Why Brazil Responded to AIDS and Not Tuberculosis
International Organizations and Domestic Institutions
You are probably familiar by now with the famous “Brazilian AIDS Miracle.” A strong, highly centralized AIDS bureaucracy, the incorporation of a well organized civic movement and strong relations with the world health and financial community has led to an impressive decline in AIDS deaths since the 1990s.
Yet many are unaware of the government’s response to other lingering epidemics such as tuberculosis (TB). In sharp contrast to AIDS, the government has not responded to TB nearly as effectively as it should and could have. People infected with the Human Immunodeficency Virus (HIV) are also often infected with TB; the Brazilian government is aware that the problem of co-infection had been spiralling in favelas and other urban areas since the 1980s.
Yet, the government did not create a highly centralized institutional and policy response to TB; rather, it completely dismantled the National TB Program through decentralization while refraining from working with the international community and civil society on this health problem. Why did the newly democratic government respond in this manner?
The government’s response was motivated by the following reasons. First, and in sharp contrast to AIDS, there was no burgeoning global health movement and attention to TB. Like leprosy and malaria, TB did not receive nearly as much attention as the “mystical,” globally popularized AIDS epidemic. As a result, the government was not racing to obtain global recognition for its response to TB, something which it did for AIDS. Second, TB did not benefit from a well-organized civil society pressing for human rights, gay rights, and health equality, as we saw with AIDS. Even now, there is not even one single TB NGO, but rather a consortium of civic organizations focusing on AIDS and other TB-related issues. Finally, the government had initially thought the TB problem had practically gone away prior to its resurgence in the 1980s. These perceptions were influenced not by morals or discrimination against the poor, but from structural factors such as a decline in TB cases during the 1960s and 1970s and the weakened allure of treating TB.
However, the rise of new global pressures, such as direct policy criticisms from international organizations such as the World Health Organization and the World Bank, and the recent financial incentives for responding to TB, which derive from the Global Fund to Fight AIDS, Malaria, and TB’s provision of new grants based on specific conditionalities, gives us new hope that the government will finally respond to the ongoing TB problem. Only time will tell, however, if Brazil will respond just as well to these new global movements and incentives as it did for the AIDS epidemic.
GLOBAL HEALTH MOVEMENTS AND DOMESTIC RESPONSE
The global health community can have a profound effect on how domestic governments respond to epidemics. AIDS policy provides a good example of how this can occur. Prior to the 1990s, Brazil’s institutional and policy response to AIDS was just as lackluster as the United States’. While the government created a National AIDS Program in 1985, it was very poorly funded and was not well integrated in civil society. Nevertheless, as the global health community (composed of various international health and financial organizations, such as the UN, the WHO, PAHO, and the World Bank) started paying more attention to AIDS, the Brazilian government’s position began to change. By the late-1980s, increased international attention and commitment to AIDS, coupled with direct pressures on Brazil, led to a radical shift in political elite perceptions and interest in responding more effectively to it. With the prospect of a major World Bank loan arriving in 1992, moreover, the government quickly increased its commitment to strengthening the National AIDS Program and working more closely with civil society. Essentially overnight, the government transformed a poorly funded National AIDS Program into a very wealthy agency that was highly autonomous and successful at imposing policy onto the states; this has led to arguably the world’s best institutional response to AIDS, leading to a host of prevention and treatment measures that has contributed to a massive decline in AIDS deaths since the mid-1990s.
And what of TB? Despite it resurgence in the poorer, more concentrated urban areas of Brazil, such as Rio and São Paulo, similar to what we saw with the first few years of the AIDS epidemic, the government did not immediately respond. In part this had to do with the fact that the global pressures and attention to TB during the late-1980s early-1990s were not nearly as strong as they were for AIDS. As a result the government’s interest mirrored that of a somewhat apathetic global health community. Under these circumstances, the response to TB would depend entirely on the newly decentralized health care system, which was poorly funded and staffed. In fact, in sharp contrast to AIDS, by the late-1980s the government completely dismantled the historically centralized, well funded National TB program through the decentralization of health care services through SUS (Sistema Unico do Sáude) in 1988.
But why was the government more biased in its response to AIDS? The main reason has to do with the fact that as has always been the case, the government responded to a new health epidemic that garnered a lot of global attention. By responding to AIDS, Brazil was able to demonstrate to the global health community that as a modern, newly democratized nation it was capable of successfully controlling a deadly virus, paving the way for social and economic prosperity. More importantly, it provided the government with the opportunity to lead the global health movement in response to AIDS. In other work, I have called this the “global race to fame” in international health and how this generates a new level of government commitment to institutional and policy reform. In contrast, TB did not benefit from opportunities and global incentives. Since TB was not a “globally popular” disease, it provided few benefits for Brazil to illustrate its medical and institutional prowess in response to its resurgence. And thus it did not provide an opportunity for Brazil to lead the global fight against TB.
Civil societal response for more effective public health policy has a very long history in Brazil, spanning back to the First Republic. As in the past, the AIDS epidemic triggered a very aggressive civic response. In sharp contrast to the past, however, this response emerged in a context of re-democratization, strongly grounded in the tenants of human rights and equality in social policy (with health being a major component of this). In addition, the movement for AIDS benefited from a burgeoning, well-organized gay rights movement that started to benefit from the outgoing military regime’s somewhat progressive stance towards gay rights (mainly through the allowance of gay publications). By the time AIDS emerged in the 1980s, there was thus a well-organized, vibrant civic network unwaveringly commitment to creating a host of AIDS NGOs that would flourish throughout the 1980s and 1990s. By the mid-1990s, over 100 AIDS NGOs existed.
Unfortunately, such a movement did not occur for TB. Prior to and throughout the re-democratization period, there existed not one single NGO focused on the TB problem. Despite data rates illustrating a parallel growth rate alongside HIV/AIDS, most notably in Rio and São Paulo, in sharp contrast to the past (especially when compared to the well-organized Lisa de Tuberculose of the early 20th century), medical elites, intellectuals, and local politicians were not interested in immediately creating a new civic movement for TB, needless to say, NGOs. In contrast to the well-organized gay and AIDS NGO community, moreover, the urban poor (even those with HIV) had no organizational resources and support to depend on, no one to help them fight for a more effective, decentralized TB program. The whole movement for “human rights” and “human equality” in health care treatment thus seemed to overlook the needs of the urban poor suffering from a clandestine—yet quickly burgeoning—TB epidemic.
Why did this occur? In large part, it was the absence of TB’s “sex appeal,” when combined with a decline in civil elite perceptions that TB was still a problem, which generated few incentives for a new civic movement to emerge. In contrast to AIDS, there was simply no mysticism associated with TB; it had not global allure and more importantly, there was no opportunity for medical elites to distinguish themselves by finding a cure. Direct and successful treatment for TB had existed for years. And the fact that TB had been for the most part eradicated during the 1960s and 1970 contributed to the misperception, both within government and especially civil society, that it was no longer a problem. And lastly, the simple fact of the matter is that TB was always, and continues to be, perceived as a poor man’s disease. Its association with the poor—in marked contrast to AIDS’ initial association with the gay white, upper-middle class—created few incentives for civic elites to mobilize for the poor.
The end result is that there was no NGO movement for TB throughout the 1980s and 1990s. AIDS NGOs and their ability to directly pressure the state would flourish, while the poor and the co-infected became increasingly marginalized. The problem became so obvious that by the late-1990s, the WHO and even the World Bank would start to criticize Brazil for its biased response to AIDS at the very costly, border-line discriminatory expense of overlooking tuberculosis.
GLOBAL HEALTH MOVEMENTS—ONCE AGAIN?
But there is hope. As was the case with AIDS, the global health community finally started to realize the TB has resurfaced as a global pandemic. In 2003, the WHO officially declared the resurgence of TB as a global health threat. And as always, the Brazilian government was eager to respond. Similar to AIDS, the National TB Program was re-centralized, with a larger staff and more resources—though, of course, still paling in comparison to the more affluent, autonomous National AIDS Program. As with AIDS, shortly after these new global pressures emerged the federal government realized that unguided decentralization processes were not yielding effective TB prevention and treatment policies. The National TB Program was thus re-strengthened through a renewed commitment by the current Lula administration (and mind you, the response to TB bodes well with his emphasis on increasing social welfare redistribution to the poor).
In addition to increased global recognition of the TB problem, the ability to obtain new sources of international funding has once again created new incentives for the government to increase its commitment to not only to the National TB Program but also to state and especially municipal health agencies. In 2006, the government was the recipient of an $11 million dollar grant from the Global Fund to Fight AIDS, TB, and Malaria. Similar to what occurred with the first World Bank loan in 1992, the acquisition of this grant, in addition to the fact that continued funding will be contingent on grant performance, has created new incentives to strengthen the National TB Program and more importantly to engage in a continuous dialogue with municipal health agencies for more effective policy implementation.
Once again similar to AIDS, the arrival of this new grant, when combined with an increased global recognition of TB, has also led to the emergence of new civic movements in response to TB. In 2003, a new civic forum for TB was created in Rio by several AIDS activists, doctors, community and church leaders; a similar movement was created in São Paulo in 2005. Referred to as the “TB Forum,” this movement is dedicated to increasing awareness of TB’s resurgence and to working with the federal and local governments to implement more effective policy measures. Since its existence it has created a host of public prevention campaigns and has organized conferences with the National TB and AIDS Program.
It is no surprise that this movement has grown in tandem with the increased attention and financial support of the global health community. The Global Fund in fact stipulates that a necessary condition for grant approval and renewal is the creation of a Country Coordinating Mechanism (CCM), which guarantees the representation of civil society on the official committee drafting grant applications. Keep in mind that the Global Fund declined Brazil’s initial application for funding in 2005, based on the fact that the CCM could not prove adequate civil societal representation. Months later, it was finally approved by demonstrating to the Global Fund that it had finally achieved this.
In sum, as we saw with AIDS at the beginning of the 1990s, the beginning of 2000s has created similar incentives for the federal government to respond to tuberculosis through the strengthening of institutions (this time, the re-centralization of the National TB Program) and interest in working closer with civil society and local governments. In response to the government’s efforts, new civic movements continue to emerge in order to help those suffering from TB. While an official TB NGO still does not exist, several related civic associations and the church are coming together to create new TB forums throughout the nation in order to consistently monitor and apply pressure on the federal government for reform.
Governments, even the most democratic and socially progressive, can be biased in the types of health epidemics they respond to; Brazil is no exception. This should be alarming to those familiar with the nation’s historical institutional response to disease. This is mainly because Brazil’s most effective campaign against epidemics emerged during the far less democratic era of the early 20th century, most notably the Vargas military dictatorship (1930-45), when the government created strong federal ministries in response to all health threats. Thus what is interesting to note is that as Brazil has become more democratic and committed to human rights, it has not been as committed to immediatelyresponding to all types of health epidemics, especially through institution building. This further suggests that democratic consolidation may not necessarily guarantee an equitable response to epidemics—and perhaps lends even more insight into why less democratic, more centralized nations, such as Cuba, have far more progressive and effective anti-AIDS policies than Brazil and even the United States.
And finally, what we have learned from Brazil’s recent response to AIDS and TB is that it is not the social pressures emanating from democratic consolidation that guarantees a strong government response to epidemics. Rather, domestic response may emanate more from new global pressures and incentives to change and to become global leaders in the fight against disease. Global pressures for institutional and policy reform, in addition to the foreign lending supporting these endeavors, continues to have a very positive affect on Brazil’s response to epidemics. Time will only tell if the new grant from the Global Fund and other donors will create the types of political and civic incentives needed to work together in order to finally arrest the growth of TB an other health ailments still troubling Brazil, such as malaria, samparo, and more recently, obesity and type-two diabetes.
Spring 2007, Volume VI, Number 3
Eduardo J. Gómez is a doctoral candidate in Political Science at Brown and a Visiting Scientist and Instructor in the Politics and Governance Group of the Harvard School of Public Health. His research focuses on government response to health epidemics, decentralization, fiscal federalism, and more recently disaster management in the United States and developing nations. When he is not writing, you can find him on the running trails of Boston and Providence, Rhode Island. You may contact him at: email@example.com
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