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The Development of HIV/AIDS Policy, 1982 – 1996 ORIGINAL ARTICLE

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The Development of HIV/AIDS Policy, 1982 – 1996 ORIGINAL ARTICLE Building the foundations for the response to HIV/AIDS in Brazil: the development of HIV/AIDS policy, 1982 – 1996 ORIGINAL ARTICLE Building the foundations for the response to HIV/AIDS in Brazil: the development of HIV/AIDS policy, 1982 – 1996 Richard Parker1 1 Professor and chair, Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Director and President, Brazilian Interdisciplinary AIDS Association (ABIA) E-mail: [email protected] INTRODUCTION pact of the epidemic extends far be- sponses to the epidemic that have yond what the numbers, in and of emerged from diverse sectors of Over the course of the past two themselves, can tell us (JONSEN; society (RAU 1994), has taken shape decades, the HIV/AIDS epidemic in STRYKER, 1993). It has by now become as a crucially important priority in Brazil has emerged as one of the apparent, in countries around the seeking to build a more coherent most serious public health problems world, that the impact of AIDS, the and effective response in the future. facing the country. By early 2002, social, cultural, political and eco- This is perhaps particularly true as many as 215,810 cases of AIDS nomic transformations produced by in the case of Brazil, where, over the had been reported to the Brazilian the epidemic, and, perhaps most im- course of recent years, internation- Ministry of Health (MINISTÉRIO DA portant, the diverse responses that al attention has increasingly focused SAÚDE, 2002). Equally worrisome, have increasingly emerged in the face on the multidimensional range of official estimates suggest that as of it, have taken shape as an espe- HIV and AIDS prevention and control many as 597,000 Brazilians have cially complex field of analysis – and activities developed in Brazil by gov- been infected with HIV, virtually that a fuller understanding of this ernmental AIDS programs and non- guaranteeing that AIDS will continue field is crucially important if we are governmental AIDS-service organiza- to be a major social policy and pub- to be able to respond more effective- tions and other sectors of civil soci- lic health challenge for the foresee- ly in the future to the dilemmas that ety. Funded both through a series of able future (BRASIL, 2002; PARKER, AIDS has posed (MISZTAL; MOSS, 1990; major loans by the World Bank to GALVÃO; BESSA, 1999; PARKER, 2000). KIRP; BAYER, 1992; MANN; TARANTOLA; the Government of Brazil, as well as While the sheer weight of num- NETTER, 1992; PARKER, et al., 1994). by a significant commitment of re- bers, in Brazil as elsewhere, may of- In Brazil, as in other countries, the sources from the Brazilian National fer some sense of the potential im- study of HIV/AIDS policy, broadly Treasury, and supported through a portance of HIV/AIDS, particularly with defined to include not only public broad-based and apparently far-reach- regard to the public health system, it policies and programs, but the wider ing process of social and political is clear that the broader social im- range of social and political re- mobilization, what has come to be Divulgação em Saúde para Debate, Rio de Janeiro, n. 27, p. 143-183, august 2003 143 PARKER, Richard described by some as a “Brazilian help provide the basis for increas- that the roots of a successful pro- model” for the response to AIDS has ingly effective responses in the future, gram were constructed over a long been suggested not only as perhaps in Brazil as well as in other coun- period of time by a wide range of the most successful experience yet tries – that the current analysis has social actors working sometimes realized in any developing country, been developed as part of an ongo- together and sometimes in conflict, but perhaps anywhere. It has increas- ing series of studies carried out over and second, at the time that the treat- ingly been identified as a model that a number of years now and reported ment access program was extended other middle and low income coun- on in a series of publications (DANIEL; in 1996, the successful outcome that tries might seek to emulate or repli- PARKER, 1993; PARKER, et al. 1994; has been widely recognized in recent cate in their own national efforts. 1999; PARKER, 1994; 1997; 2000; years was by no means guaranteed. While the Brazilian model has thus PARKER; CAMARGO, 2000). My hope is that the analysis de- played a crucially important role in Particularly because of the atten- veloped here will help to provide a many recent debates (offering hope tion that has focused in recent years foundation for a more adequate un- and optimism concerning the possi- on the unique HIV/AIDS antiretrovi- derstanding of what has emerged, in bility of successful responses to the ral treatment access program, initi- recent years, as a truly “integral” epidemic in a context otherwise ated on a broad scale in 1996, and (or at least “integrated” [PINHEIRO; characterized by few success stories), because the effectiveness of the Bra- MATTOS, 2001]) response to HIV and the actual content of this model has zilian response to AIDS has been most AIDS in Brazil, involving treatment and often been characterized only super- widely acknowledged – and the very prevention as central to a uniquely ficially, and the extent to which it idea of a “Brazilian Model” for re- Brazilian model for responding to the might actually be transferred to oth- sponding to the epidemic has drawn epidemic – a model rooted in the tra- er social, cultural and political set- greatest attention – in the years since dition of an “integral” public health tings has never been specified. the implementation of this treatment system originally championed by the The need to more clearly specify access program, in this essay I have progressive sanitary reform move- the characteristics of the Brazilian sought to return to what might be ment of Brazilian public health, and response to AIDS, as well as the his- described as “the early history” of perhaps most fully achieved (not torical and political conditions the response to HIV and AIDS in Bra- without great difficulties) in the Bra- which gave rise to it, is thus a key zilian society. The primary goal has zilian response to AIDS. step in being able to more adequately been to examine the foundations of assess the extent to which this mod- the Brazilian response that has been THE SOCIAL, ECONOMIC AND el (or at least the lessons learned so widely (and, in my opinion, just- POLITICAL CONTEXT from the Brazilian experience) might ly) recognized for its effectiveness be adapted elsewhere, in relation to and its potential leadership in the in- Before turning to the more detailed other societies facing the impact of ternational community. In the pages discussion of HIV/AIDS and AIDS-relat- the HIV/AIDS epidemic. It is with this that follow, I will try to analyze the ed policy, for readers who may not broad goal in mind – in order to ex- ways in which this response took be altogether familiar with the com- amine the policy responses to the shape historically, prior to 1996 plex reality that is contemporary Bra- epidemic that have emerged in dif- when widespread treatment access zilian society, it is important to situ- ferent sectors of Brazilian society, was extended to anti-retroviral ther- ate these issues within the wider so- and, through such an analysis, to apies – as a way of suggesting, first, cial, cultural, political and econom- 144 Divulgação em Saúde para Debate, Rio de Janeiro, n. 27, p. 143-183, august 2003 Building the foundations for the response to HIV/AIDS in Brazil: the development of HIV/AIDS policy, 1982 – 1996 ic context within which the epidemic in which the divisions of class, race, Brazilian economy and the industri- has taken shape in Brazil. What is and gender are constantly apparent al sector, the vast majority of the most immediately striking is the (BASTIDE, 1978). Brazilian population has nonetheless country’s remarkable diversity, to- The many contradictions that faced the effects of increasing pover- gether with the specific historical seem to characterize Brazilian life ty over the course of the past 15 to moment in which the AIDS epidemic have become even more striking in 20 years, and the social and public emerged. Brazil is an immense coun- recent decades as the result of a se- welfare services that would be nec- try, with a territory of more than ries of social, economic and political essary to meet the needs of the poor 8,500,000 square kilometers, and changes that seem to have produced have in fact deteriorated as resources with a population of approximately a range of new social and economic have increasingly been directed to 165,000,000 according to the most divisions which have stretched the servicing the national debt and sup- recent census. Traditionally divided fabric of Brazilian life. Rapid urban- porting structural adjustment. analytically into five major “macro- ization and industrialization trans- Linked to this economic situa- regions” (known as the North, North- formed what was once largely a ru- tion has been the evolution of Bra- east, Center-West, Southeast, and ral society, creating the so-called zilian politics over the course of the South), and divided administratively “Brazilian economic miracle” with past three decades. Following a pe- in 27 states and federal districts, the an average annual growth rate of riod of instability and uncertainty country is marked by a high degree 8.6% in the early 1970s (SMITH, 1995). in the early-1960s, a military take- of regional diversity, and by highly Yet the political economy of debt and over of civilian authority in 1964 varied regional subcultures (BASTIDE, dependence soon produced a series initiated a period of 20 years of au- 1978; PAGE, 1995; WAGLEY, 1968).
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