Elize Massard da Fonseca, Nicoli Nattrass, Luísa Bolaffi Arantes, and Francisco Inácio Bastos
Brazil has one of the largest public health systems in the world (Paim et al., 2011). It has successfully responded to epidemics such as human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS), hepatitis C, and H1N1 influenza (Fonseca et al., 2019; Nunn, 2008). Brazil has a well-developed health surveillance system encompassing legal frameworks and infrastructure. It complies with the World Health Organization’s (WHO) International Health Regulation, which establishes parameters for public health emergencies (Franco Netto et al., 2017) and provides guidelines for countries’ rights and obligations in responding to potentially border-crossing epidemics.
The capacity of the health system to react during public health crises, however, may differ from its functioning ability during normal times (Medici, 2020). However, it was expected that Brazil would perform well during the COVID-19 pandemic. According to the Global Health Security Index, a system of measurement that classifies countries’ preparedness to deal with public health emergencies across six dimensions and thirty-four indicators, Brazil ranked with the best score in Latin America (59.7 out of 100) (Nuclear Threat Initiative & Johns Hopkins Bloomberg School of Public Health, 2019). Why, then, was a country that was relatively well prepared for public health crises, that had performed in an exemplary manner in previous epidemics, and that has one of the largest public health infrastructures in the world not able to respond promptly and effectively to the COVID-19 pandemic? What went wrong?
In this chapter, we explore the evolution of public health initiatives during the COVID-19 pandemic in Brazil, the social policies adopted to allow people to quarantine, and the political and institutional factors shaping Brazil’s response. We analyze the negative role played by President Bolsonaro’s denialism and misinformation while emphasizing that a group of subnational governments led Brazil’s response, at times aligned with the Ministry of Health (MoH) but against the president’s perspective. We highlight the surprisingly proactive response by state governments given that this level of government has had little involvement in public Page 495 →health policy. Brazil is a federal system, with a federal government, 27 states, and more than 5,500 elected municipal governments. Response to the COVID-19 pandemic is a tale of intergovernmental competition, with several instances of blame avoidance and credit claiming. Public opinion vacillated, but it appears that Bolsonaro was able to reap credit for the cash transfer programs put in place during the epidemic, despite his initial opposition to increasing social spending.
COVID-19 Pandemic in Brazil
The first case of COVID-19 in Brazil was officially diagnosed on February 26, 2020, in a man returning from a trip to Italy. Later studies showed that the virus had been circulating since at least early January 2020 (Delatorre et al., 2020). In early March 2020, the MoH announced the first cases of community transmission (i.e., infections that did not stem from interactions with individuals in foreign countries). As of August 14, 2020, the pandemic had resulted in 3,224,876 confirmed cases and 105,463 deaths in Brazil (Dong et al., 2020).
At that point, the epidemic was far from being curbed—similar to that in the United States and Mexico. As of mid-August, Brazil was still facing a substantial epidemic. The curve had flattened somewhat but was plateauing at high levels in places such as São Paulo. Infections were rising rapidly in the southernmost states and in most regions of the center-west. In a large country like Brazil, a pandemic curve is likely to present different peaks at different places and different times (Bastos, 2020), which makes a coordinated response a formidable challenge.
Health Policy
Brazil has a public health system, the Unified Health System (acronym in Portuguese, SUS) that cares for 75 percent of the population, with most of the remaining 25 percent covered by private health insurance companies.
1 The country’s health policies regarding international pandemics are in alignment with the WHO, and there is a national plan for curbing influenza epidemics (Y. Lima & Costa, 2015; Ministério da Saúde, 2010). In late February, thirty-four Brazilian citizens living in Wuhan, China (the epicenter of the epidemic at that time) were repatriated, but there was no quarantine regulation in the country. The Minister of Health, Luiz Henrique Mandetta, reacted quickly to get legislation passed on not only preparing to receive these citizens but also preparing for the impending epidemic (Law 13.979/2020; Coletta, 2020). Although none of the Brazilian citizens were infected, they were required to quarantine for fifteen days in a military facility in Brazil before returning to their homes (“Brasileiros que Vieram da China Deixam Quarentena em Anápolis” [“Brazilians Who Came from China Leave Quarantine in Anápolis”], 2020).
Page 496 →The MoH and the state of São Paulo, the most populous region in the country, created committees to manage the potential crisis. Several hospitals established protocols to deal with suspected cases. The MoH, in anticipation of the winter influenza season, was already embarking on its annual influenza vaccination campaign. Additionally, most states and municipalities acted promptly. On March 13, 2020, Rio de Janeiro became one of the first states in Brazil to close schools and shops and cancel large social events. São Paulo—the epicenter of the country’s outbreak—did so ten days later (Rodrigues, 2020).
In contrast with the subnational governments, President Bolsonaro decided not to follow WHO guidelines or evidence-based health policy, apparently believing that this would have negative economic consequences for the country. The president and his supporters (the governors of four states, part of the military forces, and some government officials such as the minister of international relations and some extreme-right wing groups) advocated for health policies that reflected pseudoscience at best, and denialism at worst. They suggested that COVID-19 was a “small flu”and a “fantasy,” while drawing on discredited or incomplete “science”in support of their light-touch approach to combatting COVID-19 (“Relembre Frases de Bolsonaro Sobre a COVID-19” [“Remember Bolsonaro Phrases About COVID-19”], 2020). For instance, they relied on non–peer-reviewed papers and statements to give a patina of scientific respectability to their construction of a moral economy
2narrative framed around the right to earn a living. Conventional scientific advice, especially where this undermined the ability of business to earn a profit, was undermined or ignored.
March 2020 was a critical time with regard to both the bourgeoning epidemic and the dispute brewing between federal and most subnational governments. As the epidemic spread through the country and to the more vulnerable populations, the state governors began an aggressive campaign to promote social distancing initiatives, which were aligned with the MoH administration at that moment. Both Minister Mandetta and the state governors gained popularity for their scientifically informed guidance on COVID-19. This appears to have enraged President Bolsonaro and his supporters, who were against measures such as closing shops and schools and paralyzing commerce. Several protests against social distancing were scheduled during a critical period of the pandemic, some of which were led by the president himself.
A crystallizing moment was a virtual meeting on March 25, 2020, between the president and state governors. The previous day, President Bolsonaro addressed the nation, declaring, “Our lives have to go on. Jobs must be kept … We must, yes, get back to normal” (Phillips, 2020). During this virtual meeting, Bolsonaro accused the governor of São Paulo (a member of the Brazilian Social Democratic Party, PSDB, acronym in Portuguese) of using the health emergency as a political strategy for the 2022 presidential election. Bolsonaro is currently not affiliated with any political party but was elected under a minor, far-right political party, the Social Liberal Party.
Page 497 →In a presidential, federal system, the decisions to act during a pandemic are divided among different institutions. For instance, the president has the authority to close Brazil’s borders. It was only on March 19, 2020, however, that the Ministry of Justice closed land borders and on March 27, 2020, that it completely shut airports to incoming international flights from all over the world (Fernandes, 2020; Schreiber, 2020). Although the MoH was active in producing mass campaigns to educate the population on how to prevent the spread of the virus, the Ministry of Economy delayed financial support (e.g., cash transfers) that would allow citizens and firms to adhere to social distancing measures.
In April and May of 2020, the lack of coordination became even more evident. On April 8, the Supreme Court ruled that state governments could implement measures to respond to the epidemic within their jurisdictions and municipal governments could complement decisions taken at federal and state levels. This decision was crucial in allowing states to adopt and maintain restrictive measures. President Bolsonaro responded with several presidential decrees listing essential activities that should continue and businesses that should remain open, including religious services, gyms, construction sites, and industrial activities, among others. In April 2020 the president began an aggressive campaign in support of the use of chloroquine and hydroxychloroquine to treat COVID-19 patients. Such strong advocacy was against the advice of Minister Mandetta, who was subsequently fired and replaced by a respected physician, Nelson Teich (Mazui, 2020). Because of his vehement disagreement with President Bolsonaro’s plans to adjust the clinical protocols for COVID-19 treatment, Teich resigned less than a month after taking the position (Verdélio, 2020). Bolsonaro expressed his interest in including chloroquine and hydroxychloroquine as part of the MoH’s clinical protocol for COVID-19, but Teich preferred to wait for adequate scientific evidence. Such disputes not only spread contradictory recommendations on how to deal with the COVID-19 but also have had apparent political effects, notably strengthening support for state governors.
The president replaced Teich with a military officer, General Eduardo Pazuello, as interim minister. Pazuello had no experience in the health sector, but his background in logistics was presented as a core competency for responding to the epidemic (Savarese & Biller, 2020). The temporary health minister not only yielded to the adjustment of the clinical protocols for COVID-19 but also replaced key managerial posts in the MoH with fellow military officers (B. Lima & Cardim, 2020). This decision was highly criticized by the public health community, such as the Brazilian Association of Collective Health (Abrasco), a strong organization in Brazil since the 1988 reform that introduced the public health service (Abrasco, 2020). Pazuello later took the controversial decision to reformulate the disclosure of epidemiological data, announcing only information about death and confirmed cases in the previous twenty-four hours rather than accumulated deaths and infections (Machado & Fernandes, 2020). As a response, a consortium between Health State Secretariats and a pool of media organizations Page 498 →established an online e-panel that was updated every day to monitor and compare the official data provided by the MoH (“Brasil Tem Média de 1.069 Mortes por Dia na Última Semana” [“Brazil Has an Average of 1,069 Deaths per Day in the Last Week”], 2020). Pazuello’s decision was subsequently repealed by the Supreme Court (Xavier, 2020).
Social Policies
Since 2015 economic crises and austerity policies in Brazil severely constrained public expenditure and increased inequality (Deweck et al., 2018). In March 2020 a “state of calamity” decreed by the Brazilian National Congress allowed the federal government to increase public expenditure, which otherwise would have been frozen in line with the country’s strict laws regulating public spending. In addition, in April, Congress approved a bill named “War Budget,” which entailed a constitutional amendment to separate COVID-19–related spending from the government’s main budget. The COVID-19 emergency resulted in the federal government investing more than US$2 billion in health and social policies (Agencia Saude, 2020). This would allow Brazilians to quarantine for longer periods but also posed challenges for Bolsanaro’s anti-statist, free-market policies.
Paulo Guedes, an investment banker and minister of economy since 2019, was important politically for Bolsonaro. “Guedes may be a naively ambitious advocate of free-market policies serving the financial elite, but he provided [President] Bolsonaro with the necessary economic ‘seal of approval’ and removed the stain of a possible affinity for ‘statism’ created by Bolsonaro’s career in the military” (Evans, 2018, p. 50). Economic policy is a crucial aspect of Brazil’s politics. The Ministry of Economy is powerful in Brazil (and Bolsonaro defers to the minister of economy over decisions on public expenditure) because no one wants to experience again the debilitating effects of hyperinflation. Yet there are aspects of government spending that remain strongly entrenched and have helped people cope with the epidemic. Chief among these are cash transfer programs.
Brazil has one of the most successful conditional cash transfer programs in the world, the Family Allowance program (Bolsa Familia), with clear benefits for the health of impoverished people (Rasella et al., 2013). Brazil also created a new social program to provide salary relief to vulnerable populations: the Salary Relief program.
3 The creation of this program was a shared decision between Congress and the executive government; therefore, there were substantial controversies and disagreements between these governmental entities over the contents of these policies. We first explore the existing policies in place, then investigate the new Salary Relief Program.
The Continuous Cash Benefit (CCB) program, implemented in 1996, is an unconditional cash transfer to the elderly or extremely poor individuals with disPage 499 →abilities. During the pandemic, the Law 13982/2020 revised the criteria for inclusion in the program from those who earned a quarter of the minimum wage as household income per capita to those who earned half of the minimum wage. For those waiting to enter the program, the government provided a cash advance of R$600 (US$110). This advance was because legislative reforms in the entitlement criteria of the CCB program require regulation by the Social Security Institute, which might take several months and not be ready before the end of the pandemic (Bartholo et al., 2020). Although Congress intended to assist the elderly or extremely poor individuals with disabilities through CCB, as of mid-August 2020 this had not yet been implemented because it required further regulatory changes on the part of the federal government.
One of the most important social policies in Brazil, the Family Allowance program, was created in 2003. It targets poor families with a per capita income below US$40 per month and registered with the Unified Record (Cadastro Único). It is the responsibility of the local government to register and implement the program, which is then verified at the federal level. The Ministry of Citizenship suspended the penalties of those families that had not been able to fulfill the conditions of the program during the epidemic (such as school or basic healthcare attendance) or those with insufficient record information. As schools were closed and health services overwhelmed by COVID-19 cases, it proved impossible for families to fulfill these conditions (Bartholo et al., 2020). The Ministry of Citizenship suspended the monthly evaluation of municipalities’ performance index, which assessed the municipality’s local-level compliance with the rules of the program. In addition to the Family Allowance program some states distributed vouchers and food stipends to families registered with the Unified Record. For instance, the government of Santa Catarina waved the electricity bill and the government of Mato Grosso provided food parcels (cesta basica) for poor families. One of the consequences of this mix of national, state, and local regulations was that people living in different states were entitled to different social benefits.
Changes to the Family Allowance program meant that for the first time after more than a year (since Bolsonaro came to power) the waiting list of people wanting to enter the program was reduced from 1.7 million families to 500,000. This was thanks to a presidential provisional decree that allocated more than R$3 billion (US$578 million) to the program (because of the lack of funding, the Ministry of Citizenship could not expand the number of families in the program without this provisional decree). There was an enormous difference between new Family Allowance concessions to the south and southeast (75 percent), which are the wealthiest regions, compared to the northeast, which received only 3 percent of new concessions; therefore the governors of these states filed a lawsuit at the Supreme Court against the federal government (Mello, 2020).
In addition to calibrating existing social programs, the federal government created a new support, the Salary Relief Program. This was the most important Page 500 →social policy initiative during the epidemic because it covered both recipients of the Family Allowance and unemployed individuals with a household income below half the minimum wage. The program was announced mid-March 2020 after strong pressure from congressmen on the Ministry of Economy. Initially, the executive government announced a R$200 allowance (US$37) per month, which, after a debate in Congress, was increased to R$600 (US$110) (Piovesan & Siqueira, 2020). In May the government came under further pressure to extend the allowance for additional months. Again there was a dispute between the Minister of Economy and Congress. The former suggested an increase of the allowance by R$200 (US$38) per month for an additional two months. Congress, however, kept the value the same but allowed the additional two months (Presidential Decree 10.412/2020). As of July 2020, the program had cost R$113 billion (US$22 billion) and aided almost 109 million individuals (more than double the initial estimation) (Maximo, 2020). This meant that one in every three adults had received governmental support. Because of the economic recession, such expenditure was possible only because of the state of calamity and the war budget issued by Congress, which allowed an increase in the executive government’s expenditure.
The implementation of the Salary Relief program encountered some obstacles, however. For example, Brazil adopted a fully online strategy to enroll new individuals and not all vulnerable people had access to the internet or a cell phone. Additionally, problems with incomplete applications or documentation had to be solved in person, which led to long waiting lines in Social Security offices throughout the country (Veloso, 2020). Despite such issues, the outcomes of the program were impressive: more than 5 percent of residences in Brazil (3.5 million) survived this period by relying only on the Salary Relief program. The average household incomes of beneficiaries were 95 percent of what they would have been earning in the absence of the epidemic, and for the poorest parts of the population, it was 103 percent (Bartholo et al., 2020).
These cash transfers provided a political boost for President Bolsonaro, who, as of mid-August 2020, was considering replacing the Family Allowance with a new program, Brazil Income (Renda Brasil). This program could be a valuable asset for Bolsonaro’s re-election campaign in 2022 (Beck & Gamarski, 2020). This is ironic given Bolsonaro’s initial reluctance to increase public expenditure and his opposition to measures that could require closing the economy. However, as social policies were implemented, the popularity of the president increased considerably (37 percent good/excellent, a record during his term) (“Datafolha: Aprovação de Bolsonaro Sobe para 37%” [“Datafolha: Bolsonaro’s Approval Rises to 37”], 2020). Such policies also helped counterbalance the negative health policy decisions taken by the president. The polling data suggest that Bolsonaro was able to pass the blame onto state governors for unpopular initiatives while claiming credit for the social policies (particularly cash transfers) during the epidemic. Whether this was serendipitous or a shrewd political strategy is unclear.
Presidentialism Effect
Brazil has a complex presidential regime, which lies between the model of the US presidential system (ceding significant decision-making control to the president) and European parliamentarianism, where political parties dominate government. It is important to note, however, that Brazil is not a semipresidential system (such as France or Peru), in which cabinet formation requires formal approval from Congress. Therefore, the bargaining space between coalition members and the executives in cabinet formation (including the MoH) and bureaucratic appointments is the result of the particular shape of the party-system.
Brazilian presidents are endowed with strong constitutional powers (Amorim Neto, 2002). Besides the allocating of positions in the vast federal administrative empire, presidents can issue presidential decrees and exercise substantial control over budgetary matter. As in other countries, the president is able to use his or her position to speak directly to voters via national radio and televised speeches. These are powerful instruments that allow the president to push forward his agenda, whether for the public good or for particular interests.
Bolsonaro is a far-right populist president who came into power in 2018 through an alliance between the economic liberals and social conservatives. Bolsonaro, a low-rank congressman who never had great political aspirations, was seen as an alternative to the WorkersʼParty’s candidate. After corruption allegations that resulted in the impeachment of President Dilma Rousseff and the “lawfare” (the use of legal system against a political enemy) against President Luiz Inácio Lula da Silva, Bolsonaro was able to take advantage of this opportunity to push his campaign forward (Evans, 2018). With a moral discourse against corruption, during the initial months of his term in the presidency, he refused to form alliances with political parties in Congress. Nevertheless, he appointed Mandetta as Minister of Health, which was both a political decision (Mandetta is a member of the PSDB political party, an important political ally) and a technical one (Mandetta is a physician).
As discussed previously, Mandetta threatened Bolsonaro’s political dominance, his pseudo-scientific rhetoric, and his stance on social distancing and plans to open up the economy. After the second health minister, Teich, resigned and was replaced by active-duty Army General Eduardo Pazuello, political analysts in Brazil suggested that Bolsonaro was ensuring that if any negative public health consequences or possible judicial decisions against the president arose, the blame would be shared with the Army (Barros, 2020).
President Bolsonaro’s strong skepticism toward the science of COVID-19 (if not outright denial of it) seems to have been reinforced after returning from a visit to the United States, where he met with American populist president Donald Trump to discuss military cooperation. Bolsonaro’s discourse became radicalized toward ignoring and minimizing the pandemic (Teófilo, 2020). Like Trump, Page 502 →Bolsonaro was not keen to “stop” the national economy and gained notoriety for supporting protests against government lockdowns, for touting unproven medicines (notably hydroxychloroquine), and for downplaying the seriousness of the virus, even so far as vocally opposing state governors’ decisions to impose social distancing measures. Many of Bolsonaro’s statements contradicting the governors were typically framed in terms of his goal of reopening nonessential businesses. Bolsonaro often highlighted the economic consequences and costs of social distancing. For instance, he stated, “Brazil has to work. The best medicine for any disease is work. We have got to work” (Carvalho & Colletta, 2020). As noted previously, economic stability is valuable to politicians given Brazil’s history of economically disruptive hyperinflation. Yet, as the consequence of lockdown and social distancing globally has been economic recession rather than hyperinflation, the political advantage he may have been seeking was to avoid the blame for the recession and to pass it on to regional governors (Ricard & Medeiros, 2020).
Denying, or marginalizing, scientific advice works politically to undermine the influence and power of institutions and local or regional governments basing their strategies on scientific information and practice. In South Africa, under ex-President Thabo Mbeki—who was infamous for denying the science of HIV pathogenesis and treatment—such “AIDS denialism” was linked to particular economic interests centered around the provision of “alternative” therapies (Nattrass, 2012). In Bolsanaro’s Brazil, touting hydroxychloroquine as a “cure,” despite scientific evidence that it was ineffective and could even harm patients (Mehra et al., 2020), appeared not to be linked directly to economic interests but rather functioned to support his desired rapid return to economic growth as well as his tried-and-tested use of misinformation as a political strategy. Ricard and Medeiros (2020) argue that Bolsonaro’s use of antisystem rhetoric accompanied by “massive and orchestrated misinformation” functioned as a political weapon during his 2019 election campaign. They note a consequence was that “during this period, anti-scientific theories that had no relevance in Brazil (for example, flat earth theories or negation of climate change) acquired strong advocates on the national level and paved the way for the dangerous equivalence between opinion and science” (Ricard & Medeiros, 2020, p. 5). Politically, this encouraged Bolsanaro’s followers to understand his disregard of science as a courageous break with “the system” rather than “simple populist pyrotechnics” (Ricard & Medeiros, 2020, p. 6). This, however, placed him in a tense and contradictory position within the “system” over which he presided, especially during the COVID-19 epidemic.
Federalism and the Subnational Government Entrepreneurship
Several studies that have catalogued and analyzed Brazil’s response to COVID-19 have been unanimous in describing the lack of coordination between federal government departments and the subnational governments (Cimini et al., 2020). An analysis using the Oxford COVID-19 Government Response Tracker coding system applied to federal, state, and selected state-capital governments suggested a Page 503 →large disparity between the severity of social distancing measures supported by federal and subnational governments, with the latter contributing a great deal more to Brazil’s country-level stringency scores (Petherick et al., 2020).
There are two important aspects to explore regarding the effects of federalism in the response to the pandemic: the authority of state governments over health policy and their dependence on the federal government for debt relief.
First, the COVID-19 epidemic transformed the politics and authority pertaining to state governance of health. Whereas for almost three decades, state governments have had limited influence on Brazilian national politics given the institutional powers of the executive and the way that tax resources are distributed, disputes with President Bolsonaro over how to respond to the epidemic appeared to have unified the regional leaders in a subversion of the “rally-round-the-flag effect”
4(Melo, 2020). State governors strongly disagreed with the president on the need to enforce social distancing measures and to postpone the reopening of commerce and other activities. For instance, in April, after the president’s televised speech that underplayed the threat posed by COVID-19, the governor of Goiás, Ronaldo Caiado, a powerful leader of the agricultural caucus as well as a well-known orthopedic surgeon and one-time strong supporter of the president, declared, “There is no more dialogue with this man … Bolsonaro’s decisions to limit social distancing measures to high-risk populations won’t reach the state of Goiás.” (Berti, 2020). He went on to call on the president to follow scientific advice on COVID-19 (Berti, 2020).
The Mandetta health administration strongly supported the subnational governments’ decisions to favor social distancing measures and to follow WHO protocols and scientific guidelines. Despite the president’s preferences, most state governments remained firm in their support of social distancing, business closures, and warnings against drugs and therapies that had yet to be tested. This helped inform the population and encouraged compliance with the initiatives taken in response to COVID-19.
Bolsonaro took advantage of the division of authority over the COVID-19 epidemic to adopt a blame-avoidance strategy. Bolsonaro declared that governors and mayors would have to pay a fine to businessmen for losses resulting from quarantine. Additionally, on many occasions, Bolsonaro stated that governors and mayors were responsible for the consequences of quarantine measures, claiming that regional leaders’ decisions to shut down nonessential activities would have catastrophic consequences “far worse than the coronavirus” and that such individuals would be held accountable, along with the Supreme Court (Coletta et al., 2020). These statements and their language took the stance of an attempt to evade blame when epidemiological models and specialists, in reality, emphasized the disastrous consequences of lifting quarantine too soon (Brett & Rohani, 2020).
Second, because of the ongoing economic crisis that had affected Brazil since 2015, many states were in severe fiscal debt, particularly with difficulties in paying salaries and pensions, and were negotiating a relief plan with the federal government. The Page 504 →need to immediately respond to the COVID-19 pandemic further exacerbated the problem. In April 2020, state governors were able to secure a law in Congress that would force the executive government to provide them financial support without any conditionality.
5 The president of the Senate negotiated new legislation between state governors and the Minister of Economy in which states would receive R$120 billion (US$23 billion), including instituting bailout initiatives to honor foreign debts, suspending debts with the federal government, and transferring resources to the states (Act 173/2020). The only condition was that states would not provide the annual salary increase that civil servants were entitled to and resources would be transferred according to the number of COVID-19 cases in each state, regardless of the capacity of the state to levy taxes. Therefore, although states gained important authority to decide on the measures to fight COVID-19, they remained entrapped by the fiscal transfers and debt alleviation initiatives of the federal government.
Nevertheless, the financial support and autonomy gained by governors to decide on COVID-19 measures allowed the implementation of locally tailored initiatives. These proved particularly important as the spread of the COVID-19 occurred at different rates in different geographical regions.
Conclusion
We have argued that President Bolsonaro undermined efforts to base Brazil’s response on scientific guidelines for both the prevention and treatment of COVID-19. Yet our analysis has also emphasized the importance of resistance to his policies both within the Health Ministry and among regional governors, some of whom supported Bolsonaro in the past. Paradoxically, the president who had obstructed an effective health policy response because of its economic consequences ended up reaping the benefits of additional social spending to assist the poor cope with the epidemic. In a federal system, with a decentralized health service, it proved strategic for the president to avoid the blame for unpopular health policies (at the cost of important health communication initiative that is crucial during pandemics), while claiming credit for the provision of social policies that benefited vulnerable populations.
As of mid-2020, Brazil was the second most affected country by the COVID-19 pandemic in terms of diagnosed cases and number of fatalities. The most likely scenario is a protracted epidemic, with transient ups and downs in different regions of the country and/or populations, with no definitive control in the short and medium term.
Underneath the circumstantial politics, there was a strong, path-dependent health infrastructure able to assist Brazil avoid the most catastrophic scenario. The country has a well-developed health surveillance infrastructure in place to deal with pandemics such as COVID-19. Several state governments were able to build field hospitals that were essential in treating severe cases of COVID-19 in Page 505 →São Paulo, Manaus, and Recife—all large metropolitan areas. Additionally, Brazil has an extensive primary healthcare network, with, as of mid-2020, more than 43,000 family health teams and 260,000 community health agents. Because 80 percent of COVID-19 cases do not develop severe syndromes, primary health care is essential in caring for these patients (Collucci, 2020). Much research remains to be done, and future studies will hopefully shed more light on these successful aspects of Brazil’s response as well as on recent efforts to purchase and produce a COVID-19 vaccine locally.
Case studies of particular states will also be useful. For example, Santa Catarina was the first state to fully resume all activities, as indicated by graphic broadcasts of crowded shopping centers with few masks in sight. Unsurprisingly, the state soon experienced a rebound in the number of cases and deaths, with an increase of more than 100 percent in the interval of a few days (Holland, 2020). Maranhão, by contrast, has been relatively successful at containing the epidemic. This has been attributed to the political decisions to implement the first, timely, lockdown in the whole country and to buy critical equipment directly from foreign firms, bypassing the slow paperwork associated with purchases from local branches and the much bigger purchase power of the United States and the European Union (Carneiro & Seto, 2020) and to strong cooperation with international partners, from the US state agencies to private funders, such as the Open Society Foundations (US Embassy Press Office, 2020).
As the WHO has advised, there are other pandemics to come. One of the key lessons we can learn from COVID-19 in Brazil and from the AIDS epidemic, paraphrasing Buse, Dickinson, and Sidibé (2008), is to know your epidemic, act on its politics (p. 572).
Acknowledgments
EMF receives a research grant from the Sao Paulo Research Foundation (FAPESP) (
2015/18604–5 and
2020/05230–8), LBA receives a scholarship from FAPESP (
2019/25141–2). We thank Beatriz Portella, Lucas Rosin, Carolina Coutinho, and Joseph Harris.
Notes
1. Private insurers use SUS when in need of expensive treatments not covered by the private sector.
2. See discussion of moral economy in Nattrass (2004) and its application to AIDS denialism in South Africa under Mbeki.
3. The government also created the Emergency Labor program, designed to allow the reduction of labor hours for ninety days or temporary suspension of labor contracts for sixty days. During that time the government would either complement the salary or, in the case of contract suspension, it would cover the full unemployment insurance.
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4. This concept explains the “surge of public approval for the president when the nation is involved in an international crisis” (Murray, 2018).
5. The dispute around this bill was less a contention among political parties than among different Houses. The bill received seventy-nine votes in favor among eighty-one senators (only one left-wing senator was against and the president of session was not allowed to vote) (Tito, 2020).
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