democraciaAbierta: Opinion

Brazil: The undoing of a country known for its innovative health policies

How did a country that successfully managed past health crises be making headlines for its spiraling Covid-19 chaos? The politicization of health policy is one answer. Español

Manuella Libardi
10 July 2020, 3.25pm
A man specialized in pest control sprays insecticide at construction sites to prevent the spread of aedes aegypti in Rio de Janeiro, Brazil, in 2016
Luiz Souza/Imagespic Agency/ABACA/PA Images

Just last week, a 36-year-old Brazilian possibly became the first person to experience long-term remission from HIV., researchers at the Federal University of São Paulo announced.

This is the type of health news that fits Brazil’s long-standing place near the top of scientific research in the developing world – and even worldwide. How can a country known for innovative health policies be making headlines for its spiraling Covid-19 crisis, second only to the United States in number of cases and deaths?

While the answer is nuanced, one of the reasons is the politicization of health policy and governance. And it stands to show how quickly progress can be unmade.

Since Brazil began its redemocratization process in 1985 following more than three decades of military rulership, the country has faced significant health crises. From the Zika outbreak to the decades-long fight against HIV/AIDS, the country has confronted them by putting forth strong, cohesive strategies that were largely nonpartisan.

But now, under the populist government of Jair Bolsonaro, Brazil is not only facing the most dramatic crisis of its recent history, but also threats to its past accomplishments.

The Zika outbreak

The disease, transmitted by the same mosquito behind dengue fever, was declared a Public Health Emergency of International Concern by the World Health Organization in 2016 after it was linked to birth defects and neurological problems in babies born to infected mothers.

Brazil quickly rose to the challenge, deploying 220,000 troops and 300,000 health agents to heavily affected communities to educate the population and help eliminate all mosquito breeding grounds. The government also put together social benefits packages for families victims of the disease.

The UN characterized the “intersectoral actions by the Brazilian government against the Aedes aegypti mosquito” and its mobilization of society and sheltering of families “as examples to the world”

Brazil also embraced research that helped the country manage the outbreak. In January 2016, the government approved the widespread release of genetically modified Aedes aegypti mosquitoes throughout the country. These were mosquitos that had been engineered to pass a lethal gene to their offspring, causing them to die before reaching adulthood.

The strategy was set in motion after results published in July 2015 of tests conducted in the Juazeiro region of Brazil concluded that mosquito populations were reduced by more than 90%. The study suggested that the so-called "self-limiting" mosquitoes could be used to fight not only Zika, but also dengue fever and chikungunya, all three prevalent throughout Brazil and other parts of the Americas.

Further testing concluded the genetically engineered specimens has lowered mosquito populations by 80% or more. Today, the United States plans to release self-limiting mosquitoes in Florida and other parts of the country to curb the spread of the diseases borne by Aedes aegypti.

In 2017, when the epidemic had been contained, the United Nations highlighted Brazil’s management of the health crisis, stating that “that country provided an effective response in actions against the epidemic”. The agency characterized the “intersectoral actions by the Brazilian government against the Aedes aegypti mosquito” and its mobilization of society and sheltering of families “as examples to the world”.

The HIV/AIDS epidemic

When Brazil confronted a surge of HIV/AIDS cases in the 1990s, the annual cost of drugs for AIDS treatment often exceeded US$10,000 per patient.

In 1996, Brazil took a highly controversial move and became the first country in the Global South to provide antiretroviral treatment to the entire population. This decision was in direct defiance to the World Bank and other development agencies that discouraged developing countries from implementing “cost-effective” treatment programs.

Brazil’s continued its fight against the epidemic, often by standing in defiance of world organizations. One of the country’s most effective strategies involved threatening to disregard drugmakers’ patents to force them to lower costs.

In 1998, the Brazilian government made the access to medicine a constitutional right and, a year later, introduced the 1999 Generics Law

But in 2007, Brazil materialized its threats when the federal government took steps to make an inexpensive generic version of an AIDS drug made by Merck & Co. available in Brazil despite the U.S. drug company’s patent. Then-President Luiz Inácio Lula da Silva issued a “compulsory license” to bypass the company’s patent on the AIDS drug efavirenz. His decision came a day after the Brazilian government rejected Merck’s offer to sell the drug at a 30% discount. Brazil's policy of bargaining with drug companies over the cost of antiretrovirals – and openly disregarding some international patents – saved the country US$1 billion.

The country’s policy to offer free and universal access to antiretrovirals has helped reduce the prevalence of HIV in the country to 0.6% of the population, similar to that in the United States. Brazil's accomplishments have gained international recognition and are credited with dramatically reducing AIDS-related mortality and morbidity, including mother-to-child transmission of HIV.

Background: Generic drugs

The debate around generic drugs was fundamental in the fight against HIV/AIDS. Until the 1990s, the pharmaceutical sector in Brazil was largely unregulated. Because the final stages of production were highly competitive, local firms and laboratories often lacked the research and development capacities. In this context, marketing strategies were vital in their ability to secure enough resources to compete, which often inflated drug prices.

This dynamics resulted in expensive drugs to which most of the population lacked access. In 1991, concerned with increasing pharmaceutical expenditure and the population's deficient access to drugs, Federal Congressman Eduardo Jorge presented a bill to regulate the market. He suggested that brand names be removed from all drugs, arguing the tactic would reduce the marketing costs of the products, while reducing price and increasing populations’ access to them.

The debate gained traction only two years later, in 1993, when the Brazilian government adopted the use of generic drugs as a policy for its health and economy sector. But it wasn’t until 1998 that the government made the access to medicine a constitutional right and, a year later, introduced the 1999 Generics Law.

One aspect these accomplishments have in common is that they were implemented in different governments, under different leaderships, parties and political ideologies

The decision came amid a number of highly publicized scandals involving cases counterfeited medicines, including fake birth control pills, which led to social mobilization, from patient organizations, advocacy groups and the media, to improve the safety and quality of medicines.

By 2016, generic medicines were priced, on average, 40% lower than their innovator counterparts. In addition, the introduction of the 1999 Generics Law also contributed to the growth of the domestic pharmaceutical industry.

Future threats

One aspect these accomplishments have in common is that they were implemented in different governments, under different leaderships, parties and political ideologies. The plans and strategies carried over from one administration to the next, ensuring their continued application and further development.

The current administration, with Bolsonaro at the helm, has brought an aggressive “moral agenda” based on so-called traditional and family values into the government. By putting the secularity of the State in check, Bolsonaro has politicized concepts that proved crucial in the fight against AIDS. Some examples include reducing access to sex education, disregarding issues affecting the LGBTQ communities in its public policy, and favoring the term “abstinence” in place of “harm reduction” in its National Drug Policy documents.

As this young democracy still lacks the robust institutions needed to prevent potentially irreparable actions by a populist leader, politicizing health care in Brazil has the potential to undo the accomplishments made since the mid-1980s. In today’s political scenario, Brazil needs to remain vigilant in its separation of science and politics. Otherwise, even the country’s decades-long fight against the HIV/AIDS epidemic could be jeopardized.

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