The Activist State: Global Pharmaceuticals, AIDS, and Citizenship in Brazil

The AIDS Model

The Brazilian AIDS Program combines prevention with free distribution of antiretroviral therapies and is widely touted as a model for stemming the AIDS crisis in the developing world. In the face of the devastation brought on by AIDS, the unlikely availability of a vaccine in the near future, and the relatively few interventions that seem replicable, this is a most welcome success story. It emerges not out of utopian principles or privileged contexts but out of a desperate reality and redirection of what seemed inflexible, commercial, scientific, and state logic toward equitable outcomes.

In 1992 the World Bank and the Brazilian government approved an unprecedented $250 million aid package for the creation of a new National AIDS Program whose aim was to reverse what international experts were calling the "Africanization" of AIDS in Brazil.¹ AIDS activists, politicians, economists, and scientists organized an impressive governmental and nongovernmental administrative apparatus that is believed to have contained the epidemic's growth through massive and community-mediated prevention projects, with a focus on condom distribution, HIV testing, and behavioral change among the so-called high-risk groups.² In 1996, for the first time, national data showed a decrease in the epidemic's growth rate. The National AIDS Program and the World Bank now report that half of the projected 1.2 million HIV cases have been averted.³

In 1997 the Brazilian government began to provide free antiretroviral drugs to all of the country's registered AIDS cases. There are some 135,000 patients taking antiretrovirals today. The availability of the cocktail and lab testing, funded by the Brazilian government at an annual cost of approximately $2,000 per patient, is said to have reduced AIDS mortality and the demand for hospital services by more than 50 percent in São Paulo and Rio de Janeiro, the areas most affected. HIV transmission from mother to child is said to have been reduced by two-thirds. This policy of biotechnology for the people is being hailed as "proof that poor nations can do it" and "a model for treating AIDS worldwide."⁴ The Brazil story is now an important component of international medical activism.⁵

More than 40 million people are living with HIV worldwide, 95 percent of them in the developing world, and more than 44 million people in thirty-four of these poor countries, mostly in sub-Saharan Africa, will have lost one or both parents to AIDS by 2010.⁶ The Brazilian response to AIDS challenges the perception that it is impossible economically to even consider intervening in the pandemic's course in low-income countries and calls our attention to the possible ways in which biotechnology can be integrated into public policy and can contribute to political and human advancement in developing contexts, even in the absence of an optimal health infrastructure. Affirming the need to combine daring prevention policies with treatment, this policy opens the political and moral debate on the role of industry, medical science, government, and philanthropy in providing medications to poor countries and on the immediate and long-term implications of doing so.

In this article, I explore the role played by science and technology in the constitution of the Brazilian control of AIDS and assess the social reach and the political and medical impact of this intervention, particularly among the urban poor.⁷ After examining how this model policy came into existence through an assemblage of international financial institutions, commercial science, a reforming state, and nongovernmental mobilization—all in a context of deeplyentrenched inequality—I consider how its developments dovetail with former president Fernando Henrique Cardoso's efforts to internationalize Brazil's market. I argue that the following elements and practices were key to the success of this pharmaceutical form of control: a centralized and business-like management of an AIDS epistemic community; regional AIDS programs and epidemiological monitoring making some AIDS populations legible; activism within the state; a revitalized state-run pharmaceutical sector that was in ruins; a decentralized universal care system facilitating drug distribution; international partnerships and global visibility. Through the AIDS...