Brazil's Ascendance: the Soft Power Role of Global Health Diplomacy

Brazil’s Ascendance: The soft power role of global health diplomacy By Kelley Lee and Eduardo J. Gómez Introduction Brazil’s steady ascendance on the world stage over the past decade has been led, in large part, by the country’s growing economic might. A much lauded BRIC (Brazil, Russia, India and China) country blessed by vast resources, Brazil is predicted to emerge this century as a regional and global economic powerhouse. However, the country’s rising influence must also be understood as the product of an effective foreign policy and, in particular, the assumption of high-profile diplomatic roles in negotiating to address key global issues such as climate change, nuclear non-proliferation and trade liberalisation. Among emerging economies, Brazil has been particularly adept at leveraging what is described as “soft power”, defined as the capacity to persuade or attract others to do what one wants through the force of ideas, knowl- edge and values. Coined by Joseph Nye, the concept of soft power contrasts with “hard power” whereby coercion (underpinned by years, world leaders have begun to talk about advocates the use of health care as an instru- military and economic might) is used to in- “smart power” whereby soft and hard power ment for furthering foreign policy goals. As fluence others to act in ways in which they is combined in ways that are mutually rein- then US Secretary of State for Health Tommy would not otherwise do. He argues that, in forcing.1 Brazil’s prominence in global health Thompson stated in 2004, as part of the Bush a more interconnected world of accelerating diplomacy can be understood in this con- Administration’s efforts to rebuild its global globalisation and resultant collective action text. Its effective combination of economic standing, “medical diplomacy…[is] a way to problems, the currency of global leader- might and diplomatic acumen in addressing further America’s causes around the world. ship favours soft over hard power. In recent global health issues offers lessons for other Instead of worrying about any types of wars, countries seeking to play a more prominent if we could somehow substitute the integra- leadership role in the emerging world order. tion of health policy with our state policy, I Global health diplomacy think we could accomplish a lot more.”2 The is part of the “new diplo- Global health diplomacy as a US$63 billion, 6-year Global Health Initia- two way street tive under the Obama Administration fits macy” agenda by which Global health diplomacy is part of the “new within this approach, serving as a core part foreign policy, since the diplomacy” agenda by which foreign policy, of what US Secretary of State Hilary Clinton end of the Cold War, has since the end of the Cold War, has expanded calls the “three Ds of smart power” – defence, 3 expanded to embrace to embrace new issues, new actors and new diplomacy and development. The export processes. While the meaning of the term and training of doctors by Cuba, and NATO’s new issues, new actors can be somewhat nebulous, two main per- Medical Stability Operations in Afghanistan and new processes. spectives can be observed. The first, more and Iraq, also frame global health diplomacy specifically described as “medical diplomacy”, in this way. www.europeanbusinessreview.com 61 The European Business Review In 1998, the Brazilian Minister of Health proposed that universal access be recognized as a human right at the World AIDS Conference. Despite pressure from “Big Pharma” and the US Trade Representative, the government continued to expand domestic production and explore the issuing of compulsory licenses to produce patent protected drugs. Conversely, global health diplomacy rea’s commitment to double its aid to Africa Vargas (who served as President from 1930- has been supported as a way of harnessing by 2012, and India’s strengthening engage- 45 and 1951-1954), the economic and politi- foreign policy actors and processes for the ment with global health initiatives, are recent cal influence of Brazil’s states remained sub- benefit of global health goals. Negotiation examples. An understanding of how emerg- dued. Instead, the country remained largely of the Paris Declaration on Aid Effectiveness ing economies are engaging in global health authoritarian over the next four decades - no (2005), revised International Health Regula- diplomacy tells us much about the changing national elections, the growth of a massive tions (2005), and ongoing efforts to resolve nature of global leadership. federal bureaucracy, limited social welfare the sharing of influenza virus samples are (especially healthcare) assistance, and state- examples of how diplomatic channels have Brazil’s struggle between au- sponsored human rights violations. been called upon to facilitate collective ac- thoritarianism and democracy Amid stagnating economic performance, tion to protect and promote population Brazil’s rising status among emerging econo- and rising domestic and international pro- health worldwide. Global health diplomacy, mies can be understood within the context tests, the military dictatorship agreed to in this sense, reflects recognition within the of its historical struggle between democra- transition back to democracy in 1985. A new public health community of the broad deter- tization and authoritarianism. After gaining Constitution was adopted which, to address minants of health and the need to engage independence from Portugal in 1823, the acute political and social inequalities, guaran- with policy arenas beyond the health sector. Republic adopted a presidential system un- teed national and local elections, and human While there are tensions between these derpinned by narrow political participation. rights as a key tenant shaping social welfare two perspectives, given different starting As a federation of wealthy landed agricultural legislation. The sanitarista movement, com- and end points, and potentially competing elites, the government steadily became cen- prised of medical doctors, health profession- interests, both cast global health diplomacy tralized and eventually dictatorial. Between als, scholars and activists, played a critical role as an important source of soft power. In- the two World Wars, a rapidly industrialising in this transition period, with many members deed, the importance given to global health Brazil was touted as "the sleeping giant of going on to serve in the new government. diplomacy appears to be rising, most notably the Americas" and a potential world power. As well as embedding democracy into policy among emerging economies. The deploy- However, the landed interests of the oligar- making processes, universal access to health- ment of hospital ships by China, to supple- chic Old Republic did little to promote indus- care as a human right was written into the ment a longstanding practice of sending trialisation, urbanisation and the broad inter- Constitution through the creation of the medical teams to Africa and Asia, South Ko- ests of the new middle class. Under Gútelio Sistema Único de Saúde (SUS) healthcare sys- 62 January - February 2011 tem. It is this political history, and resultant to improve access to ARVs. legal commitment by the national govern- The practical implementation of the two Brazilian leadership was ment to provide universal prevention and agreements since 2005 has required Brazil critical to the successful treatment services, that has defined Brazil’s to draw on both hard and soft power. Faced conclusion of the Frame- engagement in global health diplomacy. with the threat of countries manufacturing generic versions of patented drugs, pharma- work Convention on Brazil’s engagement with the ceutical companies such as Merck, Abbott Tobacco Control (FCTC). HIV/AIDS and access to medi- and Roche negotiated agreements to supply cines debate Brazil patent-protected drugs at much re- When HIV/AIDS first appeared in Brazil in duced prices. In 2005 a landmark agreement of five years of public health campaigning, 1982, the government’s lackluster response was reached between 11 Latin American detailed drafting and revision, and above all, was not unlike other countries at that time. countries and 26 drug companies to lower delicate international negotiations. Led by The commencement of World Bank lending the cost of ARVs in the region. Similar deals the Tobacco Free Initiative (TFI) of the World to tackle the disease in 1992, and increasingly were agreed in other regions including Africa. Health Organisation (WHO), the FCTC is her- vocal NGO advocacy both domestically and Undoubtedly, Brazil’s rapidly growing eco- alded as a core instrument of global health internationally, prompted a reorganisation nomic clout helped leverage such deals. The governance in its aim “to protect present of the National AIDS Control Programme. In ongoing threat of compulsory licensing, and and future generations from the devastating 1996 President Fernando Cardoso signed a collaborative links between Brazil and coun- health, social, environmental and economic groundbreaking decree to provide univer- tries such as Argentina, China, Cuba, Nigeria, consequences of tobacco consumption and sal and free access to antiretroviral drugs Russia, Ukraine, and Thailand to improve the exposure to tobacco smoke”.4 The treaty sets (ARVs) through the National Health System. capacity to manufacture medicines, condoms out wide-ranging measures on what mem- The following year, production of off-patent and laboratory reagents needed to fight

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