The pandemonium caused by Covid-19 in Brazil—the Latin American country most affected by the pandemic—cries out for analytic historical perspectives. Shortly after the first cases were recorded on February 26, 2020, Covid-19 spread from wealthy Brazilians who had recently visited Europe to the poorest neighborhoods of the megacities of São Paulo and Rio de Janeiro in the southeast of the country. It also spread quickly to the low-income states of the North and Northeast regions, characterized by inappropriately funded sanitation and a high percentage of Afro-Brazilians and Indigenous populations. This essay seeks to illuminate a typical Latin American pattern of temporary official responses to epidemics, as well as explain the disdain President Jair Bolsonaro feels for the pandemic—although he recently tested positive for the coronavirus—and his salient obsession with chloroquine despite a lack of scientific evidence. I argue that the latter is not solely based on his stance as a science denier, his misplaced faith in the controversial claims of French scientist Didier Raoult, and his devotion to US President Donald Trump; rather, it has underlying political and historical components.
Brazilian healthcare before Covid-19
As in other Latin American countries, Brazil is marked by a history of acute social inequality. Although some Latin American countries have national health systems—such as Brazil’s Sistema Único de Saúde (SUS), created in 1988—they coexist with insufficient efforts to provide universal sanitation infrastructure, such as water, adequate sewage systems, garbage disposal, and housing. This contradiction worsened with the neoliberal health reforms launched in the 1980s that cut or privatized public health services. Although the Workers’ Party governments led by President Luiz Lula da Silva and President Dilma Rousseff, from 2003 to 2016, opposed these reforms, fought to eliminate hunger, and implemented a conditional cash transfer program for impoverished families to keep their children in school and vaccinated, their efforts were insufficient in significantly reducing social inequality and limiting the growth of poverty.1Fundação Getulio Vargas, Qual foi o impacto da crise sobre a pobreza e a distribuição de renda? (Rio de Janeiro: Centro de Políticas Sociais, September 2018). A revived neoliberalism, embraced by the interim government of Michel Temer (August 2016–December 31, 2018), who took office after the impeachment of Rousseff, and emboldened by Bolsonaro’s presidency beginning in January 2019, openly undermined SUS and social programs.“To the public at large (in particular those in urban centers), healthcare was seen as a handout—such as fumigation, vaccinations, and drugs—so the less fortunate could survive.”
Recent epidemic outbreaks in Brazil, most notably Dengue (persistent since the 1980s) and Zika (emergent and endemic since 2015), illustrate the connection between social disparities and health. Both are mainly transmitted by the Aedes aegypti mosquito, whose larvae live in household water containers common in poor homes that lack a connection to safe water mains. Palliative governmental responses promoted fumigation, personal hygiene, and the cleaning of plastic receptacles to eliminate the larvae. The efficacy of hygienic behavior was exaggerated in order to argue that marginalized populations who did not follow hygienic guidelines were to blame for their own fate, without questioning why those living in shantytowns and rural areas were unable to comply.2Ronaldo Pinheiro Gonçalves et al., “Contribuições recentes sobre conhecimentos, atitudes e práticas da população brasileira acerca da dengue,” Saude e Sociedade 24, no. 2 (2015): 578–593. Temporary responses normalized the social inequality and structural racism that justified unequal access to health infrastructures and reinforced the notion that some Brazilians were not considered “full citizens” in the social meaning of the term. As a result, political tolerance for poverty spread. A limited perception of public health emerged: it is a temporary patch for emergencies. This limited view encouraged short-term expectations regarding healthcare. To the public at large (in particular those in urban centers), healthcare was seen as a handout—such as fumigation, vaccinations, and drugs—so the less fortunate could survive. However, it is important to mention the range of ways low-income communities have contested this perception through the persistence of a strong counterhegemonic public-health community and of alternative health practices and ideas—such as Indigenous, Asian, or African traditional medicines.
Understanding the “Culture of Survival”
The legacy of health policy described above is encompassed by the concept of a “Culture of Survival.” It is embedded in government responses to and public expectations of disease-control interventions, promoting the idea that disease control is principally a technological operation implemented by a handful of experts and can be done without improving the living conditions of the poor.3New York: Cambridge University Press, 2015More Info → An important characteristic in these responses was blaming the victims. For example, a minister of health declared during the Zika epidemic that women from the Northeast were not free of guilt, because they wore skirts—becoming exposed to mosquitoes—and were uninterested in learning about pregnancy. (One of the clinical effects of the disease was microcephaly in the babies of infected mothers).
This premise was also seen in the campaigns of military doctors of the early twentieth century who were concerned with the immediate protection of their own soldiers. A key feature of this culture has reappeared in the responses to Covid-19 in Brazil: the overemphasis on superficial solutions that postponed the construction of solid healthcare systems and the reduction of social inequality.
The social determinants of disease are evident in the increase of Brazilian Infectious Respiratory Diseases, a category that includes common types of pneumonia and tuberculosis, with transmission modes similar to Covid-19 (droplets from coughing, talking, and sneezing). These diseases, as with Dengue and Zika, are more likely to occur among people who live in overcrowded, poverty-stricken neighborhoods, like those of the Northeast, and who lack adequate shelter and nourishment—reducing their resistance to infection—and where social distancing, isolation of the sick, frequent hand washing, and working over Zoom is almost impossible. Poor health in run-down shantytowns is also related to precarious individual solutions to misery that include underemployment, participation in crime gangs, and unstable jobs as house cleaners, nannies, and drivers for upper- and middle-class families. Domestic employees receive an income and some paternalistic protection, but rarely do employers provide health insurance as an employment benefit.“The government is using the pandemic as a smokescreen to intensify a longstanding process: opening lands for mining, agribusiness, and loggers who destroy the rainforest and its inhabitants.”
Another connection between disease and national social disparities is the constant migration of people from North and Northeastern Brazil to shantytowns in the cities of the southeast to be close to rich Brazilians who are willing to hire them for menial jobs. In addition, Covid-19 is becoming acute among Amazonian rural communities, in part due to outright policies that harm Indigenous people and their lands. The government is using the pandemic as a smokescreen to intensify a longstanding process: opening lands for mining, agribusiness, and loggers who destroy the rainforest and its inhabitants. The regulations and government institutions that protected forest and Indigenous reserves in the Amazon have been undermined. Land grabbing of Indigenous lands intensified during 2019. And, during the first four months of 2020—when deforestation happens on a smaller scale than the rest of the year due to heavy rainfall—it is estimated that the Amazon rainforest lost over 1,200 square km, which was up 55 percent in comparison with last year.
Chloroquine and authoritarianism
During the past few months, President Jair Bolsonaro’s contempt for the seriousness of Covid-19, and his obsession with technology and disregard for social inequality has escalated in the form of his earnest support for chloroquine use. After initially dismissing the risks posed by coronavirus, he said to journalists again and again that he was ready to use the drug on himself and his 93-year-old mother, if she got sick. His bravado is more than just culture war rhetoric against scientists. In spite of the differences between chloroquine and hydroxychloroquine—the former being more toxic than the latter—Bolsonaro has praised both drugs as if they were identical. Bolsonaro’s attitude is linked to his opposition to stay-at-home orders.
In mid-March the president defended what he called a “vertical” quarantine, or the confinement of at-risk groups like the elderly, which was supposedly more effective than the “horizontal” quarantine practiced in the rest of the world. In the first days of April, when it was clear that neither the horizontal nor vertical quarantines were being implemented uniformly, he embraced treatment with drugs in his fight against state governors who had unilaterally closed schools, stores, and public transportation, in an attempt to curtail the spread of Covid-19. Even though governors, mayors, and community organizations in shantytowns emphasized rational medical guidelines, like social distancing, distribution of masks, hiring private medical teams, and strengthening hospitals’ emergency capacity, they had little time, resources, or vision to address the broader social inequalities that sustained the virus. Nevertheless, these efforts demonstrate a remarkable assertion of their own leadership in the face of a lack of direction from the top.“The public’s familiarity with the drug, along with arguments based on its low cost and harmlessness, were used to try to justify its application.”
“Chloroquine,” as Bolsonaro calls it, is a well-known drug in Brazil, most notably used to prevent and treat malaria, a widespread rural disease. The public’s familiarity with the drug, along with arguments based on its low cost and harmlessness, were used to try to justify its application. Despite doubts from experts and criticisms published by mainstream journals and Brazilian public health associations, the propaganda has continued. In this way, the promotion of a “silver bullet” typical of a Culture of Survival mindset was not only reproduced but imposed. In early April 2020, Bolsonaro claimed that chloroquine was only for severe cases, but shortly afterwards he pushed the Ministry of Health to recommend it—under medical supervision—for people at the beginning stages of the disease (a somewhat contradictory decision since only acute cases are tested and can be hospitalized). In addition, health workers were supposed to use it as prophylactic. Concurrently, the president pressured the regulatory agency Anvisa (National Health Surveillance Agency) to authorize the drug for use against Covid-19, abolished taxes on chloroquine imports, bought raw materials from India to manufacture it in Brazil, and instructed the army laboratory to produce more than a million chloroquine tablets in a few weeks (a notable increase from the 250,000 tablets produced in 2019).
It was important for Bolsonaro to show the public he was taking action, in this case by raising hopes of a “silver bullet.” Additionally, his finance minister approved additional funds for SUS, the national health service, and extraordinary financial aid for the poor, making it clear that both would be temporary. In this way, the president avoided negotiating with other political actors to develop a coherent response, and he ignored the living conditions of the most vulnerable during this pandemic. Two ministers of health who recommended more studies on chloroquine before deciding on approving it were forced out due to their caution.4Luiz Henrique Mandetta and Nelson Teich resigned on April 16 and May 15, 2020, respectively. Prudence and scientific evidence were ignored by the Bolsonaristas who resorted to scientific denialism and authoritarianism. For example, Bolsonaro wrongly claimed that, during the Spanish-American War, which took place at the end of the nineteenth century, soldiers were restored to health after being injected with coconut water. He also filled the Ministry of Health with military men who would carry out his orders without hesitation.“The fixation of the Brazilian president on this drug also implicitly asks his followers for unconditional loyalty in supporting its use, and opens an opportunity to further push his tendency toward authoritarian rule.”
Even his priority in foreign policy was linked to the drug. In late May, the US government imposed a travel ban on non-US citizens coming from Brazil. To minimize the news, the Brazilian president announced, just days after the World Health Organization suspended testing the drug because of safety concerns, that President Trump sent Brazil 2 million doses of hydroxychloroquine to be used against Covid-19. Bolsonaro’s miraculous heterodox drug intertwined with the profile of a messianic ruler who likes to assert that his divine mission is to save the nation and compares his presidency to the ordeals of Jesus Christ. These allegations are well-received by his right-wing, evangelical followers, who make up a quarter of the population. The fixation of the Brazilian president on this drug also implicitly asks his followers for unconditional loyalty in supporting its use, and opens an opportunity to further push his tendency toward authoritarian rule.
According to Bolsonaro—a former army officer and an admirer of military dictatorships—his right to advocate chloroquine cannot be countermanded because he is the “comandante” of the country. His authoritarianism is reminiscent of an important characteristic of vertical disease-control interventions: the giver knows what is good for the receiver. Bolsonaro’s chloroquine quick-fix propaganda also diverts attention away from the growing investigations against him that could precipitate his impeachment.
In the meantime, the immediate menace to Brazil is the tragic feedback between the pandemic and the irrational official responses of an authoritarian government. In the long-term, Brazil’s main challenge is to overcome the temporal responses to health emergencies and the persistence of social inequalities.
Banner photo credit: Joel Rodrigues – Agência Brasília/Flickr