With regards to the trajectory of the policy response to HIV and reproductive health in Brazil — which, between 1980 and the first decade of the 21st century was very positive – it was inevitable that the incoming Bolsonaro government would cause damage, particularly with regards to sexual health. It must be said, however, that during the first 120 days or so of the new administration, public health seemed to be immune to the tsunami of decrees and draconian measures that emanated from the President’s office and which are demolishing existing structures and public financing, particularly in education, environmental law, state regulation, and protection of rights. In the words of an observer of policies in the sector, the Ministry of Health was kept under “the same management”. But, even so, there were scares.
As Veriano Terto, executive coordinator of the Brazilian AIDS Association (ABIA), pointed out in the Association’s report on AIDS policy, there were two moralistic attacks on educational materials produced by the Ministry of Health (here and here in Portuguese). Additionally, the press reported problems with regards to the purchase of contraceptives and, especially, Misoprostol for obstetric use and in legal abortions (read in Portuguese). It is also important to note that the presidential decree stipulating the end of June as the deadline for extinguishing various participatory committees (whose function is to assist the Executive in the formulation and implementation of public policies) came as a strong sign of the anti-democratic bias of the new government, which eliminated policy participation for certain populations that are very vulnerable to HIV.
Paula Viana, of NGO Grupo Curumim, with whom we talked to in order to more broadly explore what was happening in terms of sexual and reproductive health, also underlined the complete absence of dialogue with the new government and pointed out the possible negative effects on women’s health policy due to the government’s alignment with the more conservative sectors of the medical field.
By early May, however, there were no strong signs of structural changes, and the majority of the newly appointed managers were already officials from the Ministry of Health, apparently aligned with the principles of the Unified Health System (SUS). According to some technicians we talked to, the Ministry “was running policy as it stood without major changes.”
But on May 3, the Ministry issued an order to abolish the term obstetric violence from official documents (more in Portuguese). This unusual measure provoked criticism from many sectors and voices and could be read as the first sign of an approaching storm. Another decree was then published on May 17th that radically modified the Ministry’s management structure. Among other measures, the decree transformed the Department of HIV/AIDS, Viral Hepatitis and STDs into a coordinating committee, situating the management of these diseases as similar to that of trachoma and intestinal worms, diseases whose epidemiological profiles differ substantively from HIV and hepatitis. On the other hand, the government also transferred the structural function of purchasing and providing antiretroviral drugs, which had been under the management of the former Department, to the Pharmaceutical Assistance Department (DAF). The Technical Area of Women’s Health – weakened since Dilma Rousseff’s administration when it had already been reconverted to a mother-child model – was also demoted, being integrated into a new General Coordination of Life Cycles. This shift signals the potential definitive erasure of what remained of the sexual and reproductive health guidelines that had been set up in the 1980s and 1990s. This is not surprising since these guidelines are seen by ideologues of the government, such as Minister of Foreign Affairs, as a mere subterfuge to legalize abortion.
This sudden shift in the national health policy is a clear cut demonstration of how the Bolsonaro administration thoroughly mimics a permanent war, in which managers take structural measures without prior announcement, possibly with the aim of disrupting criticism and resistance. We will now conduct a brief overview of what occurred in the context of the response to HIV and Women’s Health before the publication of Decree 9.795 and then share analysis and critiques developed since May 17th about the impact of the measures that have been announced.
The response to HIV / AIDS: early symptoms
In an interview in late April, Veriano Terto, executive coordinator of ABIA, already assessed the first months of government as nothing encouraging, even though no actions had yet been taken to affect the backbone of the Brazilian response to the AIDS crisis, the access to free antiviral medicine:
Apparently, everything is normal. But I reiterate: just apparently. We have not yet had a concrete setback, but the conjuncture suggests a bleak future. The mentality of the political and ideological group in power, as well as the social sectors that support it, is openly hostile to an agenda based on principles of citizenship, human rights, and social justice. So if we do not yet have direct threats to HIV/AIDS policy, we cannot say the same thing in broader terms. Government proposals, theses, and speeches have created a social, cultural, political, and economic environment that adversely affects the sustainability of the response to the epidemic.
To illustrate the conditions of this environment, Terto mentions two episodes of censorship of educational materials. The first involved the primer for the prevention of sexually transmitted infections for trans men. Although ministry officials have alleged that the booklet has been suspended for corrections, the climate of sexual panic that prevails in the administration means that this measure cannot be understood as trivial. More disturbing, however, according to Terto, was watching the president on television, flanked by two generals, encouraging mothers and fathers to tear out pages of their teenage children’s health textbooks containing images of the sexual and reproductive anatomy. (news in Portuguese). The booklet referred to provides information on basic health care, pregnancy prevention and sexually transmitted diseases. According to Terto, it has been distributed for over ten years and there has never been any complaint as to its content in all that time. Furthermore, it is one of the few booklets for 12 to 14-year-olds regarding the initiation of sexual activity.
ABIA’s executive coordinator also referred to the presidential veto of a bill that dispensed people living with HIV from periodic social service check-ups, which are obviously designed to threaten the continuation of their health benefits:
The effects of this for a person with HIV / AIDS, who may have been out of the labor market for years or even decades and who may be suffering from the effects of treatment, is devastating. How can this person return to the job market? There is no prevention policy that deals with the question of returning to the labor market or even a campaign to combat stigma against workers living with HIV / AIDS. It creates a situation of legal insecurity for thousands of HIV positive people, which can even be harmful to their health.
Terto also criticized the national drug policy adopted by the new government that promotes abstinence as a therapeutic resource, excludes harm reduction policies and supports therapeutic communities (mostly run by evangelical churches). He said that the new guidelines break with the approach applied in Brazil since the 1990s, often in association with HIV policy, which does not reduce people to the social position of “junkies”, but instead sees them as citizens with rights, dignity, and possibilities. For the coordinator of ABIA, the new drug policy follows, above all, a moral agenda:
The return of abstinence as a treatment tool for drug addiction is pleasing to the government‘s electorate, especially evangelicals. It is an ideological and moralistic approach. As we know, and much research tells us, abstinence is not the best and most effective way to combat addiction. But that does not seem to be the interest of the current management, and not just because the emphasis on therapeutic communities is an ideological sop to their evangelical base, facilitating churches’ access to public mental health resources. We are also concerned that the new policy will adopt a stance contrary to the decriminalization of drugs. For us who work in the field of human rights, criminalizing language is always a problem because it distances and punishes when the focus should be dialogue, acceptance, and solidarity. One of the effects of abstinence-based approaches is precisely to alienate people and make dialogue difficult. This logic also negatively affects the response to HIV/AIDS. How can we debate and dialogue in order to prevent the epidemic if the official position in itself promotes social exclusion? How do we advance a discussion about discrimination and prejudice if what we have is an effort to silence all conversation about these topics? These exclusionary concepts make for a very worrying, distressing, and threating environment.”
Veriano Terto also noted that in all these setbacks, civil society, which has been fundamental in building and recognizing the Brazilian response to HIV/AIDS, has been absent from the discussions.
In this context, which include attacks on a whole set of social policies and the destruction of mechanisms of social control, the sudden restructuring of the Ministry of Health comes as no surprise, but its effects are drastic. As the public memorandum published by the National Association (ANAIDS) points out, these acts can and should be read as the end of Brazil’s national AIDS policy :
It is not just a question of nomenclature: it is the end of the Brazilian AIDS Program. The government has, in practice, extinguished in an unacceptable and irresponsible way one of the most important AIDS programs in the world, which was for decades an international benchmark in the fight against AIDS. More than a program, this decree ends an experiment in democratic governance of fighting an epidemic through social participation and intersectoriality.
A few days later, responding to the official reaction of the Ministry to these and other criticisms, ABIA published a technical note which demonstrates how the restructuring was done without transparency, reflecting a broader climate of democratic rupture. The note emphasizes that it is not known how the distribution of resources will be conducted between the various programs now allocated under the new Department of Diseases, Chronic Conditions and ISTs, where the policy of combating HIV/AIDS is now situated. Above all, this shows how this “administrative” reform negatively affects the backbone of the Brazilian response, i.e. universal access to antiretroviral medicine. In the new organizational chart, the responsibility for bidding, purchasing, storing, and distributing these drugs was transferred to the Pharmaceutical Assistance Department (DAF), which is responsible for the totality of SUS operations. This change implies indifference to the expertise accumulated by the former Department of STDs, AIDS and Viral Hepatitis and tends to make these operations more bureaucratic and less agile, potentially compromising access to antiretrovirals. More importantly, it will hamper the evaluation and epidemiological monitoring that is crucial to measuring the benefits of treatment.
Women’s health: Signs of concern, a silence that widens
In the Women’s Health Technical Area, SPW has learned that since January, technicians in the area have felt that the transition has not started but can be expected at any time. In spite of dialogues with other areas of government, such as the Ministry of Women, Family and Human Rights and the Ministry of Education, in which conservative and regressive views regarding sexual and reproductive health clearly prevail, guidelines and procedures in relation to contraception, for example, have so far remained untouched by the chaotic environment of moral war stimulated by the present government.
The technical team is still acting within the framework of established programs and policies and there was not yet “any legal or instructional tool” openly contrary to the sexual and reproductive health guidelines consolidated within the Ministry of Health. Top-level managers were still aligned with SUS principles. The lull ended when a decree regarding the “abolition of obstetric violence” was published. According to Paula Viana, the document does not have regulatory or legal character but signaled the strong influence of antifeminist positions and anti-reproductive health in current ministerial management.
The measure had, however, a reasonable level of repercussion in the press and social networks. Days later, the Federal Public Ministry of São Paulo (FMH-SP) made a recommendation to the Ministry of Health, suggesting that it refrain from actions contrary to the promotion of the term, which the FMH-SP describes as an “expression enshrined in scientific and legal documents”. Last but not least, when this briefing was being finalized in June, Brazilian Congress lifted the presidential veto of the law suspending the compulsory medical examination of HIV positive people who receive social security benefits. The House Committee on Health and Social Security has also called a public hearing to discuss the deleterious effects of the restructuring of the Minister of Health on the Brazilian HIV response.
The dynamics are however different in the women’s reproductive health policy area. As already mentioned, the MOH reorganization established by Decree 9795 reduced the Technical Area of Women’s Health to a subunit of the new General Coordinating Group of Life Cycles. According to observers we have talked to, it is not yet possible to assess what this will mean for a policy area that it had been under attack for some time. What seems certain is that the area’s financial autonomy will be restricted, at the very least. In the middle of a political storm, and even two weeks after the announcement, the potentially deleterious effects of this move did not provoke many reactions or criticisms.
In frank contrast to the rapid response of society to the impacts suffered by changes in HIV/AIDS policy, the treatment the government is giving to women’s health has answered with an uncomfortable silence. Given this, we must ask: what explains the lack of discussion and interest in a policy that continues to be of enormous importance for the welfare and human rights of the vast majority of Brazilian women, who depend on SUS for prenatal care, childbirth, and many other reproductive health needs? This silence is even in contrast with the negative repercussion of the measure regarding the “abolition of the obstetric violence”, since for the majority of Brazilian women, especially the poorest, youngest, and darkest women, there is no way to eliminate the ill-treatment, discrimination and racism that they are subjected to in the health services in the absence of a solid public policy of sexual and reproductive health.
Last but not least, the downgrading of the Technical Area of Women’s Health is also at odds with the insistent discourses deployed by minister Damaras Alves on the priority given to maternal health in the policy agenda of the JMB government. It is not excessive to say that, in this policy domain, while the lips of the administration point towards one direction the managerial hands are moving towards the opposite course.