The fight over the future of the ACA here in the U.S. has made me think about universal healthcare, disease, and rights in a global context. The fierce debate over the idea of healthcare as a “right” versus a “privilege” on Capitol Hill seems almost antiquated when compared with other countries. When a friend of mine was diagnosed with HIV in Brazil recently, I knew they would receive better treatment there than they ever would here. In Brazil, healthcare is a right, and the government provides free and universal access to antiretroviral (ARVs) medicines for people with HIV/AIDS.
The first case of the virus was registered in 1980. Its arrival coincided with the country’s redemocratization process. In the early 1980s, Brazil was emerging from a twenty-year military dictatorship. When authoritarian rule finally ended in 1986, the concept of human rights became integral in the rewriting of the country’s democratic principles. The 1988 Constitution (still in effect today) expanded the idea of human rights to encompass all aspects of human life, including health, and the document declared health care as a right for all Brazilians.
With the passage of the Constitution, Brazil implemented its Unified Health System (Sistema Único de Saúde [SUS]), which offers free comprehensive health care to the entire population. By 1991, SUS was offering zidovudine (AZT) free of charge to HIV-positive Brazilians. In 1996, President Fernando Henrique Cardoso signed Law No. 9.313, which guaranteed the free distribution of ARVs to people with HIV/AIDS. The SUS system ensured the law’s success, and the government implemented a wide-reaching response to the epidemic.
In fact, Brazil’s program has been touted as one of the best in the world. As Jane Galvão argues, “The program provides state-of-the-art ARV treatment to people in need, free of charge, through the public health system, and the government controls the costs of the program by encouraging local laboratories to produce ARVs, which decreases Brazil’s need to import vital drugs from foreign countries.” Take the cases of Brazil and South Africa. Both had similar HIV-infection rates in the 1990s. In 2012, Brazil’s HIV rate is less than 1 percent while 18 percent of South African adults are infected.
From Authoritarianism to Human Rights
Because the virus emerged in a period of heightened democratic activism, Brazil’s response to the crisis was greatly informed by social movements. Gay rights activists and health reformers were crucial in forcing the government to address HIV/AIDS within the newly established rights-based framework. Early on, activists began suing state and municipal governments for access to medications through SUS.
Judges often sided with the activists, stating that the Brazilian constitution guaranteed every citizen’s right to health, a right the government had to ensure. Because of activists, the “right” to healthcare and HIV treatment was integral to government policy towards the virus from the beginning. The success of Brazilian activists in forcing the government to act in comparison to their U.S. counterparts — whose activism fell on deaf ears — shows that both concerted activism and a legal framework that guarantees rights is crucial to ensure change.
Activists also pushed the government towards fighting the stigma that surrounded the virus. The Ministry of Health included homosexuals, sex workers, and other marginalized groups in their large-scale prevention campaigns and fight against stigma. One 2002 campaign aimed at sex workers declared, “Sem vergonha, garota. Você tem profissão!” (Don’t be ashamed, girl. You have a profession!)
The Cost of Access
Universal and free access to ARVs is not cheap, and Brazil’s negotiations with pharmaceutical companies has drastically altered the international pharmaceutical landscape. After the access to HIV treatment was signed into law in 1996, Brazil entered a period of intense discussions with pharmaceutical companies Roche and Merck to reduce costs. In 2001, the Brazilian government announced that it intended to break the companies patents and produce the drugs domestically unless the companies agreed to reduce prices. After that, Brazil successfully negotiated to reduce prices on several ARVs by 60%.
This measure, called “compulsory licensing,” drew sharp rebuke from the U.S., who filed a challenge against Brazil at the World Trade Organization (WTO). The U.S. threatened to impose economic sanctions if Brazil violated international patent laws. In response, Brazil launched a global campaign to garner support. One ad the government put out showed a mother holding her daughter with the words “Local manufacturing of many of the drugs used in the anti-AIDS cocktail is not a declaration of war against the drugs industry. It is simply a fight for life.”
The George W. Bush administration eventually withdrew its challenge. Soon after, the WTO declared that compulsory licensing (or patent-breaking) was allowed in cases of national public-health emergencies. In fact, Brazil’s position pushed the UN to declare that “access to medication in the context of pandemics such as HIV/AIDS is one fundamental element for achieving progressively the full realization of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” Brazil had successfully reshaped the international arena into a discussion of health as a human right.
But threatening to break patents wasn’t Brazil’s only course of action. Brazil also sought to dramatically increase local production of ARVs. As the former director of the Ministry of Health’s laboratory Eloan Pinheiro remembers, “the local production of AIDS drugs made access to ARV therapy possible for the Brazilian population. Without it, the price of the drugs would be beyond Brazil’s reach.” But the increasingly high costs of imported drugs threatened the program’s viability throughout the early 2000s. Legislation was passed to allow generic drug imports. Finally, in 2007, Brazil’s popular left-wing president Luiz Inacio da Silva broke Merck’s patent over the ARV drug Efavirenz when it refused to lower prices. Despite a massive uproar on the part of major pharmaceutical companies, no major meltdown in research and development occurred.
Post-Human Rights? Post-HIV?
In the past decade, however, HIV-infection notification rates have been on the rise in Brazil, especially among young men between the ages of 15 and 24. Activists have decried the government’s turn away from education programs. Some officials argue that the slight rise in rates is due to better notification strategies (which became compulsory in 2016). But other Brazilian leaders blame the rising evangelical movement in the country. One official said evangelical political opposition “caused notorious backtracking” in national policy towards HIV/AIDS. Schools no longer hand out sex education materials aimed at teenagers. Nevertheless, the Ministry of Health has been working on expanding access to ARVs, even in infected patients without a viral load. And Pre-exposure prophylaxis (PEP) is now available.
But current political changes don’t bode well for HIV/AIDS efforts. The recent impeachment of left-leaning Dilma Rousseff and the implementation of a conservative government in the face of a severe economic recession means that public health and education are on the budget chopping block. The director of the AIDS program, Fábio Mesquita — a world-renowned HIV/AIDS researcher — resigned several months after Rousseff left office, citing “incompatibility” with the current government and its efforts to cut funding. The shift towards the right in Brazil demonstrates that “health as a human right” is a flexible concept, one that can be molded to conservative ideals. But Brazil’s response to the HIV/AIDS pandemic demonstrates that when we frame health as a human right, everyone wins. Let’s hope politicians here in the U.S. and back in Brazil remember that.