Vaccine against Covid-19: arena of the Brazilian federative dispute

ABSTRACT

This essay aims to demonstrate how the Covid-19 vaccine became a center of national politi- cal dispute in Brazil, transforming the country’s cooperative federalism into confrontational federalism. This dispute triggered a health tragedy that collapsed public and private health systems. The country’s consolidated nationwide immunization program and well-structured epidemiological surveillance system could not avoid vaccine distribution problems and delays in protecting the population, which worsened the pandemic. The analysis of President Bolsonaro’s speech regarding the Covid-19 pandemic, including preventive measures and vaccination, shows that he privileged the interactions with his followers and sought to delegitimize the opposition and undermine democratic institutions. The consequences for federalism were devastating in relation to the old federative coordination mechanisms, but they also fostered innovation by strengthening horizontal coordination mechanisms. Therefore, the debate over combating the pandemic made vaccines the main political arena for power disputes.

KEYWORDS
Federalism; Covid-19; Vaccination; Address; Politics

RESUMO

Este ensaio teve como objetivo demonstrar como a questão da vacina, no contexto atual da pandemia de Covid-19, transformou-se em centro de disputa política nacional no Brasil, o que levou o federalismo de cooperação a transformar-se em um federalismo de confrontação. Essa disputa provocou uma tragédia sanitária que colapsou os sistemas públicos e privados de saúde. Embora o País tenha um programa nacional de imunização com uma trajetória consolidada, associado a um sistema de vigilância epidemiológica bem estruturado, isso não foi capaz de evitar o atraso na imunização da população e os problemas na distribuição de doses da vacina, o que contribuiu para recrudescimento da pandemia. A análise do discurso do Presidente Bolsonaro em relação à pandemia, às medidas preventivas e à vacinação contra a Covid-19 mostra que ele privilegiou as interações que se estabeleceram com seus seguidores, buscando deslegitimar a oposição e minar as instituições democráticas. As consequências para o federa- lismo foram demolidoras em relação aos antigos mecanismos de coordenação federativa, mas também inovadoras por propiciar o fortalecimento de mecanismos de coordenação horizontal. O debate sobre o combate à pandemia, portanto, tornou a vacina a principal arena política de disputa por poder.

PALAVRAS-CHAVE
Federalismo; Covid-19; Vacinação; Discurso; Política

Introduction

Since the Vaccine Revolt of 1904 in Rio de Janeiro, vaccination has not been at the center of political-ideological debates involving power disputes in Brazil. At that time, the mandatory vaccination against smallpox provoked a popular and military uprising against the government of President Rodrigues Alves. Fake news was spread about the vaccine’s effects in a major campaign to appeal to individual freedom and defense of property (such as taking the vaccine would make you ‘look like an ox’, or health agents would break into your house to vaccinate you). However, the Vaccine Revolt was also a consequence of the authoritarian urban modernization process, which removed tenements from the city center to the periphery and gave rise to Rio de Janeiro’s favelas. As for the military uprising, it was part of the power dispute among groups that intended to overthrow the government¹. The appointment of public health specialist Oswaldo Cruz as director-general of public health - leading the vaccination efforts throughout the period of the revolt - consolidated the domain of science and medicine as part of the state power structure, a combination of German medical police and British urban medicine². A decade later, the population flocked to health centers searching for the vaccine.

According to Temporão³, the milestones of vaccination’s recent history include the formulation of the National Immunization Program (PNI) and the eradication of smallpox in 1973, as part of public policies rationalization and planning and the structuring of the medical-industrial complex in the 1970s. The confrontation of the meningitis epidemic provoked debate within the Ministry of Health and in the academic environment, which ended up defining the strategy of mass vaccination in national campaigns. The success in vaccinating poliomyelitis in 1980 was attributed to the existence of the Central de Medicamentos (Ceme) (Central of Medicines) and the previous effort to set up storage conditions (including refrigeration), means of transportation, and an efficient communication campaign, starting what became a successful history of national vaccination campaigns.

The creation of the Brazilian national health system (SUS) strengthened this experience by establishing agreements with states and municipalities through the Inter-management Commissions - Tripartite and Bipartite. These arrangements offered a platform so that the competing competencies provided in Art. 23 of the Brazilian Federal Constitution of 1988 (CF/88) favored cooperative federalism, adopting a particular institutional architecture and governance model. Powerful political actors were consolidated as part of this process, such as the National Council of Health Secretaries (Conass), the National Council of Municipal Health Secretaries (Conasems), and the National Health Council (CNS).

In this context, how did the Covid-19 vaccine in Brazil become the center of a national political dispute that transformed cooperative federalism into confrontational federalism⁴, with drastic consequences for democracy and causing a health tragedy collapsing public and private health systems and leading to a severe death toll?

Historical institutionalism⁵ and sociological institutionalism⁶ analyze public policies by emphasizing the continuity of the path dependence that consolidates patterns of interaction and routine practices. These approaches deal with agents that follow a logic of adequacy to institutions (defined as a context of norms and rules that frame and constrain actions). Consequently, they explain continuity better than changes, which occur through ruptures in critical junctures, driven by external factors. The discursive institutionalism⁷ approach helps to understand these changes introducing the analysis of ideas as an instrument that goes beyond traditional politics, understanding symbolic disputes as a constitutive part of collective action, and the power of persuasion and deliberation.

This essay addresses the institutional trajectory of immunization policy in the next section. The third section discusses the critical situation represented by the Brazilian current president’s confrontational attitude toward preventive measures advocated by governors to tackle the pandemic and vaccination against Covid-19. The fourth and last section presents our final considerations.

The institutionalization of immunization policy in Brazil

The path dependence concept has been used to understand the institutionalization of governmental decision-making processes and the establishment of policy paths. Thus, the probability of following a path increases each time one moves in that specific direction due to the relative increase in its benefits compared to the other available options⁵.

The implementation of a new path occurs in response to a critical juncture formed of permissive and productive conditions. The first changes the context, increasing the likelihood of introducing new elements or changing existing elements in the established policy. The productive conditions shape the results produced by the changes implemented from the permissive conditions, institutionalizing a new policy path⁸.

The culture of immunization in Brazil - characterized by the introduction of vaccines and mass vaccination campaigns by the state from the end of the nineteenth century - resulted from historical events that constituted permissive and productive conditions, altering the trajectory of health policies and structuring the bases for the PNI. According to Hochman⁹, these antecedents observed during the institution of the republic in 1889 included a general frustration since yellow fever and smallpox epidemics - which harmed international trade and the economic and social life - prevented the country from meeting the expected modernization. These epidemics led to several health campaigns under the coordination of the public health specialist Oswaldo Cruz, culminating in the approval of the mandatory vaccination law in 1904.

Although these events characterized a moment with permissive conditions for implementing an immunization policy, these actions ceased to be a priority after 1930, in the so-called Era Vargas (15 years under the presidency of Getulio Vargas). Until the 1950s, vaccination campaigns sought to combat epidemic outbreaks without establishing permanent institutions. Therefore, in the absence of productive conditions, the institutionalization of this policy was harmed.

However, in the late 1950s, a global effort emphasized the eradication of smallpox, formalized in the resolution of the XI World Health Assembly. Thus, new permissive conditions for institutionalizing immunization resulted from international pressure, the possibility of obtaining international resources for health, and from political and ideological positions of the military government (established in 1964).

In 1965, the Ministry of Health organized the Smallpox Eradication Campaign in Brazil, conducted in partnership with health services of the states and municipalities. The campaign had its own budget and received financial and technical support from several international institutions, such as the Center for Disease Control (CDC), the Pan American Health Organization (Paho), and the World Health Organization (WHO). The agreements with Paho/WHO also contributed to the modernization and large-scale production of vaccines. In addition, the campaign led to implementing a surveillance system from 1969 onward, in partnership with state governments responsible for units of epidemiological surveillance and notification centers. These were the productive conditions for institutionalizing the immunization policy, culminating with the enactment of Law 6,259 of 1975¹⁰, which provided for regulation of the PNI and the organization of epidemiological surveillance actions and compulsory disease notification.

After the end of the Smallpox Eradication Campaign in 1973, its structure and institutional capacity were used to organize the Ministry of Health’s National Division of Epidemiology and Health Statistics (DNEES). This division was responsible for developing strategies for implementing mass vaccination actions to control various diseases, such as smallpox, tuberculosis, and yellow fever (already within the scope of the Ministry), but also measles and poliomyelitis, previously under the responsibility of health departments at the state level³. The structuring of the DNEES and the Central of Medicines (responsible for purchasing and supplying vaccines) and Law 6,259 marked the creation of institutional and political processes that perpetuated the results of the vaccination campaigns implemented since the beginning of the twentieth century. Thus, they were important mechanisms for reproducing the legacy, as defined by Collier and Collier¹¹.

The trajectory of the PNI has been consolidating since then, with the publication of the first National Vaccination Card, in 1977, which included four mandatory vaccines for the first year of life and its subsequent updates with the inclusion of new immunizing agents. In 2003, the National Health Surveillance Secretariat was created, which provided a greater connection between the PNI and the area of epidemiological surveillance, contributing to the notification of diseases and immunization activities. In 2019, Brazil was one of the countries with the highest number of vaccines offered free of charge. Within the scope of the PNI, cost-effectiveness studies are promoted for the introduction of new vaccines, in addition to epidemiological studies to assess the impact of vaccines on the morbidity and mortality profile of vaccine-preventable diseases¹². As a result of this set of actions, studies show an increase in vaccination coverage since the 1990s, with a reduction in coverage observed after 2015^12,13. One element that contributed to comprehensive vaccination coverage was the PNI’s decentralized strategy of operationalization, with responsibilities attributed at the federal, state, and municipal levels, requiring cooperation between the federated entities. The decentralized implementation of vaccination actions through health facilities within the scope of primary care, either routinely or during campaigns, contributed to achieving a population coverage of approximately 76% in 2020¹⁴.

An example of the success of the PNI and the cooperative federalism to control vaccine-preventable diseases was the rapid control of the H1N1 pandemic that hit Brazil in 2009 and 2010. In response to the WHO’s declaration of a pandemic and the identification of cases in Brazil, the Ministry of Health implemented a strategy that involved the expansion of the network of laboratories for diagnosis, the purchase and production of medicines, negotiation with several laboratories for the acquisition of vaccines with technology transfer, the distribution of medicines and vaccines by the states to local governments, and the launch of information campaigns in various media¹⁵. The vaccine was made available in November 2009, and 88% of people in the priority groups were vaccinated, exceeding the target of 80%, which represented 42% of the Brazilian population, a percentage higher than that achieved in other countries. As a result, the number of H1N1 deaths dropped from 2,146 in 2009 to around 100 in 2010¹⁶.

Despite having research centers, vaccine production facilities recognized worldwide such as the Butantan Institute and the Oswaldo Cruz Foundation (Fiocruz), and the success of its immunization program, Brazil reduced its production capacity for pharmaceutical ingredients. Factors linked to the trade liberalization policy and low investment in science and technology led to a reduction in the national production of pharmaceutical ingredients from 55% in 1980 to 5% in 2020¹⁷.

In Brazil, vaccination against Covid-19 began on January 17, 2021, in São Paulo, shortly after the National Health Surveillance Agency (Anvisa) approved the emergency use of the vaccines CoronaVac, produced by the Butantan Institute with the Chinese laboratory Sinovac, and AstraZeneca, developed by the University of Oxford with Fiocruz. In the following two days, the other states and the Federal District began immunizing their populations¹⁸. However, 38 countries had already started immunizing their populations in 2020, including major powers such as the United States, Germany, France, Russia, and also Eastern European countries such as Croatia, Lithuania, and Slovenia; and Latin American countries such as Mexico, Chile, and Argentina¹⁹.

In addition to the delay in starting vaccination, there was a shortage of available doses due to the federal government’s initial bet on just one vaccine: AstraZeneca/Oxford produced and packaged by Fiocruz, but still dependent on imports of Active Pharmaceutical Ingredients (API). The shortage would have been more significant if not for the government of the State of São Paulo’s initiative to produce CoronaVac, incorporated into the National Vaccination Plan against Covid-19, only after much pressure from governors²⁰. However, it did not prevent stoppages in the distribution of vaccines in February²¹, relevant reductions in the quantities of doses to be delivered in March and April 2021²², and the temporary suspension of vaccine production by Butantan due to the postponement of the arrival of an API shipment from China²³. The shortage of doses made logistics difficult and increased the costs of distributing vaccines²⁴. Consequently, on April 13, almost 32 million doses had been administered in almost three months²⁵, much lower than the 80 million administered during the H1N1 pandemic in a similar period.

Other factors that negatively impacted the chances of success of the Covid-19 vaccination were related to consequences of the health sector’s chronic underfunding aggravated by the application of Constitutional Amendment 95, resulting in a reduction of BRL 20 billion in the budget of health only in 2019, according to the National Health Council (CNS)²⁶. The impact on the budget for the PNI alone was almost BRL 400 million when comparing the amounts approved in the budget for 2020 (BRL 4.9 billion) and 2019 (BRL 5.3 billion). Despite the approval of exceptional funding of BRL 604 billion to face the pandemic in 2020, the federal government failed to spend BRL 80.7 billion, or 15%, which, in 2021, had already been included in the spending ceiling calculation²⁷.

Considering the existence of such a well-structured immunization program in Brazil, what could explain the delay in starting the immunization of the Brazilian population against Covid-19 and the problems in the distribution and administration of vaccines?

Critical juncture: pandemic and pandemonium

The Brazilian National Immunization Program (PNI) is an ideal object of institutionalist analysis as this approach tends to privilege studies of public policies over long periods, in which institutions develop in standardized sequences and incremental changes. The institutionalist analysis enables identifying long-term causal effects, and the institution’s strategies consolidated through time tend to be irreversible or more resilient, building a resistant web of actors and governance structures around them^28,29. However, PNI has not presented such resilience.

Institutions define frameworks and shape the actors’ incentives and strategies. However, the results of power disputes are defined based on the actor’s accomplishment³⁰. Their ability to act critically allows building discursive coalitions or epistemic communities that point toward institutional reframing. Beyond symbolic disputes, power disputes occur materially, involving resources and positions of power.

Faced with the Covid-19 pandemic that requires the government’s total institutional capacity, Brazil witnesses a political, institutional, and technical rupture with the standards established during the history of the PNI - whose strategic choices, learning, and incremental changes led to the success of vaccination campaigns. However, at a critical juncture, policy autonomy increases through structural flexibility or through a higher probability of decisions that change existing institutions³¹.

Evidently, a pandemic represents a critical juncture insofar as it generates a high degree of insecurity concerning institutionalized patterns of actions, relationships, and the exercise of power. History gives us countless examples of how events that get out of control, such as pandemics and wars, increase autonomy to create scientific and institutional frameworks and developments. In addition to causing deaths, insecurities, and increasing inequalities, pandemics provide scientific and institutional development.

In the current critical health situation, possibilities have opened for scientific and technological innovations, as was the case with the large international investment in the development of several vaccines in record time in the unusual scientific collaboration between competing companies and in the appreciation of the WHO’s role in conducting collaborative processes between countries and producers.

In Brazil, the pandemic was preceded by major political changes since the impeachment of President Dilma Rousseff in 2016 through a legal-media-parliamentary maneuver amid economic troubles and the legitimacy crisis of government leaders³². The subsequent government led by President Michel Temer (2016-2018) changed the structure of the Ministry of Health (MoH), for example, replacing the drug distribution center with a private company, which affected drugs - and vaccines - purchase and distribution processes. Another measure that weakened the vaccination strategy was the ordinance issued by Health Minister Luiz Henrique Mandetta in January 2020 (under Jair Bolsonaro’s presidency). The ordinance ended the mandatory link between the primary care multidisciplinary teams and the Núcleo Ampliado de Saúde da Família (Expanded Family Health Center) model.

The ban on the candidacy and subsequent imprisonment of former-President Lula da Silva (Workers’ Party - PT) favored the election of President Jair Bolsonaro in 2018. His election resulted from an ‘anti-PT’ alliance formed by conservative sectors, represented by neo-Pentecostal leaders, bankers, agribusiness, prominent business people, police, militia, and military, who harnessed part of the middle and lower classes. The notion of a critical juncture in health policy must, therefore, be seen as part of a political process external to the institutional framework of the Brazilian national health system (SUS) but affecting it profoundly, since the health crisis transforms health policy and institutions into the main arena in which political and economic interests will clash.

The crisis in the vaccination policy must be considered within the geopolitics of President Bolsonaro’s government. The Brazilian government demonstrated unconditional alignment with President Trump’s administration in the US, reproducing his criticism of international organizations, such as the WHO, and conspiracy theories against China, accused of spreading the virus - in addition to denying the severity of the pandemic and the effectiveness of non-pharmaceutical measures to combat the spread of the virus. The Minister of Foreign Affairs insulted the partnership established between the Brazilian vaccine producer Butantan Institute (linked to the government of the State of São Paulo) and the Chinese state-owned pharmaceutical company Sinovac, creating a diplomatic problem that affected the supply of active pharmaceutical ingredients to produce the vaccine. In addition, the minister acted deliberately against the interests of India, another strategic supplier, by aligning with developed countries in the World Trade Organization and voting against the proposal for the temporary suspension (during the pandemic) of patents on vaccines and medication²⁰.

The political altercation between the federal government, scientists, and subnational authorities took place around symbolic disputes and effective measures of action and inaction by the MH, initially questioning the severity of the disease, the effectiveness of prophylactic measures, and issues related to the health authority and operation of the information system. Subsequently, the issue of vaccine production and acquisition becomes central in the dispute, along with the restrictive measures to enforce social distancing enacted by subnational governments.

Since community transmission was observed in the country in March 2020, all states began to adopt social distancing measures³³, which, although asymmetrical in terms of the degree of restriction³⁴, were based on technical criteria and the states’ autonomy. On the other hand, the president’s reaction was to deny the severity of the disease, contrary to the recommendations of the WHO, national scientists, and other public authorities. The symbolic dispute was expressed in Bolsonaro’s statement in March 2020: “It won’t be a little flu that will bring me down”³⁵. He also suggested that Brazilians are strong people and the coronavirus would not spread in the country, saying that Brazilians “jump into the sewer and do not catch anything”³⁶. The pandemic recorded more than 5,700 cases and 200 deaths at the end of that month²⁵.

Associating preventive measures with weakness, he started to advocate a ‘vertical isolation’ only for people at risk, such as the elderly and patients with comorbidities, while urging others to return to normality. Such statements were always followed by agglomerations where the President and his entourage never wore masks. Instead of non-pharmacological preventive measures, he began to recommend, in his public appearances, the use of what became known as a ‘preventive kit’, a set of medicines without scientifically proven effectiveness. The Brazilian Army used public resources to import, produce, and distribute chloroquine, and the government accepted donations of this drug. The president kept encouraging the population to self-medicate and influenced the prescription of specific drugs. The growth of cases and deaths led to another fatalistic and irresponsible tone. The president shifted the center of the debate to a false opposition between health and economy, making statements such as: “So what? What do you want me to do? I’m not a gravedigger. I do not perform miracles”³⁷. “Are people dying? But many more will die if the economy continues to be wrecked”³⁸.

He added that the virus was going away and that it would be essential to resume economic activity, putting the population and business people against the governors who issued restrictive measures to increase social distancing. The federal government also tried to concentrate the power of establishing measures to restrict the transport of goods, movement of people, and maintenance of services during the pandemic³⁹. However, the Brazilian Supreme Federal Court (STF) questioned the measure’s constitutionality and decided to reaffirm the autonomy of subnational entities in decisions regarding competing competencies. Bolsonaro mobilized business people and protesters to pressure STF judges and confront the governors’ authority, declaring: “It’s War! You have to play hard with the governors”⁴⁰. This statement was said on May 14, 2020, when Brazil had counted more than 200,000 cases and almost 14,000 deaths from Covid-19²⁵.

The then Health Minister Luiz Henrique Mandetta was led to quit the position after opposing the adoption of chloroquine as a drug to treat Covid-19 patients (as desired by the government). His replacement, Nelson Teich, also left the position while the President proclaimed “I am in charge”⁴¹, reaffirming his supposed authority in prescribing medicines and defining essential activities (formally not subjected to restriction measures), regardless of the technical opinion of the MH. The ministry was progressively militarized. General Eduardo Pazuello was sworn in, appointing three dozen soldiers to leadership positions in the MH. However, the general and his appointees did not know SUS, the PNI, and health policies.

The loss of data in the MH was part of a set of factors that disqualified the health authority, generating distrust about the pandemic data. The narrative, part of the political dispute, was that governors and mayors were manipulating data. In June 2020, Bolsonaro even called on his followers to invade hospitals to film vacant beds and deny overcrowding⁴². The lack of credibility on data from the MH led to the creation of a consortium of press agencies receiving information directly from the state health departments. Thus, one of the bases of institutional support of the health authority, the health information system, built along the trajectory of the SUS, started to be demoralized. By the end of that month, 1.4 million cases had been recorded, with almost 60,000 deaths from Covid-19²⁵.

Politics is made up of symbolic disputes and also of actions and lack of action. In the case of vaccine production and purchase, the government adopted a necropolitics, as defined by Mbembe⁴³, i.e., the exercise of power exposing the population at risk of dying. The necropolitics of the vaccine shows the contempt for the lives of the population on the part of an authority that uses its power to kill political opponents and sabotage initiatives to produce and purchase vaccines. In a criminal complaint against national government authorities in response to Covid-19, public health specialist Gonzalo Vecina and others demonstrated that there was “insufficient and late budget allocation for vaccine acquisition” in 2020; “slow and insufficient pace of budget execution within the scope of the National Health Fund throughout the 2020 financial year”; and “lack of provision for resources in the 2021 annual budget bill to deal with Covid-19”⁴⁴.

In July, September, and October 2020, the Butantan Institute sent letters to the MH to offer millions of vaccines that could be delivered by the end of the year if the purchase was made. The absence of responses from the ministry led Butantan to seek other sales strategies, meeting with parliamentarians, governors, mayors, judges, and members of the Federal Court of Accounts (TCU).

Still, President Bolsonaro stated on October 19, 2020:

My Minister of Health has already said that this vaccine will not be mandatory, period... Nowadays, at least half of the population says they do not want to take this vaccine⁴⁵.

On that day, Brazil had 5.25 million cases and almost 155,000 deaths caused by Covid-19²⁵.

Pressure on the MH from the Forum of Governors and the National Front of Mayors to purchase vaccines produced by the Butantan Institute increased, which led Minister Eduardo Pazuello to establish a purchase contract. Upon being informed, Bolsonaro warned his followers on social media: “We will not purchase this vaccine”. After the purchase was canceled, Minister Pazuello (who was in isolation because he had Covid-19) received a visit from the President. In a video with the president, the minister explained the decision of taking back his word on purchasing the vaccine from Butantan Institute in an exemplary sentence of hierarchical obedience: “One commands and the other obeys, simple as that”⁴⁶. The general’s failure to direct the MH was evident with the uncontrolled growth of the pandemic and the absence of sufficient vaccines to prevent the development of new strains of the virus, leading to his replacement by the fourth Health Minister within a year. Minister Marcelo Queiroga responded to calls for change by advocating vaccination. However, he opposed lockdown and restriction measures to increase social distancing, aligned with the presidential guidance.

The next Brazilian presidential election will occur in 2022, and vaccines have already gained central relevance in this political dispute. The potential candidates building their electoral platform around the issue of vaccines were the Governor João Doria of the State of São Paulo and President Bolsonaro (aiming for re-election). Governor Doria gained political prominence with the leading role in allocating state resources to develop the vaccine (CoronaVac), funding the partnership between Butantan Institute and the Chinese state-owned company Sinovac. An example of the dispute between the two potential candidates around this issue is the statement of President Bolsonaro on November 10, 2020. The president ‘celebrated’ when the National Health Surveillance Agency (Anvisa) temporarily suspended the tests with CoronaVac for clarifications due to the death, by suicide, of a volunteer participating in the trials. “Death, disability, an anomaly. This is the vaccine that Doria wanted to force the people of São Paulo to take”²⁵. On that day, 5.7 million cases and almost 163,000 deaths from Covid-19 had already been reported²⁵.

When João Doria announced that he could start vaccination by January 2021, the federal government announced the construction of a new Fiocruz factory to increase the vaccine production capacity developed in partnership with Oxford/AstraZeneca⁴⁷, which was in a similar situation to the development of CoronaVac. Minister Eduardo Pazuello’s statements about the vaccine ignored CoronaVac, betting everything on Oxford/AstraZeneca, which provoked a manifestation of state health secretaries, in a letter from Conass demanding that the immunization program be composed of all approved vaccines⁴⁸.

The offer of another 70 million doses made to the MH in August 2020, by the company Pfizer, also did not receive any response from the Brazilian government until December 2020, when the government went public to explain that it did not accept the terms of the contract that exempted the company from responsibility for unforeseen consequences. The President commented on December 18, 2020, on the Pfizer/BioNTech vaccine that he would not get vaccinated, adding, “If you turn into an alligator, that’s your problem”⁴⁹. The country had almost 7.2 million cases and more than 185,700 deaths due to the pandemic²⁵.

With the imminence of the production of the first doses by Butantan, the MH finally announced the purchase of 100 million doses on January 7, 2021. However, it demanded that the São Paulo government deliver all the syringes in stock to the MH, thus removing the media effect if the state wanted to be the first to start vaccinating the population. An injunction from one of the judges of the STF, Ricardo Lewandowski, was necessary to ensure that the state of São Paulo retained the syringes needed to vaccinate its population²⁰.

The Brazilian Congress called the MH after the ministry was summoned by the STF and inquired by governors for not having presented a vaccination schedule. After going back and forth on the schedule, Minister Eduardo Pazuello finally uttered a terse sentence, revealing a total lack of planning: “The vaccine will start in Brazil on D-day and H-hour”⁵⁰.

Even after Anvisa granted the emergency authorization of use for CoronaVac vaccine, Bolsonaro questioned its effectiveness of the CoronaVac vaccine, advocating unproved early treatment:

I don’t give up on early treatment, I don’t give up. The vaccine is for those who haven’t caught it yet. This vaccine is 50% effective; that is, if you toss a coin, it is 50% effective⁵¹.

On that date, January 18, 2021, it was already possible to observe the second wave of the pandemic in Manaus (State of Amazonas, North of the country), and Brazil had more than 8.5 million cases and 210,000 deaths caused by the pandemic²⁵.

The beginning of vaccination showed that the population remembers the success of previous vaccination campaigns and immediately went to the health units to be vaccinated. However, the delay in immunizing the people and the difficulties in the purchase, production, and distribution of vaccines placed Brazil in 64^th position, in a ranking with another 164 countries, with only 11.1% of people receiving at least one dose by April 13, 2021¹⁹. At the same time, the president’s popularity declined, demonstrating public opinion’s dissatisfaction with the government’s handling of the pandemic and vaccination.

Final considerations

According to Fukuyama⁵², some countries coped better than others in fighting the pandemic, with no correlation with the political regime. The author identifies state capacities, social trust, and leadership as factors responsible for success. On the contrary, dysfunctional states, polarized societies, and poor leadership are responsible for mishandling the fight against the pandemic.

In the Brazilian case, the existence of state capacities responsible for vaccination (represented by the PNI consolidated public policy and institutionality and the capillary network of SUS primary care), were not enough to ensure effectiveness in combating the pandemic and get the population vaccinated in time to avoid an exponential increase in the spread of the virus and deaths. How leaders such as President Jair Bolsonaro dealt with the pandemic undermined institutional capacities and social trust, both through symbolic disputes and actions - such as the militarization of the Ministry of Health (MH) and inaction in the purchase of vaccines. Fundamentally, the MH renounced its role of offering federative coordination, deciding not to use the ministry’s purchasing power to reduce prices in the importation of materials, ingredients, and vaccines. The MH did not engage effectively in the consortium created by the WHO, failing to present the country’s demand for vaccines. Also, it did not launch clarification campaigns for the population and was not agile in purchasing different vaccines offered to the country. Finally, the MH failed in the logistics coordination and definition of protocols and failed to present and follow a national vaccination schedule.

The symbolic dispute included: public statements and demonstrations, in addition to legal measures involving the denial of the severity of the disease and the consequences for the health system; dissemination of proven ineffective drugs; disavowal of governors and mayors who created restrictive measures to increase social distancing and reduce contamination; disqualification of non-pharmacological measures; delegitimization of the health authority; dismantling of the MH’s information system and organizational practices concerning the fight against pandemics and the PNI; unauthorizing by the WHO; and generating diplomatic tensions with countries that produce essential ingredients for vaccine development. These trends extended to the development and purchase of vaccines, from the political-electoral dispute with the governor of São Paulo, spreading suspicions about the effectiveness and risk of taking the vaccine, to the measures that prevented the purchase of this and other vaccines in 2020, when other countries already contracted producers.

What is the role of these ideas and measures in the policy constitution? Discourses must be analyzed not only concerning the ideas they communicate but also the context (discursive interactions)⁵³. Regarding the discursive contexts, President Bolsonaro privileged interactions established with his followers on social media and with those ‘fans’ agglomerating in front of the president’s workplace (Palácio do Plantalto). An environment of informality was established, conducive to the identification between sender and receiver, reifying the image of an ordinary person, who issues honest judgments, even prosaic, but devoid of rational political calculation, to obtain an advantage. Information technologies facilitated the creation of personal channels between the authorities and their followers and the production of fake news, which became essential components of political and electoral disputes.

While the election of authoritarian populist leaders is based on rhetoric that privileges criticism of politics, creating an ‘us’ - the people - against the ‘them’ - political and economic elites - authoritarian populism in power goes far beyond this rhetoric, seeking to undermine democratic institutions and remain in power. Ruling for their followers, populist leaders seek to delegitimize the opposition, constantly mobilizing supporters with a narrative that identifies the leader as the true people’s representative. Identifying truth with faith changes discourses and attitudes, reducing the risks to the leader’s credibility⁵⁴. Thus, the president who was against the purchase of vaccines operated to take credit for purchasing immunizations, building narratives that, although inconsistent, are always accepted by those who have faith in the politician as ‘a myth’.

In addition to the communicative process, symbolic disputes represent important power resources that, in the case of a pandemic, have consequences to the population health and political consequences to democratic institutions. Different studies have sought to identify the impact of the president’s statements in terms of the destruction of social trust in the measures advocated by the WHO and national scientists to combat the pandemic (non-pharmacological or measures such as purchase and production of vaccines that would speed up the vaccination process). These studies conclude that the pandemic was treated in ideological and partisan terms, and the alignment of subnational governments with the president determined the pattern of action, the timing, and the rigor of the measures adopted.

The ideological alignment with the president was related to health consequences at the municipal level. Research developed by the Federal University of Rio de Janeiro, in partnership with the French Institute IRD, found that the municipalities in which President Bolsonaro obtained the most votes in the first round of elections had a higher incidence of the disease. This positive correlation has been called the ‘Bolsonaro effect’ in the spread of the pandemic: for every 10 percentage points more votes for Bolsonaro, there was an 11% increase in the number of cases and 12% in the number of deaths⁵⁵.

Research on how the presidential statements against social distancing during the pandemic affected the population has shown that impacts were not restricted to his supporters⁵⁶, although preventable deaths may be higher among them⁵⁷. Another study, using an index of social distancing through cell phones, corroborates the assertion that presidential speeches exposed the population to risk situations, especially in municipalities with the highest levels of media penetration, presence of active Twitter accounts, and a large proportion of evangelicals. We conclude that the leaders’ statements are more than words, provoking actions and behaviors⁵⁸.

The consequences concerning democratic institutions responsible for health policy and the federative arrangement were also studied. It was found that:

[...] the governance model built throughout the institutionalization of SUS, in line with the constitutional model of shared federalism with a social purpose, did not withstand the critical juncture that brought the pandemic together with the authoritarian style of populist leaders in power, giving rise to a model of confrontational federalism, with severe consequences for democracy and public health⁴⁽¹¹²⁾. [our translation].

This happened because of the occupation of the MH by military appointees in leadership positions, in a process where technical personnel was fired or politically intimidated. Democratic governance mechanisms such as the CNS and the Tripartite Commission were disregarded, and the decision-making process was encapsulated around the military working in executive positions and the intervention of professionals, doctors, and business people not familiar with the public bureaucracy.

In a study on the consequences of combating the pandemic for federalism in the United States, Kettl⁵⁹ points out that the absence of leadership by the national government made room for state leadership to gain prominence. However, more than the verification of the thesis that states are public policies laboratories, and beyond the mere partisan differences, Kettl observed the expansion of fragmentation, i.e., a divided state.

In the Brazilian case, the consequences for federalism were both disruptive of intelligence and federative coordination mechanisms and innovative, since the absence of coordination on the part of the MH and the president’s sabotaging attitudes led to seeking and strengthening horizontal coordination mechanisms, such as the Forum of Governors, the regional Consortia, in addition to the prominent role played by Conass. Unlike the North American case, the existence of SUS presupposes constitutionalized concurrent competencies and legal attributions defined by health legislation for the national interlinking of health policies, in addition to a long tradition of national vaccination campaigns coordinated by the MH. The Brazilian federative arrangement was questioned by the president, who appealed to the STF to prevent subnational governments from adopting restrictive measures to increase social distancing, such as lockdowns. The STF, however, protected the autonomy of states and municipalities so they could take the necessary measures to combat the pandemic. With this decision, the STF broke its trajectory of decisions favorable to the Union in all federative conflicts that occurred since CF/88⁶⁰.

Faced with this decision and criticism of the federal government’s lack of coordination in combating the pandemic, President Jair Bolsonaro created the narrative that the STF prevented him from carrying out such coordination, and therefore, the blame for the health and economic crises would lie with governors and mayors. Based on Discursive Institutionalism⁷, this way of framing this political issue can be analyzed as an attempt by the president to maintain his political support and weaken political actors from subnational spheres, and as a resource in an attempt to change the decision of the STF and increase its decision-making power on actions to combat the pandemic.

Additionally, in April 2021, the STF determined the installation of the Parliamentary Commission of Inquiry (CPI) on Covid-19 in the Senate, in response to a writ of mandamus presented by parliamentarians, which investigated the actions and omissions in the federal government’s response. Testimonies by specialist Pedro Hallal, professor at the Federal University of Pelotas, and Jurema Werneck, executive director of Amnesty International to the CPI, on June 24, 2021, confirmed that at least 400,000 deaths out of a total at the time of 507,240 could have been avoided if the MH had assumed the timely coordination of the purchase and application of vaccines offered in the international and national market⁶¹.

The inaction of the MH in the process of acquiring vaccines led subnational governments to seek purchase through direct negotiation with the Butantan Institute and with private laboratories, which could result in a situation of federative tension and deregulated competition, increasing regional inequalities: member states of the Central Brazil Development Consortium joined forces to purchase vaccines⁶², as did the states that are part of the Northeast Governors Forum, which have already contracted 37 million doses of the Sputnik vaccine V, from Russia⁶³. Other direct attempts at negotiations with the Butantan Institute were carried out, for example, by the Governor of Rio Grande do Sul⁶⁴. A consortium of municipalities was also created through the National Front of Mayors to purchase vaccines in the international market⁶⁵. However, such initiatives ended up having no practical results since the federal government, from the moment the government of São Paulo started vaccination, decided to take charge of the purchase and distribution of vaccines.

The turn of the government in favor of vaccination took place with the fall in the president’s popularity, pressure from business people to buy the vaccine, and the entry of the new health minister who defends vaccination, non-pharmacological measures, such as the use of masks, hand hygiene, and controlled isolation, but condemns the lockdown as used sometimes by mayors and governors, in agreement with the president. However, the inability to provide adequate vaccines, as a result of the denialist policy that prevented the purchase at the opportune moment, together with the encouragement of agglomerations, the need to use urban transport and the search for means of survival have been seen as enabling the emergence of new strains, compromising the effectiveness of vaccines and the government’s popularity.

Our study sought to demonstrate the growing importance of discourse analysis as a resource in power struggles while considering that its effectiveness in dismantling successful institutional trajectories should be accompanied by other instruments of power, both in terms of actions and omissions, able to ensure that discourses and practices are capable of dismantling successful public policy trajectories. The militarization of the MH should be seen as a symptom of the resilience of public health policy to an arbitrary denialist project with political and economic interests, even if it has not been able to face it fully.

The existence of political actors with veto power, such as the STF; vocalization of complaints, such as Conass; autonomous scientific and civil society organizations, such as Anvisa; and actors of collective action, such as parliamentarians and governors, prevented an even greater tragedy. However, a coalition that boosted denialism and supported the president was formed by bloggers (who spread fake news on social media), business people (who financed such activities and profited from the sale of ineffective drugs), doctors, media associations, and the Federal Council of Medicine itself (who omitted or openly supported the use of these ineffective drugs), sectors of the civil and military bureaucracy (that also supported the president and despised scientific recommendations), in addition to parliamentary leaders (who sought to prevent the creation of a parliamentary investigation committee to analyze the process).

Vaccination against Covid-19, as in the Vaccine Revolt at the beginning of the twentieth century, proved to be an exceptional element contributing to analyzing the Brazilian political economy and sociability. While, in the Vaccine Revolt, the president promoted mandatory vaccination, which provoked military and popular rebellion; in the current case, the president was the main obstacle to defining restriction policies to increase social distancing containing contamination and develop and purchase vaccines to face a pandemic properly. In both cases, the debate over combating the virus made the vaccine the main political arena where power disputes occurred. In the first case, the dispute opened space for a successful trajectory of the vaccination policy. In the second case, the critical juncture created possibilities of an unprecedented health tragedy, the fraying of the federative pact, and the loss of institutional capacities built up over the years.

• Financial support: non-existent

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Publication Dates

• Publication in this collection
  11 Apr 2022
• Date of issue
  2022

History

• Received
  15 Apr 2021
• Accepted
  04 Nov 2021