Chronic state failures and mass atrocities have characterized 20th-century Latin American history. At the same time, one of the first human rights doctrines of our world came out of the region in 1948, beating the United Nations by more than six months. The resilience of Latin American communities through brutality and suffering is reflected in their political realities today — every style of governance is each society’s unique response to the trauma their nation has encountered.
After a left-leaning “Pink Tide” swept the region in the early 2000s, the pendulum swung back towards right-wing parties. In 2020, several societies have responded in favor of right-wing parties, and the election of Jair Bolsonaro in Brazil and Luis Lacalle Pou in Uruguay highlighted the growing importance of economic stability and crime in the electorate.
Now, the COVID-19 pandemic presents the new challenge of public health. In this era, the disease has put these systems of governance to the test, challenging their ability to provide for the general welfare. While Uruguay’s bold COVID-19 response has helped it thrive, Brazil’s politicization and dismissal of the disease has taken the lives of millions. Bolsonaro’s reaction has been devastating to Brazilians with more than 6 million cases and 170,000 deaths as of November 2020. On the other hand, Uruguay has had a relatively successful COVID-19 response. The Pan American Health Organization (PAHO) team of Dr. Wilson Benia, Specialist in Health Systems and Services; Giovanni Escalante Guzmán, international public health senior advisor; and Dr. Andrés Bálsamo from the Epidemiology Division told the HPR in an email interview that as of November 11, Uruguay had 3,620 confirmed cases of COVID-19 with 62 deaths, one of the lowest case tolls in the world.
This raises the question: What accounts for the differences in these countries when they share striking historical similarities, not to mention a prevalence of right-wing parties? The stories of right-wing resilience in both Brazil and Uruguay are a testament to the importance of proper political leadership and attitude towards public health policy. Uruguay’s successful empowerment of scientists has allowed it to handle the COVID-19 crisis relatively well, especially compared to Brazil’s politicization of the topic.
Decentralization as a Saving Grace
Brazil is an interesting case study for its institutional design and the impact of leadership on the utilization of a universal public health system. Michael Lago, the executive director of the Institute for Health Policy Studies, explains in an interview with the HPR that a health care system is important, but so are the people running it. Brazil has a universal health system, a point for pride for the nation, but Lago explains that the success of this system relies on the right politicians to uphold, enforce and utilize the right health policies. What Lago is describing is a situation where even with an adequate public health system, it’s up to politicians to actually utilize it through effective coordination of public health policies.
Lago sheds light on the positive aspects of the decentralization of the public health system, the Sistema Único de Saúde. Even though this decentralization could impede nationwide health efforts, Lago described it as saving grace with Bolsonaro in charge of the federal government because it allowed state governors the freedom to react differently and institute appropriate measures. For example, cities in northern regions of Brazil such as Manaus had a serious approach to COVID-19 because the city’s mayor took the threat very seriously and activated the city’s health system in response. In addition, Brazil’s Bolsa Familia program for families provides a basic income of 600 reais (around $112) to account for the widespread loss of work and has aided in promoting stay-at-home-orders.
However, COVID-19 has also exposed the gaps in Brazil’s decentralized system because of its lack of attention to unequal geographic distribution. “The COVID crisis is a great illustration on how this decentralized system is important, but also why it fails,” Lago explained. Despite the basic income, Lago notes individuals in less privileged areas often live more tightly and in unhygienic conditions due to poverty, making social distancing and other hygienic to combat COVID-19 nearly impossible. This can also impact resource distribution.
For example, in the Amazonian region, where the more advanced treatments needed for COVID-19 are concentrated in the city, a shortage of physicians and ICU beds has led to the collapse of health services. Such a problem preceded the pandemic, as Lago explains that wealthier regions have always had better access to healthcare, so COVID-19 has only exacerbated this disparity in resource distribution.
Most broadly, the federal government’s failure to prioritize public health is mainly responsible for Brazil’s failure to contain COVID-19. Bolsonaro’s reaction has been devastating to Brazilians with more than 6 million cases and 170,000 deaths as of November 2020. Bolsonaro dismissed the virus as a threat, instead saying Brazilians need to stop being “sissies.” Even after Bolsonaro’s own bout with COVID-19, he continues to ignore any proactive public health measures, despite professional health advice. “Brazil has invested less than 4% of its GDP on public health, which is nothing in comparison to other universal health systems,” explained Lago. “The UK, for instance, has almost 8%. If you look at France and Germany, it’s almost 10%.”
Even with a universal healthcare system aimed at providing access to all, it takes the right government leadership to address disparities and ensure the system meets its potential. This is especially challenging, however, when health is politicized and turned into a political strategy. Lago notes that politicians like Bolsonaro have created a “false dilemma” between public health and economic success. For example, the Brazilian president has repeatedly claimed that COVID-19 restrictions would come at an economic cost, a relationship that essentially stresses saving the economy over saving lives. “It’s really scary that, for a specific electoral purpose, a politician could do so much harm to the country,” says Lago. “That’s also why I think we need a more autonomous health systems, rather than harmful leadership.”
Uruguay: Small Country, Big Response
One of Brazil’s neighbors has had quite a different experience. In a country that is known for its impressive egalitarianism and liberated social atmosphere, Uruguay has handled the pandemic relatively well. Despite most measures not being mandatory, Uruguay’s political culture has allowed for the compliance that COVID-19 needed. The experts from the PAHO explained that Uruguay has fared relatively well in response to COVID-19 due to the strength of its pre-existing public health infrastructure and the leadership of politicians and health experts to enact policies that utilize as well as enhance the ability of the healthcare system.
Similar to Brazil, the team explained that Uruguay’s law mandates a “right to health,” serving as the premise for its country’s primary healthcare benefits programs. But now, with COVID-19, the execution of this mandate has been quite different from Brazil, as it has led to efforts that aim to ensure adequate healthcare access and clear communication of pandemic guidelines. In particular, Uruguay instituted a number of innovative policies: They allowed home care in certain cases and instituted a telemedicine system. In all, Uruguay successfully promoted a unitary recommendation, “#Quedateencasa” (stay at home), centralized transparent data, and provided contact tracing. Combined with their low population density, these measures can explain Uruguay’s commendable approach to COVID-19.
Close in Geography, Far in Reaction
How could a country so geographically close to Brazil be so far in its COVID-19 response? The team notes it was due to “great leadership in managing the epidemic from the Ministry of Public Health and the Presidency.” In other words, we can look to the choice of leaders to enact a comprehensive health system. At first, it may appear that the discrepancy between Uruguay and Brazil lies in Bolsonaro’s right-wing populist politics, but Kathryn Sikkink, a professor at the Harvard Kennedy School who lived in Uruguay during the first several months of the pandemic, reveals that there’s actually a bit more to the story.
Sikkink explained that a leftist coalition called Frente Amplio (Broad Front) governed Uruguay up until 2020; this coalition expanded healthcare, education, and labor rights for individuals. “Part of Uruguay’s success isn’t just things they did in 2020, it’s the fact that they have a strong health care system, a strong education system, and a large middle class,” Sikkink said. Interestingly, despite being welfare states with their universal health care promises, a right-wing party now governs in Uruguay, with Frente Amplio losing to the center-right National Party in 2020, before the onslaught of COVID-19. But while Bolsonaro is an opponent of science, “the Health Minister and the government [of Uruguay] decided that they would have tried to have a policy based on science,” explained Sikkink. “Colleagues of mine at the university said that, to their surprise, the Health Minister came to health experts at the university and said he wanted to learn from them.”
Right-wing politicians letting science guide their decision-making in Uruguay contrasts with the Brazilian right’s denial of COVID-19. “Uruguay was never polarized in the way the United States is polarized right now, or Brazil [is] polarized,” Sikkink said. “There’s still a respect for experts.” In other words, public health is not a politically salient issue in Uruguay and so politicians haven’t stifled experts, instead, these experts speak up and leverage their public health system in a stronger way.
On the other side of things, another major contributor to Uruguay’s success is its people’s response. “Uruguayans have a higher level of trust in government, so the government policy called was virtually all voluntary,” noted Sikkink, “and because there was higher trust in the government, then people kind of did what the government asked.” In addition to trusting their government, Sikkink explains that Uruguay is a well-educated and relatively equitable society, thus leading to less poverty — something that Lago earlier pointed out was an important favor in COVID-19 compliance capability. Going forward, Sikkink fears that although Uruguay’s response was impressive, its success is threatened by Brazil’s dangerous situation. In fact, the PAHO team described the border area with Brazil as Uruguay’s “greatest risk” because of its highly porous nature. “It could be that Uruguay just won’t be able to escape its geography,” warns Sikkink.
Will the hardships of COVID-19 be the hardships of its vaccination era?
A pandemic doesn’t know borders, a pandemic doesn’t know politics and a pandemic certainly doesn’t know health policy. If it’s one thing we can learn from Uruguay’s nonpartisan response, it’s that the COVID-19 response should be based on science, not politics. It’s up to political leaders to decide to let scientists and public health experts lead the way in COVID-19 response and with vaccines now a possibility, the leadership of experts will be more important than ever before due to the logistical and medical challenges they bring. Factors such as societal equality, a strong healthcare system, and political leadership are going to significantly impact if, when and how vaccines are distributed and more importantly, who gets them.
But those are only as important as the decisions of their political leaders. Brazil’s geographic inequality and decentralization could plague vaccination efforts and Uruguay now faces a steady increase in case numbers, which both the PAHO team and Sikkink warned about due to its porous border with Brazil. Even though this pandemic has required a strong domestic response, politicians must now look to their regional counterparts and coordinate a cooperative response that ensures the success of all involved parties. Uruguay might have been doing well, but now, Uruguayan politicians must work with Brazilians to maintain that success. Scientists have done their part. Now, it’s up to politicians to do theirs.
