed, developed highly-effective vaccines. Now, the UK is preparing for a phased lockdown relaxation, families are looking forward to reunions and summer holidays, and offices are laying plans for reopening. 

Yet, like a skull in a Renaissance painting, the coffins, makeshift graves and bereaved faces of Manaus are a warning against complacency. This nimble enemy is not done with us yet. Matthew d’Ancona, Editor

An emergency medical service response team picks up a 73-year-old woman with kidney issues in Manaus, Brazil, on 12 May 2020. Paramedic crews wearing PPE are forced to treat every patient as a potential case. 
Coffins are loaded into a truck having arrived at Manaus Port by ship to meet the increasing demand caused by the pandemic. In May 2020, Manaus is grappling with the highest coronavirus mortality rate in Brazil. 
Vanda Ortega, a 32-year-old nurse and member of the indigenous Witoto tribe, starts her round of healthcare visits in the Parque das Tribos, an indigenous neighbourhood in the suburbs of Manaus. Her mask reads: “The Life of Indigenous People Matters”. 
Municipal workers wearing varying levels of PPE remove the body of Estevao Pereira from his home. He was 92 years old, and died during the night having shown symptoms of coronavirus.
Women from the Parque das Tribos indigenous community mourn beside the coffin of 53-year-old Chief Messias of the Kokama tribe, who died of Covid-19 on 14 May 2020. 
Family members wearing protective masks attend the graves of their relatives during a mass burial of pandemic victims in the Parque Tarumã, the city’s largest cemetery. So many people died in Manaus in April and May 2020 that some authorities started performing nighttime burials.
An ambulance arrives at hospital with a suspected Covid-19 patient and is met by medical staff in full PPE.
Medical workers overlook beds of coronavirus patients being treated in the intensive care unit at the Gilberto Novaes Hospital in Manaus. 
Critically ill Covid-19 patients, sealed from the world by equipment in order to reduce the spread of the virus, have filled every bed in the Gilberto Novaes hospital’s intensive care unit.
A nurse holds the arm of a coronavirus patient at the Gilberto Novaes Municipal Field Hospital on 21 May 2020. The hospital was built specifically for coronavirus patients, and in May was operating at full capacity, with all 156 beds and 39 intensive treatment units occupied. 
A nurse injects a woman in the Parque das Tribos neighbourhood in Manaus as part of a push to vaccinate against flu and test for coronavirus among indigenous communities. 
Doctors try to help Lino de Castro Sale, who is suffering from breathing problems, as he arrives at the Gilberto Novaes Municipal Field Hospital. The medical team who examined him later confirmed that he had coronavirus.  
Raimundo dos Santos cries and holds the body of his wife, Lucia Rodrigues dos Santos, who died aged 60 of undetermined circumstances in the Zumbi dos Palmares neighborhood of Manaus. Members of the SOS Funeral team, a public service provided by Manaus City Hall to help low-income families hold burials, wait to take her body. Demand for the service has increased dramatically during the pandemic. 
Medical staff prepare to receive a woman with Covid-19 who is in a critical condition and has been flown from Parintins, a small city on the banks of the Amazon, to Manaus.  
A doctor and a nurse discuss a coronavirus patient as she arrives at the Gilberto Novaes Municipal Field Hospital on 27 May 2020. According to World Health Organization, at this stage in the pandemic Brazil had 374,898 confirmed cases of Covid-19 and 23,473 deaths. By the beginning of March 2021 the total number of coronavirus deaths in Brazil had surpassed 250,000.
Medical staff move a coronavirus patient who is in a critical condition from the airplane that brought her to Manaus. Intensive Care Unit flights have been made daily to remote areas in Amazonas state in order to bring seriously ill patients back to the capital, where the medical services are bigger and more efficient.
A man mourns at the Nossa Senhora cemetery next to a worker who is filling in new mass graves, dug for suspected and confirmed victims of Covid-19. 
Evangelical pastor Izaias Nascimento, 49, leads a religious service at the house of a worshipper on 16 June. During the day Nascimento provides funeral services for families on low incomes who need to bury their loved ones, most of whom are victims of the pandemic. At night, he provides families with comfort as a pastor.
A man walks through a new section, reserved for victims of the pandemic, at the Nossa Senhora Aparecida cemetery in Manaus on 30 December 2020. The same month, Latin America and the Caribbean became the second region after Europe to top half a million deaths from Covid-19, according to an AFP count based on official tallies. Of the 500,800 deaths recorded among the 29 countries in the region, more than half were in Brazil.
Relatives mourn during the funeral of Maria Estela Maris Melo, a Covid-19 victim, at the Nossa Senhora Aparecida cemetery.
Emergency doctor Marcos Fonseca Barbosa helps his mother Ruth Fonesca, 56, who is suffering from severe coronavirus symptoms. Marcos has been forced to treat his mother at home due to a shortage of hospital beds in Manaus following an increase in coronavirus cases. In April and May 2020 the situation was nightmarish: refrigerated trucks parked in front of hospitals to pile up the dead and cemeteries dug mass graves. But the situation is worse in 2021. Between 1 and 11 January at least 1,979 people were admitted to hospitals due to the virus, compared with 2,128 for the whole of April (the worst month since the start of the pandemic).
Relatives react as municipal workers from the SOS Funeral service place the body of Adamor Mendonca Maciel into a coffin in his home on 16 January 2021. He died aged 75 of Covid-19.
The body of Adamor Mendonca Maciel is removed by SOS Funeral workers from his home in Manaus.
A man holds an oxygen tank on 15 January 2021 as the crisis in Manaus intensifies. The health system is at breaking point. Intensive care units at hospitals have been at 100 per cent capacity for the past two weeks, and medical workers are battling a shortage of oxygen and other essential equipment.
A coronavirus patient, one of 12 patients to be transferred in a military airplane, is assisted by medical staff at the Ponta Pelada airport in Manaus.
Relatives of patients infected with Covid-19 queue to refill their oxygen tanks at the Carboxi company in Manaus. Many have been waiting for 12 hours, in overwhelming heat, to try to save the lives of their loved ones after the city was plunged into chaos by the explosion of Covid-19 cases.
A Brazilian Air Force airplane, carrying vials of China’s Sinovac coronavirus vaccine, arrives at the Ponta Pelada Airport in Manaus, Brazil, on 18 January. Severe oxygen shortages in hospitals prompted local authorities to impose a curfew and airlift patients to other states in an attempt to deal with the second coronavirus wave.
Vanda Ortega, a nurse and member of the Witoto indigenous tribe, takes the temperature of a Covid-19 patient at a hospital set up in the indigenous Parque das Tribos neighborhood.
Dilza Maria Pereira Rodrigues, 71, receives treatment for Covid-19 at home, following 15 days of treatment at the hospital in Manaus. Across Brazil the situation is desperate: people queue in long lines or pay exorbitant prices for an oxygen tank, while others die of asphyxiation in hospitals.
A burial takes place in an area reserved for Covid-19 victims at the Nossa Senhora Aparecida cemetery.
A worker wearing PPE moves empty coffins inside the storage room of SOS Funeral services.
Olga D’arc Pimentel, 72, is vaccinated by a health worker with a dose of the Oxford-AstraZeneca vaccine in the Nossa Senhora Livramento community on the banks of the Rio Negro near Manaus, on 9 February 2021.
Aerial view of the Nossa Senhora Aparecida cemetery, where many of the city’s Covid-19 victims are buried. With over 3,000 burials in January, the pandemic has accelerated the expansion of the largest cemetery Manaus.

Photographs by Michael Dantas, Jonne Roriz, Andre Coelho, Marcio James and Ricardo Oliveira: Getty Images/AFP/Bloomberg

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