RESPONDING TO CONTESTED EPIDEMICS: DEMOCRACY, INTERNATIONAL PRESSURES, AND THE CIVIC SOURCES OF INSTITUTIONAL CHANGE IN THE UNITED STATES AND BRAZIL

BY

EDUARDO J. GÓMEZ B.A., UNIVERSITY OF VIRGINIA, 1997 A.M., UNIVERSITY OF CHICAGO, 2001

A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE DEPARTMENT OF POLITICAL SCIENCE AT BROWN UNIVERSITY

PROVIDENCE, RHODE ISLAND MAY 2008

© Copyright 2008 by Eduardo J. Gómez

EDUARDO J. GÓMEZ Date and Place of Birth: November 19, 1973 in Arlington, Virginia Permanent Address: One Market Street, Apt. 631 Camden, NJ 08102 Email: [email protected] Phone: (267) 408 3445

EDUCATION 2008 2001 1997

Brown University: PhD in Political Science University of Chicago: AM in International Relations (w/Honors) University of Virginia: BA and MA in Politics

ACADEMIC APPOINTMENTS • Assistant Professor of Public Policy, Rutgers University at Camden (July 2008-present)

PUBLICATIONS Journal Articles (peer reviewed): “A Temporal Analytical Approach to Decentralization Processes: Lessons from Brazil’s Health Sector Reforms," Journal of Health Politics, Policy, and Law (February 2008). “Decentralization and Municipal Governance: Suggested Methodological Approaches for Cross-Regional Analysis,” in Studies in Comparative International Development (38:3), November 2003. “Bureaucratizing Epidemics: The Challenge of Institutional Bias in the United States and Brazil,” Journal of Global Health Governance (Inaugural Edition, Volume 1, #1). “Learning from the Past: State-Building and the Politics of AIDS Policy Reform in Brazil,” Whitehead Journal of Diplomacy and International Relations, Volume VII, No. 1, Winter-Spring 2006.

Book Chapters (**peer reviewed): “Brazil’s Response to AIDS and Tuberculosis: Lessons from a Transitioning iv

Government,” in Richard Coker, Rifat Atun, and Martin McKee (Eds) Health Systems and Communicable Diseases: Challenges to Transitional Societies (McGraw Hill and University of British Columbia Press, forthcoming). “Friendly Government, Cruel Society: AIDS and the Politics of the Gay Community’s Response in Brazil,” Javier Corrales (Ed). The Comparative Politics of Gay and lesbian Movements in Latin America and the Caribbean: A Reader (University of Pittsburgh Press, forthcoming). ** "Understanding Decentralization: The Need for a Broader Approach," (Introduction) with Paul Smoke and George Peterson, Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective (Edward Elgar Press, 2007). ** "The Institutional Genesis of Fiscal Decentralization Management: Lessons from Brazil," (Chapter 7) in Smoke, Gómez, and Peterson, Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective (Edward Elgar Press, 2007). ** "Decentralization’s Horizontal, Vertical and Policy-Fluctuation Mechanisms: Method for Cross-Regional Comparative Analysis," (Chapter 3) in Smoke, Gómez and Peterson, Decentralization in Asia and Latin America: Towards a Comparative Inter Disciplinary Perspective (Edward Elgar Press, 2007). ** “Decentralization in Asia and Latin America: Processes, Outcomes, and Underlying Dynamics,” (Concluding chapter), with Paul Smoke, Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective (Edward Elgar Press, 2007).

Co-Edited Book Volume: Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective, co-edited book, with Paul Smoke and George Peterson (Edward Elgar Press, 2007).

Policy Articles and Reports: “The Politics of Government Response to HIV/AIDS in Russia and Brazil: Historical Institutionalism, Culture, and State Capacity,” Working Paper #4, Harvard Initiative for Global Health. “Why Brazil Responded to AIDS and not Tuberculosis: International Organizations and Domestic Institutions,” ReVista: The Harvard Review of Latin America, Spring 2007. Colombia in Crisis: Game Strategies for International Military Response, RAND v

Corporation, PM-1110-A, with Angel Rabasa and Kim Cragin (November 2000). INVITED TALKS (recent) • Center for Global Development, Washington, DC, June 11, 2008. • University of California, San Francisco, Institute for Global Health (scheduled) • Obesity in the U.S. Military: A National Security Concern? US Coast Guard, Philadelphia, PA (scheduled)

PREVIOUS SEMINARS/COLLOQUIA AND CONFERNCES • Seminars/Colloquia: Yale (1999); World Bank (2000); Harvard (2000; 2002; 2006); IMF (2001); RAND (2001); McGill (2002); Princeton (2002); Oxford (2004); University of London (2004); Woodrow Wilson Center for International Scholars (2005); UCSD (2006). • Conferences: Annual Meeting of the American Political Science Association (poster: 1997, 1999; panel: 1998, 2004; 2007). • Midwest Political Science Association (poster: 1998; panel: 1999). • New England Political Science Association (panel: 2003; 2004).

FELLOWSHIPS AND HONORS ● Nominated for the best dissertation in the field of Politics and History by the American Political Science Association. • The Carolina Post-Doctoral Program for Faculty Diversity, University of North Carolina at Chapel Hill (2 years post-doc, declined). • American Political Science Association, Centennial Fellow (2006). • American Political Science Association, Latino Fund Travel Grant (2004). • Pre-Doctoral Visiting Scientist, Harvard School of Public Health (by invitation, 200308) • Thomas J. Watson Institute for International Studies, Brown University, PreDissertation Research Grant, $2,000, Summer 2005. • Tinker Foundation, Research and Travel Grant (2001, 2002). • Irene Diamond Graduate Fellowship, Brown University (2001-2002). • University of Chicago, Center for Latin American Studies, travel grant (09/99). • University of Chicago, Honors Distinction Award for Masters Thesis, Committee on International Relations, Division of Social Sciences (09/00). • University of Virginia, Jefferson Society ΦΠΘ (elected, winter 1996). CONSULTING George Soros Foundation: Open Society Institute (OSI), Global Health Division, Washington DC – Consultant (August 2005-February 2006); I was commissioned to vi

write two papers: one on fragile states and public health and the other on the role of civil societal response to epidemics.

PREVIOUS FULL-TIME WORK EXPERIENCE & INTERNSHIPS • RAND Corporation - Research Assistant, Washington D.C. (August 2000-August 2001). I worked for the ARROYO Center on a project looking at democratization and military reform in Latin America. Main responsibilities included collecting data and writing background reports for senior analysts. • The World Bank - Research Assistant, Washington D.C. (1997-1998). I worked in the Poverty Reduction and Economic Management Division (PREM) and the Division of Social and Human Development, Latin American and Caribbean Division. I was mainly responsible for data collection and writing reports for senior economists.

MILITARY SERVICE U.S. Air force (1992-94) – Enlisted Airman (E-3), with Honorable Discharge

ACADEMIC AND COMMUNITY SERVICE • Referee for the Journal of Politics, Comparative Political Studies, New England Journal of Political Science, Health Policy & Planning, and the Journal of Global Health Governance. • Editorial board member of the New England Journal of Political Science. • Created the RAND Workshop on International Politics, Economics, and Security, RAND, Washington DC Office (10/00-08/01). • Founder of the newly formed academic section titled “Decentralization and SubNational Governance,” Latin American Studies Association (currently chaired by Alfred Montero, Carleton College). • Founder of the International House Forum on Globalization, University of Chicago; still in existence, recently renamed as the “Global Voices” program.

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PREFACE AND ACKNOWLEDGEMENTS This dissertation was an exploration into the possibilities that the discipline of Political Science had to offer for better understanding representative government and its commitment to citizens in periods of health crisis. The goal from the start was to provide a new theoretical framework and method for better understanding how and when governments respond to epidemics and the remaining institutional challenges that need to be addressed. This dissertation should therefore be of interest to those political scientists, medical historians, public health and medical scholars interested in understanding the political process of building effective institutions in response to health epidemics. This study could not have been possible without the support of several individuals and institutions. In the United States, colleagues such as James Morone, James Mahoney, James Green, Marion Orr, Thomas Bossert, Michael Reich, Paul Smoke, Philip Oxhorn, Kurt Weyland, Yanzhong Huang, and students from Brown provided intellectual stimulus and guidance. While writing this dissertation, my colleagues and students at the Harvard School of Public Health were especially encouraging and helpful in developing and expanding my ideas. In Brazil, President Fernando H. Cardoso, Marta Arretche, Fernando Limongi, Gilberto Hochman, Verinao Terto, and Ezio Santos Filho provided invaluable support and guidance. Institutions such as the Oswaldo Cruz Foundation, ABIA, and CEBRAP were also helpful in facilitating archival research. My life long academic mentors were especially helpful throughout the writing of this dissertation. In particular, I wish to thank James Morone, Herman Schwartz, John Echeverri-Gent, Jonathan Rodden, Steph Haggard, Dali Yang, Javier Corrales, Paul Smoke, and David Waldner. I am especially grateful to David for inspiring me to learn viii

more about the historic formation of institutions. My hope is that all the independent studies that I took from him as his undergraduate student at the University of Virginia finally paid off in my ability to contribute new questions and ideas to the study of state formation processes. And lastly, I give thanks to my friends and family. I am particularly indebted to the support of my good friends Dan Ehlke, Jeremy Johnson, Ivo Dimitrov, Patrick Crotty, Gordon Parker, Tony Dell’Aera and Jim Morone. Jim was especially wonderful in guiding me, protecting me, and pushing me to finish. I will miss the various coffees and scones that we shared over my ideas and ambitions. And lastly, my father, Guillermo Leon Gómez, and my grandparents, Januario and Lucila Gómez, were vital for helping me get through the emotional rollercoaster of graduate life. I don’t know if I could have made it without them. I therefore dedicate this dissertation entirely to them.

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TABLE OF CONTENTS CHAPTER 1 – Introduction: Democracies and Contested Epidemics, pp. 1-21. CHAPTER 2 – The Two Phases of Epidemic Politics: Structures, Perceptions, and Institution-Building, pp. 22-54. CHAPTER 3 – Building Public Health Regimes: National Security, International Pressures, and the Emergence of Reform Partnerships (1900-50), pp. 55-158. CHAPTER 4 – Historical Happenings Going Forward: Understanding the Civic Sources of Institutional Change, pp. 159-183. CHAPTER 5 – Responding to AIDS in the United States: Elite Contestation, International Pressures, and the Absence of Institution-Building (1980-90), pp. 184-250. CHAPTER 6 – Responding to AIDS in Brazil: Democratization, International Pressures, and Institution-Building (1980-95), pp. 251-310. CHAPTER 7 – Responding to Obesity in the United States: International Pressures, Personalism, and the Absence of Institution-Building (pp. 1-70), pp. 311-383. CHAPTER 8 – Responding to Tuberculosis in Brazil: International Pressures and Institutional Collapse (1980-present) (pp. 1-67), pp. 384-447. CHAPTER 9 – Conclusion, pp. 448-458. BIBLIOGRAPHY – PP. 459-491.

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LIST OF TABLES, GRAPHS, AND ILLUSTRATIONS TABLES Table 3.1 – U.S. Congressional Acts and Government Programs in Response to Syphilis, P. 116. Table 5.1 – Presidential Budget Request, p. 204. Table 7.1 - Examples of Policy Guidelines for Obesity and General Nutrition published by the HHS and NIH in the 1970s and 1980s, p. 327. Table 8.1 – Global Fund Grant for Brazilian TB Program, Phase 1 & 2, p. 420.

GRAPHS Graph 1.1 - AIDS, TB, and Malaria Cases and Deaths (2005), p. 15 Graph 1.2 - Biggest Killers in Latin America, p. 16. Graph 1.3 - Global Fat: % of Obese Adults for Several Nations, p. 17. Graph 2.1 – Global, Civic, and Bureaucratic Partnerships for Institution-Building, p. 49. Graph 3.1- Polio Chronology, p. 80. Graph 3.2 - National TB Trends (cases and case rates), p. 98. Graph 3.3 - Major National Diseases (1870-1920), p. 100. Graph 3.4 - Syphilis in the United States (all types, per 100,000), p. 114. Graph 3.5 - Brazil: Syphilis Cases (all types, per 10.000), p. 140. Graph 4.1 – Tripartite Partnerships, p. 162. Graph 4.2 – Accumulation of Knowledge, p. 176. Graph 5.1 - AIDS Cases and Deaths in the U.S. (1982-2003), p. 188. Graph 5.2 - HIV/AIDS in the U.S. Military, 1986-2006 (cases), p. 197. Graph 5.3 - Congressional Outlays for the CDC, p. 225. xi

Graph 5.4 - Number of CDC staff (1984-89), p. 226. Graph 6.1 - U.S. and Brazil: AIDS Cases (1981-2004), p. 256. Graph 6.2 - U.S. and Brazil AIDS Deaths (1981-2004), p. 257. Graph 6.3 – Brazil: Cases of Major Disease (1980-93), p. 259. Graph 6.4 - Brazil: Rate of Yearly % Change in Case Notification of Major Diseases (1983-1992), p. 260. Graph 6.5 - Brazil: % of Total Investments Provided by International Organizations, p. 288. Graph 6.6 - Government Spending for AIDS, TB, and Malaria (2003-06), p. 297. Graph 7.1 - Obesity and Overweight Data (1990-2002), p. 315. Graph 7.2 - Childhood Overweight Trends (1974-2004) (ages 2-19), p. 316. Graph 7.3 - Content Analysis of News Paper Articles Discussing General Overweight and Obesity Issues (1988-1995), p. 318. Graph 7.4 - Content Analysis of News Paper Articles Discussing Obesity as a National Epidemic, p. 319. Graph 7.5 – Number of Military Personnel Separated from Failure to Meet Weight and Body Composition Standards, p. 320. Graph 7.6 – Number of Presidential Appointments to the President’s Council on Physical Fitness & Sports (1917-present), p. 347. Graph 7.7 - Content Analysis of Clinton and Bush's Personal Commitment to Exercise and Obesity, p. 350. Graph 7.8 - Content Analysis of the Number of Times Shalala, Thompson, and Leavitt Publicly Discussed their Personal Commitment to Exercise, Fighting Obesity, and Individual/Civic Responsibility (1993-2005) p. 358. Graph 8.1 – Brazil: National TB Trends (1980-2002), p. 390. Graph 8.2 - Brazil-Rio: Number of TB and AIDS Cases (1983-2004), p. 391. Graph 8.3 - Brazil-Sao Paul: Number of TB and AIDS Cases (1987-2005), p. 392.

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Graph 8.4 - Brazil - Number of Cases and Deaths from HIV/AIDS and TB (1980-2003), p. 393. Graph 8.5 - Brazil-Rio: % Change in Yearly TB and AIDS Cases, p. 395. Graph 8.6 - Brazil-Sao Paulo: Yearly % Change in TB and AIDS Cases, p. 396. Graph 8.7 – Rio: TB Cases and Deaths (1930-1953), p. 397. Graph 8.8 – Rio: Total number of Deaths Attributed to TB (1855 to 1953), p. 398.

ILLUSTRATIONS Illustration 3.1 – The Greatest Crime in Christendom, US Food Administration, c. 1918, p. 92. Illustration 3.2 – O Desafio da Tuberculosis, p. 101. Illustration 3.3 - Globally Isolated and Globally Integrated Public Health Regimes, p. 154. Illustration 4.1 - Causal Mechanisms Linking the Origins of Institutions to their Subsequent Change, p. 183. Illustration 6.1 – Informal Means to Institution-Building, p. 298. Illustration 7.1 – America Feeds the World, p. 341.

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CHAPTER 1

Introduction: Democracies and Contested Epidemics Democratic theorists have long assumed that transitions to democracy will naturally lead to the introduction of generous social welfare programs (Flora and Heidenheimer, 1984; Hicks, 1999). Some have argued that the introduction of free elections, accountability through increased legislative representation, checks and balances and a modern welfare state tend to increase politicians’ commitment to social welfare (Immergut, 1992; Haggard and Kaufman, forthcoming). Indeed, in his book titled Development as Freedom, the famous economist and political philosopher, Amartya Sen, has argued that democracy and its institutions are necessary for ensuring the freedom, health, and prosperity of nations. More importantly for our interests, Sen argues that democratic institutions are necessary for protecting civil society from the peril of natural disasters, such as famines and health epidemics, in turn guaranteeing basic civic freedoms and development (Sen, 1999: p. 188). While these types of institutions may help democratic elites commit to general social welfare needs, the evidence in this dissertation suggests that these same elites may not be as committed when it comes to responding to health epidemics. This is especially relevant when it comes to responding to certain kinds of epidemics, such as contested

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epidemics, where their gradual evolutionary nature 1 and the conflicting perceptions and interests that they generate among political and bureaucratic elites leads to an initial lack of consensus over the need to immediately respond to them. For even within long established democracies, such as the United States, and even within nascent democracies, such as Brazil, a nation that grounded its transition to democracy in 1985 on the tenets of human rights and increased social welfare and equality, political elites were not committed to meeting the immediate needs of civil society. Thus puts forth a puzzling question: Why would full-fledged democracies fail to immediately respond to health epidemics, especially when it is well known that local governments and civil society are in immediate need of assistance? Should not the presence of free elections, an open media, and political party competition inspire political elites to immediately respond? And should this not motivate politicians to perceive new epidemics as serious national threats? Furthermore, if building public health institutions (the outcome of interest) is important for insuring that prevention and treatment programs are effectively implemented, then why don’t representative democracies immediately pursue these ends? This is especially puzzling when it is well know by political elites that local governments (especially within large federations) often lack the resources needed to quickly respond to epidemics, and that the devolution of health policy is not yielding favorable policy outcomes. The failure to immediately transform institutions becomes even more

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The timing of contested epidemics is different from what we would normally conceive of as an epidemic, that is, a disease that spreads very quickly and kills thousands within a matter of months. Such was the case with 1918 Influenza, 1957 Hong Kong influenza, and other diseases, such as the plague and cholera in the past. In contrast, contested epidemics are more gradual, killing thousands and some instances eventually millions but over a much longer period of time. As discussed in this dissertation, good examples of these types of epidemics are polio, syphilis, TB, AIDS and more recently obesity.

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perplexing when one considers the speed with which prevention and treatment policies are implemented; for this is often done much faster and earlier than any attempted effort to reform public health institutions. This dissertation sets out to address these questions while proposing several conditions under which large democratic federations, such as the United States and Brazil, eventually respond through new institution-building processes (defined shortly). What this dissertation finds is that although federal elites do not perceive contested epidemics as immanent national threats worthy of an immediate institution-building response, they do eventually respond but for reasons other than democratic accountability and the needs of civil society. Instead, they respond when epidemics pose threats to the national security, or when new pressures from international organizations arise and provide opportunities for aspiring nations to make their mark in the global fight against disease. The outcome of interest in this study is what I call institution-building for public health. This entails to the following outcomes: first, the creation of a new federal agency, or division within an existing agency, that is responsible for implementing policy and meeting the needs of civil society; second, it includes the immediate and persistent allocation of presidential and/or congressional funding for an expansion of these agencies, both for improved human resources and technical capacity; third, it entails presidential and congressional stewardship in helping consolidate research and policy responsibility among federal agencies; and lastly, it includes the immediate and persistent allocation of technical, infrastructural, and financial resources (for prevention and treatment policy) to municipal health agencies. This kind of response is especially

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important in cases where municipalities are distant from city capitals and when they lack the resources needed to respond on their own. The outcome of concern in this study is therefore not public health policy but the formation and rebuilding of public health institutions. This is based on the premise that the construction of effective bureaucratic institutions, that is, those that are autonomous, centralized, and capable of immediately intervening at the lowest tiers of government, is a necessary pre-condition for the implementation of prevention and treatment policy within large, highly decentralized federations. 2 To date, political scientists and public health experts have not studied the politics of building effective public health institutions within these types of democratic settings; nor have they studied the international and domestic structural conditions that influence this process. This dissertation therefore submits the first systematic comparative analysis of the politics of building public health institutions within large democratic federations. This research should be of interest to not only health policy analysts but also to those scholars of comparative politics interested in examining the state-building consequences of exogenous shocks other than war and economic crisis (Tilly, 1975; Herbst, 2000; Centeno, 2002; Hui, 2005; Levi, 1992). When it came to analyzing the timing of these institution-building outcomes, this study found that an immediate response was always hampered by the presence of conflicting presidential, legislative, and bureaucratic perceptions and interests in reform, which are themselves the product of different antecedent structural conditions at each of these levels of government. In this contested democratic environment, institutionbuilding can eventually occur, but it will emerge in response to structural conditions that 2

The scope of my argument therefore only pertains to large, highly decentralized democratic federations, such as the United States, Brazil, Russia, India, and China. I will come back to this issue in the theoretical section and conclusion.

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are indirectly related to the epidemic and more importantly, the needs of civil society, such as the rise of national security threats and pressures from the global health community. After examining several historical and contemporary case studies within the context of the United States and Brazil, this dissertation indeed found that democratic elites did not immediately engage in institution-building processes whenever contested epidemics emerged. Governing elites only engaged in this process whenever epidemics were perceived to pose new national security threats, as seen in the United States, or when new global pressures and incentives motivated modernizing politicians to respond to them, as seen in Brazil. In no case did the “bottom up” pressures of a vibrant civic democracy, or the rise and influence of bureaucratic officials convince politicians to “get the institutions right” for public health. In essence I argue that these differences in elite perceptions and interests in institution-building were shaped by the nation’s relationship with the global health community. In those nations that have always been more receptive to the rise of new global health movements and criticisms and, in response, interested in increasing their international reputation as effective disease combatants, and for those that have always been receptive to international financial and technical assistance, institutional change occurred. In contrast, in those democracies that have been isolated from the global health community and that do not have these kinds of incentives, institutional change occurred, but only when epidemics threatened the national security. Absent this condition, and as recently seen in the United States, democracies never engage in institution-building processes. Competing ideological and scientific views between politicians and

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bureaucrats, when combined with the negative affects that fiscal constraints have on inter-bureaucratic cooperation for agency expansion, generates conditions that are not conducive to presidential and congressional commitment to reform. And this will occur despite a surge in global pressures and the efforts of several nations to become more active participants in an increasingly globalized public health community. With regard to the more globally-receptive regimes, I argue that the rise of new global pressures, the emergence of what I call “the race to global fame” 3 in global health politics, and the availability of international funding to achieve these ends continues to provide incentives for democracies to engage in institution-building processes. As the chapters focusing on Brazil’s response to syphilis and TB, historically, and more recently in response to AIDS illustrates, both of these conditions are necessary for a convergence of presidential, legislative, and bureaucratic elite perceptions and interests in reform. While threats to the national security during brief historical periods in Brazil also contributed to this process, for the most part international pressures, the race to fame and the availability of resources to achieve this goal were the most important catalysts for reform. Absent these conditions, as is typically seen during the first few years of an epidemic’s spread, political elites will always prefer to decentralize the government’s response to epidemics, in turn clashing with the interests of bureaucratic officials that are seeking a more centralized institutional response. More specifically, I argue that as a new global health consensus emerges over the need to respond to a contested epidemic, and as this in turn generates greater pressures 3

As explained in more detail in Chapter 2, the “race to global fame” is an independent variable defined as presidents’ ongoing interest since political independence in trying to increase their nation’s reputation as effective disease combatants. It is more commonly seen among lesser developed democracies that are aspiring to become as effective as more advanced, industrialized democracies in their response to epidemics.

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and criticisms of a nation’s response, this will prompt modernizing elites to immediately engage in institution-building processes. This is done in order to increase their international reputation as effective disease combatants - and eventually world leaders in the plight against disease. At the same time, presidents are motivated by the ability to acquire international resources, such as loans from the World Bank or grants from the Global Fund to Fight AIDS, TB, and Malaria, in order to achieve this. This is especially important in a context of increased fiscal instability and hard budget constraints. These two factors (though with the race to global fame being of primary concern), leads to a change in presidential perceptions and interests in institution-building and is viewed as a necessary condition for the rise and influence of previously marginalized bureaucratic officials seeking this kind of institutional response. More specifically, as we’ll see with the case of Brazil and its response to AIDS, I argue that this change in presidential perceptions provides a new window of opportunity for previously marginalized bureaucratic officials to successfully pursue and maintain the support of the President and the Congress (or relevant national legislature) for continued bureaucratic expansion. While presidents and legislatures may be interested in reform, in order for this to occur and, more importantly, persist over time, bureaucratic officials must consistently pressure and convince them that institutional change is necessary. Thus a change in presidential and congressional perceptions is necessary but not, in itself, sufficient for a successful institutional response. Nevertheless, the ability of bureaucratic officials to achieve institution-building will rest entirely on their ability to resuscitate a historically-based coalition composed of civic organizations and public health bureaucrats that have always shared similar views

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about institution-building responses to epidemics; these two actors will also be closely aligned with new global health movements pressing for civic incorporation and the same institution-building outcomes. This, in turn, leads to the rise of what I call tripartite partnerships for institution-building. When this occurs, and when presidents are supportive of their endeavors, institutional change will occur-and will eventually lead to successful policy implementation. In the absence of these global pressures and incentives, however, presidents and their legislative and bureaucratic supporters will not have incentives to pursue institutionbuilding. As we’ll see with Brazil’s historic response to syphilis and TB during the initial years of their epidemic outbreak, i.e., before new global pressures emerged, and more recently with the resurgence of TB, in the absence of these international pressures governments will refrain from institution-building and instead rely on decentralization as a primary response. Moreover, this will occur even when federal health officials adamantly advise against this, based primarily on the fact that policy responsibilities have been decentralized too quickly and that sub-national (especially municipal) governments are unprepared to adopt new policy measures. However, if in this context institutionbuilding does occur, as seen during the Getúlio Vargas dictatorship in Brazil (1930-45), it will be in response to an epidemic’s threat to the national security. Yet I argue that such a response is an anomaly for Brazil, and that prior to Vargas and even today, international pressures and reputation has been a more important catalyst for reform. In contrast, when it comes to democracies that are more globally-isolated and/or resistant to global pressures, such as the United States, I argue that federal elite perceptions and interests in institution-building will derive mainly from domestic

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structural conditions. I define globally-isolated regimes as those that are resistant to global pressures and recommendations for institutional and policy change. Moreover, they are those that do not actively seek international financial and technical assistance, but rather try to lead the way in this area. In this context, presidential and legislative elite interest in institution-building will be motivated more by the threat that contested epidemics pose to the national security, such as its negative affects on the fighting capabilities of military soldiers. Historically, malnutrition and syphilis provide the best examples of this. While the U.S. government did not immediately respond to these epidemics and the needs of civil society, once they started to threaten the military’s fighting capabilities the president, the congress, and military officials immediately responded by creating new federal agencies, programs, and provided funding to state-governments to curb syphilis’ and malnutrition’s spread. In recent years, a similar response has occurred for avian flu. Yet the failure of the flu to emerge as a serious national security threat did not prompt a unanimous federal elite consensus and coalition for institution-building. In the absence of the military’s support, due mainly to their perception that the flu never emerged as a national security issue, institution-building has been limited to bureaucratic layering and the recentralization of policy authority within pre-existing federal agencies, such as the Department of Homeland Security. While these new innovations have not led to a complete institution-building response, it has nevertheless unmasked the fact that the U.S. government prefers a more centralized, interventionist role for public health but only when epidemics challenge our national security.

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The personal threat that epidemics pose to our leaders has also been rather influential. For example, FDR’s decision to create the March of Dimes was very much influenced by his polio condition, and some historians have argued that he would have never created this organization had it not been for his personal battle with the disease (Rogers, 1996). Several decades later, the recent overweight and obesity epidemic has had a similar affect on President George W. Bush, several of his health secretaries, Governors and even former President Bill Clinton. While this personalistic response has certainly helped to put obesity on the national agenda, in the absence of a clear national security threat it has not been sufficient to warrant an institution-building response. Indeed, the chapters in this dissertation illustrate that when contested epidemics do not pose national security threats, conflicting perceptions and interests between the president, legislative elites, and the public health bureaucracy will persist, in turn leading to the absence of institution-building. In recent years, this outcome has occurred in the United States, both for AIDS and the more recent obesity epidemic. These differences in elite perceptions and interests in institutional change were driven by the absence of a national security threat for the president and his coalition in the congress, on one hand, and the enduring commitment (and by now tradition) of the PHS’s immediate response to epidemics, on the other. These competing perceptions have led to a persistent conflict of interest among federal elites and an inability to create a consensus for reform. In this isolated context, it has been the public health bureaucrats, mainly within the CDC, that have lead the way when it comes to defining the emergence of a new epidemic and immediately responding to it through new state and community assistance programs, regardless of the moral connotations and stigma surrounding said epidemic.

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As we have seen throughout history and more recently with AIDS and obesity, public health bureaucrats will always immediately embed themselves in civil society in order to learn more about their needs while helping construct a bridge between civil society and the Congress. PHS officials have also repeatedly gone out of their way to pressure the government for a more immediate institution-building and policy response, while requesting additional funding in order to ensure that they can sustain their initiatives. Nevertheless, and this is key, PHS agencies, such as the CDC, will never pursue institution-building on their own. For while the certainly talk the talk, they never walk the walk. Constraining fiscal conditions and the need to merely survive has instead generated a continued interest in responding to contested epidemics on their own, rather than working in a more collaborative manner with other health agencies. This is done in order to distinguish themselves as effective public health agencies, thus garnering more political attention and financial resources. While this form of agency survival instinct has motivated the perceptions and interests of bureaucratic elites to immediately respond to contested epidemics, agency survival has repeatedly surpassed any interest in proactively seeking institution-building by working with other health agencies in a more collaborative manner. Thus in the absence of national security threats institution-building responses within more globally-isolated democracies will be hampered by the presence of presidential and congressional elites that do not prioritize institution-building, on one hand, and federal bureaucrats that prioritize their own career survival over bureaucratic development, on the other. Since the early 20th century, these two challenges have continued to weaken the United States’ response to contested epidemics. As a

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consequence, local governments have always responded on their own, even when bereft of resources and in need of immediate assistance. Some Brief Lessons and a General Road Map What these findings therefore suggest is that both old and new democracies never immediately respond to the needs of civil society whenever contested epidemics emerge. Instead, their response is often delayed and occurs only in response to structural conditions that are indirectly related to the epidemics and the needs of civil society. What this also suggests is that democracies are quite biased in the types of epidemics they do respond to. If there are no national security threats or global pressures for reform, forget about it … democratic elites will always rely on decentralization as a primary response, even when fully cognizant of the fact that decentralization is an inefficient approach to combating disease. In what follows, I will provide a review of the literature discussing the politics of government response to health epidemics and my own theory about how and when two large democratic federations respond – the United States and Brazil. You will notice that most of the work done on this topic tends to focus on the domestic and comparative politics of HIV/AIDS, with essentially nothing published on the politics of government response to different kinds of epidemics. Chapter 3 discusses the historical construction of public health regimes in both countries, showing how and when governments engaged in institution-building and pursued new institutional reforms that went against the initial formal design of their public health regimes. Chapter 4 explains why this history was important, mainly in preparation of the four in-depth case studies of democratic response and institution12

building in a new era of globalization. It also explains the significance of this history for understanding institutional change in the recent era of globalization, while providing new insights for the theoretical literature addressing the historical ideological and structural pre-conditions necessary for institutional change. This is followed by a discussion about how this approach can help establish bridges between two strands of theoretical literature in American and Comparative politics that have traditionally been isolated from one another: that is, theories of institutional origins and institutional change. The subsequent chapters go into rich detail about recent government responses to contested epidemics. Chapter 5 explains why the United States failed to create a new federal agency and/or modernize existing ones in response to AIDS. In contrast, Chapter 6 explains why Brazil was able to achieve this and the ongoing political and bureaucratic incentives for sustaining an effective institution-building response to AIDS. In Chapters 7 and 8, I examine how these governments responded to non-sexually transmitted diseases. In Chapter 7, we examine the United State’s response to the recent obesity epidemic and how consistent isolation from global pressures and the absence of national security threats has once again failed to motivate elites to engage in institutionbuilding processes. This is followed by a discussion in Chapter 8 of Brazil’s similarly lackluster response to the recent resurgence of tuberculoses in major cities. While concrete institution-building was never pursued, the recent arrival of new global pressures and the opportunity for Brazil’s political elites to once again prove muster as effective disease combatants provides hope that the government will be just as responsive to TB as it has been for AIDS.

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Broadening our Comparative Horizons Allow me to submit just a brief note on case selection. In contrast to recent scholars in political science, in this dissertation I decided to look at several different types of health epidemics in order to see how democracies responded to them. While I confess to having committed the supposed sin of selecting on the dependent variable when examining the biggest contested epidemics of our time, I took a more experimental approach when examining how different types of epidemics (i.e., sexually versus non-sexually transmitted diseases) affected democracies and their response. Doing this gave me a better sense of how committed they were to civic needs and whether they were consistently biased in the types of epidemics they responded to. (I’ll save the answer for later.) In addition, it was important for me to do this because essentially all of the work in comparative politics to date has focused on HIV/AIDS. But this is very problematic, and for several key reasons. First, any analysis that focuses entirely on AIDS falls short of capturing the “big picture” when it comes to disease and death around the world. That is, while AIDS has surely emerged as one of the biggest infectious diseases of our time, in recent years it has not ranked the highest in number of case prevalence around the world. Actually, and as Figure 1.1 illustrates here, among the more commonly known diseases, such as AIDS, TB, and Malaria, the latter ranks highest in terms of case prevalence.

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Graph 1.1 - AIDS, TB, and Malaria Cases and Deaths (2005) 450,000,000 400,000,000 Malaria cases 350,000,000 300,000,000 250,000,000 200,000,000 150,000,000 100,000,000

AIDS Cases Malaria deaths TB Deaths TB Cases

50,000,000 AIDS Deaths 0 Source: Kaiser Family Foundation, 2007

And even within particular regions, the number of AIDS deaths pales in comparison to these other diseases. In Latin America, for example, AIDS does not even come close the number of deaths attributed to malaria 4 (see Figure 1.2). I do not even mention here the recent surge in complications associated with overweight and obesity, such as type-II diabetes, which in recent years has burgeoned within industrialized and developing nations. The sudden growth of health ailments and deaths attributed to obesity-related diseases, as well as the general surge in obesity among nations (see Figure 1.3), has recently motivated the World Health Organization to create a new division

4

The reader may be wondering why I did not include malaria as a case study. The reason has to do with the simple fact that it has never been contested by political and bureaucratic elites. In Brazil, for example, case and deaths rates have been so high that elites never disputed the need to create and maintain an effective national malaria program. Brazil continues to maintain a very successful malaria campaign and is arguably one of the world’s leaders in the fight against this disease.

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Graph 1.2 - Biggest Killers in Latin America 1,400,000 1,200,000 1,000,000 800,000

Malaria

600,000 400,000

AIDS <200k

TB <200k

200,000 0 95 96 97 98 99 01 Source: Pan American Health Organization, 2007

02

03

04

05

and data base on the new global obesity pandemic and its negative side-effects (World Health Organization, 1999; and see http://www.who.int/topics/obesity/en/). Thus, in sum, focusing exclusively on AIDS leads us to overlook other equally if not more pressing public health concerns around the world. Because of this, exclusively focusing on AIDS serves as an extreme injustice to those that are suffering from other types of diseases. For in addition to not revealing the “big picture,” these studies fail to disclose the lack of attention that democracies have towards individuals suffering from other ailments and the repeated difficulties they have in trying to influence policy. Therefore by focusing exclusively on AIDS, comparative scholars fail to provide insight into the politics of other types of epidemics, which in turn can unmask hidden truths about how committed democracies actually are to their citizens. Unfortunately, like most nations, political scientists tend to focus only on those epidemics that are “globally popular,” that is, those that tend to encapsulate the media’s 16

attention, draw in money, fame, and notoriety. I confess to initially having done the same when I started to work on the Brazilian government’s response to AIDS. But by failing to address the politics of other less popular epidemics, especially those that reside mainly among the poor, we have no sense of how committed democratic leaders are to citizens’ needs. As political scientists concerned with discovering the true nature of representative government, failing to do this not only serves an injustice to others but it also tarnishes our own reputation as social scientists genuinely concerned with the overall quality of democracy. Graph 1.3 - Global Fat: % of Obese Adults for Several Nations 40 USA

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Saudi Arabia UK

30

Isreal Canada

25

Finland

20

Japan Netherlands

15

Spain Sweden

10

UK France

5 0 66

70

75

80

85

89

Source: WHO, 2007

In order to avoid this problem, this dissertation has focused on several different types of epidemics. In the following chapters, you’ll see how democracies have responded to both sexually transmitted and on-sexually transmitted diseases, in turn revealing to what extent governments are biased in the kinds of epidemics they respond 17

to. One will note that when it comes to getting the institutions right for public health, democratic elites are indeed rather biased in their response, deciding to respond only when lingering contested epidemics have emerged to finally elicit a global response and pressures for reform, or when they threaten national security interests. In essence, moreover, you will find that both old and new democracies are not that different when it comes to institution-building for public health. But one will also find that regardless of the durability and overall quality of democratic institutions, it is only those nations that are more open to global pressures and suggestions for institution-building that ultimately succeed in “getting the institutions right” for public health. In fact, this dissertation shows that even lesser developed democracies, such as Brazil, will outpace and arguably far surpass the ability of wealthier, more advanced democracies, such as the United States, to achieve these ends. Therefore this study closes with a discussion of the extent to which the quality and durability of democracy actually matters when it comes to institution-building for public health, and the general lessons that the United States can learn from lesser developed nations, such as Brazil. Method and Data Before moving on to the theoretical chapter, it is important that we take a minute to briefly discuss the methodological approach that I have taken in this study. In general, this dissertation takes a Most Similar Systems comparative design, where two similar cases are compared yet diverge from one another on key causal variables and outcomes (Przerworski and Teune, 1970). The purpose of this comparison is not to create a generalizable theory about how and when governments respond to epidemics, but rather

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to compare and accentuate the rich history and politics of particular cases, while testing competing theories and illustrating their limitations. In this dissertation more specifically, I have employed this method in order to accentuate the unique histories and politics of government response to a variety of epidemics in the United States and Brazil, to show the limitations of competing theories discussing how and when democracies respond to epidemics, while generating new hypothesis that can be tested at subsequent points in time (Katznelson, 1997). In a sense, my effort is to revive the seemingly forgotten tradition of configurative analytical approaches to comparative politics, where the focus is to highlight the unique political motivations and reform strategies of actors rather than devising new generalizable theories (Katznelson, 1997). Scholars may be wondering why I have selected the United States and Brazil. At a glance both nations appear to be rather different, given their differences in levels of socio-economic development, GNP, infrastructural and military prowess, and culture. This suggests that these cases are not comparable. Yet, I argue that if one looks closer and establishes commonalities at units of analysis that are more pertinent to the issue of concern, such as the domestic political and structural conditions leading to institutionbuilding for epidemics, one finds more commonality than difference between these two cases. In this sense, I agree with Richard Locke and Kathleen Thelen’s (1995) position that analysts need to look closer at the cases being compared before assuming similarities in causality and outcomes based on the formal design of institutions. I justified my Most Different Systems design based on the fact that the United States and Brazil exhibited the following similar characteristics: the presence of a large federation, continual decentralization, the strength of sub-national political actors

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(especially governors), and the presence of reform-minded public health bureaucrats during the historical period (1900-45). For the more recent period of globalization and democratization (1980-present), both nations were similar in the following regard: the presence of presidential systems, hard budget constraints at the bureaucratic level, devolution, 5 deeper global economic integration, the ongoing need to create legislative coalitions for reform, the presence of reform-minded public health bureaucrats, the presence of a pro-active civil society, and similar pressures from the global health community. I found these similar structural characteristics to be much more important than the broader structural differences between these nations. While the general goal of the thesis was to establish the unique similarities and differences in government response to epidemics, at the same time I proposed several new theoretical propositions that applied to the United States and Brazil. While I did not take the extra step in testing these propositions across a host of similar and different case studies, which would have produced a more generalizable theory, I did nevertheless conduct a within case analysis in order to provide more observable implications of my hypothesis about how and when the U.S. and Brazil respond to epidemics (Lijphart, 1975). However, in stead of extending the unit of analysis to the sub-national level, as other scholars have suggested (Putnam, 1993; King, Keohane and Verba, 1996; Snyder, 2001), I instead kept the unit of analysis at the federal level while using the temporal analytical framework of my theory (which is explained in more detail in Chapter 2) in order to extend the observable implications of my theory across time: that is, before and after the emergence of international pressures and/or national security threats. With this 5

Devolution being more advanced then the decentralization process. In contrast to decentralization, devolution means the complete decentralization of fiscal and administrative responsibilities to local governments.

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framework in mind, I further extended the observable implications of my theory within cases by comparing government response to two different types of epidemics, such as sexually (syphilis and AIDS) and non-sexually transmitted diseases (polio, mal-nutrition, TB, and obesity). The data used in this study is both qualitative and quantitative in nature. The qualitative evidence is based on in-depth interviews with government officials, civic organizations, and academics in both countries. With regards to the type of literature examined, this study used a lot of archival materials, as well as contemporary articles and newspaper clippings. The quantitative data was obtained from various public health departments, while the historical data was obtained from visits to government archives. In the next chapter, I will introduce several theories about how and when governments respond to epidemics. The purpose of this chapter is to demonstrate the theoretical limitations of recent political science approaches to this topic, while proposing an alternative theory and method of analysis.

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CHAPTER 2 The Two Phases of Epidemic Politics: Structures, Perceptions, and Institution-Building The comparative politics of government response to health epidemics is a new and emerging area of research. However, most of the work done on this topic has focused on government responses to HIV/AIDS, with little if any attention comparing AIDS to other types of epidemics. In addition to being myopically focused on policy implementation, a lot of this work has focused on the domestic “bottom up” pressures of policy reform. It pays scant if any attention to the role of international pressures and the reform of public health institutions. The purpose of this chapter is to briefly describe these theories, highlight their shortcomings while providing an alternative theoretical framework that accounts for how and when democracies respond to epidemics. Institutions and the Bottom-Up Pressures for Reform Of recent interest to political scientists has been the role of electoral institutions 6 and how they provide electoral incentives for politicians to respond to health epidemics. In this line of work, scholars argue that politicians often formulate and implement AIDS policies

6

Electoral institutions represent the type of electoral system present, such as an open- versus closed-list system for candidate selection and/or the fragmentation and polarization of party systems. In open-list systems, candidates compete among each other for party nomination; this is said to decrease party unity while amplifying the influence of sub-national politicians. Conversely, in a closed-list design, candidates are selected by the party leadership, which in turn creates a more cohesive party system. Both of these systems determine the degree of party fragmentation and polarization present, which has consequences for the implementation of policy (Haggard and Kaufman, 1995).

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in order to increase their chances of winning elections. Elections hold political leaders accountable and generate incentives for them to respond through innovative prevention and treatment programs (Whiteside, 1999; Patterson, 2000; Ruger, 2005; Sen, 1999). Nevertheless, other scholars hold that this is not often the case, and that the urgency to respond to an epidemic, such as AIDS, often motivates politicians to depoliticize the issue (Putzel, 2001). Some have also shown that general apathy, imposed racial boundaries by political elites and discrimination generates few incentives for politicians to use AIDS as a key electoral strategy (Gauri and Lieberman, 2006, 2004; Strand, 2005; Boone and Batsell, 1993; Fassin and Dozon, 1998). Another shortcoming to this approach is that it fails to take into consideration other personal and/or structural factors that motivate politicians to respond. Such factors include the role of history, morals, economics, national security, and other motivational forces that shape the immediate perceptions of political elites and their electoral strategies. Considering the wide variation in electoral strategies noted above, this alternative view suggests that a more fruitful approach eschews any a-priori assumptions of the influence of electoral forces. Rather, and as this dissertation illustrates, it concentrates on the non-electoral historical and contemporary structural conditions that shape politicians’ perceptions of a national health threat, and how this, in turn, influences their institutional and policy choices. An alternative institutional approach looks at the role of federalism and decentralization. Here, scholars focus on how inter-governmental relationships influence the President and the Congress’ response to an epidemic. Those that take this approach often focus on the “bottom-up” pressures of pre-existing and successful policy

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innovations at the state-level, aided by preexisting federal commitments to health policy devolution (Kirp and Bayer, 1992; Gauri and Lieberman, 2004, 2006; Teixeira, 1997). This is captured by the extent to which a governor’s early policy innovations exert sufficient pressures and incentives for national politicians to mimic sub-national reforms. Some hold that this bottom-up dynamic explains why the national government was initially delayed yet eventually – and aggressively - responded to AIDS in Brazil and the United States, but only after sub-national governments implemented progressive antiAIDS programs (Kirp and Bayer, 1992; Gauri and Lieberman, 2004). The findings in this dissertation nevertheless reveal that while these bottom-up pressures may have been instrumental in explaining the timing of policy reform, this was not the case when it came to explaining the timing of institution-building: that is, the creation of an effective public health bureaucracy and the timely provision of resources to bereft municipal governments. For while it may have been the case that the government quickly responded through policy implementation, this was not the case when it came to constructing effective AIDS institutions. Instead, institutional change emerged much later and was never influenced by bottom-up pressures. Institution-building was either the product of international pressures or direct threats to the national security, which emerged at a much later point in time. This suggests that institution-building responses to epidemics are much more delayed when compared to the timing of policy reform. Scholars have also recently focused on the role of civic organizations, such as NGOs, and the extent to which they prompt government response. Because of the absence of federal government intervention during the initial years of an AIDS epidemic, most of the early work on AIDS politics approached this issue from a community-

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centered perspective, where civil society played a key role in increasing public and government awareness of the problem (Altman, 1989; Shilts, 1987). When well organized, some argue that civic mobilization and pressures on the government can safeguard nations from an uncontrollable health epidemic (Willian, 2000; Whiteside, 1999). Others claim that NGOs working through international organizations have been instrumental in sustaining pressures on the federal government (Reich, 2002), while providing much need health services in cases where the national government is incapable and/or apathetic to the needs of civil society (Lucker, 2004; Boone and Batsell, 2001). The problem with this literature is that it assumes that collective mobilization is necessary and sufficient for an early government response. The in-depth historical analysis conducted in this dissertation suggests otherwise. In addition, while others have pointed out that social discrimination has deterred politicians from responding to the immediate needs of civil society (Gauri and Lieberman, 2006), others note that the center’s fear of political opposition through NGO mobilization and political sponsorship has contributed to this problem (cite article from home). And as I show later on in this dissertation, political apathy and a lack of policy commitment, which is attributed to the absence of a perceived national health threat, will generate no immediate interest in working with NGOs. Other theorists claim that this problem can be avoided by solidifying the representation of civil society within federal institutions. Elsewhere known as “open institutions” (Montero, 2001; Gomez, 2003), this view holds that when NGOs, civic elites, and sub-national politicians have legally guaranteed representation at either the legislative or bureaucratic level, mainly through the creation of formal committees or

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government sponsored national associations (Skocpol and Weir, 1985), politicians will commit early on to incorporating their views during the policy-formulation process. While this may go against the immediate interest of politicians (due to a loss of authority), the expectation is that this enhances a politicians credibility and commitment (North and Weingast, 1989) while strengthening policy effectiveness through sustained civic representation (Lowenson, 2003; Skocpol, 1993). But again, a closer look at Brazil during the first few years of the AIDS epidemic shows that the presence of open institutions does not guarantee that political and bureaucratic elites immediately respond to civic needs. As we’ll soon see, despite the Brazilian government’s creation of the National AIDS Commission in 1987, Ministry of Health officials vary rarely if ever met with NGO leaders. This, in turn, reflected the genuine lack of interest and motivation for insuring that the needs of civil society were met during the first few years of the AIDS epidemic. Yet another shortcoming to this literature is its unrelenting focus on health policy. Few if any studies have focused on the coalitional politics leading to the creation of effective public health institutions and their ability to implement policy. I argue that understanding how and when bureaucratic institutions are created and change is important for better understanding their subsequent ability to implement policy. There are several concrete empirical reasons for why we should focus on institutions. First, building autonomous, centralized bureaucratic institutions is important for clarifying divisions of responsibility and for successful health policy intervention within large, highly decentralized federations (Schneider, 2001; Gómez, 2006). Second, focusing on institutions gives us a better sense of how committed political elites are to

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responding to epidemics. The creation and modernization of institutions is much more challenging than the reform of prevention and treatment policy, especially if one considers the large set up and exit costs involved and resource scarcity (Pierson, 2000). Because of this, I argue that institution-building responses to epidemics, when compared to policy implementation, are a stronger indicator of political commitment to reform. And finally, a focus on institutions is also important because of the policy community’s recent interest in learning more about bureaucratic capacity, the sources of administrative corruption that impede the successful implementation of public health policy, and the endogenous and exogenous conditions influence this process (Suhrcke, Rocco, and McKee, 2007; Lewis, 2006; Wagstaff and Claeson, 2004; Hecht and Raj Shah, 2006; Moss, et al, 2006; Burnside and Dollar, 2000; World Bank, 1998). But there are several theoretical reasons for why we should focus on institutions. First, doing so contributes to the burgeoning literature in comparative politics emphasizing the importance of treating formal institutions as an outcome to be explained, rather than as a primary cause. This new literature emphasizes the non-institutional origins of institutions, such as the coalition formation processes and the conditions leading to successful elite consensus for institution-building (Waldner, 1999; 2002; Pierson, 2000b; Doner, Ritchie and Slater, 2005). These scholars argue that political scientists have a tendency to treat formal institutions as key independent variables. But the problem is that unforeseen events and short-term gains tend to generate outcomes that could not have been predicted by formal institutional designs (Alexander, 2001). This, in turn, unmasks the poor classification of institutions, which discounts their predictive powers (Waldner, 2004; Pierson, 2000b; Alexander, 2001).

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To get around these problems, this dissertation focuses on the structural and coalitional origins of institutions, while treating institutions as an outcome to be explained. By doing this, and as I explain in greater detail in Chapter 4, we can better understand the exogenous and endogenous sources of institutional change, their stability and thus policy predictability. Focusing on the historical origins and the strength of the reform coalitions underlying institutional change also helps us to better anticipate the types of exogenous and endogenous shocks that lead to institutional change at subsequent points in time. This does not mean that comparative scholars have failed to address the issue of institution-building in response to heath epidemics. While this issue has recently been addressed by some comparative scholars, the problem is that they have made only passing reference to it. It has never been the topic of an in-depth comparative historical or contemporary analysis. Nevertheless, I would render a grave disservice to these scholars if I failed to mention their work. Varun Gauri and Evan Lieberman (2004, 2006) and Constance Nathanson (1996) are the only social scientists to date that have addressed institution-building responses to HIV/AIDS. They claim that successful policy responses in Brazil and France rested on the government’s creation of a highly centralized AIDS bureaucracy that was autonomous and capable of rendering policy in a timely manner. In both studies, presidents were motivated by the goals of policy efficiency. Furthermore, Gauri and Lieberman (2004) assert that this was a purely domestic response, and that international forces had absolutely no influence over this process (Gauri and Leiberman, 2006, p. 58). 7

7

Indeed, Varun and Lieberman (2006) explicitly claim that: “Because AIDS has been the first major epidemic during globalization (Altman, 1999; Barnett and Whiteside, 2002), international actors have

28

The problem with this approach is that governments do not immediately respond to epidemics through institution-building processes. Presidents often fail to immediately assess the strengths and weaknesses of their public health agencies when new epidemics emerge, often preferring to rely on decentralization processes and wait until case prevalence rates reach a new apogee and/or international pressures emerge. As the detailed case studies in this dissertation illustrate, during the first few years of an epidemic’s spread presidential and bureaucratic elites are often apathetic about bureaucratic capacity and instead opt to rely on decentralization processes, even when knowledgeable of the fact that local governments are incapable of responding on their own. What all of this suggests is that presidential and bureaucratic interests in institution-building are much lower than what we would normally expect, especially in periods of health crisis. This further suggests that elite perceptions are shaped by structural conditions that are unrelated to the consequences of an epidemic threat and that they, more importantly, do not reflect the interests of civil society. But what this also means is that previously mentioned theories do not take into consideration the historical and contemporary structural conditions leading to sudden changes in elite perceptions and interests in institution-building. What is more, they do not specify the types of structural conditions that have the greatest impact on elite perceptions and why. Without this kind of analysis, we cannot anticipate and better predict when and to what extent elites will respond to epidemics through institution-building.

attempted to establish global governance regimes to prevent the further spread of HIV … We call this the ‘Geneva Consensus.’ Pressures to adopt the Geneva Consensus can help to explain similar patterns of overtime change across countries, but on its own, this influence cannot account for important differences in the specific trajectory of country responses” (Gauri and Lieberman, 2006: p. 58).

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And finally, a major shortcoming to these theoretical approaches is that they do not take into consideration the role of international pressures and their influence on decision-making processes. For all the aforementioned approaches assume that elites initiate reforms in the absence of international pressures, as noted above (Gauri and Lieberman, 2006). While this may be the case for elites rejecting international pressures and recommendations for policy reform (such as prevention and treatment policies, and the financing of anti-viral medication), this is certainly not the case for those that are receptive to such pressures. We’ll return to this issue shortly. In closing this literature review, the findings in this dissertation reveal that none of the aforementioned theories emphasizing the bottom-up pressures for reform were adequate in explaining not only the implementation of policy, but also the creation and reform of public health institutions. If indeed bottom-up pressures are inadequate for explaining the timing of reform, we have little choice but to narrow down the unit of analysis to the individual thought processes and interests of federal political and bureaucratic elites. This suggests that the causal direction of my argument is “top-down” in nature, and that we should carefully consider the structural conditions that shape and re-shape federal elite perceptions of a national health threat.

The Structural Sources of Elite Perceptions and Response Given the “top-down” nature of my argument, the underlying assumption here is that political and bureaucratic elite perceptions are divorced from the views of civil society. While civic organizations may be influenced by their own sets of personal beliefs and ambitions, they by no means influence the perceptions and interests of political elites. This is especially the case when, as Robert Oskegard (2007) argues, there is no historical 30

legacy of civic incorporation into formal institutions, such as policy-making committees, a genuine political commitment to these institutions, and/or a history of close interaction with civil society. Second, the assumption in this model is that threat perceptions are not immediately contrived. That is, elites engage in what Raymond Cohen (1978) once called an observational and appraisal perception-building process, where elites first observe new cues of information about a potential threat and, later on, critically analyze it based on their particular beliefs (Cohen, 1978). I argue that elites often engage in this two-step perception-building process several times during the emergence of a new health threat. The perceptions that elites are finally influenced by are the product of a long process of repeated observation and appraisal, with the final decision shaped by new conditions that overawe, or no longer make attractive, previously held beliefs and the structural conditions that underpin them. The model introduced here is thus purely structuralist in nature. In contrast to other literature, it provides little room for individual experiences, beliefs and choices in perception-building processes (Cohen, 1978; Pruitt, 1965; Stone, 1989). It does this by showing how the emergence of new global structural and/or domestic conditions eventually alters the ways in which federal elites perceive of a contested health threat, thereby relinquishing (often hastily) their long-held beliefs and traditions. Prior structural approaches explaining the emergence of individual threat perceptions have focused on how an individual’s social environment, such as their network of friends and the values and norms of “acceptable” behavior they purport, shape individual beliefs and perceptions of threats (Green and Stroble, 1996). With regards to political institutions, a structural approach emphasizes the historical institutional and non-

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institutional (e.g., scientific traditions and moral) legacies that contribute to the emergence of perpetuating paradigms and beliefs about how elites should respond to crisis events (Jervis, 1976). 8 Similarly, recent work by Robert Oskegard (2007) shows how a health epidemic’s threat to a leader’s political support base, and thus his political survival, as well as its perceived threat to the national security increases a leader’s belief and perception of a national health threat, prompting an aggressive policy response (Oskegard, 2007). According to this approach, once a new epidemic has emerged elites choose among a host of competing values and beliefs when formulating their perception of a threat. They eventually chose 9 and adhere to only those beliefs that comport with the unique history, experience, and preferences of elites’ political institutions and beliefs. For as Robert Jervis (1976) maintains, any information deviating from these beliefs is immediately questioned, attacked through a host of defensive mechanisms, such as bolstering one’s beliefs with additional evidence and/or using other evidence to undermine an alternative claim; this resembles what Cohen (1978) once called the appraisal process of perception-building. Analyzing the weight of structural forces on threat perceptions is important because it provides us with a clearer understanding of why elite perceptions are so difficult to change. Understanding this allows us to better anticipate how elites will respond to new types of health threats and the kinds of structural conditions that are capable of overawing previously held beliefs. This approach also highlights the

8

Of course, one must note that Jervis’ (1976) theory applied to the international realm. Note that the mere presence of a choice at this critical juncture does not refute my position of a structuralist claim. Indeed, and as others have observed, both historical institutionalists and rational choice theorists agree that structural approaches entail an element of choice at critical junctures (see Thelen 1999).

9

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problematic areas of political legacies and institutions that need to be reformed before institutional change can occur. While antecedent structural conditions lead to and often reinforce elite perceptions, new types of structural conditions can nevertheless lead to a change in threat perceptions. Indeed, elites may decide to forgo of their long-held beliefs whenever new structural pressures provide immediate 10 incentives and payoffs for doing so. And this can occur even when initial elite paradigms are unchallenged by countervailing data and/or theories, a condition which others have argued is necessary before elites change their views and policy preferences (Jervis, 1976). For example, when new criticisms and pressures from international organizations question a government’s ability to contain the spread of disease and develop, this can inspire modernizing presidents to change their views and support new reforms in order to reveal their ability to do so. The payoff comes in their ability to concomitantly increase their global reputation as modern nations capable of development, in addition to possibly leading the world in the plight against disease. At the domestic level, moreover, the rise of a new national security threat posed by an epidemic can have the same affect. Both factors motivate presidents and supportive health officials to forgo previously held beliefs and perceptions, even in the absence of countervailing empirical data. In sum, what all of this suggests is that focusing on the domestic and international structural conditions reinforcing and changing elite perceptions, respectively, is critical for understanding institutional stasis and change in periods of health crisis. To date, the literature on the comparative politics of heath epidemics has not discussed this issue. Absent this discussion, we are left to assume that elite beliefs and perceptions are fixed, 10

This is thus consist with the assumption that political elite operate within short-term time horizons.

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repeatedly generated by certain types of regime characteristics and their histories. Nevertheless, and as we’ll see more clearly with the case of Brazil, sudden changes in the global structural environment, such as the rise of new global pressures, can quickly change elite perceptions and interests in institution-building. Understanding why initial elite perceptions are fixed and why they suddenly change requires that we better understand the domestic and international structural conditions leading to institutional change. In order to better understand this, I argue that we should divvy up the institutional change process into two time periods: the First and Second Phase of Epidemics Politics. This approach facilitates our ability to understand the structural sources that affect elite perceptions and how the introduction of new structural conditions later on (during the Second Phase) alters elite perceptions in favor of institution-building.

The First Phase of Epidemic Politics The first phase of epidemic politics marks the beginning of political and bureaucratic elite response to epidemics. In most instances, it is a time of fear and uncertainty; it almost always generates an immediate host of demands from civil society and the medical community. But more importantly, it is a time marked by the absence of global consensus and pressures for an immediate government response, as well as the absence of an epidemic’s threat to the national security. The absence of these conditions fails to positively influence federal elite perceptions and interests in institution-building. And as we’ll soon see, some governments, such as the United States, but also more isolated federations, such as Russia and China, often remain in the first phase period, notwithstanding the emergence of increased global pressures for institutional change. 34

Institution-building responses during the first phase thus rely entirely on domestic political and bureaucratic elite perceptions of a new health threat. That is, it relies more on the domestic structural and ideological constructions of what an epidemic is and if elites perceive them as worthy – or rather, nationally significant enough – for an immediate institution-building response. Moreover, and this is key, the first phase is marked by a high degree of initial competing perceptions generated at the presidential-, legislative-, and bureaucratic-level, which in turn is prompted by responses to antecedent structural conditions that are unique for each of these levels of government: This leads me to my first two hypotheses: H1: During the first phase period, presidential, legislative, and bureaucratic elites will have different competing perceptions over what a national health threat is and its wider implications. Regardless of the durability and the degree of representation in government, I posit that there will never be an immediate federal elite consensus over the need to respond to citizens’ needs through new institution-building initiatives. While the perceptions of the President and supportive coalitions in the Congress will be negatively influenced by a lack of credible evidence and moral considerations, the presence of supportive congressional members, constituent pressures, and a historic commitment to professionalism in bureaucracy will generate competing perceptions and a lack of consensus for reform. H2: Second, these competing perceptions will be influenced by antecedent structural conditions that are unique to elites at these three levels of government. For some elites, such as presidents and legislative members, these conditions will derive from contemporary political circumstances, while for others, such as bureaucrats, they will derive mainly from deeply ingrained historical institutional legacies and informal relationships with civil society. Perceptions during this period are thus shaped by contemporary and historical structural conditions.

Perceptions and Response at the Presidential and Legislative Level During the first phase period, presidential perceptions will be negatively influenced by the absence of global pressures and an epidemic’s threat to the national security; the quality of empirical evidence about the spread of disease; and conflicting ideological 35

views and valued interest group penetration. With regards to the former, the absence of global pressures and recommendations for institutional change will fail to influence the perceptions of presidential elites. This is especially the case for those nations that have been historically much more receptive and integrated into the global health community. In the absence of such pressures, presidents will have not incentives to reveal their developmental capacity and maintain their international reputation as nations committed to combating disease. Furthermore, during this period the absence of an epidemic’s threat to the national security will fail to change presidential perceptions and interests in reform. This is especially the case when epidemics fail to affect a nation’s military capacity and thus its national defense system. This factor is more likely to affect the threat perceptions of presidents that lead major military powers and that value national security more than the interests and pressures of their citizens and the global health community. At the same time, presidential perceptions will also be influenced by the quality of epidemiological evidence that exists about a potential health threat. In lesser developed nations, where conditions of underdeveloped and poor health care systems are often present, it is often the case that the government must deal with a host of urban and rural diseases. In this context, presidential perceptions will be influenced more by what I call the “multiple diseases” problem, where the presence of several diseases will fail to convince the president that the presence of a new disease poses an imminent threat to the nation. Despite the presentation of epidemiological evidence pointing to the contrary, presidents will fail to be persuaded, even if shown that the actual growth rate of a newly emergent disease is much faster than others. Absent global pressures and national

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security threats, presidents will not perceive newly contested epidemics as a priority; support for institution-building will not occur. And lastly, surrounding moral values and institutional contexts will also matter. During this period, the perceptions of presidents having and/or representing political parties harboring specific types of moral values and political views will be influenced the presence of pro-active and well-organized interest groups in civil society seeking to influence policy reform. The perceived electoral importance of these groups will be valued greatly when presidents share the same types of moral beliefs. In such a context, presidential perceptions will be shaped by moral interest groups. These groups will not support policy and institutional reforms for epidemics considered to be acquired through immoral activity, such as HIV/AIDS. However, the penetration and influence of moral interests groups may not be uniformly spread out throughout government, such as the bureaucracy. And finally, under these conditions presidents will be capable of mustering a supportive legislative coalition. For as long as presidents can show that there is no credible threat, they will always prove capable of assembling a coalition that is not interested in institution-building. Yet these interests will always be countered by those legislative elites that are not supportive of the president and that are committed to responding to the immediate needs of civil society. This, in turn, creates a highly polarized legislative setting which makes it nearly impossible to create a broader coalition for reform (Haggard and Kaufman, 1995; Sartori, 1976; Panebianco, 1988). Perceptions at the Bureaucratic Level

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And finally, during this period the behavior of public health officials will be different from presidential and legislative elites. In general, I argue that public health bureaucracies will be much more sensitive to the needs of civil society and committed to sound policy implementation. But their ability to respond will be constrained by conflicting perceptions of how to go about achieving this objective and the imposition of hard budget constraints, which, in turn, generate incentives to respond independently in stead of working in a cooperative manner with other health agencies. The degree of conflicting perceptions and interests within bureaucracies will be more extreme within nascent democracies. This is because centralized political control and weak checks and balances systems will make some bureaucrats more beholden to the interests of powerful executives and political parties rather than to their organization (Haggard, 1997). These differences in allegiance allow for the penetration of different types of antecedent structural conditions affecting two types of bureaucratic actors: status quo versus pro-reform bureaucrats, where the perceptions and interests of the former reflect that of the president, who is not seeking institution-building for the same aforementioned structural reasons – i.e., the absence of global pressures, credible evidence and the “multiple diseases problem.” Like the president, status-quo elites will prefer a decentralized response to health crisis, whereas pro-reform elites prefer a centralized, institution-building approach. Given their preferences, status-quo elites will oppose any effort to create a more centralized response to epidemics. On the other hand, the perceptions and interests of pro-reform bureaucrats will be positively influenced by legacies of professionalism, a historically-based commitment to centralized institution-building, and their interest in working more closely with civil

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society to achieve these ends. As explained in more detail shortly, this in turn sets the ground work for the emergence of tripartite partnerships between pro-reform bureaucrats, civic organizations, and international organizations for the expansion of public health administration. However, a persistent tension between pro-reform and status-quo bureaucrats will lead to stalemate and an inability to build a coalition for reform. Lacking the support of the president, adequate resources and influence, during this period proreformers will be marginalized, ignored, and even ridiculed by status-quo officials. As a consequence, no institution-building will occur. On the other hand, within more stable and enduring democratic systems, where checks and balances systems have been present for a longer period of time, bureaucratic perceptions and interests will be more uniform and motivated by structural conditions that affect all bureaucrats in the same manner. For example, pre-existing commitments to secular and objective views towards epidemics, regardless of their moral nature, will positively influence their threat perceptions. This convinces bureaucrats that the government should immediately intervene. This view will also motivate bureaucrats to work closely with civil society, showing them that they are not influenced by ideological issues, and that they are driven more by the urgency of human need. Second, bureaucratic perceptions will be influenced by the long-standing belief that working closely with civil society is important for obtaining information about the etiological origins and nature of an epidemic’s spread, as well as its social ramifications. This is typically a long held bureaucratic tradition passed on by agency heads. This contributes to the perceived need of immediately responding to an epidemic.

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And finally, bureaucratic perceptions will be positively influenced by the opportunity that epidemics provide for agency directors to apply for additional funding. This occurs in a context where public health agencies face hard budget constraints and/or a substantial decline in their authority. Under these conditions, agency heads perceive an epidemic as posing a national threat and will strategically use it in order to justify a continued increase in budgetary outlays. Epidemics are thus perceived as a means to agency survival. However, agency survival will generate a repeatedly tendency of agency heads to work independently whenever a newly contested epidemic emerges, rather than working with other agencies for a more coordinated response to the epidemic. This done in order to increase the reputation of agency heads, which in turn helps to secure additional funding. In contrast to the president, while agency heads do acknowledge the fact that a new epidemic has emerged, paradoxically their reform interests will mirror that of the president, which is not to engage in immediate institution-building. I argue that this kind of response is more likely to occur within a fragmented public health system, where several public health agencies are trying to respond to the emergence of a newly contested epidemic.

The Second Phase of Epidemic Politics The key difference between the first and the second phase of epidemic politics lies in the emergence of a new global health consensus pressuring governments to respond in an effective and un-biased manner. 11 It is a time when nation states and international

11

Unbiased in the sense that nations often have preferences for focusing on some epidemics, not others – such as AIDS versus TB. As I discuss shortly, these biases have a lot to do with biased global attention to

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organizations work together to suggest that governments reform not only their health policies but also their institutional response to disease. Second, it is a time when epidemics finally emerge to pose a serious national security threat. I argue that the presence of these two structural conditions is determined by a government’s relationship with the global health community. For those nations that are more receptive to international pressures, technical advice and donor aid assistance, the emergence of a new global consensus and pressures will generate new incentives for institution-building. Conversely, in the more globally-isolated regimes, national security threats and to a certain extent the health of individual leaders will be more important catalysts for reform. Global criticisms and pressures will not influence the government’s institutional response. Absent a perceived national security threat, moreover, no institution-building will occur. And this will happen even when political elites themselves are threatened by a new health epidemic. Globally-Receptive Public Health Regimes: International Pressures and Perception Shift For the more globally-receptive public health regimes, by far the biggest difference between the first and the second phase of epidemic politics is the sudden convergence in federal elite perceptions and interests in institution-building. For reasons that are explained in more detail shortly, during this period those nations that are more historically integrated into the global heath community, measured in terms of their active participation in international conferences and their receptivity to donor aid and technical assistance, will witness a hasty convergence in federal elite perceptions of a genuine epidemic threat and interest in reform. certain epidemics, the opportunity for increase a nation’s global reputation, and the availability of more money for some epidemics and no others; on this note, see Gómez (2007).

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This leads me to my first conjecture about the second phase period: H1: Nations that have been historically integrated into the global health community will eventually see a convergence in federal elite perceptions and incentives to both create and continuously strengthen their public health agencies in response to epidemics. Second, it is only after a new global health movement and its pressures emerge that previously conflicting elite perceptions and interests converge in favor of institutionbuilding. This historical element is important. When nations have a long history of working with the global health community, either through conference participation, technical partnerships, or borrowing money from international lending agencies, they will have a tendency to be more responsive to global pressures for reform. A history of working closely with the global health community generates enduring partnerships and expectations that nations will continue to do so whenever new epidemics emerge. The Race to Global Fame This global partnership must be precipitated, however, by what I call the “Race to Global Fame” in international health politics. This occurs when an increase in international pressures prompts modernizing presidents to accomplish two things: on one hand, to prove to the international community that they have the capacity to effectively respond to epidemics while, on the other hand, providing them with an opportunity to possibly lead the world in the plight against disease. This response is a direct reaction to international criticisms and a desire by modernizing presidents to show that they indeed have the ability to respond in an effective manner. In addition to being more commonly found among middle-income nations, I argue that this response is more likely to emerge among nations that have a pre-existing history of being actively involved in the international

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community, either through active conference participation or by sponsoring conferences themselves; the converse also holds. 12 This, in turn, creates a historic legacy of being involved at the international level and generates even more incentives for aspiring presidents to increase their international reputation and influence. Because the race to global fame provides new opportunities to increase a nation’s prestige and influence, it immediately captures the interests of aspiring presidents. With the exception of leaders that are not concerned with their international reputation, 13 most presidents have incentives to reveal their ability to contain disease at the international level. This also provides an opportunity for them to increase their legitimacy at the domestic level. Legislative and bureaucratic elites may certainly play a key role in educating and motivating the president, but it is the latter that is most affected by this process. This leads me to the following conjectures: H2: For more globally-receptive regimes, the race to global fame will radically alter the perceptions that presidents have of a contested epidemic while creating new incentives to engage in institution-building processes. Pursuing institution-building is seen as the primary means to increase a nation’s international reputation and influence. H3: Second, this change in presidential perceptions is a necessary pre-condition for the emergence of a new federal elite consensus between legislative and bureaucratic elites in favor of institution-building. This leads to a narrowing of elite perceptions, at all levels of government, and more importantly, new opportunities for institution-building to occur. Indeed, institution-building in the second phase will not occur unless presidential perceptions are first positively influenced by the race to global fame. Notwithstanding 12

A good example is the African region, where most nations have only become independent since the 1960s and never been historically involved in the formation of international conferences and coalitions. 13 This may be the case for leaders that are non-democratic in nature and concerned mainly with acquiring domestic legitimacy and support. Historically, this has been the case with authoritarian systems and nascent non-democratic regimes in Africa, the Middle-East, and select Latin American nations.

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incessant pressures from pro-reform bureaucrats and civil society prior to the emergence of global pressures, presidents will not respond and support institution-building initiatives unless they have international reputational incentives for doing so. Nevertheless, when this is achieved previously ignored reform bureaucrats will now have the opportunity and incentive to exert greater pressure for reform; furthermore, because of their relationship with international organizations, they will now have the bargaining leverage needed to help enact and more importantly sustain a centralized institution-building response. As we’ll see in more detail shortly, this perspective questions the recent literature emphasizing that globalization and international pressures generate more incentives for bureaucrats to press for greater decentralization in order to decrease their responsibilities and focus on alternative issues that focus on the international economy (Welch and Wong, 2001). It is also important to note that this kind of response is repeated by presidents at different points in time, for different kinds of epidemics, yet in response to similar kinds of international pressures. It is important to note, however, that this type of response is not the product of increasing returns, where traditions and beliefs within institutions are shared and passed down among successful political elites (Elster et al, 1988; Pierson, 2000; Aurther, 1984), or where organizational and policy learning has occurred to inspire successive presidents to maintain a particular kind of institutional response (Pierson, 2000; Hecklo, 1974; Pierson, 1998). Instead, in this model presidents respond independently but in similar ways to international pressures at different moments in time. This suggests a constant causal process that is contextually determined and repeated over

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many years (Stinchcombe, 1968). It is the summation of these similar responses that yield at a similar response, a similar path, an institution-building path, to contested epidemics. And finally, it is important to note that access and receptivity to international financial resources is seen as a necessary for achieving the race to global fame. For while presidents may be interested on their own in increasing their international reputation, in a context of ongoing fiscal crisis and government downsizing, acquiring international resources may finally provide the means through which such reputation building can occur. This is not to say, however, that access to resources is the key variable shaping elite perceptions and interests in reform. In a context of increased globalization and integration, reputation building is still viewed as the primary catalyst for change. While this may have been the case for Brazil, future research will need to broaden out the analysis to see if indeed reputation building plays an more important role in shaping elite perceptions than access and the strategic usage of international resources. The structural factors that affect political and bureaucratic elite perceptions within more globally-isolated public health regimes are different, however. In this context, I argue that successful institution-building requires the following pre-conditions. First, an epidemic’s threat to the national security, specifically the threat that a new disease poses to a nation’s military fighting capabilities. Under these conditions, all governing elites – i.e., presidents, legislators, and bureaucrats - will agree that the construction of new federal agencies, laws and regulations are needed to defend the nation. Moreover, these conditions will create incentives for elites to increase the amount of money going to the

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states for the financing of health infrastructure and the implementation of prevention and treatment policies. These national security conditions also lead to the rise of new political coalitions seeking to create a more centralized institutional response to epidemics. These coalitions are comprised of presidents, war officials and civic organizations that are committed to defending the homeland. A consensus for centralized institution-building can emerge even within a context of prior government commitment to the decentralization of public health services, where the states and the municipalities are required to act as first responders. I hypothesize that these responses are more likely to emerge in nations that have a longer history of national defense and commitment to national security, such as the United States, but also Russia and China. This leads to my first hypothesis with regards to institution-building within globally-isolated regimes: H4: Globally-isolated regimes will have incentives to build and modernize centralized public health agencies when epidemics finally emerge to pose a new national security threat. This occurs when governing coalitions are finally convinced through a rapid increase in case rates among military enlistees that a national security threat is present. It is only under these conditions that all federal officials perceive the situation to be urgent and finally agree to create a more centralized institutional response. The Emergence of Institution-Building Partnerships between International Organizations, Domestic Reform Bureaucrats, and Civic Organizations For those nations that are more receptive to international pressures, I posit that the second phase of epidemic politics not only contributes to a narrowing of perceptual pathways and incentives for institution-building, but it also has the potential of resuscitating historically-based informal partnerships between pro-reform bureaucrats, civic organizations, and international organizations seeking to centralize and strengthen public 46

health institutions. I argue that these reform partnerships have deep historical roots and arise every time a new global health consensus emerges. In this tripartite partnership, domestic and international actors part bread in their efforts to incessantly pressure the President and the Congress for an increase in budgetary support and centralized bureaucratic autonomy. In this model, domestic reform bureaucrats and civil organizations have incentives to strategically use the rise of new global pressures as leverage when bargaining for an expansion of public health administration; in this sense pressure strategies take on a boomerang effect, where domestic actors appeal to and use international movements as a means to strengthen their positions at the domestic level (Sikkink and Keck, 1998). I argue that such an approach is necessary for continued bureaucratic expansion. Of all of the actors involved, it is pro-reform bureaucrats that benefit the most from this partnership. They therefore take the lead in establishing these partnerships. The emergence of new global pressures provides incentives for bureaucrats to finally respond to civil society and to strategically use NGOs and their linkage with international organizations for bargaining leverage. By working with and appealing to a supportive international community, this further increases their influence and ability to obtain continued government support. In a sense, this provides what Dan Carpenter (2001) calls a social network of supportive actors that increases the reputation and influence of bureaucratic reformers. Because of this, these tripartite partnerships are often led by reform bureaucrats and their willingness to aggressively seek out and work with civic organizations. Up to this point (that is, during the first phase period), they do not view civic organizations, such as NGOs, as a key resource for organizational advantage, but

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mainly as partners sharing similar ideals and interests. This is mainly due to the fact that presidential perceptions and interests have not changed. Nevertheless, in order for this tripartite partnership to survive and emerge later on, there must first exist a well organized civic movement that is eager to use global pressures towards their benefit. Second, there must also be a pre-existing belief and tradition between civic elites and pro-reform bureaucrats in working together for an immediate institution-building response to epidemics. As explained in more detail in Chapter 4, this informal understanding provides bureaucratic reformers with the civic resources needed to increase their influence and to sustain an institution-building response. It is important to emphasize again that successful trio partnerships can only emerge after the president’s perceptions and interests have changed – due to the race to global fame. As noted earlier, this provides a new opportunity space for the emergence of influential pro-reform bureaucrats seeking new domestic and international partnerships. If these tripartite partnerships emerge before the race to global fame occurs, this will fail to provide sufficient incentives for presidents to support new institution-building initiatives. When they do emerge, however, these tripartite partnerships provide mutual incentives streams whereby pro-reform bureaucrats, civic organizations, and international actors benefit from institution-building responses to contested epidemics. This is crucial for the continued survival of this informal movement, as well as the continued expansion of public health administration. The preferences, decision, and benefits of each actor are broken down as follows:

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Graph 2.1 – Global, Civic, and Bureaucratic Partnerships for Institution-Building Global Pressures

Reform Bureaucrats

NGOs/Civic Organizations Pro-Reform Bureaucrats: Reformer bureaucrats have two immediate objectives: first, to create and expand public health agencies in response to epidemics and, second, to advance their careers. While they may share similar beliefs with civil society, which some social welfare scholars argue is a pre-requisite for successful institution-building (Heclo, 1974), maintaining and expanding their careers is valued over these ideologically beliefs, especially in a context of low pay and probability of continued employment. Because of this, and as exemplified by the

arrow above, reform bureaucrats take

the lead in forming this tripartite partnership. Without their personal career ambitions, this kind of coalition will not emerge. Civil society must therefore wait for a change in federal bureaucratic interests before they can successfully lobby the government. In their efforts to become more influential, reform bureaucrats initiate a strong working relationship with civic elites that are now supported by new global health movements and by a president that is interested in increasing their global reputation. Presidents support any initiative that incorporates the views of civil society, given the fact that the international health community is now mandating this process (Altman, 1999).

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These initiatives give reform bureaucrats credibility and influence, and is fueled by their recycling and use of historically-based agreements with civic organizations sharing similar beliefs and interests in institution-building responses to epidemics (we’ll return to this issue in Chapter 4). By working more closely with civil society, reformers are also capable of obtaining additional money and support from international lending institutions, such as the World Bank. Close working relationships with NGOs are used as a justification for requesting additional funding. This helps to secure and advance bureaucratic careers while providing further incentives for them to work closely with civic organizations and international organizations. In contrast to the views of some theorists (Boone and Batsell, 2001), NGOs are thus used by reform bureaucrats as a strategic resource rather as an equal partner in the government’s response to an epidemic. 14 The government’s sudden interest in working with NGOs after global pressures emerge (again, keeping in mind that they are ignored by the government during the first phase) lends credence to the notion that NGOs are used as a strategic resource for bureaucratic advancement through institution-building. This paints a rather different picture of democratic bureaucrats: for they are much more self-interested than initially perceived, only deciding to work closely with civic organizations only when it is perceived – first and foremost – that doing so will provide bureaucrats with career benefits. Civic Organizations: The preferences and benefits of civic elites are somewhat similar. Like pro-reform bureaucrats, they too desire to build a centralized bureaucracy in

14

Again, recall that Catherine Boone and Jake Batsell (2001) argue that the federal government often works through NGOs in order to provide health services. They therefore argue that NGOs are perceived as important partners and that the NGOs and the government rely on each other.

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response to epidemics. They share with pro-reform bureaucrats a long-held belief that institution-building is necessary for a successful response to epidemics with decentralized federations. In addition, given the rise of global support for their initiatives, they now have incentives to re-approach 15 the federal government with more vigor and in a more organized, professional manner. They make sure to take advantage of pre-existing open institutions 16 guaranteeing their representation in bureaucracy 17 (e.g., National AIDS Commissions). And finally, the payoffs are simply the construction of a new, more effective public health agency, one that continues to expand and provide health prevention and treatment measures in a timely manner. Global health community: The preferences of the global health community essentially run parallel to the other two actors. Like pro-reform bureaucrats and civic organizations, they desire the creation of a centralized agency in order to enhance the timely provision of health services. They also desire the incorporation of civil society into the policy-making processes. Their payoffs are somewhat different, however: for unlike pro-reform bureaucrats, they are not interested in any career benefits or any increase in prestige and influence. But the most important outcome that emerges from this tripartite partnership is that it resuscitates the presence of historically-based informal elite relationships and understandings between pro-reform bureaucrats, civil society, and the global health

15

I say “re-approach” here because as you recall from our earlier discussion, the government never listened to the immediate needs of civil society prior to the emergence of new global pressures and incentives. Thus in the Second World of epidemic politics, they re-approach the government with more vigor. 16 As defined in chapter 2, “open institutions” are federal bureaucratic guarantees that civil societal interests are heard; these usually take the form of official AID Commissions or in the case of the congress, legislative hearings that guarantee civic representation. 17 It could indeed be the case that pre-existing open institutions generate further incentives to re-approach bureaucracy in a more organized, professional manner. This issue is explored in further detail in chapter 2.

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community. This is grounded in prior resolutions, which converge into informal institutions (Helmke and Levitsky, 2004), that centralized institution-building is necessary for the timely eradication of disease. As we’ll discuss in more detail in Chapter 4, the sustainability of this informal arrangement through the aforementioned mutual benefit streams is a necessary condition for the continued expansion of newly created public health agencies. In other words, trio partnerships provide a continued stream of informal pressures on the President and the Congress to maintain institution-building efforts through the continued allocation of money and political support. Personalism in Epidemic Politics And finally, yet another condition that can lead to changes in political and bureaucratic elite perceptions and interest in institution-building is the personal threat that epidemics pose to governing elites. This is what I call personalism in epidemic politics. While present mainly within globally-isolated public health regimes, personalism occurs when presidents and other high level officials, both at the national and sub-national level, are eventually threatened by an epidemic that was previously ignored but finally emerges to threaten their individual health. Despite this personal element, however, I posit that in the absence of a clear national security threat, even this will prove insufficient to elicit an institution-building response. This further suggests that the presence of a national security threat is a necessary and sufficient condition for reform. These limitations notwithstanding, it is argued that personalism leads to two possible scenarios, which in turn are important for setting the groundwork for institutional change. First, an unwavering commitment by the President to increase public awareness about a new epidemic spread and how to avoid it. This can lead to new 52

recommendations for family members and even government officials on how best to cope with their health struggles while calling on them to be more responsible towards other family members and friends. It can also motivate presidents to convince others that it is their “civic duty” to adhere to their recommendations and to support a national campaign or set of policies in response to a new epidemic. But more importantly, it puts a contested epidemic on the national agenda, which in and of itself is a major accomplishment, a necessary prerequisite for institutional change to occur. Second, personalism at the presidential level can also have wide diffussionary affects, whereby presidential interests in policy reform motivate high level bureaucrats and even sub-national politicians to pursue similar policies and in some instances new institutions, such as laws and regulations. The diffusion of new policy ideas and concerns at the federal level inspires sub-national politicians to not only pursue similar policies but also to engage in new institution-building processes. Thus while a personal threat has not prompted institutional development at the federal level, it may do so at the sub-national level. In the future, given higher levels of visibility and electoral accountability at this level of government, I expect that institutional and policy change at this level will be much more progressive when compared to the federal government.

**** In the chapter that follows, we will discuss the historical emergence of public health regimes in the United States and Brazil. It will trace the two phase of epidemic politics for several different types of epidemics, repeatedly illustrating the fact that federal elites did not immediately respond to them through institution-building processes, and that it

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takes unrelated structural conditions, such as national security threats and global pressures, to elicit such a response.

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CHAPTER 3 Building Public Health Regimes: National Security, International Pressures, and the Emergence of Reform Partnerships (1900-1950) The premise of this chapter is that both old and new democracies will not immediately respond to epidemics through institution-building. Instead, there will always be a delay in political elite perceptions and incentives to engage in these activities. When they do eventually act, however, democracies will respond for reasons other than immediate human need. This kind of response can occur even within recently democratized nations, such as Brazil, that go as far as to base their transitions from authoritarianism on the tenets of human rights, equality, and universal access to social welfare. Moreover, it can even occur in more industrialized democracies, such as the United States, where representation and accountability has been present for a longer period of time. Consistent with what we discussed in Chapter 2, this chapter argues that we cannot predict the type of institution-building responses that emerge from the degree of democratic consolidation and more importantly, the type of public health regime 18 present. That is, we cannot assume that just because there is a well-established system of

18

By public health regime, I mean the formal rules that political and bureaucratic elites abide by when creating institutions in response to epidemics. A good example is an elite consensus that a decentralized versus centralized administrative response is important for successfully curbing an epidemic’s spread. In this book, regimes are viewed as formal institutions (a system of rules) that are more enduring than governments: Office holders and government officials can be easily displaced through military coups or war. Regimes, on the other hand, are often more enduring and resistant to crisis conditions.

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governance and a consolidated public health system that nations will always and immediately respond to epidemics through institution-building initiatives. Sometimes they do, some times they don’t. And as this chapter will illustrate in rich detail, for several cases in the United States and Brazil since the early-20th century, democracies and non-democracies did not immediately respond. While these institution-building outcomes did nevertheless emerged several years later, their emergence was not due to the formal institutional designs and interests of political and bureaucratic regimes, but rather from the unexpected emergence of new political underlying coalitions for reform, coalitions that were responding to the rise of alternative international and domestic structural conditions, not to civic needs. What this chapter therefore suggests is that we cannot predict how and when democracies, both old and new, will respond to epidemics. Because of this, and as the conclusion of this chapter explains in further detail, any future prediction of institution-building outcomes will rely on our ability to more accurately define and re-classify public health regimes based on the different types of underlying pro-reform coalitions that emerge in response to alternative types of structural conditions. And lastly, what this suggests is that we can no longer assume that advanced democracies such as the United States will be any better than lesser developed nations in their ability to strengthen their public health institutions in response to epidemics. In fact, one could even argue that more nascent democracies, and even some non-democracies, such as Cuba and China, may eventually outpace the United States’ ability to achieve these objectives. This is indeed the paradoxical benefit of a highly centralized political

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regime, where the absence of inter-party contestation and the separation of powers facilitate reform in periods of crisis (Yang, 2006; Shirk, 1993). Before delving into the detailed case studies, let’s take a brief look at the origins of public health regimes in the United States and Brazil. A closer inspection of formal political and bureaucratic institutional designs will show that regardless of the type of public health regime present, such as a highly decentralized versus centralized public health system in the United States and Brazil, respectively, both old and new democracies will not immediately 19 respond to epidemics through institution-building. As the remainder of the chapter shows, this finding suggests that there are other domestic and international structural conditions that eventually convince political elites to create and modernize public health agencies. These structural conditions derive from a nation’s relationship within the global health community. They do not derive from the epidemic and the needs of civil society. For example, when democracies isolate themselves from the influence of global pressures and recommendations for policy change and instead try to lead the global health community in this regard, as seen in the United States, alternative domestic structural conditions, such as national (military) security threats and personalistic 20 threats will be more important in influencing the emergence of new political elite perceptions and interests in institution-building. This, in turn, will lead to a new underlying coalition for reform. As we’ll see in this chapter, this was the case with

19

That is, response within the first 5 years of an epidemic outbreak. As discussed in the previous chapter, a personalistic threat emerges when an epidemic poses a direct threat to political and bureaucratic leaders; these threats can motivate them to perceive epidemics as worthy of an immediate institution-building response. As this chapter illustrates, this happened during the polio epidemic under FDR and will to a certain extent re-emerge again for the obesity epidemic under President George W. Bush.

20

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syphilis, mal-nutrition, polio, and malaria in the United States during the early- to mid20th century. On the other hand, when nations are more receptive to global community pressures and recommendations for institutional and policy change, as seen with Brazil’s response to syphilis and tuberculosis, new reform elites will emerge to build agencies and/or modernize pre-existing ones. Nevertheless, in these cases as well, the actual epidemic itself will not prompt institution-building; global pressures and the domestic incentives that they generate will. The overall punch-line here is that in both old and new democracies, governments will not immediately respond to epidemics in order to save lives. Citizens and their needs are not an immediate priority. Instead, democratic elites will wait until epidemics affect their national (military) security, personal livelihood, or when new global pressures and incentives for institution-building emerge. Democratizing elites thus appear to prioritize other structural factors that are not directly related to immediate human needs. Nevertheless, these kinds of institution-building responses are not unique to the historical record. Subsequent chapters in this dissertation will show that these types of responses persist. This, in turn, suggests that increased democratic consolidation and accountability over several decades has not made large democratic federations more accountable and committed to institution-building in response to epidemics. Indeed, I daresay that no institutional learning has occurred when it comes to responding to contested epidemics. I will elaborate more on this issue at the conclusion of this dissertation. But for now, let’s examine the United States and Brazil’s historic response

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to epidemics and closely analyze when and to what extent political elites were committed to reform.

PUBLC HEALTH REGIMES IN THE UNITED STATES AND BRAZIL: DECENTRALIZATION, CENTRALIZATION, AND GLOBAL RESPONSE ~ Decentralization and Global Leadership in the United States ~ Public health regimes in the United States and Brazil started off on entirely different institutional paths. While they were more decentralized in the United States, in Brazil they were always more centralized and autonomous from regional interests. In the United States, beginning in the early 18th century a dual public health regime emerged whereby the states and local governments bore the brunt of policy responsibility, mainly through municipal health boards and in some instances merchant marine hospitals. On the other hand, the federal government occasionally intervened through various Congressional Acts in order to regulate port areas through the creation of the Merchant Public Health Service in 1798. By the early 20th century, however, America’s public health regime converged to a more decentralized form of epidemic control, consolidated through the government’s increased recognition of the states’ autonomy over health policy, on one hand, and the creation of the U.S. Public Health Service in 1912, which formally recognized the states’ autonomy, on the other. Prior to devolution, however, the President and the Congress, and eventually the National Treasury by 1799, had the right to regulate and impose quarantines in port areas, especially those most likely to introduce diseases from foreign ships (Williams, 1951). As epidemics continued to threaten port security and commerce, the Congress began to delegate more authority to the Treasury Department and, in turn, the Merchant Public 59

Health Service (which at the time was a subdivision of the Treasury Department and eventually renamed as the U.S. Public Health Service in 1912) in order to enforce quarantines (Williams, 1951). This period marked the beginning of the federal government’s interest in responding to epidemics through institution-building. But note that it did so mainly for national security reasons and for the protection of commerce, not for safeguarding the needs of civil society. During this period the government never interfered with urban political machines and their control over health boards (Riordan, 1994). Rather, the government only intervened when epidemics threatened port areas (border security), merchant and naval personnel (and thus military security). The concern for border security was so high that by 1922 ownership of the U.S. Public Health Service was transferred over from the Department of the Treasury to the Federal Security Agency (Williams, 1951). This effort initiated the President and the Congress’ seemingly path dependent interest in federal institution-building only when epidemics posed a direct threat to the national security. We’ll see this tendency reemerge again with the government’s response to syphilis and malnutrition during this period, and again several decades later when the absence of a national security threat failed to elicit an institutionbuilding response to AIDS and obesity – with the specter of avian bird flu and bioterrorism being the possible exception. When epidemics did not affect port and military security, the government relied entirely on state and local health departments as first responders 21 (Panem, 1985; Williams, 1951). While the President, the Congress, and the Department of the Treasury 21

Because most epidemics since the early-20th century were perceived as originating at the urban level, and because the states have always had constitutionally-based authority over public health policy, our institutional response to epidemics has always been decentralized (Frist, 2002).

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were busy constructing a national public health service, during the late-18th and early-19th century a spate of public health departments at the state and municipal level emerged, gradually increasing in size and becoming more autonomous from the center. By the early 20th century the federal government began to recognize the states as primary responders. Notwithstanding the emergence of a highly centralized U.S. Public Health Service in 1912, it did not freely intervene at the local level, even when new epidemics, such as polio, emerged. From then on, the PHS’s role was relegated to policy intervention only at the request of state and municipal officials. What emerged during this period was thus a highly decentralized public health regime (Nathanson, 1996), where local and state health departments were the only ones responsible for containing epidemics; moreover, this was a constitutionally-based guarantee and soon thereafter a tradition that continues to this day, even in the face of more recent epidemics and natural disasters. Global Leadership In addition, during this period the United States became more involved in the global health movement. Its major goal was two fold: to become a global leader in providing direct assistance to other nations in the eradication of disease, while at the same time encouraging the participation of major philanthropic organizations. On the other hand, during this period the government was not receptive to the global health community’s recommendations for institution-building and policy reform. While the U.S. was committed to helping others, it also established an early tradition of being isolated and unresponsive to global pressures. This set the stage for the government’s continued interest in leading the global health community rather than being led by it. 61

Historically the U.S. Public Health Service was very pro-active in helping other nations respond to epidemics. Beginning in the 1950s, for example, it led the campaign to eradicate malaria in several Western and Central African nations. It worked closely with the USAID (United States Agency for International Development) to finance several malaria eradication programs and worked with the World Health Organization (WHO) to ensure that nations, such as Brazil, were responding (Ethridge, 1992). During the 1960s, moreover, the CDC proudly led the fight against the small-pox epidemic of Africa and Asia, as well as Brazil (Ethridge, 1992). But it was with smallpox eradication that the CDC started to reveal its true leadership potential. The CDC Director at the time, Dr. William Foege, made several trips to Asia to convince health officials that they needed to redouble their efforts against smallpox (Ethridge, 1992). In 1973, Foege also went to India to direct the last and final phase of the WHO’s smallpox eradication program. Through these efforts Foege and the CDC helped to lead the fight against not only smallpox but a host of other epidemics across Africa, East Asia, Central and South America (Ethridge, 1992). Throughout the early- to mid-20th century, the government also encouraged U.S.based philanthropic organizations to help other countries combat disease. During the early-20th century private philanthropy played a vital role in helping nations build their public health infrastructure. In Brazil, for example, the David Rockefeller foundation helped establish several rural outposts for the eradication of yellow fever, malaria, and a myriad of other rural epidemics (Hochman, 1998). Other philanthropists emerged, such as Mrs. Irene Diamond (subsequent co-partner with her husband, Aaron, of the Aaron Diamond Foundation), to give thousands of dollars for combating malaria and other

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diseases. Rockefeller and Diamond were the Bill & Melinda Foundation and Warren Buffett’s of their day, and together they helped finance several public health initiatives throughout Latin America and Africa (McNeil, 6/27/06). In contrast to its stern commitment to global leadership, it is important to note that during this period the U.S. Public Health Service was not as receptive to international criticisms and recommendations for institution-building and policy. That is, notwithstanding the WHO and other governments’ suggestions for institution-building and more effective policy response (especially towards burgeoning epidemics in the south, such as malaria, syphilis, and later polio), the PHS tended to ignore these suggestions and responded on its own. Because of its unwavering dedication to combating world pandemics, and because it had the most resources, technological and medical prowess, the PHS always saw itself as more of a global leader rather than a follower. Over the years this engendered a government and PHS that unlike Brazil had no incentives to engage in institution-building in order to “show off” to the global health community that it could succeed in stunting the spread of disease, and thus modernizing. Consequently, and as the detailed case studies in this chapter illustrate, the United States’ isolated public health regime created a institution-building logic that was, and continues to be, shaped more by domestic interests and incentives, not by global pressures. While our government was always eager to provide assistance for combating various diseases and even malnutrition (Lovett, 2005), elite perceptions were never influenced by global forces. Over the years the U.S. has become more isolated within an increasingly integrated global health community. Despite the emergence of a new global consensus

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that all nations should work together in order to share resources, knowledge, and combat epidemics and health inequalities (thus establishing new international norms), since the 1980s the U.S. has not been eager to collectivize and work with others (Kickbusch, 2002). As we will see later in this dissertation, the only time the U.S. has intervened is when it has been in its own medical and economic interests, or when the U.S. military, political leaders, and its citizens (in this order) feel threatened (Kickbusch, 2002). This has motivated recent scholars to encourage our government to work more closely with the WHO, UNAIDS, and other international organizations, such as the newly formed Global Fund to Fight AIDS, Tuberculosis, and Malaria (Yach and Bettcher, 1998; Kickbusch, 2002). Despite these recommendations, and as we’ll soon see with the recent response to AIDS and now obesity, our government continues to refrain from working closely with the global health community and receiving recommendations for institutionbuilding and policy reform, especially when they threaten the interests of corporate America. The early politics of building public health regimes in Brazil were rather different, however. For as the next section explains, since political independence Brazil has had a more globally-receptive, integrated public health regime. This, in turn, generated different political interests and motivations for institution-building. It also established the groundwork for continued global integration and incentives for reform. ~ Centralization and Global Integration in Brazil ~ In contrast to the United States, after political independence the Brazilian government created a more centralized bureaucratic response to epidemics. Two years prior to the declaration of the Republic in 1889, political elites responded to a host of epidemics, such 64

as yellow fever, malaria, and smallpox, by creating a highly centralized public health agency: the Departmento Geral de Saúde Público (DGSP), which persisted till the end of the Republican in 1930, and which was linked with the Minister of Justice in the interior. This institution was designed with the expressed intent of monitoring and curbing the spread of disease. The DGSP acted as a highly centralized bureaucracy freely intervening in state and local government affairs. What is important to note is that throughout this period state elites, mainly the President and his medical staff, were highly autonomous from civil society. Because epidemics were perceived as posing a serious threat to economic development, these elites did not want the DGSP to be influenced by the interests of powerful governors and agricultural elites (Hochman, 1993; Hochman, 2004). Civil society had absolutely no influence over the policy-making process (Vascondelos, 2004). The only members of civil society that had any influence were medical doctors, professors, and intellectuals (Lima and Britto, 1996). Yet even then there influence was limited, relegated only to suggestions of how to improve medical access and treatment. They were not physically represented in the DGSP, and thus could not directly influence policy. Even with the arrival of a new government in 1930, led by a politician by the name of Getúlio Vargas, this pattern of centralized bureaucratic control continued and expanded. Vargas increased the amount of fiscal resources going to the Ministerio de Educacão e Saúde Público (which replaced the DGSP in 1931), bolstered its centralized managerial authority, while creating in 1942 the Servicio Especial de Saude Publico in order to provide health care services to all workers, free of charge (Acurcio, 2004). Like

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his predecessors, Vargas tried to maintain and strengthen the federal campaign to curb the growth of epidemics in order to ensure the modernization and growth of his government. Global Integration In contrast to the United States, the Brazilian government has always worked closely with the global health community in order to eradicate disease. Since the early years of the Republic, the government has worked with several international health organizations, medical researchers, and philanthropists in order obtain financial assistance, medical treatment, and expand the ministry of health (Carrara, 1996, 1997). Brazil’s reciprocal partnership with the global health community is long standing. And as we’ll see in this and subsequent chapters, it is an ongoing tradition that has shaped how and when political elites build state institutions for more effective policy intervention. As the detailed case studies in this chapter illustrates, at the height of the yellow fever, syphilis, and tuberculosis epidemic the Departmento Geral de Saúde Público (DGSP) sent several medical doctors to Western Europe (especially France 22) to share research and to learn more about Western approaches to disease eradication. This was done mainly through their attendance at various international conferences. Through conference participation and open forums the medical community was also able to share knowledge and discuss their commitment and approach to disease eradication (Peard, 1999). In large part this stemmed from the government and the scientific community’s interest in revealing to the global health community Brazil’s ability to overcome disease, modernize, and prosper (Peard, 1999). In essence it marked the beginning of what I 22

One only needs to look at the excessive amount of French health policy books in the archival stacks of the Fundacão Fio Cruz (Brazil’s largest public health archival library) to get a sense of Brazil’s close working relationship with France since the early-20th century. In fact, most of the books that I found on early syphilis and tuberculosis eradication, as well as general public health administration, were in French.

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called in Chapter 2 as Brazil’s “Race to Global Fame,” where, as discussed in more detail shortly, presidents and military dictators have always had incentives to show the international health community that they are a modern state equally as capable – if not better than others, even industrialized nations – at strengthening the federal bureaucracy for more effective policy intervention. During this time the medical community also worked closely with several international philanthropic organizations. The early campaign to eradicate yellow fever and malaria witnessed, for example, several faith based organizations, such as the Santa Casa de Misericórdia, and the medical community working closely with the David Rockefeller Foundation, the Irene Diamond Foundation, and the Red Cross in order to obtain financial assistance and acquire resources (Stepan, 1976). It was a period of medical and scientific experimentation, progress, and collaboration with the international philanthropic movement (Stepan, 1976). The government and the medical community were also quite receptive to international recommendations for how to build a more effective public health bureaucracy. In addition to medical advice, these philanthropic organizations were also important for providing recommendations to the DGSP on how to construct rural outposts for malaria treatment, which in turn helped the DGSP expand its presence in the hinterland (Hochmann, 1998). It was the first time that any international organization provided technical advice on how to expand and strengthen public health administration. Thus in sum, in sharp contrast to the U.S., Brazil has always had a more receptive and cooperative working relationship with the global health community. It did not try to lead the global health movement, nor was it resistant to international assistance and

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recommendations. The government had both reputational and technical incentives for working closely with the global health community. As we’ll see in more detail soon, this relationship was very important for the subsequent emergence of a global health movement that could effectively pressure the government for institution-building while providing leverage to new civic movements and bureaucrats helping ensure government committed to reform.

~ The Limits to Historical Institutionalism ~ Given these differences in the formal institutional design of public health regimes, that is, the United States’ highly decentralized response to epidemic control versus Brazil’s more centralized approach, we should expect different institutional and policy outcomes in response to epidemics. For instance, bureaucratic centralization in Brazil should have led to an unbiased, equitable top-down response to all types of epidemics, regardless of their moral connotations and developmental impact. In the United States, on the other hand, political convergence in favor of decentralization (which was backed by the constitution) should not have led to federal institution-building in response to epidemics, especially after the U.S. Public Health service began to recognize the states’ autonomy over public health policy during the early-20th century. Therefore, based on the formal design of public health institutions, Brazil should have done far better than the U.S. when it came to the timing and depth of institution-building: that is, it should have immediately responded to all types of epidemics by building and/or strengthening the DGSP, whereas the U.S. should not have responded through institution creation and federal intervention

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after the turn to decentralization. However, a closer look at the historical record reveals a somewhat different story. Indeed, a closer examination of the emergence of Brazil’s public health regimes reveals an interesting paradox. The more centralized and autonomous bureaucratic institutions became over the years, the more biased the government became in its response to certain types of diseases. As the following case studies illustrate, despite the DGSP’s centralized authority, the early Republican government was quite selective and biased in the types of epidemics it responded to. Troubled with having to respond to a spate of urban and rural health epidemics, or what I referred to in Chapter 2 as the “multiple-diseases problem,” initially the DGSP only responded to those epidemics that it believed to be the most devastating to the national economy. And this occurred despite the consistently higher prevalence of tuberculosis in the cities, especially Rio (see Figure 1.3 below). This, in turn, unmasked the government’s preference to respond to epidemics that it perceived as more important and worthy of reform, such as yellow fever and malaria. Thus, and similar to what we saw in the U.S., federal elite perceptions during the first phase were influenced by structural factors other than the epidemic itself. And yet, as the detailed case studies on tuberculosis and syphilis will show below, the medical community and civil society thought otherwise. During the first phase period, this led to a high degree of inter-elite contestation between governing elites and civil society. This bias in the government’s institution-building response to yellow fever and malaria delayed institution-building reforms for tuberculosis and syphilis, other epidemics that were not perceived by political elites as worthy of an immediate response.

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Note that this biased institutional response was not unique to Brazil’s early Republican government. As we’ll soon see with the government’s more recent response to AIDS and tuberculosis, this problem has emerged again, notwithstanding the government’s immediate recognition of a new epidemic threat. Similar to what we saw in the past, we’ll soon see contemporary political elites build massive federal agencies for certain diseases, such as AIDS, but not for others, such as tuberculosis. Once again, this biased institutional response reflected the timing and influence of new global health pressures and the contrasting domestic incentives for institution-building (Gómez, 2007a). Thus in closing, during the Brazilian Empire (1822-89) and the Republic (18891930), there was absolutely no way that we could have predicted the types of institutionbuilding activities that emerged in response to epidemics by merely understanding the type of public health regime present. As the case studies in this chapter illustrate, despite its highly centralized bureaucratic approach, in the end the government was not as responsive to all types of epidemics throughout the early 20th century. Due to initial conflicting perceptions, triggered by the challenge of having to selectively respond to a host of epidemics, the absence of a new global health movement, its pressures and therefore the absence of a international-domestic partnerships, political elites did not immediately respond to all of its epidemics through a institution-building process. Rather, politicians only responded to those epidemics, such as yellow fever and malaria, which they perceived to be the biggest obstacles to economic development. Other epidemics, such as tuberculosis and syphilis, which were clearly the biggest epidemics in larger urban centers, did not receive this type of attention and response.

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In the United States, on the other hand, the consensus towards a completely decentralized response to epidemics did not prohibit the federal government from periodically intervening through the creation of new federal agencies and increased financial assistance to the states. As we will see later in this chapter, despite its decentralized approach to public health, there were instances in which the U.S. immediately responded to syphilis, mal-nutrition, and polio, for example, through federal institution-building initiatives. However, this occurred only when epidemics threatened U.S. national security, mainly through its negative affects on the fighting capacity of military enlistees, and/or when epidemics threatened the personal lives of high level politicians, such as polio’s effect on FDR. Therefore under certain structural conditions federalism and decentralization did not stop the government from building new public health agencies and intervening at the local level. Furthermore, despite deteriorating fiscal conditions, due mainly to the financing of two world wars and the great depression, devolution did not preclude the Congress from allocating more money to the states in order to directly influence the implementation of prevention and treatment programs. As in the past, the government overawed federalism and intervened. But it only did so when epidemics threatened its national security interests. Should we have expected this type of response? No, not at all. There is no way that we could have predicted these institution-building outcomes based on the formal design of America’s public health regime by the early 20th century: that is, a completely decentralized public health system, which was formally recognized by the U.S. constitution and the Public Health Service.

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These findings lead me to suspect that there were other structural conditions that shaped how and when elites responded to epidemics through institution-building. As the following sections on polio, syphilis, and mal-nutrition illustrate, the underlying political and bureaucratic coalitional logic of institution-building was different in the United States, reflecting its isolation from the global health community and its more domestic political interests. In contrast to Brazil, the underlying politics of responding to epidemics through institution-building was eventually shaped by national security issues, on one hand, and the personal threat that epidemics pose to political leaders, on the other. Absent global pressures and trio relationships within the U.S., our presidents and the Congress would only respond because of domestic concerns. ~ Focusing on Formal and Informal Causal Relationships ~ To sum up, for the United States and Brazil it is clear that the mere presence of particular types of public health regimes – decentralized in the U.S., centralized in Brazil – could not have predicted both the timing and scope of institution-building that occurred. Instead, institution-building was a product of each country’s unique underlying global and domestic political coalitions, which emerged after the epidemic arose. Consequently, for all of the epidemics discussed below, regardless of their etiological origins and moral connotations (sexually- versus non-sexually transmitted, for example), there was always a delay in the government’s institution-building response. Moreover, the degree of democratic consolidation and electoral accountability present, which was much stronger in the U.S. when compared to Brazil, had absolutely no influence on the government’s commitment to institution-building. Both old and new democracies were apathetic towards immediately responding to epidemics. As I discuss at the conclusion of this 72

dissertation, this seems to suggest that the durability and quality of democracy can in no way predict the types of institution-building activities that occur in response to epidemics. This leads us to the final issue of what precisely are the causal variables that we should be focusing in on and better yet, how we should go about conducting future comparisons. If formal historical and more contemporary formal institutional designs do not predict the types of institution-building activities that emerge in response to epidemics, then perhaps it is time that we start focusing on the underlying noninstitutional political, bureaucratic, and international conditions that shape elite perceptions and interest in doing so. As the conclusion of this chapter argues, and as the following case studies illustrate, re-classifying public health regimes based on the presence of certain types of underlying political, bureaucratic, and domestic-global political and bureaucratic relationships may do a better job of predicting both the timing and scope of institution-building activities, and thus the bureaucratic capacity of nations to effectively respond to epidemics. We begin our analysis with the origins of the U.S. Centers for Disease Control (CDC). This section illustrates how the government’s preoccupation with war and national security led to the creation of a public health agency that was designed for war purposes only, thus instigating fear and uncertainty of continued survival after the war ended. I argue that this uncertainty generated a path dependent proclivity towards immediately viewing new epidemics as a means to bureaucratic survival, in turn generating bureaucratic territoriality, competition, while eventually hampering interagency coordination in response to epidemics. My focus on the CDC, and not its

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Brazilian counterpart, stems primarily from the fact that the U.S.’s institutional response was driven more by domestic structural conditions (as noted earlier), not global forces; this, in turn, required the presence of a more pro-active, autonomous bureaucratic agency that to a greater extent relied on its own capacity and incentives for institution-building.

BUREAUCRATIZING EPIDEMICS: THE CDC’S BIRTH AND SURVIVAL Since the mid-20th century, the U.S. Public Health Service has had to rely on its own devises when respond to epidemics: that is, instead of relying on the Congress for continued financial and political support, it has always had to rely on its own resources and commitment to combating disease. Furthermore, as a consequence of the government’s persistent isolation from the global health community, there also never emerged an informal tripartite partnership between civic organizations, the public health bureaucracy, and international health organizations, which could provide bureaucrats with the resources and the leverage needed to help convince political elites of the need to engage in institution-building activities. What emerged instead was a PHS regime that had to learn and adapt on its own; moreover, it is one that has had to operate within a challenging bureaucratic environment: that is, within a highly fragmented yet increasingly professionalized public health system, one that by the 20th century created the basis for a very weak and ineffective response to epidemics. It was in this context broader that the PHS gave birth to the Centers for Disease Control (CDC). Created in 1942, the CDC was initially called the Malaria Control in War Areas (MCWA) unit of the PHS. It was a special unit of the PHS that was created for the sole purpose of protecting military soldiers from the spread of malaria in the south. The

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MCWA was located in Atlanta, Georgia, near several military outposts were soldiers were training for battle in Europe (Ethridge, 1992). The CDC was thus created for national security purposes. Because of this, it was not initially perceived as a permanent federal agency that would continue to operate after the Second World War was over. This context gave birth to an agency that had to immediately start worrying about its survival soon after opening its doors in 1942. This stemmed from the fact that shortly after the Second World War, the President and the Congress re-considered the need for its continued existence, despite the ongoing problems with polio and other diseases (Ethridge, 1992). Nevertheless, by the 1950s the CDC had served its purpose. This prompted the President and the Congress to dramatically reduce CDC funding and assistance in expanding the size and technical capacity of its personnel. What is more, during this period, despite bitter disagreements between CDC directors over how to respond to malaria and other diseases, the President and Congress failed to provide any assistance in quelling disagreements, finding common ground, and consolidating inter-agency responsibility (Etheridge, 1992). As we will see again in Chapter 5 with the government’s response to AIDS, this is a leadership problem that persisted throughout the years and continued to hamper the PHS’s ability to respond to new epidemics. The upshot to all of this is that by the late-1940s the CDC became an organization that nobody aspired to work for (Etheridge, 1992). It had no money; it had no prestige; and consequently, it provided little career advancement. Under these conditions, what could the CDC do to survive?

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The Birth of Viewing Epidemics as a Means for Agency Survival The CDC quickly found itself in danger of disintegration. Other agencies were surviving, thriving. With the government’s rapid shift in attention to scientific research, the National Institutes of Health (NIH) obtained more money and prestige. Consequently, because it had fulfilled its mission by 1950, the CDC found itself on the verge of collapse. This prompted the agency to pursue any means necessary for its continued survival. The best and only way it knows how was to once again prove muster as an effective disease combatant. Under CDC Director Langmuir, for example, the creation of new intradepartmental agencies was introduced in order to provide more support for CDC expansion. With the specter of a possible biological threat to the U.S., in 1951 Langmuir proposed the creation of the Epidemic Intelligence Service (EIS). The Congress loved the idea. After all, it had to do with national security, and boded well with the times. As Astor (1983) once put it: “the creation of the EIS, reasoned Langmuir, would provide the country with a large cadre of experts whose skills could be immediately mustered in the event of a bio-logical warfare attack. The legislators were sufficiently impressed, and the EIS was established” (Astor, 1983: p. 5). This level of support was important for its continued existence. To this day, the EIS continues to recruit the brightest minds in the fight against disease (Carey, 1985; Russell, 1986). Thus in order to survive, the CDC did something that it knew the President and the Congress would support: that is, to create a new departmental agency for the purposes of increasing our national security. As we saw in the past, this boded well with a democracy that only pursued institution-building whenever epidemics threatened the national security. On its own, however, this initiative was insufficient for guaranteeing 76

the CDC’s survival. Soon, it started to turn to other epidemics to justify its continued existence. Indeed, for the early 1950s marked the genesis of CDC views and perceptions of health epidemics as means for agency survival. It did so by trying to increase its response to other epidemics at the time, such as polio, in order to show that it could still successfully combat urban disease. It did the same thing for international viruses, such as the Asian flu influenza of 1957. In her seminal contribution to the history of the CDC, Elizabeth Etheridge (1992) states that: “the increasing incidence of poliomyelitis early in the decade and the Asian flu pandemic of 1957 gave the Atlanta institution an opportunity to prove itself. In a five-year period, the CDC moved from a position of relative obscurity in public health to one with major responsibilities for epidemic control” (Etheridge, 1992: p. 67). The CDC had something to prove, and it was using all it had to distinguish itself as an agency worthy of survival. Responding to polio provided the best opportunity for achieving this objective. Realizing the government and civil society’s desperation for a polio vaccine, in 1955 the CDC proposed the usage of gamma globuli, a blood extract containing anti-bodies, as a serious possibility. This was promising because there was evidence suggesting that polio circulated in the blood. Eisenhower immediately authorized the CDC to experiment with gamma globuli and to work closely with the states for its implementation. This infuriated the director of the National Foundation for Infantile Paralysis (aka, the March of Dimes), Basil O’Connor, beyond measure. O’Connor began to compete with the CDC and started questioning gamma globuli’s effectiveness. Shortly after the states started using the new

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vaccine, a CDC report came out showing that gamma globuli was not working. This immediately increased the CDC’s prestige and further contributed to its legitimacy. And lastly, the CDC’s investigation into the famous Cutter Laboratory incident of 1955, in which lab workers accidentally injected the live polio virus into the Janus Salk vaccine, which was then distributed to hundreds of children, contributed even more to its prestige. The CDC’s Epidemiological Intelligence Service (EIS) was the agency responsible for discovering and reporting the incident. This brought the EIS and the CDC much notoriety. As one historian put it: “For the epidemiologists of the Communicable Disease Center, the Cutter incident was the crisis that made their reputation” (Smith, 1990: p. 369). By the 1960s, this strategy paid off. Under the Lyndon Johnson administration the amount of money given to the CDC increased substantially (Etheridge, 1992). In response to the CDC’s impressive work on polio, and in part because of Johnson’s commitment to social policy through his Great Society campaign, Johnson started to invest more money into the CDC’s family planning programs and its led-based poisoning projects (Etheridge, 1992). 23 This effort made it clear to the Congress, which also became more supportive of the CDC’s mission, which it would survive and thrive under Presidents Johnson and Carter. Johnson’s new financial commitment to the CDC also suggested something else. It suggested that publicly discussing an epidemic and responding to it in new and innovative ways could lead to a sizeable increase it budget from the Congress. As we’ll 23

But note that in itself this was not a institution-building response. As noted in Chapter 2, for a complete institutional response to occur, governments not only need to provide additional resources to health agencies but they must also create new agencies in response to an epidemic, and/or merge responsibilities between them; even further, a necessary condition is providing direct assistance to the states and, especially, bereft municipalities.

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see in the next few chapters, this expectation persisted and contributed to the CDC’s ongoing interest in immediately responding to epidemics, especially in periods of fiscal retrenchment. The CDC was thus born for one specific reason: to protect military soldiers and, thus, our national security. It was a time when malaria was perceived as an epidemic that would threaten the fighting capabilities of our military enlistees both at home and abroad. It was not born out of the need to protect civil society and meet local government needs. The aftermath of the malaria campaign brought with it a great sense of fear and uncertainty. For instead of praising the CDC for its accomplishments and expanding its presence, the government began to question its existence and by 1950 recommended that it be dismantled. Thus in sum, the CDC was a federal agency that was born out of great fear and uncertainty about its future existence. It was a fear that continued over the years (decreasingly slightly under Johnson and Carter) and a fear that instigated a habitual instinct that would perpetuate over the years: that is, to view epidemics as a means for agency survival in periods of fiscal and bureaucratic retrenchment. In the chapters that follow, we will see the CDC behave this way again during the first few years of the AIDS epidemic and then yet again with the recent obesity epidemic. This has repeatedly constrained the CDC’s willingness to engage in inter-agency collaboration, which is a key element of institution-building responses to epidemics.

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Polio Politics (1900-57) 24 At the turn of the 20th century, polio was by far the largest epidemic to affect the nation. Despite the emergence of the Influenza virus of 1918 which killed an estimated 400,000

within two years, the number of polio cases and deaths continued to increase throughout the 1950s. It was the first major epidemic that the U.S. Public Health Service (the CDC

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Graph 3.1- Polio Chronology, seen above, was taken fro the following website: http://www.geocities.com/harpub/pol_all.htm. In this website, the author, Dr. Jim West, claims to have obtained the raw numbers from a myriad of official government sources; I quote him here: “The data for the last half of the 20th century was gathered from U.S. Vital Statistics. The very earliest numbers, from 1887 to about 1904, and the post polio numbers, are interpolated from the general historical commentary regarding those periods (see bibliography on Homepage and NYC Health Commissioner Haden Emerson's compilations). While the graph is not perfectly accurate, due to changing methods of diagnoses and recordkeeping within the medical system, it does give a reliable overall picture of polio cases in terms of known literature and records. The source for the U.S. and Swiss discoveries of paralysis in calves is from Van Nostrand's Encyclopedia of Science and Engineering (1995), vol. 5, p1725. The phrase "Pesticides As A Panacea: 1942-1962" is a subtitle found in Encyclopedia Britannica, Macropaedia (1986). Refer to other graphs (Overview) for specific pesticide comparisons with polio incidence.”

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and NIH) responded to. 25 Various theories existed for polio’s cause and spread, ranging from the filth and dirt brought over from the new European immigrants, to the pesty little black flies that flew in and out of kitchen windows. Similar to what we will soon see with the HIV/AIDS virus of the early-1980s and the recent obesity epidemic, notwithstanding the government’s knowledge of polio’s spread it did not immediately respond to it. And the reasons were rather clear. First of all, polio did not pose an immediate threat to U.S. national security, mainly the ability of military soldiers to fight in war. Nor were major military installations immediately threatened by the disease. Second, no major political or bureaucratic official had been affected by the epidemic. During the first phase period, these structural conditions suppressed the president’s perceptions of the urgency of having to respond to polio, and thus generated no incentives to engage in an immediate institution-building response. But these views were not held by the public health establishment. Local health departments as well as the US Public Health Service were clearly arguing that a national epidemic had emerged. They were motivated more by the genuine need to respond to a burgeoning epidemic, not a national security threat. This was influenced by their long held commitment to scientific progress and disease eradication. What all of this meant was that during the first phase of polio politics, federal politicians and the bureaucrats could not agree on the need to construct a more centralized institutional – or even policy – response to polio. This period was therefore marked by a high degree of inter-elite contestation and no interest in institution-building.

25

Keep in mind that the Influenza virus of 1918 emerged before the creation of the CDC and NIH. This is why I have not studied this epidemic.

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Unless convinced otherwise, the President and the Congress would remain committed to a more decentralized approach to epidemic control. In this context, the White House believed that polio should be first taken care of by municipal health departments, not by the federal government. Prior to FDR, polio was never perceived as a national health threat worthy of an immediate federal response (Rogers, 1996). Instead, both Presidents Woodrow Wilson and Herbert Hoover believed that all types of epidemics should be handled by local health departments, that the tenants of federalism and decentralization should reign, and that the President should neither create and/nor modernize public health agencies for aggressive federal intervention. Our government did not respond to polio until it directly threatened the life of a very influential political figure on the national landscape, Franklin D. Roosevelt. A former New York state senator (1910-13) and Assistant Secretary of the Navy (1913-20), and Vice Presidential democratic nominee (1920), before being elected into office Roosevelt was a well known politician and highly regarded. His illness thus garnered a lot of media and political attention. . Indeed, Rogers (1996) writes that the government’s attention to polio was essentially non existent until after FDR was diagnosed with the virus in 1929. Obtained during his annual retreat to his summer home in Campobello Island, just off of the coast of New Brunswick, Canada, within a matter of weeks FDR became paralyzed from the waste down. It immediately affected every aspect of his life, however clandestine and discrete he tried to keep it. But more importantly, it immediately affected his persona, him and only him, no one else. Within a matter of days he transformed from a tall, powerful political figure to a common man, equally as susceptible to disease and death. He was quickly reduced to one of “those sicklies” that

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the government had previously ignored. As the historian Finis Farr writes: “There can be no doubt of it, those months of pain put Franklin Roosevelt into the human race, and the permanent crippling that resulted from his disease kept him there. One no longer envied Roosevelt, his head start on life” (Finn, 1972: pp. 127-28). Polio’s affects on FDR dramatically changed his perception of the epidemic. Prior to his illness, he showed no interest in immediately responding to it. It was only after his illness that he changed his perception and interest in polio. Rogers (1996) asserts, for example, that polio immediately transformed FDR into someone that empathized with those suffering from the epidemic; it made him more compassionate and caring, more interested in the government’s progress in combating the disease (Rogers, 1996: p. 167). His illness also changed civil society’s perceptions of the epidemic and the social stigma surrounding it (Rogers, 1996). It was no longer perceived as a poor, filthy man’s disease. It was now perceived as something that anyone could get. Personalism changed polio politics. While increased global pressures and the global race to fame would affect Brazil’s institution-building response to syphilis and tuberculosis, polio was an all-American disease. 26 Because of this, it triggered a more domestic response. Personalism at the executive-level finally led to a series of new national health campaigns, co-sponsored by the government, and vertical reforms that enhanced the federal government’s ability to intervene in order to save lives and spur interest in prevention. In addition, because these reforms were personally inspired, they were never influenced by global recommendations and pressures for institutional change but more from the President’s views about what should be done and how. 26

Keep in mind that during the early-19th century, the U.S. had by far the most cases of polio in the world. Consequently, back then it was referred to as a genuine “American epidemic.” As we’ll see later, others have recently said the same about our current struggle with obesity (see Chapter 7).

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Unsatisfied with the government’s response and committed to eradicating the disease, FDR eventually worked with a long-time friend and law partner, Basil O’Connor, to create the National Foundation of Infantile Paralysis in 1938. Housed in the Waldorf Astoria hotel in New York City, the Foundation was a private initiative, such that it was not financed by the government nor was it affiliated with the U.S. Public Health Service. Nevertheless, FDR was unwaveringly committed to it, as if he ran the program. He invested a lot of money and time in order to ensure that it was well equipped to intervene at the lowest tiers of government. FDR’s commitment generated a lot of private sector interest and led to thousands of dollars in donations. Within two years, the Foundation surpassed in wealth any other philanthropic organization at the time, such as the National Tuberculosis Association (founded in 1904), the National Society of Crippled Children (now know as the Easter Seal Society, which was founded in 1919), and the American Heart Association (1924) (Offit, 2005). FDR’s personal commitment to the new polio campaign motivated him to work closely with Basil on a host of institutional and financial initiatives. Within just a few years, they transformed the National Foundation into a large, well organized hierarchical organization, with a central office in New York and a host of regional offices at the state and local level (Oshinksky, 2005). FDR worked with Basil on several fund raising campaigns, including the infamous presidential birth day balls, which raked in thousands of dollars (Oshinksky, 2005). FDR and Basil also worked very closely with Hollywood. FDR’s friend, Eddie Cantor, was a famous movie star and used his cinematic influence to persuade movie goers to donate one dime to the National Foundation’s campaign; this gave birth to the famous “March of Dimes,” which still exists to this day.

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FDR’s personalism set the groundwork for further research and innovation. The National Foundation stood as a model for what a major philanthropic organization could achieve. In addition to working with local volunteer communities (many of which were women’s clubs) in order to provide treatment services, the National Foundation became the largest grantee for polio research, far surpassing the NIH’s budget. It ended up financing Dr. Jonas Salk’s research and discovery of the polio vaccine in 1957, providing a good example of what private philanthropy could achieve when backed by a popular president (Oshinsky, 2005). FDR’s personal experiences with polio thus finally motivated him to help create a new federal response to the epidemic. His personal conviction provided the unwavering political, financial, and popular support needed to continue the fight against polio. It was a quasi-political response, with the bulk of it managed by private philanthropy and donations. But note that it was FDR’s personal conviction which prompted this new federal campaign. And it was the only campaign created in response to the epidemic. It emerged because FDR understood what other people felt and because he finally realized how urgent the situation was. A centralized, state-guided response was needed, which suggested to him that in periods of health crisis, federalism and decentralization may eventually cause more harm than good. Personalism did more than engender a new presidential commitment to reform; it also motivated FDR to provide recommendations to the general public. More specifically, it called on all family members and civil society to take on a more personable and responsible approach to protecting themselves and their loved ones from health ailments. FDR, Basil, and their staff at the municipal level incessantly reminded family members

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that they were personally obligated to protect themselves and their loved ones from polio. And furthermore that it was their duty as American citizens to support the national campaign (Oshinksky, 2005; Rogers, 2006). Above all the government incessantly reminded them that prevention was a family responsibility and that individual responsibility and care, the tenants of personalism as experienced first hand by the president, made this possible. Personalism under FDR also established a pattern of how future presidents would respond to contested epidemics. Future personalistic responses emerged whenever an epidemic had the greatest chance of affecting the lives of political executives, such as the president, state officials, and bureaucratic leaders. Historically, syphilis, malnutrition, and even HIV/AIDS did not have these kinds of affects. However, polio and other future epidemics, such as obesity years later, certainly did. Indeed, for as we’ll soon see with the current Bush administration, personalism has reemerged as yet another reason for building a new federal campaign in response to the more recent obesity epidemic. The threat of possibly gaining weight and challenging Bush’s long-held personal commitment to physical fitness prompted him to create new executive orders while providing recommendations to families on how they can take better care of themselves and their loved ones – something similar to what FDR did with polio. Unlike FDR, however, while Bush eventually fell short of creating a new federal agency for obesity, he has nevertheless done far more than any other president when it comes to placing obesity on the national agenda and motivating other bureaucrats and politicians, especially at the sub-national level, to pursue institutional and policy reforms.

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Coalitional Politics But the crucial question we must ask ourselves is the following: why was there no immediate institution-building response to polio? Why did FDR originally ignore polio and why did it take personalism to eventually illicit a quasi-institution-building response? Addressing this question requires that we better understand the underlying formal and informal coalitional politics that went into the creation of FDR’s national campaign and why it never emerged prior to his illness. First, and as noted earlier, before FDR became ill with polio, the epidemic did not pose a serious threat to national security. Because of this, the President had no interest in responding through new institution-building initiatives. In the absence of a pro-reform coalition favoring an institution-building response, the government immediately relied on decentralization. As we discussed earlier, by the 1920s the U.S. Public Health Service was committed to a more decentralized approach to public health, especially at the urban level (Chester, 1951). In addition, and as we’ll soon see again with malnutrition during this period, Presidents Woodrow Wilson, Herbert Hoover, and FDR believed that local governments should be the first responders to epidemic outbreaks. Later on in this dissertation we’ll see how this tradition persists and how it hampered the government’s ability to respond to more recent epidemics, such as AIDS, obesity, and even natural disasters, such as Hurricane Katrina. While there was interest in creating a more centralized bureaucratic response to polio and other urban epidemics, especially under the leadership of Surgeon General Thomas Parran, few within government agreed with this perspective. When compared to the President, the Congress and most health officials’ commitment to decentralization, Parran and his comrades did not have the domestic (or international) support needed to 87

convince the President and the Congress that they needed to create a more centralized bureaucratic approach. Furthermore, because bureaucratic officials in favor of a more centralized approach were not influential, those civic associations pressing for this kind of response were not well organized, influential, and thus eager to get involved. Prior to FDR, and even after him for other epidemics not associated with polio, such as syphilis and heart disease, civic associations fighting for the sickly did not have the bureaucratic leverage needed to convince the government that it needed to immediately respond through new institution-building activities. In contrast to Brazil, moreover, there was no global movement for polio which civil society could use to increase their influence when working pro-reform bureaucrats. Taken together, then, it was the absence of a firmly established coalition between civil society and pro-reform bureaucrats, in addition to polio’s domestication (that is, its isolation from global health politics), that failed to generate sufficient pressures and interests in institution-building. In other words, it was the absence of a trio movement (as seen in Brazil) that contributed to the problem. These conditions facilitated - and indeed encouraged - FDR’s initial apathy towards polio and his lack of interest in immediately responding to it through the creation of a new federal agency and/or the reform of pre-existing public health institutions. Personalism was thus the only reason why FDR responded to polio. And even then, his response did not lead to new institution-building initiatives. For what was crucially absent in order for this to occur was polio’s direct threat to the national security. Without this condition, institution-building would not be pursued.

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As the next section illustrates, however, polio would not be the only health epidemic failing to prompt institution-building. Mal-nutrition, the precursor to our current obesity problem, also failed to instigate such a response. Instead, and as we’ll soon see with syphilis as well, national security concerns would once again be the primary reason for the government’s interest in institution-building. Food, War, and State Building (1900-1947) Perhaps the best precursor to the obesity epidemic of the 21st century was the early-20th century response to malnutrition. While Americans of the 21st century would pay the price for over-eating, citizens of the early-20th century faced the opposite problem: food scarcity and mal-nutrition, which in turn led to under-weight dilemmas. Mal-nutrition was the weight epidemic of the early 1900s. And it would remerge again during and even after the great depression. Nevertheless, and as we’ll see again with obesity almost a decade later, the federal government once again refrained from expanding and strengthening our public health system in response to the burgeoning epidemic. Instead, it only responded through institution-building means when food scarcity and mal-nutrition posed a direct threat to the fighting capacity of military soldiers – in other words, when it posed a national security threat. In addition, the early-20th century marked the genesis of the government’s repeated pattern of neglecting to regulate the food industry. During this period the food industry thrived and consolidated itself as a powerful political force shaping future congressional coalitions against the regulation of fatty foods. Herein I demark the two phases of “weighty” politics. The first phase emerged with the problems of mal-nutrition during the early-1900s, prior to World War I. During this period food shortage was a major problem, as well as malnutrition. While obesity 89

was also an issue (Stearns, 1997), though mainly among the affluent classes and new immigrants crafting fatty menus (the Italians, for example, where well known for their smoky sausages, soups, and pastas), mal-nutrition was by far the biggest problem among the urban poor. Laura Lovett (2005) argues that during this period New York City’s local government became increasingly concerned about how it would respond to child malnourishment, which was estimated to be 23% in 1906 (Levitt, 2005; Spargo, 1906). Food shortages and redistribution posed yet another challenge. In response, the government asked families to cut back on the consumption of scarce foods, such as flour, meat, sugar, and butter (McIntosh, 1995). Nevertheless, despite the government’s growing awareness of the mal-nutrition problem it did not immediately respond, either through the creation of new federal agencies or the increased provision of financial and technical assistance to the states (McIntosh, 1995). This is not to say, of course, that there was no federal response. Prior to WWI, the government did take malnutrition seriously. Prior to and during WWI, the US Department of Agriculture and the US Children’s Bureau was proactive in organizing health clinics at the local level and disseminating information about malnutrition – mainly through educational pamphlets and films on children’s health (Lovett, 2005). In addition, in response to food shortages, a sudden rise in prices for milk and dairy, the Senate called for the provision of subsidies for milk and other food products, including relief measures such as cooperatives, subsidized stores, public kitchens, and school lunch programs (Lovett, 2005; Dupuis, 2002; Levenstein, 2003b). However, and this is key, there was no effort to create a new federal agency – or even subdivision – prior to 1918, the year the first world war started. Furthermore, there was no steady stream of funding

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to schools. The only organization working to provide these services was the Commonwealth Fund, a private philanthropic organization that was financed by Standard Oil, but not until 1918 (Lovett, 2005). Up through the 1930s, the Commonwealth Fund was the most proactive organization providing educational and technical assistance to the cities. Indeed, the President’s first institution-building response to malnutrition emerged when in 1917 Woodrow Wilson appointed Herbert Hoover as the “Food Czar” of the National Food Administration. This was done in order to ensure that military soldiers were adequately nourished for the war in Europe, as well as providing food for the poor in several European nations (Levenstein, 1993). The National Food Administration was focused entirely on the war on providing food for soldiers and starving war-torn citizens in Europe. When it came to the poor, Presidents Wilson, Hoover, and even FDR relied on local charities, such as the Commonwealth Fund and the Red Cross, as well as local health departments (Levenstein, 1993). Furthermore, the only executive order issued in response to mal-nourishment was targeted at Hoover and the National Food Administration (NFA); this executive order was issued in order to increase the NFA’s autonomy and influence. Newly empowered, Hoover’s NFA began to ask families to make, save, and donate food for hungry soldiers at war (Levenstein, 1993; Lovett, 2005). In 1918, Hoover created the “Food Will Win the War Campaign,” which was explicitly designed to encourage families to ration food in order to donate more to US fighting soldiers and families in Europe. Slogans such as “Meatless Mondays” and “Wheatless Wednesdays” where used to encourage families to ration food.

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Illustration 3.1 – The Greatest Crime in Christendom, US Food Administration, c. 1918

Posters, as seen above, were published by the U.S. Food Administration emphasizing that gluttony was a sin. The “Food Will Win the War” campaign was designed to conjure up individual self-sacrifice and commitment, to craft a sense of communitarianism and solidarity in helping our government maintain a healthy fighting force. Several years later, before the Second World War emerged, the government did the same thing again, but this time it further increased its institution-building response to malnourishment. Notwithstanding a record high number of families and children 92

suffering from malnourishment prior to and throughout the two world wars, and despite the Secretary of Labor, France Perkins,’ increased awareness of the problem, the President once again failed to immediately respond through institution-building efforts (Levenstein, 1993). Yet again, FDR relied on local charities and health departments to be the first responders. In fact, during part of the inter-war period (1931-1934), federal direct aid for the poor suffering from malnourishment actually decreased, as did local government spending for malnourishment and public health in general (Levenstein, 1993). War, once again, prompted institution-building (Tilly, 1990). The slogan that Herbert Hoover created in 1917, “Food will Win the War!,” was once again used by the Farm Security and War Food Administration” 27 As in the past the campaign was used to encourage farmers to produce and ration more food in order to maintain a steady supply of rations sent to US soldiers and citizens in other nations (Thomas, N/D). In 1941, in response to a record number 41% of enlistees rejected from military service due to malnutrition, the Food and Nutrition Board (FNB) of the National Research Council (NRC) was established to advise the government on better nutrition as it pertained to national defense. Charged by Roosevelt with the task of developing a set of dietary guidelines, the FNB developed the first set of Recommended Dietary Allowances (RDAs) (McIntosh, 1995). Next, in 1941 FDR created the “War Food Administration.” The administration was responsible for convening experts and providing advice on the kinds of food soldiers should consume, as well as controlling food policy for FDR’s New Deal program

27

This picture was obtained from the following website: www.airgroup4.com/u6as.jpg

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(Levenstein, 1993). Henceforth any domestic initiative for food policy was driven by FDR’s concern for the war. Next, FDR gave Paul McNutt, director of the Defense Health and Welfare Services (DHWS), complete authority to expand the DHWS and create a special Division on Nutrition, which served to further buttress the War Food Administration’s needs (Levenstein, 1993). While the government was focused on the war, there were others in civil societies that were focused on better nutrition and food processing. There was a growing movement in civil society and the medical community to regulate the food industry, specifically its food content and advertising. This was viewed as important because it helped to potentially decrease the consumption of foods contributing to malnutrition. For example, if consumers knew the fat content of their foods, or its precise nutritional value, then they would choose foods that were more nutritional. Collectively pressuring the government for increased food processing and marketing regulations was thus perceived as an effective policy response to malnutrition. Similar to our current struggles with obesity today, these efforts nevertheless fell short of influencing the food industry, which was an oligopoly owned by manufacturers such as General Mills and Standard Brands. In 1911, led by Arthur Kallet and Frederick Schlink of the Consumers Research Inc., as well as other concerned citizens, a new social movement emerged to pressure Senators for an amendment to the Food and Drug Act of 1906 (Levenstein, 1993). The goal was to increase the regulation on food additive processing. In response, the food corporations joined the United Medicine Manufacturers of America in organizing a powerful lobby against this proposed legislation. Among the provisions they found most objectionable was a proposal that false and misleading

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advertising be penalized (the 1906 act banned only false labeling), something that would jeopardize their extravagant health and nutritional claims. Consumer Research Inc. and the growing movement in favor of federal regulation never succeeded in countering this response. For in addition to the food industry’s strong relationship with an administration favoring increased food production for war purposes, even the American Medical Association (AMA) was supporting the food industry’s plight to destroy this anti-regulatory movement (Levenstein, 1993). While the passage of an amendment would eventually emerge several years later, this resistance foretold of future difficulties in the government’s ability – or better yet, willingness – to increase its regulation of the food industry. This problem will re-emerge again under the current Bush administration and its ability to shape the administration’s reactionary, unsupportive response to a burgeoning global movement in favor of increased food regulation in response to obesity.

Reform Coalitions Thus while institution-building did eventually emerge in response to the two world wars, it is important to note that this never occurred prior to and in between the wars. During the first few years of the malnutrition epidemic, because growing malnourishment in urban centers did not immediately threaten our national security, this failed to instigate a new underlying political coalition in favor of institution-building. Instead, the President, the Congress and most public health officials once again believed that the local governments should be the first responders. In addition, and as we saw with polio, there never emerged an underlying civic and bureaucratic coalition pressing for an immediate institution-building response. While 95

there were some bureaucrats, mainly from the USDA and the Children’s Bureau, suggesting a greater re-centralization of authority, prior to the two world wars they were never influential. Moreover, during this period, and even after the two wars, they did not create an enduring coalition with civic organizations, such as Consumer Research Inc., for the creation of a new agency and/or subdivision within the USDA increasing the regulation of food additive processing and misleading marketing campaigns. During this period there was also no “global malnourishment” movement that civil society and pro-reform bureaucrats could use to persuade the Hoover and FDR administrations to pursue new institution--building initiatives. In fact, it was a time when the government was trying to once again lead the world in the fight against malnourishment (Lovett, 1995). Herbert Hoover’s appointment to the Commission for Belgian Relief (considered to be largest professional relief organization of its time) stood as a prime example of US leadership in providing food for starving Belgian’s under German occupation. Indeed, during WWI the government donated thousands of dollars to help other nations combat the malnourishment problem. The government focused primarily on war-torn Western and Eastern Europe. During this period, the country of Armenia received the most assistance (Lovett, 1995). Yet again the upshot was that, as we saw with polio, the absence of a global health movement for malnutrition and worse still, the government’s reluctance to join the global health community provided few incentives for the emergence of a collective civic movement that desired to establish partnerships with bureaucratic reformers in the USDA and the Children’s Bureau. As we’ll soon see, this was the linchpin to success in Brazil. Furthermore, these conditions provided few incentives for pro-reform bureaucrats to

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establish a connection with concerned world health organizations and those segments of civil society interested in institution-building. Similar to what we saw with polio, during this period there was therefore no interest in creating an informal trio movement between civil society, pro-reform bureaucrats, and the global health community. This, in turn, generated insufficient pressures from within the USDA and other agencies for the creation of a new federal agency regulating the food industry. Institution-building eventually occurred, but again it emerged several years after the urban malnourishment epidemic. In response to increased rejection of military enlistees due to malnutrition problems, FDR emerged to create a new reform coalition with several officials in his government, creating a new agency, the “War Food Administration,” which provided new food regulations for soldiers and families. FDR’s health officials and PHS bureaucrats quickly jumped on board. Complete reliance on decentralization came to a brief halt. But note that it took a war to prompt this kind of institution-building response. As we’ll soon see again, this security-based public health regime, if you will, would emerge again with the threat that syphilis posed for military recruits. It is a institution-building trend that will reemerge over and over again: that is, build and modernize federal agencies only when they pose a national security threat … other than that, forget about the people, let insolvent local governments take care of them!

~ BRAZIL ~ Tuberculosis Control and State Building (1900-45) Similar to what we saw in the United States, post-independence Brazil did not immediately respond to the emergence of a new epidemic by creating and/or modernizing 97

federal agencies or providing resources to state governments. One would think that a burgeoning non-sexually transmitted disease, such as tuberculosis (TB), would instigate an immediate institution-building response because of the absence of moral stigma. One would also expect that Brazil’s highly centralized bureaucratic approach to epidemic control would have led to the Departmento Geral de Saúde Público’s (DGSP) expansion and intervention for TB. However, this never occurred. Brazil: Graph 3.2: National TB Trends (cases and case rates) 1200 1000 Cases

800 600 400 Rate of Change 200 0 1870 Source: Nascimento, 1997

1920

As this section illustrates, despite the presence of a robust civil societal and federal bureaucratic response to TB that would, unfortunately, dissipate by the end of the First Republic (1889-1930), it would take new global health movements and pressures for reform, in addition to international criticisms of Brazilian underdevelopment, to finally prompt an institution-building response. Before this occurred, however, the President, the Congress, and most federal officials’ perceptions of the need to respond clashed with the interests of reformers in civil society and influential public health bureaucrats seeking an

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immediate institution-building response. The First Phase of TB Politics was therefore marked with a high degree of political, bureaucratic, and civic elite contestation over the need to strengthen Brazil’s centralized response to TB. Nevertheless, with the emergence of new international criticisms at the apogee of the TB epidemic (thus demarking the beginning of the Second Phase period), essentially all federal elites finally agreed that an institution-building response was needed. This process was driven by the emergence of a politician turned fascist political leader that eventually became unwaveringly committed to institutionalizing Brazil’s response to TB, Getúlio Vargas (1930-45). In addition to his unwavering concern for national development and security, Vargas eventually became interested in showing the international health community that he could overcome an epidemic and succeed in creating a modern nation. Although his concern about his growing international reputation did not begin until early 1940s, this initiative marked the beginning of what I described in Chapter 2 as the “race to global fame:” that is, a repetitive and reproductive motivational force that generates new reputational incentives for modernizing presidents to finally construct and/or expand federal agencies for more effective policy implementation. Later on in this dissertation we’ll see this dynamic reemerge with the response to HIV/AIDS and more recently TB. Similar to what we saw in the United States with polio and later with syphilis, the emergence of TB during the First Phase period did not elicit an immediate institutionbuilding response. Initially political elite perceptions where influenced more by the fact that TB was not perceived as a “nationally significant” disease, such that it was not riddled throughout the nation, as was the case with yellow fever, malaria, samparo,

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syphilis, and the like (Nascimento, 1997; Nascimento, 1991; Antunes et al, 2000). This perception emerged despite the fact that urban centers were gradually becoming more populated. At the time, and as Figure 1.3 illustrates, the government confronted what I called in Chapter 2 as the “challenge of multiple diseases,” which had negative affects on political elite perceptions. That is, the President and his health ministers at the time were grappling with how to respond to a host of infectious diseases and the need to continually strengthen their health systems response. The President had to be convinced beyond a shadow of a doubt that TB should receive more attention than Yellow Fever, Malaria, and a host of other ailments. And this was needed notwithstanding the fact that TB was actually killing many more individuals and at a faster rate. Despite health bureaucrats calling the alarm, the Presidents still did not immediately respond (Nascimento, 1991). Brazil: Graph 3.3: Major National Diseases (1870-1920)

1800 1600

TB Malaria Variola

1400 1200 1000

Yellow Fever Typhoid

TB

800 600 400 200 0 1870

1880

1890

1900

1910

1920

Source: Nascimento, 1991

Rather than expanding and strengthening the DGSP the President issued several national decrees requiring the increased sanitation of municipalities (Netto and Pereira, 100

1991). Led by the mayors and several doctors in civil society, such as Pereira Passos, the Mayor of Rio (who was an engineer by training), and Dr. Oswaldo Cruz, then director of the DGSP, from 1890 to 1910 the President mandated the clean up of Rio’s cities, port areas, and urban housing (Netto and Pereira, 1991). Even before the Republic, from 1876 to 1886, 5 decrees were issued and a ministerial suggestion (aviso) for the DGSP’s sanitary police (Netto and Pereira, 1991). What is even more surprising is that government inattentiveness emerged at a time when civil society’s response to TB, and its pressures on the government for an immediate institution-building response, was high. Indeed, from 1870 to the 1920s, at the height of the TB epidemic (Antunes and Waldman, 1999), a host of influential medical Illustration 3.2 – O Desafio da Tuberculosis; in this political cartoon, Dr. Oswaldo Cruz sits on his throne, giving council to his people on how to respond to tuberculosis. Civil society approaches and seeks his help.

and intellectual elites arose to educate the

government and civil society about the importance of responding to tuberculosis. On June 4, 1900, Medical elites and intellectuals in Rio and São Paulo formed several Ligas do Tuberculosis in order to increase public awareness about the epidemic while at the same

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time providing treatment services through the creation of several health sanitariums (Filho, 2001; Nascimento, 1991). These Ligas also worked very closely with the Santa Casa de Misericórdia, which were lay brotherhood organizations (spanning back to conquest in the 1500s) that were the first to provide housing and treatment for the poor suffering from tuberculosis and other diseases. The Ligas (and thus civil society) were thus the first and only responders to tuberculoses at the height of the epidemic (Filho, 2001; Nascimento, 1991). In an effort to influence government policy, during this period the Liga was also very closely aligned with a burgeoning global health movement seeking a more assertive policy response to TB. In 1900, Liga members started attending international conferences in Europe and even organized an international conference in Rio, such as the X Congresso Internacional de Higine e Demografica. They started educating the government about the successful efforts of several Western European nations combating TB through the centralized expansion of the public health bureaucracy and increased intervention at the local level (Nascimento, 1991). The Liga started emulating prevention and treatment programs in Europe and the United States, while highlighting the fact that these nations also had civic leagues and organizations committed to combating TB (Ribeiro, 1956). This was done in order to convince the President and the Congress that it needed to emulate Western Europe’s (especially Scandinavia’s) approach, rather than relying on the decentralized work of Liga members and other charities (Nascimento, 1991). Through these initiatives, Liga members were able to inform the global health community of their unwavering commitment to tackling the epidemic, on one hand, while

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at the same time pressuring the government to respond more effectively through new institution-building initiatives, on the other (Nascimento, 2005; Filho, 2001). In addition to helping increase international and domestic awareness about TB, through these initiatives the Ligas were also increased their popularity and legitimacy within government and civil society. Their reputation further increased with the Ligas countless conferences, public lectures, and the publication of their findings in several conference proceedings (Nascimento, 1997; 2005). The Liga community quickly emerged as an ally and resource for those bureaucratic reforms in government that agreed with them on the need to strengthen the government’s centralized response to TB, rather than relying on municipal and rural governments as primary responders. But even this wasn’t enough. Notwithstanding their increased international and domestic reputation, between 1900 and 1920 these civic elites were never capable of convincing the President and the Congress of the need for reform. Even the government’s most prized medical doctor, urban engineer, and director of the national public health program, Dr. Oswaldo Cruz, could not influence the government’s position. Dr. Oswaldo Cruz, seen in this picture, was closely aligned with the Liga movement and worked closely with them to pressure the President for reform (Nascimento, 1997; 2005). In 1906, realizing that TB was now the largest killer in Rio and in São Paulo, Cruz proposed the construction of a new bureaucratic agency committed to combating TB (Nascimento, 2005); it was to centralize all aspects of TB prevention and treatment, thereby ending the overburdened, underpaid work of the Santa Casas and the Ligas. But the government didn’t budge; it completely ignored Cruz’s request (Nascimento, 1997; 2005).

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In an effort to placate Cruz and the burgeoning civic opposition, the government’s only response at the time came with the appointment of Dr. Carlos Seidle as the new director of the DGSP. Seidle was appointed because of his extensive experience with TB research and commitment to finding a cure (Nascimento, 1991; 1997). He was also a well known academic and maintained close ties with university intellectuals and Liga members. The appointment of Seidle generated even more bureaucratic and domestic pressures for the creation of a new federal agency. The government finally responded. In 1920, President Epitácio Lindolfo da Silva Pessoa authorized the creation of the Inspectoria de Profilia da Tuberculose. The new agency was responsible for working with municipal health departments for greater TB prevention (mainly education) and treatment. Nevertheless, it quickly became apparent to many that the Inspectoria was very inefficient and incapable of adequately responding to TB (Antunes et al, 1999). It lacked the resources, manpower, and above all, the government’s commitment to TB eradication (Antunes et al, 1999). In essence, it was what I referred to in Chapter 2 as a cosmetic institutional response intended to placate civic and bureaucratic interests rather than effective government intervention. Because of this, it was not perceived as a genuine institution-building response. As we’ll soon see with the more recent emergence of TB in Chapter 6, cosmetic institutionalism would once again emerge to placate interests rather than to strengthen the government’s ability to implement policy. National Security, Global Pressures, and Institution-Building It took the emergence of TB’s threat to the national security and Brazil’s broader developmental prospects, followed shortly thereafter by the government’s increased 104

involvement in foreign affairs and new global pressures for reform to finally convince the government to respond to TB in an institution-building manner. Brazil’s institutional response to TB began to emerge with the arrival of President Getúlio Vargas in 1930. A politician that was wholeheartedly committed to transforming Brazil into a modern nation, Vargas was genuinely concerned with the TB problem as well as any other health issue potentially thwarting economic development and Brazil’s broader national security (McCann, 2006). More generally, Vargas was committed to creating a government that was more centralized in nature and autonomous from the regional political forces that he claimed paralyzed government during the First Republic. During his first few years in office, his centralized institutional response to TB also impart reflected his broader commitment to centralized institution-building as a means to greater policy efficiency. During the 1930s, Vargas’ concern with national security and development motivated him to implement a series of institutional reforms ensuring a more rapid response to Tuberculosis. Soon after entering office, Vargas worked with the DGSP to establish several hundred sanitarian posts for TB, riddled throughout the country (Vargas, 1938). His commitment to expanding sanitarium outposts and funding several prevention and treatment programs increased dramatically after 1938, when he institute d the Estado do Novo (Vargas, 1938). Vargas believed that unless TB was aggressively controlled though a top-down, vertical institutional manner the disease would undermine the labor force and destabilize the economy, thus leading to greater instability. Later on during his reign, Vargas’ integration in world affairs, mainly through his active participation as an ally in the Second World War, prompted him to be more concern with his international partnerships and how he was being perceived as a leader.

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Through his active involvement in foreign military affairs, Vargas’ interest in enhancing his reputation as an effective political leader increased substantially; in hand with this came his concern about his international reputation as a leader committed to eradicating TB. Vargas’ concern about his international reputation has a positive influence on his perceived need to strengthen Brazil’s public health institutions. Indeed, there is no disputing the fact that a substantial increase in global pressures and incentives by the early-1940s positively influenced Vargas’ perception of the need to further respond to TB. As someone committed to modernizing Brazil, Vargas was very attentive and responsive to any criticisms questioning his ability to govern. In addition to receiving criticisms from Western Europe and the Liga movement, Vargas also received them from the United States. In 1942, for example, he was attacked by a famous American hygienist, Dr. Charles Wilson, for Vargas’ “backward” health care system and repeated inability to successfully respond to TB. . Wilson went on to claim that the U.S. outpaced Brazil in its response to TB (Filho, 2004). This incensed Vargas beyond measure (Filho, 2001). While upset, he nevertheless accepted these criticisms and used them as a new opportunity to pursue more aggressive institution-building. He wanted to show the U.S. and other nations that he could eradicate TB and succeed at modernizing Brazil. In 1941, for example, Vargas created two new federal agencies. First, he created an agency that was focused exclusively on monitoring TB. This was called the Servicio Nacional de Tuberculoses (SNT), which was housed in the Ministerio de Educacão e Saúde Publico (MESP). Next, Vargas created Brazil’s first ever national program for tuberculosis, the Campanha Nacional Contra Tuberculoses (CNCT). An agency within

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the MESP, the CNCT was highly autonomous and had ample resources. It created a vertical program for TB prevention and treatment. The CNCT also introduced a deconcentrated form of TB provision, whereby it established medical sanitarium posts throughout the cities and the country side, while retaining complete financial control through the CNCT. In contrast to its Republican democratic predecessor, Vargas wanted to ensure that his government could effectively monitor and manage every aspect of TB policy. This, in turn, helped to increase administrative efficiency while avoiding corruption at the local level. In addition, the re-centralization of administrative authority for public health was a very radical move at the time, since it completely abolished the government’s prior decision in 1926 to give the city of São Paulo complete control over all aspects of health policy (Filho, 2001). The CNCT marked the birth of the famous - and enduring - National TB Program. Under subsequent democratic and military regimes, it continued to grow and at one point usurped approximately 50% of the total health budget (Barreira, 2000). It also benefited from garnering multiple sources of revenue, mainly from the Ministry of Health and the Ministry of Education, while receiving contributions from several governors (RuffinoNetto and Figueiredo de Souza, 2001). While the NTBP continued to expand under the military, the last few years of the authoritarian government (1974-85) saw a gradual devolution of health administration and policy to the states, followed by a hasty devolution of policy autonomy to the municipalities in 1988. By 1990, in the absence of civic pressures and federal ministerial interest in maintaining a centralized response to TB, the National TB Program was completely dismantled. It was supplanted with the decentralized SUS program (Sistema Unica do Saúde) in 1990, introducing new

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administrative inefficiencies and a lack of government responsiveness with the resurgence of tuberculosis in the 1980s. In sum, like the United States during the early-20th century, even the newly independent, democrat Brazil government did not immediately respond to one of the biggest health epidemics of its day – TB (see Figure 1.3). Rather, it took an undemocratic centralized government concerned with TB’s effects on national economic security and development followed by a fascist political regime that became more globally integrated through war fighting efforts in Europe and its concern along with this its sensitivity to international pressures and criticisms. On its own, the newly independent Republic did not respond to all kinds of epidemics in the same manner. And lastly, and in sharp contrast to the response to syphilis during this period (as we’ll soon discuss), although there was a new civic movement, the Liga de Tuberculoses, that united medical and intellectual elites, bureaucrats, and the international movement in response to TB, this partnership did not lead to an effective institution-building response between 1920 and 1930 (the year Vargas came to power). While the government eventually created the Inspectoria do Tuberculose in response to TB in 1920, it was more of a cosmetic institution, built to appease rather than effective policy intervention. In addition, because the perceived importance of TB among politicians was still low, and because of their apathy in constructing an enduring institution, once it accomplished what the Liga wanted the government decided to completely sever its ties with the movement. This response was further consolidated by the re-centralization of bureaucratic control under Vargas in the 1930s, which pleased former Liga members.

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With the introduction of new vertical institutions, on one hand, and eventually the discovery of a cure for TB through the introduction of chemotheretic treatment by the 1950s, on the other, the Liga movement eventually died out. Especially as the number of TB cases rapidly declined due to advances in medicine and improved standards of living brought about mainly through import substitution industrialization of the 1960s and 1970s, medical and intellectual elites lost interest in sustaining the Liga movement. As we’ll soon see in Chapter 8, the end result is that in contrast to HIV/AIDS, the resurgence of TB did not benefit from a long lasting civic movement, one that was well equipped and motivated to immediately fight for the needs of the TB infected – often the poor. In addition, there was no well organized civic movement that could once again work closely with the global health community, as the Liga had done during the first two decades of the 20th century. What is important to take from this historical discussion is that the influential relationship between the Liga movement, pro-reform bureaucrats, and the global health community, which to some extent helped to prompt institution-building under Vargas, was essentially gone by the late-20th century. The massive bureaucratic expansion and vertical programs that occurred under Vargas, which gradually dovetailed into his broader campaign of nationalization and institutional development, when combined with the absence of any opportunity for new viral discovery, generated few incentives for civic elites to maintain the tradition of working hard to incessantly pressure the government for a more effective institutional response to TB. As a consequence, the underlying endogenous civic elite consensus to continuously pressure the government for institutionbuilding quickly waned by the 1990s. As we’ll soon see in Chapter 8, it is only recently

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that a new civic movement for TB has emerged. But this time it stems mainly from successful reforms in the AIDS policy sector and the new global financial opportunities and incentives for civic movements responding to the financial opportunities provided by the newly formed Global Fund to Fight AIDS, TB, and Malaria in 2001. The Rise of Tripartite Partnerships for Institution-Building Although the new coalitional arrangement between civil societal elites (the Liga), proreform bureaucrats (Oswaldo Cruz), and the global health community failed to initially persuade the President and the Congress to expand the DGSP in response to TB prior to the arrival of Vargas, it did nevertheless succeed in establishing an informal and enduring coalition between these actors. his coalition between international actors, civic elites and public health officials led to the emergence of what I described in Chapter 2 as new tripartite partnerships between civic organizations, public health bureaucrats, and international health movements seeking an institution-building response to epidemics. This movement established an underling inter-elite tradition and enduring expectation of working together in order to consistently pressure the President and the Congress for reforms. Furthermore, and this is key, this partnership established a new pattern of strategically using the emergence of new global health movements and its commitment to eradicating disease as a means to increase public health bureaucrats’ legitimacy and leverage when attempting to persuade the President and the Congress for greater administrative expansion and transfers to municipalities. This, in turn, strengthened the tripartite partnership’s working relationship and facilitated the reemergence of similar civic movements decades later.

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Nevertheless, it is important to close by noting that concrete institution-building only emerged when the President finally perceived the TB situation as nationally significant and worthy of an immediate response. Despite quickly escalating death rates during the early 20th century and pressures from civil society, concrete reforms did not emerge for three decades, under a fascist political regime Prior to Vargas, because of the challenge of having to respond to a host of diseases and the President’s disbelief that TB was something special, there was no perceived need to work with international actors, the Liga de Tuberculoses, or those reform health officials, such as Dr. Oswaldo Cruz, who worked with Liga members to seek an institution-building response. In contrast, the structural factors influencing Vargas’ perception to response, which in turn allowed for the influence of previously formed tripartite partnerships, was TB’s perceived threat to national security during the 1930s and, later, the rise of a well organized global health movement that constructively criticized him and the government for its repeated inability to control TB. While the tripartite partnership certainly helped convince the President that institution-building was necessary, the success of this movement hinged first and foremost on Vargas interest in national security and fending off global pressures while responding through institution-building processes in order to increase his global reputation and secure Brazil’s long run developmental prospects. Tripartite partnerships were thus a necessary but insufficient condition for reforms to occur. This is not to say that the historic formation of tripartite partnerships were insignificant for institution-building.; To the contrary; for their historical emergence set the groundwork for their future re-emergence whenever new global health movements emerged.. As we saw during the early 20th century, the rise of global health movements

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for TB in the late-1990s would once again emerge to help civic organizations and reformers within government resuscitate their long lost partnerships with international actors for pressuring the government for a more assertive, centralized institutional response to TB. As the next chapter will discuss in more detail, moreover, the historic formation of these tripartite partnerships were necessary for the subsequent emergence and influence of federal pro-reform bureaucrats in response to the more recent HIV/AIDS epidemic. For it provided previously marginalized bureaucratic reformers in the federal AIDS bureaucracy with the informal civic resources needed to strengthen their legitimacy and influence within and outside of their agency, which in turn made them all the more successful in their ability to incessantly and successfully pressure the President and the Congress for a continued expansion of the National AIDS Program. This state formation process was not unique to tuberculosis. As we’ll see in the next section, the government responded the same way to syphilis. Institution-building would once again be delayed, influenced yet again by the emergence of new global pressures, not the immediate needs of civil society.

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SEX POLITICS, INSTITUTION-BUILDING, ANS SYPHILIS CONTROL (1930-50) ~ UNITED STATES ~ The politics of government response to sexually transmitted diseases in the United States and Brazil were strikingly similar to how they responded to the non-sexually transmitted diseases discussed above. That is, despite an increase in prevalence rates and deaths both governments did not immediately respond through new institution-building initiatives. Eventually, the governments responded through the creation and financing of bureaucratic agencies. But the reasons for doing so were different and shaped by the governments’ unique position vis-à-vis the global health community: an isolated America would temporarily respond for national security reasons, while Brazil eventually responded due to increased global pressures consolidated through the formation of informal tripartite partnerships between the global health community, civic organizations, and reform bureaucrats within public health agencies seeking an institution-building response to syphilis. Similar to what we saw with the non-STD epidemics discussed above, the first and second phase of the government’s response to syphilis in the United States were strikingly different. During the first phase, the absence of syphilis’ national security threat did not prompt an immediate institution-building response. And this occurred despite the requests of federal officials for a more centralized bureaucratic response. Thus no new reform coalition emerged between the President, the Congress, and federal health officials. There was instead a high degree of inter-elite contestation. Nevertheless, during the second phase all of this changed. By WWII, syphilis emerged as a serious national

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security threat, as case rates of syphilis increased throughout the military. Then, and only then, did we see a new underlying coalition for institution-building emerge.

Graph 3.4: Syphilis in the United States (all types, per 100,000) 700 600 500 400

Cases

300 200 100

Deaths

0 1918

1936

1945

1966

Source: Brown et al, 1970

However, during the first few years of the syphilis epidemic, notwithstanding the fast-paced growth of case prevalence, the president relied entirely on local health departments as the first responders. In so doing, the center was adhering to its commitment to decentralization, which boded well with the interests of aspiring mayors in large urban centers. There was no immediate commitment to building a new federal agency and/or strengthening the U.S. Public Health Service. . But as the number of rejected applicants for military enlistment increased due to their testing positive for syphilis, the government began to perceive the situation differently. Because this essentially meant a potentially rapid decline in the number of enlistees capable of fighting in Europe, the President and Congress began to realize that it needed to respond by creating new federal agencies and programs. It was only under 114

these conditions that the government began to draw up plans for creating new federal agencies and providing a steady flow of resources to the states (Brown, 1970; Ness, 1940). Ness (1940) in fact writes that during this period the President, the Congress, the Secretary of War and large civic organizations readily agreed that they should start working together to create new federal agencies and programs in response to syphilis (Ness, 1940). As I discuss in more detail shortly, this led to the emergence of a new reform coalition seeking to establish – albeit temporarily – a more centralized bureaucratic and policy response to syphilis. Moreover, this coalition agreed to provide new streams of funding to state-governments in dire need of resources, going as far as to provide funding for sex-education programs. A brief review of the number of Congressional Acts and federal programs enacted by the Congress during the two wars lends credence to the fact that the government’s response to syphilis was primarily influenced by national security concerns (see Table 1.1).

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Table 3.1 – U.S. Congressional Acts and Government Programs in Response to Syphilis Year 1918

1918 1937

1938

1939 ?? 1940

1941

Congressional Acts and Programs Chamberlin Kahn Act - Acts creates the Division of Venereal Diseases in the U.S. Public Health Service; it provides information about the maintenance and upkeep of syphilis programs at the statelevel; Act also provides grants to the states for syphilis control. US Inter-Departmental Hygiene Board - This was an educational campaign against syphilis and other VDs; Congress provides grants to universities to conduct VD research and teaching. National Venereal Diseases Control Act - Federal and state authorities map out a plan of attack against VD; Congress provides funds for medical and public health attack; this act also provides money to the states for syphilis and other VD control. La Follett-Bulwinkle Bill (Congressional Act) - Congressional funds provided to the states; expansion of Venereal Diseases Division of the PHS to improve research, treatment schedules, patient follow up, record keeping, and program analysis. Eight Point Agreement Program - Program were the Department of War and Navy and the Federal Security Agency work in close cooperation with the PHS to monitor syphilis’ spread while prohibiting prostitution activities near military bases. Social Protection Program, Defense Health and Welfare Services of the Federal Security Agency - Program created 24 field officers throughout the country to work with other agencies, such as law enforcement, pubic assistance, recreation, child protection, and health agencies to monitor syphilis and possibly invoke the May Act; program entailed repression of commercial prostitution in order to protect soldiers; provision of social services and treatment for prostitutes; 24 field agents also work with local governments to enforce these policies. May Act - Made prostitution (or any immoral activity) illegal near military bases.

Speed-Zone Epidemiology - First major federal campaign to control gonherrea spread; through this initiative, the 1952 PHS works closely with the states and urban health departments. Source: Authors’ calculations based on several sources.

First, in 1918 the Congress responded with the passage of the Chamberlin-Kahn Act, which mandated the creation of the Division of Venereal Diseases (DVD) within the U.S. Public Health service. In an effort to reduce the number of enlistees infected with syphilis, the Chamberlin-Act authorized the allocation of direct grants in aid to those states and local governments committed to implementing new anti-VD programs.

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In addition, that same year the Congress created the U.S. Inter-departmental Hygiene Board. The Board’s responsibility was to disseminate a host of sex education pamphlets, create anti-VD placards and even use the movie industry to increase public awareness about syphilis (Brown, 1970). What is more, in 1919 the Congress appropriated $200,000 for administrative expansion and $400,000 to the InterDepartmental Social Hygiene Board for medical research (Parran, 1936). And for the first time, the PHS, through the new Division of Venereal Diseases (DVD), provided financial and technical assistance to the states. In 1918, for example, it provided an estimated $1,000,000 in direct grant assistance to the states (Science Illustrated, 1949). At the same time, it dispatched 24 PHS agents to work with the governors in order to ensure that their programs were being implemented effectively (Parran, 1936). The federal government’s new commitment to horizontal and vertical reforms led to a massive policy diffusion affect. Several state governments started to mimic the federal government’s efforts. By 1920, Lock (1939) writes that 88 laws were enacted by 35 states in order to increase prevention and treatment for syphilis. There was thus a new sub-national institutional commitment to combating syphilis (Lock, 1939). But what the federal government did shortly after WWI lent further credence to the fact that national security was its primary motive (Ness, 1940; Parran, 1936; Brandt, 1985; Thompson, 1987). Shortly after the war ended, the President authorized the Congress to pull the plug on the Division of Venereal Diseases (Ness, 1940; Brandt, 1985). The government no longer viewed syphilis as a national threat and therefore had no incentives to sustain its programs (Lock, 1939). In fact, shortly after the war Brandt

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(1985) claims that the Congress decided not to reauthorize funding for the U.S. InterDepartmental Hygiene Board. This sent a clear message that in the absence of a national security threat, the government no longer cared about the ongoing syphilis problem (Brandt, 1985). The government also stopped providing financial assistance to the states. By 1935, the Chamberlin-Kahn Act ceased to exist. Congress went from allocating $1,000,000 in 1918, to $100,000 in 1921 and then to only $58,000 in 1936 (Science Illustrated, 1949). This was attributed to the “return to normalcy,” such that the national security threat was gone and the government no longer felt compelled to help state and local governments respond to syphilis (Science Illustrated, 1949). The government’s sudden withdrawal from agency build up coupled with a rapid decline in financial aid to the states in turn created fewer incentives for local governments to maintain their anti-VD programs (Parran, 1936). The end of the federal campaign and commitment to syphilis generated a flurry of criticisms. However, most of these criticism did not come from civil society (though of course, there were civic groups and communities, especially in the south, voicing concern), but instead from the PHS. PHS bureaucrats emerging from progressive schools of thought took a more secular, professional approach to STDs. They did not attribute it to race or class. Instead, they viewed syphilis through a purely scientific lens and, more importantly, as a serious national threat worthy of immediate institution-building; they didn’t care about war; they cared about health. These views were harbored by perhaps the biggest proponent for institutionbuilding at the time: Surgeon General Thomas G. Parran. A medical doctor by training,

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Parran was the only political appointee to critique the government’s short-lived commitment to institution-building. He also criticized the government for failing to maintain its VD propaganda campaign (through the U.S. Inter-Departmental Hygiene Board) and various educational campaigns implemented during the two world wars. Having served as an assistant Surgeon General during the First World War and having led the federal campaign against syphilis, Parran was incensed after the Congress quickly withdrew its support for financing national and sub-national anti-VD programs. Often disliked for his candid, somewhat brusque critique of FDR’s policies, Parran published his criticisms in a book that he wrote while serving in office titled Shadow on the Land: Syphilis. In it, he criticized the government for its ephemeral commitment to institution-building, the absence of effective federal programs for combating syphilis, and the government’s unwavering interest in national defense: “For the country as a whole we have carried on guerilla warfare against syphilis, with spirited skirmishes and valiant forays in some of the states which sow casualties to their credit. There never has been a coordinated drive against it by all the states, with the exception of the wartime effort which died a-borning. It is for this reason, I believe, that there is no evidence to be found of a general decline in the attack rate of syphilis for the country as a whole. We have indications of improvement, but they are few and scattering. Nowhere here can be seen the dramatic reversal of trend of the Scandinavian countries in which as the result of long continued, popularly supported government action, syphilis has become a rare disease. … Unfortunately, the enthusiasm that had gone up like a rocket [i.e., for a national institutional response to syphilis] came down like a stick. The national spirit swung like a pendulum from “anything to win the war” to aversion for the war status. Discipline was replaced by the license of the roaring twenties. President Hardin’s phrase “getting back to normalcy” was the excuse for dumping useful effort and bureaucratic regimentation on the same rubbish heap. Congress apparently thought the spirochetes of syphilis were ‘demobilized’ with the army. More accurately, no further thought whatever was given to syphilis, and this first national public health effort came to an untimely end” (Parran, 1937: p. 67 and p. 85).

One takes from these writings Parran’s belief that FDR should not have stopped building the Division for Venereal Diseases, nor should the President have decreased the amount of money going to the states. He continued to advocate the fact that syphilis was a national disease, and that as such the federal government needed to continue with a 119

more centralized bureaucratic response. In fact, in Shadow on the Land Parran wrote two chapters comparing the United States to the centralized bureaucratic response to syphilis in the Scandinavian states. He praised their on-going commitment to strengthening their national public health administration, national anti-venereal programs and their unwavering commitment to financing state and local government policies. In the tradition of a configurative historical analyst (Katznelson, 1997), moreover, Parran conducted this comparison not to concoct a generalizable theory about the importance of state intervention. Instead, he did it to accentuate the problems that the U.S. government had in its commitment to institution-building after the war and doing so for the purposes of safeguarding military – not humanitarian - security. (In a sense, I follow in Parran’s footsteps here, as the purpose of my comparison between the United States and Brazil has been to compare the United States’ decentralized versus Brazil’s centralized institutional approach to epidemics, and how centralization in Brazil has led to a more successful institution-building and thus overall policy response to HIV/AIDS and other diseases.) In sharp contrast to the President, the Congress and the new Social Hygiene movement in civil society, Parran also believed that responding to syphilis had nothing to do with race. In fact, he opened one of the chapters of his book with the controversial statement: “Syphilis is the white man’s disease” (Parran, 1936: p. 60). In contrast to the Social Hygiene movement, he constantly vocalized his belief that the black race had nothing to do with the origins of the virus and that it was the white man that created and contributed to its spread (Parran, 1937: pp. 60-62). As Surgeon General, and given the social and political circumstances of the day, these were very bold statements to make.

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Nevertheless, he persisted and continued to criticize the government for its ephemeral commitment to institution-building. What is more, Parran worked very closely with stigmatized groups in civil society. Noticing that the black community, especially in the south, had the largest number of syphilis case rates, and after further noticing that it was not receiving adequate – if any – assistance from the PHS (especially after the war), he began to work closely with these communities and other philanthropic groups committed to increasing sex education and treatment. For example, Parran worked closely with the Julius Rosenwald Fund in Mississippi to co-sponsor several new projects that increased the capacity of municipal hospitals to treat syphilis patients and to provide them with educational materials. Jones (1981) notes that Parran worked hard to maintain and increase the Fund’s partnership with the PHS, which started in 1929. Parran was also committed to increasing the recruitment of African Americans into the medical and nursing profession, an initiative that the Julius Rosenwald Fund was already committed to. By the mid-1930s, thanks in part to Parran’s incessant vocal criticisms of the FDR administration, civil society began to increase its interest and response to the problem. Parran’s efforts to transform syphilis into a “national issue” boded well with civil societal concerns and desires for more federal involvement. As Locke (1939) illustrates, a gallop poll 28 taken in 1939 revealed that most citizens were in favor of greater federal

28

A Gallop poll survey at the time indicated that civil society was in favor of government intervention for VD control. Specifically, they were in favor of the PHS distributing information concerning VD’s spread: 90 yes, 10 no; should this bureau set up clinics for the treatment of VD: 88 yes, 12 no; should congress appropriate $25,000,000 to help control VD?: 79 yes, 21 no; in strict confidence and at no expense to you, would you like to be given by your physician a blood test for syphilis?: 87 yes, 13 no; would you favor a law requiring doctors to give every expectant mother a blood test for syphilis: 88 yes, 12 no; do you think congress should appropriate money to aid states in fighting VD?: 86 yes, 14 no; would you be willing to pay higher taxes for this purpose?: 69 yes, 31 no (Brown, 1970).

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intervention; moreover, Locke (1939) attributed this to Parran’s aggressive public awareness campaign. In addition, the news media started printing more articles on syphilis. Brown (1970) notes that in 1935 there were only 5 newspaper articles in the New York times discussing syphilis while within the next five years there were 255 (Brown, 1970). A new social movement in favor of greater social awareness about syphilis started to emerge, which was mainly triggered by the government’s sudden withdrawal from public intervention (Locke, 1939). For the first time, civil society was much more interested in discussing the issue in public and working with their representatives to get more done (Locke, 1939). Notwithstanding Parran’s incessant efforts to pressure the government into creating and more importantly sustaining a centralized bureaucratic response to syphilis, his criticisms ultimately fell on deaf ears. Even the kind-hearted liberal democrat FDR started to complain about Parran’s incessant bickering (Brandt, 1985: p. 163). Parran quickly found himself making more enemies than friends. Nevertheless, in 1937, in response to both Parran’s criticisms and the general perceived need to maintain a federal commitment to syphilis, FDR and the Congress agreed to create the National Venereal Control Act. This was yet another step in the government’s institution-building response to syphilis, a commitment which was instigated by syphilis’ threat to national security during WWI. Through this act, federal and state governments agreed to map out a new plan for responding to syphilis, while the Congress agreed to allocate more money to the states (Etheridge, 1992; Brandt, 1985). However, this was only a prelude to the massive institution-building that would occur

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during the Second World War, which in turn unmasked the government’s real interest: institution-building for national security, nothing else.

World War II – The Second Institution-Building Phase In 1939, on the eve of WWII, the President and the Congress once again started to place a high priority on syphilis control. Medical doctors and the social hygiene movement were alluding to studies indicating that many of the new Army enlistees were testing positive for primary and secondary syphilis. By 1940, Jones and Price (1950) claim that the Army absorbed 98.9 percent of all the military selectees with syphilis and other venereal diseases. Approximately one-fourth of all black enlistees had syphilis, while only 1.7 white enlistees were infected (Jones and Price, 1950). Once again, syphilis emerged to threaten the government’s military capacity (Ness, 1940). And once again, the government responded with a flurry of new institution-building activities. First, in 1939, building on the 1937 National Venereal Disease Control Act, the President and the Congress agreed to create the Eight Point Agreement Plan. Under this plan, a new phase of horizontal inter-agency collaboration emerged between the Department of the War, Department of the Navy, the Federal Security Agency and the U.S. Public Health Service to increase surveillance and response to syphilis and other venereal diseases on or near military camps (Ness, 1940). Through this plan, moreover, prostitution was prohibited near military compounds. Any prostitutes found in the area were either imprisoned or confined to Rapid Treatment Centers for one to two weeks (Brown, 1970). The Eight Point Plan marked a new federal commitment to regulating prostitution in order to protect enlistees from venereal disease.

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At the same time, in 1939 the Congress passed the La Follett-Bulwinkle Bill. Through this bill, the Congress re-started its vertical financial assistance programs to the states in order to increase medical research and treatment for syphilis. In addition, and similar to what had occurred with the Chamberlin-Kahn Act of 1918 (during WWI), the Bill authorized an increase in budgetary outlays for the expansion of the Division of Venereal Diseases in the PHS. And two years later, in 1941, the Congress created the May Act of 1941. The May Act added to the Eight Point Plan by making it illegal to engage in prostitution activities near military bases. Moreover, through this Act the federal government required that local police monitor and enforce the law, though many, including Parran, believed that it was never really enforced (Brandt, 1985). And finally, at the same time the government, through the Federal Security Agency, created the Social Protection Program. Through this program the Federal Security Agency created over 20 federal security field agents to work with a myriad of state and municipal social welfare agencies to monitor prostitution activity and where necessary invoke the May Act. The program sought to enforce the government’s new commitment to regulating prostitution and working with local officials to both imprison and provide medical treatment. In essence, it was an effort by the Federal Security Administration to enforce the May Act and to ensure that local governments were in full compliance. In summation, it is important to note that during the height of the syphilis epidemic the government did not immediately intervene through new institution-building activities. Instead, and similar to what we saw with malnutrition, it did so only when syphilis began to threaten the military’s fighting capacity. As Table 1.1 illustrates above,

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most of the congressional acts that were passed by the Congress were done in time of war. The only congressional act that was passed outside of this period was the 1937 National Venereal Disease Control act, which appears to have been created in anticipation of another war and increased pressures from Surgeon General Thomas Parran for a more centralized approach to syphilis. The Origins of PHS Perceptions, Response, and Social Embeddedness During the inter-war period, it is also important to not that Surgeon General Parran’s initiatives helped to establish a bureaucratic tradition that reemerged decades later with the response to AIDS: that is, the Surgeon General (and other PHS officials’) commitment to taking a pro-active, secular approach to combating STDs. Specifically, Parran, through his various proactive political and scholarly works, established a bureaucratic tradition and expectation that public health officials should immediately perceive and treat STDs as a national health threat. More importantly, he believed that public health officials should not be influenced by morality, ideology, or any kind of military and/or economic conditions when responding to STDs (Parran, 1937; Kuller and Kingsley, 1986: p. 70). This tradition persisted over the years and continued to shape how public health officials responded to STDs. As was the case with syphilis in the past, and in sharp contrast, yet again, to the President and the Congress’ initial perceptions and responses, our future public health officials immediately perceived the AIDS epidemic as an urgent health epidemic worthy of immediate institution-building. As we’ll see in Chapter 5 with AIDS and Chapter 7 with obesity, the PHS would once again emerge to incessantly

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pressure the government for an immediate response through the consolidation of interagency responsibilities, bureaucratic expansion, and federal funding for state programs. Parran and the PHS also established an ongoing tradition of working closely with stigmatized groups in civil society. For Parran, this entailed working closely with the black community and supportive philanthropic organizations, such as the Julius Rosenwald Fund, for more financial and technical assistance. Because Parran did not view syphilis as a racial or moral issue, at the height of its outbreak he consistently emphasized the need to establish a strong working relationship with the marginalized segments of civil society, such as the black community, which was often ignored and devoid of health education and above all treatment. As we’ll soon see in Chapter 5, this tradition of PHS social embeddedness emerged again with the AIDS outbreak in 1981. Similar to what we saw under Parran, during this period the PHS (mainly the CDC) was the only state organ that immediately started to work with stigmatized AIDS victims, such as the gay community. It had also worked with the gay community during the 1970s in response to Hepatitis B and C (Altman, 1985). Parran’s initiatives thus set the groundwork for an on-going bureaucratic tradition of working closely with stigmatized groups during the first few years of an epidemic. For both syphilis and AIDS later, this was important for helping build trust in a government that otherwise seemed apathetic to the needs of civil society. The Politics of Institution-Building But what precisely were the underlying political coalitions that led to the creation of conflicting political and bureaucratic perceptions and interests in institution-building? Better understanding the informal bureaucratic and civil societal coalitions that shaped 126

bureaucratic perceptions and interests in institution-building helps to explain why the president was delayed in his response while eventually responding to syphilis’ national security threat rather than a genuine epidemic and, more importantly, the immediate needs of civil society. Although there were underlying bureaucratic elite and civil societal coalitions that pressured the government to respond to syphilis via institution-building, as noted earlier this movement ultimately failed to convince the executive and the Congress to do so prior to the two world wars. In fact, when it came to convincing the President and the Congress that syphilis posed a direct threat to the national security, an alternative coalition emerged between high level officials in the Department of War and the military, on one hand, and medical elites and a civic association called the Social Hygienists, on the other. They worked together to persuade the president and the congress that syphilis was threatening the military’s fight capabilities. Indeed, Brandt (1985) writes that during the first and second world war, the Social Hygienists frequently met with the Secretary of War and the Congress to display data revealing that syphilis was directly impacting the health of military troops, and that if nothing was done the military could witness a decrease in its fighting capability (Brandt, 1985). Through these efforts, the Secretary of War finally obtained the President and the Congress’ support. A new coalition for institution-building emerged, but would only survive the war periods. As noted earlier, this coalition led to the creation of the U.S. Inter-Departmental Social Hygiene Board in 1918, which was an initiative designed to increase public awareness of syphilis and other venereal diseases. The Social Hygienists continued to work with the government and continued to reinforce the President, the Congress, and the

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military’s perceptions that responding to syphilis was imperative for the advancement of military forces. Eager to win the war, the Social Hygienists, in addition to their broad coalition in civil society, namely the American Social Hygiene Association and a swath of private physicians, helped to bolster the President and the Congress’ views that institution-building was needed in order to win the war. The government’s interests in national security and its perception that combating syphilis equated to wining battles was therefore supported by a very influential, well organized civic network incessantly providing scientific evidence confirming the president and the Congress’ perceptions of the urgent need to respond for national security reasons. Nevertheless, there were other bureaucratic-civil societal coalitions that were not of the same footing. This coalition was composed of bureaucrats located in the PHS, which was led by Surgeon General Parran, and their partnership with civic associations favoring an immediate institution-building in response. Major philanthropists, such as the Julias Rosenwald Fund, the David Rockefeller Foundation, and a host of other groups in civil society, such as Booker T. Washington’s national coalition for Black Health awareness, which started in 1910 and eventually transformed into an official Black “Health Improvement Week,” 29 began working with the PHS to build a coalition pressing for PHS expansion (McBride, 1991). By the 1920s, the PHS entered into an official partnership with these civic associations in order to pressure the government for a

29

As David McBride (1991) explains, the Negro Health Week movement became a nationwide campaign centered at the Tuskegee Institute. As he argues, each April black community leaders in education, health, and church affairs organized a program to increase public awareness of health problems and selfimprovement measures for the school, home, and communities. The Negro Health Week movement gained increasingly public support throughout the 1920s and 1930s included the assistance of the U.S. Public Health Service (McBridge, 1991: p. 27).

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consistent horizontal and vertical institutional and policy response to syphilis, regardless of its affects on the military. Despite the formation of this informal coalition, however, and as long as the President and the Congress’ interests were in defending the homeland, this coalition would not succeed in overcoming the influence of national security-based concerns. What this essentially meant was that the President would not endorse any institutionbuilding activities prior to and after the two world wars – and even in the inter-war periods. The executive’s unwavering interest in national security allowed the Social Hygiene coalition to emerge and help convince him to respond for national security purposes. The Social Hygiene coalition also had the support of other civic associations, which were led by prominent white men, while the PHS coalition did not: their supportive coalition was predominantly black, marginalized, and politically ineffective. The end result was the formation of a public health regime that was built for national security purposes, not for address the immediate needs of civil society. In the next chapter, we’ll see how the absence of AIDS’ threat to the military’s fighting capacity generated little interest in institution-building. As a consequence, the highly fragmented, uncoordinated PHS response was very weak, especially when compared to the more centralized, consolidated response in Brazil. ~ BRAZIL ~ In contrast to the United States, early-20th century Brazil did not find itself in a war time situation. Brazil’s presidents did not need to build a large military force that could supply the lion’s share of defense forces overseas. In contrast to the U.S., presidential and bureaucratic perceptions and responses to syphilis were therefore never shaped by 129

national security concerns. Instead, and as this section illustrates, the government’s perceptions and response were eventually shaped by new global pressures and incentives for institution-building. But this did not mean that the government was committed to immediately responding to syphilis. Like the United States, and similar to the AIDS situation 60 years later, political elites did not initially perceive syphilis as an epidemic threat worthy of immediate institutional change. Despite an increase in syphilis growth rates throughout the late 19th century, the government did not create a new national program for syphilis control until 1914, several years after the epidemic emerged 30 (Cararra, 1999). This was mainly because syphilis was perceived as something “natural,” that is, a social disease that was expected to spread and thrive in Brazil’s hot, sensual tropics. To understand this, one must recall Brazil’s unique history of venereal disease: specifically the widely-held perception in government and civil society that Brazil was “born out of the devil,” that it was “sinful in nature,” willfully spreading VDs throughout the nation (Carrara, 1996). As a famous Brazilian scholar once put it: Brazil was “syphilized” since the very beginning (Freye, 1946). Although federal elites were not immediately responsive to syphilis, the absence of its threat to Brazil’s national security provided the opportunity space for the emergence of alternative forms of global and domestic pressures for institution-building. Once again, the tripartite partnership that emerged in response to tuberculosis also arose 30

Early 20th century epidemiological data for all forms of syphilis prevalence and death does not exist. I spent three trips to Brazil trying to locate this data in Rio and São Paulo. Colleagues inform me that this data was never recorded by the government because of the inaccuracy of DGSP and MESP surveys and because it was perceived as such as widespread, common disease that medical elites were frankly not interested in carefully monitoring its spread. After the introduction of penicillin therapy in 1943, however, the government did start to monitor and publish syphilis case rates, mainly to display its effectiveness in combating the disease.

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for syphilis. As we saw with tuberculosis, what was necessary for the emergence of a tripartite partnership was the presence of a new global commitment to combating syphilis and how partnerships with civil organizations and federal reform bureaucrats seeking an institution-building response led to an influential coalition for reform. Civil society’s partnership with the global health community once again increased their reputation and influence, in turn leading to the creation of new civic associations and through these associations the creation of informal pacts with pro-reform bureaucrats seeking to work with them in the Departmento de Saúde Público (DGSP) and later the Ministerio de Educacão e Saúde Público (MESP), which replaced the DGSP in 1931. These bureaucrats were also closely aligned with global health officials favoring bureaucratic expansion and the participation of civil society in the policy-making process. Thus, as we saw with tuberculosis, the emergence of a new global movement in response to syphilis was a necessary condition for the emergence of a tripartite movement responding to syphilis. Second, this tripartite partnership added to the credibility and the political influence of reform bureaucrats within the DGSP and MDSP for one key reason: that is, the “race to global fame.” As mentioned in Chapter 2, this arises when President have an interest in becoming recognized for combating an internationally recognized epidemic; the race to be recognized as a modern state committed to combating syphilis, both through research and institution-building; the race or, better yet, incentive for the president to catch up and surpass the Scandinavians and the even the United States in Brazil’s ability to contain disease and develop.

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Prior to the First World War, and similar to what we saw in the United States, the Brazilian government never immediately responded to syphilis. The President felt no urgency to respond due mainly to the absence of syphilis’ national security and wider economic threat. In addition, and in sharp contrast to the U.S. Public Health Service, the director and most of the bureaucrats in the Departmento Geral de Saúde Público (DGSP) were quite apathetic to the burgeoning growth of syphilis cases and deaths (Carrara, 1996; 1999). In essence this derived from the fact that the government had to respond to a host of diseases riddled throughout the nation (again, revisit Figure 1.3 above). Because of this and the fact that syphilis was perceived among government officials and civil society as a cultural norm in society, the President and his health officials had no reason to immediately respond through new institutions-building initiatives. Instead, the government’s primary focus at the time was economic development and developing the appropriate institutions necessary for continued prosperity. During this period, civil societal views towards syphilis were rather different. From 1900 to the end of the Second World War, there emerged a host of new civic movements pressuring the government for reform. Community leaders and medical professionals were interested in increased state intervention at the community level. Led by famous doctors and university professors, the new civic movement favoring these initiatives was called the sifilógrafo movement (Carrara, 1996). Similar to the views of progressive medical elites in the U.S. during this period, the sifilógrafos believed that syphilis was a serious medical issue and that the government should immediately respond by strengthening the DGSP and later the MESP. Like the PHS in the U.S., moreover, these elites believed that that there was nothing immoral about syphilis and that civil

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society should not be afraid to openly discuss it and seek medial attention (Miranda, 1936). Again similar to their American counterparts, DGSP and MESP officials believed that there was nothing “racial” about syphilis, since most politicians and health officials were not of the opinion that its etiology stemmed from the black population or the indigenous (Carrara, 2004). Instead, and similar to U.S. Surgeon General Perran’s views at the time, Brazil’s health officials perceived syphilis as a white man’s disease, brought over by Portuguese colonizers during the 16th century (Carrara, 1997). The sifilógrafos also pressured the government to introduce new sex education and prevention campaigns. Sex education was seen as essential for syphilis prevention (Vieira Ferreira, 1930; Primera Conferencia Nacional de Defesa contra a Sífilis, 1941). The sifilógrafos helped convince the government to disseminate new sex education pamphlets, to sponsor sex-ed commercials in movie theaters, post messages on public billboards, while forcing state and local governments to provide sex education in class rooms (Fernandes, 1931; Miranda, 1936; Zéo, 1941; Carrara, 1996). And finally, they were a major proponent for having the government finance medical treatment at the state and municipal level. The sifilógrafos noticed that other nations were doing the same, especially in Western Europe, and the felt compelled to pressure the government into mimicking their efforts (Araujo, 1939). Above all the major issue that the sifilógrafos were pressing for was the increased bureaucratic centralization of syphilis control. These civic elites believed that it was the responsibility of the government to immediately respond to epidemics through institution-building (Carrara, 1992; 1996). This entailed strengthening and expanding the DGSP and MESP, on one hand, while working closely with state governments, on the

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other. The sifilógrafos were quick to point out that Western Europe had created a strong centralized response to syphilis; they repeatedly made reference to this fact in several public health journals (d’Esaguy. 1938). During this period the sifilógrafos also believed that as in the U.S., federalism and decentralization would not facilitate the government’s response to syphilis. Federal political elites in Brazil and the U.S. felt differently, however, as they believed that the governors should be the primary responders. But the sifilógrafos were not of the same footing, and they used every opportunity they could to voice their concern. Prior to and throughout the First World War, the sifilógrafos were very eager to get involved at the global level (Carrara, 1997). As modernizing elites, they wanted to show the global health community that they were committed to helping contain syphilis. And there were several reasons for doing so. First, as an emerging nation, the sifilógrafos wanted to prove to the global health community that Brazil had the ability to hastily eradicate syphilis through scientific break through and policy (Carrara, 1997). To prove their point, the sifilógrafos participated in a host of international conferences sponsored by other (mainly Western European) governments (Primera Conferencia Nacional de Defesa contra a Sífilis, 1941). Sifilógrafos often traveled Europe to discuss their research and approach to syphilis control. At one point, a famous Brazilian doctor, Dr. Gustavo Werneck, made such a good impression that in 1911 he was awarded an honorary medal at a conference in France for his breakthrough in the fight against syphilis (Primera Conferencia Nacional de Defesa contra a Sífilis, 1941). As a modernizing nation, these elites also wanted to distinguish themselves from the rest of Europe – especially France – by showing that they were approaching the

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syphilis epidemic from a purely scientific, non-moral perspective (Carrara, 1996). France was especially known to have a moralistic, regulatory, and somewhat condemnatory approach to syphilis control (mainly through the imprisonment of prostitutes). The sifilógrafos, in contrast, wanted to demonstrate their alternative approach, which was focused on sex education and prevention (Carrara, 1999). They were also tired of the global health community’s assumption that Brazil’s hot tropical weather promoted sexual excess, which in turn contributed to syphilis’ wild-fire spread. The sifilógrafos were out to prove a point: that Brazil could overcome disease, modernize, and prosper. The federal government appreciated these efforts and soon joined them in their cause. Receptive to the global health community and equally as committed to displaying Brazil’s commitment to syphilis eradication (though initially mainly through the sifilógrafos’ initiatives), the DGSP sponsored several of the sifilógrafos’ trips to Europe. In addition, even though the President was more focused on expanding the state and developing the economy, he relied on the sifilógrafos and state governments as primary responders but nevertheless had incentives to support their work. Doing so sent a clear message to the world that the government was fully committed to disease eradication and economic growth. The sifilógrafos’ active involvement in the global health community and their growing international reputation helped them to convince the President that syphilis was a serious problem and that he needed to respond through institution-building initiatives. However, it is important to emphasize here that these civic pressures were still no sufficient enough to convince the President to respond. While they helped increase his attention to the problem, without being directly criticized and pressured by public health

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experts in other nations, the President would not engage in any new institution-building efforts. Because of their active participation and influence at the global level, the sifilógrafos’ reputation increased dramatically (Primera Conferencia Nacional de Defesa contra a Sífilis, 1941). This facilitated their ability to establish and strengthen their connections with high level public health officials. The sifilógrafos’ connections with the global health movement also contributed to the reputation and influence of those bureaucratic officials that started to work with them. This included officials from the Departmento Geral de Saúde Público (DGSP) and eventually the Ministerio de Educacão e Saúde Público (MESP). What is important to note is that many of these public health officials were born out of the sifilógrafo movement, which further contributed to the latter’s credibility (Carrara, 1999). And because they were born out of these civic movements, they shared similar ideals and interests with regards to the role of government in public health intervention. Scholars also confirm the fact that the tripartite partnership emerged before the government responded to syphilis. In his detailed account of the civic movements that emerged in response to syphilis and later HIV/AIDS, Sergio Carrara (1999) explains that the sifilógrafo movement arose in tandem with the new global health movement focusing on syphilis and prior to the government’s eventual institution-building response. He shows that the sifilógrafos were politically inclined and strategically used their connections with the global health community to convince a seemingly apathetic government of the need to reform its public health infrastructure (Carrara, 1999). The rise

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of this global health movement and its pressures added to the credibility and influence of the tripartite partnership and those DGSP bureaucrats working within it. Indeed, what made the tripartite partnership successful in its ability to eventually convince the President to respond was its ability to strategically use the emergence of new global pressures for institution-building (Carrara, 1999). While in the United States the impetus for change emerged from the President and the Congress’ national security concerns, in Brazil it emerged from the rise of new global pressures and the formation of a tripartite partnership seeking to maintain the President’s interest in reform . Nevertheless, it is important to note that by itself (and as we saw with tuberculosis) the tripartite partnership could not influence the President’s views towards syphilis and his decision to engage in institution-building processes. For what was once again necessary for the trio partnership success was the concomitant emergence of new international pressures and criticisms directed at the President and how this, in turn, generated new incentives for modernizing to pursue institution-building. In other words, what all of this meant was that structural conditions other than the epidemic itself and, more importantly, the needs of civil society prompted the government’s commitment to institutional change. Indeed, institution-building efforts began in earnest in 1920, several years after the syphilis epidemic and the tripartite partnership emerged. That year, change in presidential perceptions and interest in institution-building stemmed primarily from the rise of new global pressures and the opportunity to once gain demonstrate to the world Brazil’s development capacity. Similar to what we saw earlier with tuberculosis, during this period the president received a lot of direct criticisms from the international health

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community, mainly from doctors and scientists in other nations (Filho, 2001). They were mainly concerned with the poor quality of Brazil’s public health system and their seemingly biased response to other kinds of diseases – only those posing a major economic threat, for example (Filho, 2001; 2004). Their criticisms were often manifested in countless newspapers and articles, as well as conference proceedings. International philanthropists, such as the David Rockefellar and Irene Diamond Foundation joined in on these criticisms. These pressures generated new incentives for then President Epitácio Pessoa (1919-22) to once gain show the rest of the world that he could effectively respond to any kind of epidemic and thus secure Brazil’s developmental trajectory. Responding through new institution-building endeavors also increased his global reputation. It was time when Brazil was striving to make its place in history and show the rest of the world that it was just as modern and capable of development. The emergence of these new global pressures thus weighed far more heavily on the president’s perceptions and interest responding to new state-build initiatives, far more so than any collective movement. In 1920, a myriad of new horizontal and vertical institutions were implemented. First, the executive and the congress decided to create a new public health agency that completely nationalized the response to syphilis. That year, it created the Inspectoria de Profilaxia de Lepra e das Doencas (IPLD) (Primera Conferencia Nacional de Defesa contra a Sífilis, 1941). The Inspectoria was dedicated to centralizing the funding of prevention and treatment services at the community level. It was highly autonomous and drew heavily from congressional coffers (Primera Conferencia Nacional de Defesa contra a Sífilis, 1941). It was well staffed and had unwavering executive and

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congressional support. The mere fact that it was a new federal agency focusing on venereal disease sent a clear message that the government was finally committed to institution-building. At the state level, in addition to providing new streams of funding the President issued several executive decrees requiring that public health agencies at the state level provide new health services. In 1920, the government issued Lei art #5, which mandated that state governments provide free treatment and educational services to the municipalities. Furthermore, any agency that did not adhere to this law was to be fined from 100.00 to up to 500.00Réis (R$) (Primera Conferencia Nacional de Defesa contra a Sífilis, 1941: p. 168). As a consequence of these measures, a host of state governments began to create new anti-venereal centers focusing on syphilis eradication. Dr. Joaqim Mota (1941) notes that 709 centers for the treatment of syphilis were created throughout the states, with 55 created in the government capital, which at the time was located in Rio. Because of these efforts he argues that the number of syphilis cases reported declined by 50% (Mota, 1941). The government also started working closely with the private sector. In 1920, it began to work with the largest medical charity organization at the time, the Fundacão Gafrée-Guinle. Founded in 1920 by the Familia Guinle with a generous gift of 16.000:00$000 (dezesseis mil conts), the Fundacão was a private hospital and clinic committed to conducting lab research in addition to increasing public awareness and education about syphilis. Next to the sifilógrafos and their Sociedade Brasileira de Dermatologia e Sifilographia, the Fundacão was the most vocal proponent of sex education in schools and private industry. It worked closely with academia and the

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sifilógrafos and incessantly approached the Congress for additional funding. After several failed attempts to obtain a formal dual-financing contract from the Congress (due mainly to co-financing disputes), in 1923 the Congress agreed to dispense additional money for 10 clinics that the Fundacão established in the periphery (Mota, 1941). With this funding, the foundation could concentrate and commit its resources to treating patients. Because many of the state and municipal health agencies at the time were understaffed and poorly financed, the Fundacão was critical for helping the government treat patients. It took in the lion’s share of syphilis patients in Rio, in addition to financing the provision of medical treatment (mainly injections). The federal government sustained its partnership with the foundation until syphilis was eradicated with the introduction of penicillin treatment by the mid- to late-1940s (see Figure 1.5). Graph 3.5 - Brazil: Syphilis Cases (all types, per 10.000) 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 1948

1949

1950

1951

1952

1953

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1955

1956

Source: Fundacao Gaffree e Guinle, 1958

The major institution-building campaigns were still to come. While the federal government created the highly centralized Inspectoria de Profilaxia de Lepra e das Doencas in 1920, with the arrival of the Getúlio Vargas military dictatorship in 1930 the government centralized all aspects of health insurance and public health (as noted earlier in this chapter.) In 1938, in an effort to strengthen the Ministerio de Educacão e Saúde 140

Público (MESP), Vargas eliminated the Inspectoria and incorporated all of its staff and policies into the MESP. Vargas was a true institution builder. He was a centralizer. He had a disdain for the fragmentation of federal agencies and fervently believed that all public heath issues should be centralized under one roof (Hauchmann, 1998). In slight contrast to President Epitácio Pessoa’s intentions, Varga’s motivation to create the Ministerio de Educacão e Saúde Público (MESP) was not prompted by international pressures and efforts to maintain Brazil’s international reputation. Instead, and similar to what we saw earlier in response to tuberculosis, Vargas was more concerned with national security, economic development, and the centralization of political power (McCann, 2006). If anything, during this period syphilis’ threat to Brazil’s national security, measured mainly in terms of economic development, is what motivated Vargas’ intentions to create and expand the MESP in response to syphilis. However, and similar again to what we saw with tuberculosis, Vargas’ response to international pressures changed as he became more involved in international military campaigns. This occurred when Vargas decided to join the allies in WWII. By joining the global war effort, Vargas became interested in joining the United States and other European nations in not only securing the world from Nazi fascism but also safeguarding citizens from disease and pandemic spread. Indeed, for it was in 1944 that Vargas sent one of his best medical doctors, Dr. Geraldo de Paula Souza, to work with Drs. Szeming Sze of China and Karl Evang of Norway to propose the creation of the World Health Organization. From that point on, Vargas became very concern about his international reputation and image as a president committed to eradicating disease. As we saw with

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TB, this finally motivated him to press harder for an expansion of the MESP and other programs focused on eradicating syphilis in Brazil. In closing this historical section on Brazil, I cannot emphasize enough the fact that the impetus for institution-building did not derive from the new democracy’s immediate, altruistic interest in containing syphilis and saving lives. Instead, the government’s response emerged from changes in global and domestic structural conditions and their effects on domestic politics. Specifically, institution-building was the product of two forces: on one hand, the new global pressures and the reputational incentives that responding to disease provided for presidents and fascist politicians, followed – albeit briefly – by threats to national security. Although national security would play an important role during the first few years of the Vargas presidency, international pressures and reputation would once again emerge to positively influence his perceptions of the need to reform institutions. Although tripartite partnerships did not emerge as a key player in the institutionbuilding process throughout this historical period, it did nevertheless establish the groundwork for an enduring informal coalition between the global health community, reform bureaucrats within public health agencies, and well organized civic organizations seeking an immediate institution-building response to epidemics. As we’ll discuss in the next chapter, the formation of this tripartite partnership was vital for the future success of pro-reform bureaucratic officials seeking to expand and strengthen their response to HIV/AIDS. Specifically, in response to the emergence of similar global pressures for institutional change, they were able to find and strategically use their historic partnerships

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with those civic organizations seeking an expansion of federal administration and technical assistance in response to AIDS.

~ Conclusion ~ This chapter has shown that both old and new democracies do not immediately respond to contested epidemics. Instead history shows that democracies will always delay their response, eventually deciding to respond for reasons other than meeting the immediate needs of civil society. As seen in the United States and Brazil, political elites pursue institution-building only when epidemics either pose threats to the national security, when they threaten the personal lives of influential political leaders (the U.S.), or when pressures and incentives from the global health community, pushed forward with the recommendations of pro-reform bureaucrats and civic organizations, generate incentives for presidents to pursue institutional reforms (as seen in Brazil). As we’ll see in the next four chapters, however, these happenings are not unique to the historical record. Despite an increase over the years in democratic consolidation and political participation (especially in Brazil), both nations still have not learned from prior experiences: That is, there continues to be a 5 to 8 year delay in the creation and/or modernization of public health agencies (or as seen in the United States, nothing at all) in order to implement policy effectively and help municipal governments. History also reveals that delayed institution-building responses are a product of competing perceptions and incentives for reform at three distinct units of analysis: presidential, congressional, and bureaucratic. As outlined in Chapter 2, such is the political nature of contested epidemics. In the past, and as we’ll see again in the future, it has taken major macro-structural conditions, such as war and new national security 143

threats and the emergence of new global pressures to overcome these conflicting perceptions and to reach a consensus for reform. Nevertheless, it is important to note that these structural conditions are not unique to the early 20th century. For as we’ll see in the remainder of this dissertation, they also reemerged later to shape how and when federal elites agreed to create and/or rebuild public health agencies. What is more, their absence in some instances, such as the United States and the failure of AIDS to pose a national security threat, explains why subsequent elites never engaged in new institution-building initiatives. Moreover, this occurred despite the repeated requests of U.S. public health officials that such a response was needed, especially within a highly decentralized federal context, where local governments are distant from the center and often lack the resources needed to respond in a timely and effective manner. Pressuring the government in this manner is a repeated bureaucratic endeavor – and by now tradition - that dates back to the days of syphilis, malnutrition, and reemerged yet again with AIDS and more recently obesity. This chapter has also shown that contrasting elite perceptions are influenced by the government’s receptivity towards new global health movements. As seen in the United States, political elites that are less receptive to international criticisms and recommendations for institution-building will be influenced more by domestic factors, such as national security threats and personalism. In contrast, within more receptive governments, such as Brazil, elite perceptions and incentives for reform are heavily influenced by global structural shifts, such as a rise of other nations’ criticisms of Brazil’s response, pressures form international philanthropic organizations, and the incentives that these criticisms and pressures generate for government’s to increase their global

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reputation as modern nations capable of combating disease. While an epidemics threat to national security and development also instigated reforms in Brazil (primarily under Vargas), sensitivity to international pressures and concerns with global reputation predated Vargas and emerged later during his reign in power. As we saw with Brazil’s response to tuberculosis and syphilis, these global shifts also provide incentives for the formation of informal coalitional relationships between international health organizations, civic organizations, and reform bureaucrats within public health agencies seeking an immediate institution-building response. This, in turn, creates tripartite partnerships that provide bureaucrats with the influence needed to consistently pressure the president for an institution-building response. But again, note that while these new tripartite partnerships were not successful at initially convincing the presidents to respond through new institution-building initiatives, they were nevertheless vital for creating an informal coalitional partnership and tradition that would persist over the years, ultimately providing, as the next chapter explains, future bureaucrats with the civic resources needed to incessantly pressure and convince presidents of the need to continuously expand and strengthen public health agencies. Indeed, and as explained in further detail in the next chapter, it was a new resource within civil society that pro-reform bureaucrats, marginalized and constrained within their own agencies, would resuscitate and use within a new context of international pressure in order to strengthen their legitimacy and ability to obtain the funding and political support needed to expand the National AIDS Program. Thus, institution--building in responses to epidemics was not unique to historic Brazil. In subsequent chapters in this dissertation, we’ll see the successful influence of

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global health movements and pressures for institution-building re-emerge in a period of increased globalization and democratization (1980-present). Within this geopolitical context, governments are once again forced to decide if they will either be resistant or receptive to new global pressures.. We will see how Brazil, in contrast to the United States, has once again positively responded to new international recommendations for institution-building; and so much so that Brazil currently outpaces the United States and a host of other industrialized nations in their ability to reform federal agencies for a more effective response to epidemics. In contrast to Brazil, the U.S.’s response to AIDS and more recently obesity continues to show this repeated pattern of rejecting global health pressures and recommendations for institution-building, while instead trying to once again lead and influence other nations’ policies in ways that favor the government’s selfinterested economic and public health concerns (Kickbusch, 2002). As in the past, we’ll see how this resistance to global health movements creates few incentives for presidents and the Congress to consolidate and strengthen the United States’ highly fragmented, ineffective U.S. Public Health Service in response to more recent epidemics, such as obesity. The Origins of Bureaucratic Stewardship Amidst the political chaos of conflicting elite perceptions that typically characterize the first few years of an epidemic, it was refreshing to see how committed public health agencies were to immediately responding to the needs of civil society. While conflicting perceptions and interests delayed presidential and congressional response, since the early20th century public health bureaucrats in the United States and Brazil never allowed this to influence their perceptions and institution--building pursuits. Moreover, reform 146

bureaucrats in both cases always brushed aside Puritanical morals, racism, and in sharp contrast to representative government, repeatedly viewed all types of epidemics as serious national threats worthy of an immediate response. What is more, in both countries public health agencies were the only state organs willing to immediately start working with stigmatized groups in civil society. That is, groups such as African Americans and their struggles with syphilis in the United States, in addition to poor urban workers in Brazil suffering from tuberculosis, were the beneficiaries of immediate bureaucratic support. This response stemmed from the high degree of bureaucratic secularism and professionalism that prioritized science over politics, an ethos that emerged from early progressive movements in the United States and modernization drives (especially under Vargas) in Brazil. And these traditions persist. For as we’ll soon see with the next morally and racially stigmatized epidemic to emerge in the United States, HIV/AIDS, once again it was the U.S. Public Health Service that immediately embedded itself in civil society, working closely with the increasingly marginalized gay community, drug addicts, and the poor. In fact, during the first few years of the epidemic, when presidents in both the United States and Brazil were not responding to the immediate needs of civil society, it was the U.S. Public Health Service that far outpaced Brazil’s Ministry of Health in its vertical assistance to stigmatized communities. This helped to build trust in a government that seemed apathetic to their needs. As in the past, while PHS bureaucrats were not successful in persuading the President and the Congress to build new institutions in the absence of war and national security threats, their vertical assistance nevertheless helped set the groundwork for subsequent federal intervention, though mainly through policy

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reform. This unmasked the somewhat startling fact that it was the PHS that was much more secular and committed to immediately working with stigmatized groups in civil society than their seemingly more liberally-minded counterparts in the south. But this does not mean that the President and the Congress have always been receptive to bureaucratic needs. For as we saw in this chapter, especially in the United States the bureaucracy was only influential when the President and the Congress viewed epidemics as threatening the national security and/or the President’s livelihood. On the other hand, Brazil’s public health bureaucracy was influential only after the President’s interests were changed by national security concerns and especially global pressures. After this occurred, bureaucracy’s historic partnership with well organized civic organizations and their linkages with international health movements aided this process. This tripartite movement gave reform bureaucrats the leverage needed to help convince the President that institution-building was vital for successfully curbing the spread of disease. Note, however, that in both cases it was not the federal bureaucracy that convinced the President and the Congress to pursue institution-building. While bureaucracy played an important role in providing recommendations for reform, their influence relied to a great extent on the President’s concomitant change in perception and interest in institution-building; and these changes were influenced more by the structural conditions outlined above. The Genesis of Bureaucratic Survival In closing my discussion of the federal bureaucracy, what this chapter has also shown is that presidents building public health regimes for the sole purposes of ensuring national 148

security will create agencies that are only strengthened and sustained in time of war. But when this is over, and as seen most clearly in the U.S. with the CDC during the 1940s, agencies are perceived as almost pointless excess, in need of pruning. This creates a public health agency that incessantly worries about its survival as soon as any national security threat is over. As we saw with the polio, this creates incentives for health officials to repeatedly view and use newly defined epidemics as a means to increase agency legitimacy and influence, primarily by working independently in a time of crisis. Worse still, it creates an agency that no aspiring bureaucrat would like to work for, thus dramatically reducing its technical capacity, morale, espirit de corps, and overall willingness and ability to respond to epidemics in a timely and effective manner. By the 1950s, the U.S. government created a public health agency that had a habitual instinct of immediately viewing epidemics as means to agency survival, and eventually, with the emergence of other PHS agencies competing for resources, such as the NIH, bureaucratic territoriality and disdain towards inter-agency cooperation. Ironically, as the PHS expanded over the years and increased its sense of professionalism, secularism, and technical know-how, its survival instincts at the same time precluded any type of institution-building from occurring – such as inter-agency collaboration. This is a pattern that we’ll see happen over and over again, with AIDS in the 1980s and more recently with obesity. Agency survival is now a deeply ingrained tradition within our war-born public health system; it is now a deeply institutionalized instinct; and it is one that persists and stems not from the government’s history of responding to citizen need, but from its ongoing self interest in prioritizing national security issues above the immediate needs of

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civil society. When it comes to building institutions for public health, protecting the homeland through a strong national defense system has always been much more important to our democratically elected officials than responding to the immediate needs of civil society. The Limits to Historical Institutionalism: Focusing on Underlying Mechanisms Allow me to close this chapter with the broader institutional lessons learned from this chapter. As we saw earlier, federal elites in the United States and Brazil behaved in ways that were wholly unpredictable given the types of public health regimes present. That is, highly decentralized institutions in the United States eventually saw federal elites building new agencies and intervening at the sub-national level, while highly centralized bureaucratic institutions in Brazil were often delayed and biased in their vertical response to certain kinds of diseases. This finding submits an interesting paradox and questions the causal efficacy (and thus predictability) of historical institutional designs. Going forward, scholars seeking to avoid these paradoxes may wish to consider selecting cases based on the underlying (non-institutional) coalitions that motivate federal elites to create and/or modernize public health agencies. As we saw above, focusing on the reform coalitions that emerged during the second phase of epidemic politics, such as new national security threats and global pressures, may do a far better job at predicting institution-building outcomes than a comparison of cases based on formal public health regime characteristics – e.g., a centralized versus decentralized public health system. Scholars and policy-makers concerned with better describing and predicting the performance of public health regimes may want to focus on the domestic and

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international coalitions that emerge in favor of institution-building during the second phase of epidemic politics. In essence what I am arguing here is that public health regimes should be reclassified into two major subtypes, both having unique domestic and global coalitional relationships that always lead to the formation and/or modernization of public health agencies. The first subtype is what I call Globally-Resistant Public Health Regimes (GRPHR), whereas the second is what I call Global-Integrated Public Health Regimes (GIPHR). It is important to note that the terms “Resistant” and “Integrated” refer not to the amount of foreign aid governments provide to the global health community (which has always been considerably higher in the United States), but rather to the receptivity and willingness of nations to cooperate with the international health community for the creation and/or reform of public health agencies, on one hand, and the global reputational incentives for doing so, on the other. Globally-Resistant Public Health Regimes should be further broken down into the following subtypes: national security and personalistic regimes. This more accurately reflects the geopolitically isolated domestic politics of government response to epidemics. In these types of regimes, presidents, the Congress, and bureaucratic officials perceive epidemics as posing immanent threats to the national security and/or to the personal security of political leaders. These structural conditions are unique to GRPHRs. In this kind of regime, democracies are not openly receptive to global health criticisms and suggestions for institution-building. As a result, increased global health integration does not provide new incentives to follow the advice of international organizations. Furthermore, the emergence of global pressures for change does not provide incentives to

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increase the nation’s reputation as a modern nation capable of containing the spread of disease. The only global incentives that these regimes have are to lead other nations in the fight against disease, either through bilateral aid or technical assistance. As Table 1.2 illustrates, in order for a GRPHR to emerge, the following reform coalitions must be present: First, coalitions between the President, Congress, and Military/Security Agencies in favor of institution-building. Here, previously conflicting perceptions between these actors converge as soon as an epidemic poses a threat to the national security, or to the security of a president. Second, in this model the influence of pro-reform bureaucrats and/or civic associations is weak prior to the emergence of a national security threat. For the most part this is due to the absence of government receptivity to new global health movements and consequently the absence of any incentives for bureaucrats and civil society to work together and to form a tripartite partnership. As Table 1.2 illustrates, the outcome from these coalition patterns is the creation of federal agencies and/or the modernization of pre-existing ones for increased federal intervention. These institutions are immediately created in response to the national security threats that epidemics pose. Yet it is important to note that these types of regimes arise well after the epidemic has emerged – or what I described in Chapter 2 as the Second Phase of epidemic politics. 31 If these security regimes are not present, as we’ll

31

As you recall from Chapter 2, the first and second phase of epidemic politics refers to the timing of the epidemic and the different politics involved. During the first phase, epidemics emerge as a crisis and elicit competing perceptions and views over how and to what extent the federal government should respond through institution-building. The second phase, on the other hand, refers to when the epidemic has lingered for some time and the new structural conditions (global or domestic) that prompt a change in elite perceptions and interest in institution-building. Thus for both of the regime re-classifications noted above, governments are operating in the second phase of epidemic politics, where either domestic national security threats, personalism, or global structural shifts converge previously conflicting elite perceptions and interests in institution-building.

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see in the future with AIDS and obesity in the United States, then institution-building will not occur. On the other hand, Globally-Integrated Public Health Regimes (GIPHRs) can be classified by the following reform coalitions. First and foremost, the President and Congress’ receptivity and willingness to respond to the emergence of new global health pressures for a more effective institution-building response; second, the new incentives that this provides for Presidents to increase their global reputation as modern nations capable of hastily defeating epidemics through institution-building and the new coalitions that they forge with reform bureaucrats to achieve this; and third, the presence of tripartite partnerships, where pro-reform bureaucratic officials, civic organizations, and world health organizations forge coalitions to help sustain the government’s commitment to institution-building. In this chapter, the case of Brazil best exemplifies the GIPHR model. As we saw earlier, these regimes can emerge in response to both sexually and non-sexually transmitted diseases. Furthermore, these regimes are enduring and always arise whenever a new global health consensus emerges about the presence of a pandemic threat and the need for institution-building. Nevertheless, as we saw with Brazil’s response to tuberculosis and syphilis, and as we’ll see again with its response to AIDS and the recent resurgence of tuberculosis, GIPHRs will never arise during the first few years of an epidemic – i.e., the first phase. Rather, they wait for the emergence of a new global health consensus, pressures, and incentives for nations to increase their global reputation and fame as governments capable of controlling epidemics and prospering.

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GIPHRs are not unique to Brazil, however. As I discuss at the end of this dissertation, and as I have discussed elsewhere (Gómez, 2007b), they are most likely to be found in middle- and low-income nations. As Table 1.2 illustrates, the GIPHR framework can apply to a host of cases, and I expect that most will be found among those democracies that have recently made the transition from authoritarianism or state-led socialism. As Figure 1.6 illustrates, other examples may include the nations of Brazil, Mexico, Vietnam, Cambodia, and Nigeria. All of these are nascent democracies that have been receptive and cooperative with the international health community and that have in recent years created new public health agencies for AIDS, TB, and other epidemics. In future work, I expect to find that the more globally-integrated regimes will eventually surpass their isolated, more industrialized counterparts in their willingness and capacity to create and/or rebuild public health agencies in response to epidemics.

Illustration 3.3 - Globally Isolated and Globally Integrated Public Health Regimes Institution Building

GRPHRs

GIPHRs Brazil Vietnam, Cuba, India

United States Russia, China

Global Integration

Tripartite Partnerships

Methodological Benefits to Regime Re-classification And finally, there are several methodological benefits that emerge from re-classifying public health regimes based on these underlying reform coalitions. 154

First, re-classifying public heath regimes based on types of domestic and international coalitions can provide a more accurate description of the type of health regime present. Consider the paradox that I submitted earlier: centralized institutionbuilding and intervention (albeit delayed) in an increasingly decentralized context in the United States; on the other hand, a similar yet delayed and biased institution-building response within a historically centralized bureaucratic context in Brazil. These paradoxes emerged because these public health institutions were never accurately defined, based on the underlying domestic and international coalitional relationships noted above. In the absence an accurate description of public health regimes, we will continue to see unexpected institution-building outcomes and fail to predict the outcomes that emerge from these regimes. Thus in no way can we rely on the formal design of these regimes (i.e., decentralized or centralized) as reliable predictors of outcomes. In contrast, by focusing on underlying coalitional partnerships and re-classifying nations based on these types of coalitions, we may be able to better describe and predict when and to what extent institution-building will occur. This sets the groundwork for our understanding of recent institution-building dynamics in the United States and Brazil, which is the focus of the next four chapters. For instance, the consolidation of GRPHR regimes can explain why the United States never created a new federal agency and/or modernized the PHS in response to AIDS and more recently obesity. More specifically, by understanding that the U.S. has historically built federal agencies only in response to epidemics that pose national security threats and/or threaten the lives of high level politicians, we can now better understand why AIDS never elicited an institution-building response.

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On the other hand, the recent threat that the avian bird flu virus has posed to our national security has elicited a new institution-building response. And now that overweight and obesity is gradually starting to threaten our military’s fighting capabilities and therefore our national security (The Associated Press, 7/5/05), we should expect President Bush or the next administration to create a new federal agency in response to the problem. This kind of response would be similar to what we saw with the malnutrition problem of the early-20th century and the creation of the War Food Administration. On the other hand, the GIPHR concept also helps to explain why Brazil’s centralized bureaucratic response to AIDS was not as successful as we thought it would be in response to AIDS. Furthermore, it explains why Brazil was so biased in its response to AIDS and not TB. When AIDS emerged in Brazil, the government still had a centralized bureaucratic response to epidemics – INAMPS. As in the past, predictions based solely on this institutional design would have led us to expect a government that would have immediately responded to AIDS through the increased centralization of bureaucratic authority and the provision of timely resources to state-governments. One could argue that this did indeed occur with the creation of the DST/National AIDS Program in 1985 (though note the 4 year delay; Lieberman and Gauri, 2006). However, and as we’ll soon see in Chapter 6, the AIDS program was purely cosmetic in nature, such that it was nicely designed but wholly ineffective in its ability to respond to the new epidemic. As the GIPHR framework would predict, it was not until the emergence of new global pressures from international health organizations, financiers, and as seen in the

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past, the new incentives that this provided for Brazil’s President to once again reveal his nation’s developmental potential (the “race to global fame”) emerged that the government finally responded through the strengthening and expansion of the DST/National AIDS Program. This change in executive perceptions and incentives was once again influenced (though not caused) by the re-emergence of the historically-based tripartite partnerships linking pro-reform bureaucrats, civic organizations, and international organizations committed to institution-building in response to epidemics. As we saw with syphilis and TB control in the past, it was thus the underlying coalitional relationships that emerged within a global-integrated public health regime that eventually led to a more effective institution-building response to AIDS. The key point here is that if we had simply relied on the formal design of Brazil’s public health regime in 1981, we could not have accurately predicted the type (better yet, quality) of institution-building that eventually emerged in response to AIDS. In contrast, a more accurate description of Brazil’s public health regime based on GIPHR indicators would have, as in the past, predicted with greater certainty both the timing and the scope of institution-building in response to AIDS – as well as policy success. For as was the case in the past, the expansion of the DST/National AIDS Program beginning in 1992 did not occur until after the government decided to work closely with the global health community, until it could once again reveal its potential as a modern nation capable of combating disease (as we saw with Vargas and his response to tuberculosis and syphilis towards the end of his administration); expansion also did not occur until a new tripartite partnership emerged that once again helped to convince the government to engage in institution-building.

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In the conclusion of this dissertation, I’ll look at some other examples of global reactionary versus integrated public health regimes. I’ll argue that this kind of regime reclassification is imperative for accurately describing and predicting the underlying political nature of public health regimes and their political willingness and capacity to build federal agencies. In essence, it explains the underlying political commitment to ensuring that nations complete what Moises Naim once called “the second stage of reform”: that is, reforming public institutions in order to ensure that they are capable of effectively implementing policy (Naim, 1994).

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CHAPTER 4 Historical Happenings Going Forward: Understanding the Civic Sources of Institutional Change We now leave history to go into four in-depth contemporary case studies. In the next few chapters we’ll enter the more recent era of globalization and re-democratization (1980present). Similar to the early-20th century, it marks the emergence of new global interests in political and economic norms and the integration of markets into the global economy. More importantly for the topic at hand it marks the emergence of a new global health consensus and pressures to respond more aggressively to epidemics. But before we delve into the cases studies, it is important that we take a moment to briefly understand the theoretical implications that our previous chapter had for institution-building in the contemporary era. It is also important to understand its contributions to the literature on institutional origins and institutional change – two strands of literature in American and Comparative Politics that have been viewed as distinct from one another. Understanding this will give us a better sense of how Brazil was eventually able to outpace the United States when it came to building a more effective bureaucracy in response to HIV/AIDS. Let’s begin by briefly recapping our discussion of the creation of federal agencies in response to different types of epidemics in historic Brazil and how this relates to institution-building patterns in the contemporary era. I focus my analysis on Brazil because it was the only nation to be receptive to global health pressures for institutionbuilding during both the historical and contemporary periods. Revisiting Brazilian history 159

helps to explain the re-emergence of the informal bureaucratic traditions and the civic resources that contemporary federal bureaucrats have been able to use in order to expand and strengthen the National AIDS Program. As we saw in the previous chapter, new civic movements in Brazil, namely the Sifilógrafos and the Liga do Tuberculose, emerged in response to syphilis and tuberculosis, and worked closely with the global health community and federal officials to pressure the government for an immediate institutional response to these epidemics though initially to no avail, which comports with my first phase argument. Civil society’s response increased the groups’ reputation at the domestic level, which in turn created incentives for reform bureaucrats within the Ministry of Health (themselves pursuing institution-building) to reach out and work with them in order to strengthen their position within government. This eventually facilitated their ability to work with the President for more effective institution-building. 32 It was the birth of a new informal coalition, an informal tripartite partnership between civic organizations, the global health community, and reform bureaucrats; that led to a sustained commitment to bureaucratic expansion and sound policy implementation. Two reform traditions emerged from the historical period. First, the mutual incentives for federal bureaucrats and civic organizations to work together whenever a new global health consensus and pressures for institutional change emerged. Second, the ability of pro-reform bureaucrats to strategically use their informal working relationship with the Sifilógrafos and the Liga do Tuberculose as an external pool of resources for

32

Though again, recall that a necessary pre-condition for the rise of these tripartite partnerships (between international health movements, reform bureaucrats and civic organizations) was the change in presidential perceptions that a genuine epidemic emerged and that institution-building should be pursued. This occurred after the race to global fame influenced the president’s perceptions.

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institutional change: more specifically, the bureaucrats’ ability to use their shared beliefs and norms (civic resources) with these civic organizations as leverage and justification for continued bureaucratic reform. As we saw in the previous chapter, these beliefs were explicitly stated views and a mutual consensus existed between these two actors that the government should create and/or strengthen centralized public health agencies in response to epidemics. 33 Their ability to define and reach common ground was facilitated by the fact that reform bureaucrats in the past emerged out of these civic movements. These movements were, in turn, composed of intellectuals, artists, and professors from the most prestigious medical universities in Brazil. Nevertheless, I argue that the benefits associated with using these informal resources emerged not in the historical period but in the more recent era. I therefore view these informal resources as historically-based informal partnerships and traditions that contemporary bureaucrats call upon and use as an exogenous pool of resources for political bargaining and organizational expansion. That is, using these historically-based resources increases the domestic and international legitimacy of pro-reform bureaucrats in the contemporary period, which in turn strengthens their bargaining power and influence with the President, the Congress and other federal agencies. This enhances their ability to consistently persuade the government of the need to continuously support the expansion of National AIDS Program. As we’ll see in the next few chapters, it is very important to note, however, that the emergence and influence of these informal resources are, as in the past, entirely dependent on two necessary preconditions: first, the rise of a new global health consensus

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Others have noted that this consensus is a necessary precondition for the emergence of informal institutions (Helmke and Levitsky, 2004).

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and direct pressures for institution-building, and, second, the new opportunities that these global pressures provide for presidents to increase their international reputation as effective disease combatants. This is “the race to global fame,” which was described in Chapter 2. Graph 4.1 – Tripartite Partnerships Historical Period (1900-50)

Contemporary Period (1980-present)

Global Health Pressures

Brazil

CS

U.S.

Global Health Pressures

Brazil

PRB

U.S.

CS

PRB

Resuscitation of informal resources CS = Civic Organizations; PRB = Pro-Reform Bureaucrats = informal partnerships for institution-building

As the graph above illustrates, informal partnerships between civic organizations (which have ties to international health movements) and bureaucratic officials originating from the historical period (1900-50) are eventually resuscitated and used by pro-reform bureaucrats (PRBs) in the contemporary period (1980-present). Through their education and knowledge of these historic partnerships, in addition to their ties with contemporary

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civic movements that closely resemble those of the past, PRBs actively seek to resuscitate and use these civic connections to their organizational advantage. As noted in Chapter 2, there are concomitant institutional and career incentives to doing so, as using civic organizations as a resource increases bureaucratic reformers influence and bargaining power for continued administrative spending, while helping advance their careers. In addition, their incentives to engage in these partnerships continue as international organizations, such as the World Bank and the WHO, supporting the incorporation of civil society into the institutional and policy-making process approach health officials with more money and attention. I argue that these incentives lead to the resuscitation of the historically-based bureaucratic-civic organizational partnerships for institution-building, which is initiated and maintained by contemporary reform bureaucrats. In a sense, this argument resembles what James Mahoney (2000) once called a chain reactionary causal sequence, where an individual and/or group’s positive reaction to prior actions motivate them to continue following down a particular path. Although the gap in time is much longer than what Mahoney emphasized, the logic is essentially the same: contemporary reformers positively react to the fact that their historic bureaucratic predecessors established partnerships with civic organizations in order to increase their legitimacy and influence in government. This long chain reactionary sequence in turn rejuvenates and sustains longheld traditions of forging partnerships for institution-building whenever new epidemics emerge. As we will see in Chapter 6, this reactionary sequence was necessary for the successful reform and expansion of the National AIDS Program by the 1990s.

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We will also see the emergence of this reform dynamic for TB in Chapter 7, though to a more limited extent, since the tripartite partnership in favor of bureaucratic expansion for TB is just now starting to emerge. The simultaneous arrival of new civic movements and global pressures for institution-building and policy reform, stemming mainly from the World Health Organization and more recently the Global Fund to Fight AIDS, TB, and Malaria, is once again motivating contemporary TB bureaucrats to resuscitate these historically-based partnerships with civil society. These efforts are very recent and have not yet led to concrete institution-building outcomes, but nevertheless have set the groundwork for such reforms to emerge at a later point in time. Theoretically, these findings also say something about the conditions leading to successful institutional change. 34 First, it is important to understand that institutionbuilding in the contemporary era was not prompted by the exogenous shock of a health epidemic. Keep in mind that this was also the case historically. In the following chapters, you will see that regardless of the type of health epidemic present, i.e., HIV/AIDS, TB, or overweight/obesity, it was never the epidemic itself that prompted institution-building. Rather, and as seen in the successful case of Brazil, it was the national executive’s response to new, gradually emerging international pressures for institutional change, first and foremost, then (and critically here) the re-emergence of reform tripartite partnerships between international organizations, bureaucracy, and civic organizations, that eventually prompted reform. This finding suggests that institutional change occurred in the absence of exogenous shocks. Normally, we would expect such shocks (or what others have referred to as “critical junctures”) to lead to immediate institutional change (Mahoney,

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Please note that the term “institutional change” is used as a synonym for institution-building.

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2000; Collier and Collier, 1991). But this never occurred for all of the epidemics examined in this dissertation since 1900. These findings further suggest that there are other exogenous conditions leading to institutional change, and that change also occurs in a more endogenous, gradual manner. In the case of Brazil, I posit that institutional change was the product of unique international and domestic movements that did not emanate from within government and in response to health crisis, but rather from gradually escalating historical and contemporary global health pressures and coalitions that eventually empowered contemporary bureaucratic reformers. Reformers found their strength and unity in their ability to resuscitate informal partnerships with globally-integrated, pro-active civic organizations. Institution-building was therefore a gradual reform process, occurring in response to the presence of deeply ingrained historic partnerships that needed to be rediscovered in the contemporary era. As in the past, the emergence of new global pressures for the strengthening of health systems in response to epidemics provided an opportunity for contemporary reformers within government to re-kindle long-forgotten ties and traditions with civic organizations sharing mutual interests and incentives for institution-building for more effective policy implementation. My findings therefore comport with recent theories highlighting the endogenous and exogenous conditions leading to institutional change. For example, Kathleen Thelen (2003) holds that endogenous transformations can emerge in the absence of exogenous shocks (that is, outside of the institution). She argues that pro-reform elites can gradually create their own endogenous crisis situations, which in turn leads to institutional change.

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Under these conditions, reformers from within emerge in order to press for new ideas 35; they also perceive their institutions not as constraints to action but as potential resources that can be used for their interests and abilities to successfully pursue reforms. Using the case of the artisan guild in Germany since 1837, Thelen (2003) puts forth two possibilities for endogenous institutional change--adaptation, and survival: that is, institutional layering, where, building on Schikler (2001), new additions are made to existing parts of an institution that cannot be easily reformed (which is similar to my conception of bureaucratic modernization); and second, institutional conversion, where parts of an institution are reused or reshaped in ways to meet new interests and goals. Richard Deeg (2005) also agrees with Thelen’s (2003) notion that endogenous change can occur in the absence of exogenous shocks. Like Thelen he suggests focusing on increasing returns as endogenous mechanisms of reproduction in order to better understand the processes leading to either their breakdown or adaptation. Analyzing financial sector reforms in Germany, where more successful reforms occurred among banks that gradually learned and sought new types of banking policies in response to global pressures rather than pursuing outdated banking procedures, Deeg argues that institutional change occurs because of the diminishing returns that these mechanisms eventually generate. The problem with Deeg (2005) and Thelen’s (2003) approach, however, is that neither approach adequately specifies the sources of reformers’ new ideas and, more importantly, why these reformers and ideas were so influential. While Deeg provides insight into the emergence of new ideas, he does not clearly specify their origination. To 35

I emphasize the term within here because “ideas” for institutional and policy change can often emerge from outside of the organization, such as from international organizations or epistemic communities (Finnemore, 1993; Goldstein and Keohane, 1993; Haas, 1992)

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his credit, he does discuss the emergence of gradual exogenous pressures from the international financial community, which gradually altered the interests and ideas of bankers (Deeg, 2005: p. 15). We take from this the possibility that reformers could have gradually obtained new ideas from changes in the global financial community, or financial sector reforms occurring in other nations. This, in turn, would generate new ideas and interests in reform, reaching what Paul Pierson (2000) once called the endogenous “threshold” for change – that is, the gradual accumulation of micro-decisions eventually reaching an apogee and a decision (Pierson, 2000). But did these new ideas and interests emerge from international bankers? Or did they emerge from domestic bankers and other corporate or even government reforms? Based on Deeg’s (2005) analysis, we can’t tell. However, I argue that being more specific as to where and when new ideas fuelling institutional change come from is important for understanding the ideational sources of institutional change. Second, Deeg (2005) and Thelen (2003) cannot explain why reformers were so influential. We are left believing that their emergence and ability to gradually create endogenous crisis and propose new ideas for change is sufficient for institutional change to occur. What is more, we cannot assume that even severe exogenous shocks that add credibility to the interests of marginalized reformers within institutions will be sufficient for change (Thelen, 1999; 2003). As the findings in this dissertation illustrate, these types of assumptions are erroneous, as the mere presence of an exogenous shock (epidemic) and even the gradual creation of endogenous conflicts (e.g., in the case of Brazil, between bureaucratic reformers seeking a centralized institutional response versus those wedded to a decentralized response to epidemics) and the introduction of new ideas for change

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within health ministries proved insufficient for successful institutional change to occur during the first phase of reform. Rather, what was necessary for change to occur was the willingness and ability of reformers seeking change to rekindle ideas that where historically-based, deriving from historic pacts between bureaucrats and civic organizations that provided the former with the legitimacy and influence needed to successfully pursue reforms. Because of this, I argue that we need to better understand the exogenous, historically-based structural conditions that give rise to the influence of reformers within institutions, rather than simply assuming that gradual endogenous crisis and learning on the one hand, or sudden emergence of favorable exogenous shocks (what others have called critical junctures) on the other hand, will always lead to institutional change. In this light, I agree with Robert Lieberman’s (2002) notion that it is important that we first understand the external social conditions that increase the ideational influence of reformers within institutions. That is, where did these reformers get their new ideas, and what kinds of social networks bolstered their claims? More specifically, what were the structural historical and contemporary circumstances bolstering the ideas of these reformers and how did these circumstances increase their organizational power? Lieberman (2002) criticizes scholars that argue on behalf of the influence of new ideas but that do not discuss the underlying political structures that give strength to their rise and influence. In contrast, he suggests that scholars need to show “how they [ideas] come to be prominent, important, and powerful, even determinative in shaping political behavior and defining political rationality.” 36 Did their ideas and sources of power derive

36

He goes on to quote Sheri Berman (2001): “Political scientists must be able to explain … why some of the innumerable ideas in circulation achieve prominence in the political realm at particular moments and

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from contemporary conditions? Or did they derive from deep historical legacies and traditions, shared by bureaucrats and civil society? Indeed, as the following chapters illustrates, successful reform bureaucrats in Brazil obtained their institution-building ideas from the informal partnerships that they formed with civic organizations in the past (the Sifilógrafos and the Liga do Tuberculose) and, yet again, in the contemporary period with similar civic movements, such as the Sanitarium movement and the more recent Foro de Tuberculose. As noted earlier, the idea to create an effective, centralized bureaucratic response to epidemics stemmed from a long held consensus and tradition among bureaucratic elites and proactive civic organizations. These were informal beliefs and agreements that stretched back to the early-20th century. Thus, the institution-building ideas that contemporary bureaucratic were harboring had a rich history; they entailed deep bureaucratic-civic ideas, norms and traditions, which essentially guaranteed them support within civil society and the global health community. Contemporary bureaucratic reformers thus chose ideas that were, in historical terms, socially and globally weighty in nature. With a president that was now interested in reform (due to the “race to global fame” element, as we discussed in Chapter 2 and in the previous chapter), these ideas were now extremely influential. This suggests that the historically-ingrained social conditions surrounding the emergence of new reform ideas within institutions determines to what extent institutions are capable of being altered. My discussion of Brazil’s institutional response to HIV/AIDS supports this argument. While pro-reform bureaucrats chose their ideas wisely, they also depended on

others not. Since no intellectual vacuum ever exists, what is really at issue her is ideational change, how individuals, groups, or societies exchange old ideas for new ones.”

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the support of well-organized civic organizations (NGOs) and international organizations that supported their views. At the same time that reformers were arguing for a recentralization of bureaucratic authority in response to AIDS, world health organizations and international financial institutions were supporting their ideas, at times even making them conditions for further financial assistance. We’ll see this phenomenon at work in the World Bank loans for Brazil’s institution-building response to AIDS, and more recently the Global Fund to Fight AIDS, TB, and Malaria’s mandate for the incorporation of civil society in the policy-making process in response to TB. Thus, while I certainly agree with Robert Lieberman’s (2002) assertion of the importance of understanding the propitious social conditions increasing the ability of reformers to implement new ideas, he ultimately fails to adequately explain the antecedent structural conditions that predict and give rise to the emergence of these supportive civic networks. Is it the presence of a crisis, such as civic unrest, fiscal crisis and/or health epidemics, which leads to their emergence? Or is it the emergence of worsening social inequalities and social injustice? In other words, what are the antecedent structural conditions that give rise civic organizations that seek partnerships with bureaucratic officials? Without this kind of analysis, we cannot predict when these civicbureaucratic partnerships will emerge and the types of international and domestic environments bolstering their influence. In contrast, this thesis does submit the antecedent structural conditions that give rise to supportive civic organizations, which in turn strengthens the position of bureaucratic reformers. As we saw in the past and as we’ll see again in the future, the rise of new global health pressures and the presence of an epidemic are necessary and

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sufficient conditions for the rise of supportive networks in civil society and the global health community. This fact explains how the rise of new global pressures for a more aggressive response to epidemics leads to the re-emergence of civic organizations seeking an immediate institution-building response. Increasing global pressures also motivates bureaucratic reformers to pursue reforms and eventually to re-connect with these civic elites. Moreover, the persistence of global pressures continues to embolden the legitimacy and influence of civic and bureaucratic reformers, which helps to rejuvenate and sustain their informal alliance. Going forward, I argue that when these two conditions are present, new supportive social networks will emerge that ultimately succeed in crafting new tripartite partnerships between international organizations, civic organizations, and bureaucratic reformers, in turn leading to a persistent and successful institution-building response to health epidemics. Unifying Theories of Institutional Origins and Institutional Change Finally, note that my analysis up to this point has pointed to a new area of comparative research: that is, understanding the linkages between theories focusing on the origins of institutions and institutional change. Up until this point, scholars of American and Comparative Politics have tended to treat these two areas as separate schools of thought, failing to clearly explain how they can be linked together to provide a more persuasive and fuller account of the institutional development process. More specifically, these approaches do not clearly state how the informal processes leading to the formation of institutions also accounts for their subsequent change. Below, I propose that there are several methodological and theoretical benefits associated with a unifying approach.

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One can make the case that the recent scholarly work done on the origins of institutions has been inspired by the seminal contributions of David Waldner (2001) at the University of Virginia. Waldner has been the first political scientists to systematically reveal the various methodological and theoretical problems that emerge when scholars fail to consider the originating conditions leading to the birth of formal institutions. In accord with Ira Katznelson (1997), Waldner argues that Comparative scholars have overlooked the methodological and theoretical importance of this kind of research, mainly because of the fact that they have tended to focus on the formal design of historical institutions, such as presidential versus parliamentary systems, and their utility in explaining cause and outcome. This has led to what he calls a “shift in contrast space,” where scholarly attention has shifted from focusing on the origins of institutions to formal institutional design and the outcomes that they generate. Yet both Waldner (2001) and Katznelson (1997) maintain that this shift has taken us away from a deeper understanding of the causal complexity of forming institutions and our ability to better understand their nature and predictive affects. Furthermore, Waldner suggests that there are several methodological problems associated with this shift in contrast space. They include the following: unexamined origins and unmeasured selectivity, circumstances in which scholars place too much of an emphasis on the causal efficacy of formal institutions without considering the influence that antecedent reform coalitions have on the outcomes to be explained. This results in poorly described and measured institutions. Second is the problem of conceptual and ontological ambiguity, in which, as a consequence of unmeasured selectivity, scholars fail to clearly define and explain what institutions precisely are, thus complicating our ability to predict their performance and

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outcomes. Finally, Waldner notes the problem of explanatory inadequacy, in which the scholar fails to provide clear causal mechanisms linking established institutions to their outcomes and, more importantly, the provision of causal mechanisms unique to the theory proposed. In such a case the importation and usage of theories from other schools of thought, such as rational choice, is questioned due to the imposition of theoretical constructs foreign to the detailed case studies examined. In response of these shortcomings, Waldner submits an a theoretical framework that avoids these methodological errors. In what he calls the Standard Explanatory Framework (SEF) of the origins of institutions, Waldner suggests that we focus on the following a theoretical causal mechanisms for understanding the formation of political regimes: first, an examination of the conflicts of interest between rulers and the ruled; second, the ruling coalitions that are born out of these conflicts; and finally, how these coalitions lead to the creation of institutions. These mechanisms allow for clearly explained, linked, chronological causal pathways that analysts can use to explain the emergence of institutions, while providing a better description, and thus prediction, of their performance. This SEF standard template is a theoretical in nature, such that it expects scholars who choose to utilize it to apply their own theoretical frameworks. Waldner claims that this approach allows us to avoid the above mentioned methodological shortcomings while providing new theoretical insight into the origins and performance of institutions. This work has inspired a host of recent studies on the formation of institutions and their performance. Following Waldner, Richard Doner, Bryan Ritchie and Dan Slater (2005) have recently focused on the origins of institutions and their accountability for

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variations in bureaucratic and policy outcomes across several Southeast Asian nations. Building on Waldner’s SEF approach, their analysis begins with the claim that what explained differences in the formation of effective economic ministries in Asia was not the rational intentions and designs of governing elites pursuing economic efficiency, as others have argued (Evans, 1995; Amsden, 1998), but rather the exogenous “systemic shocks” to governing elite coalitions. Also important was how institution-building became a means to political survival within conflict-driven military regimes. More specifically, they assert that tripartite systemic shocks, such as sudden threats to an elite’s ruling constituency base and the specter of civic rebellion, national security threats brought on by war and the need to acquire resources for protection, in addition to fiscal crisis, imposed daunting fiscal constraints on elites and limited their ability to sustain ruling coalitions. In an effort to appease supporters through side payments and thus broaden their governing coalition, they created new bureaucratic institutions that implemented new export-led strategies for growth. The creation of these institutions and the policies resulting from them provided the revenue needed to maintain side payments, expand coalitions, avoid social unrest and remain in power. Thus, in short, the creation and reform of bureaucratic institutions was pursued not for economic efficiency gains but for political survival. The key message the authors want to drive home is that, by focusing on the initial structural and political conditions leading to the formation of institutions, we can better describe the rise and performance of certain types of embedded economic ministries (Evans, 1995) and thus better predict variations in institutional outcomes across similar types of authoritarian regimes. Finally, through this approach they found that political

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leaders and appointed bureaucrats were not as autonomous as one might expect (based on Weberian designs), and that they were not focused on economic efficiency and gains after all. Building on this work, Dan Slater (2007) has tried to establish a bridge between theories focusing on institutional origins and change. In his paper titled “Altering Authoritarianism: Dynamics of Infrastructural and Despotic Institutions in Indonesia,” Slater claims that by examining the contentious politics that go into the formation of authoritarian institutions, we can understand how these institutions gradually evolve and change at subsequent points in time. Examining the case of Indonesia under Suharto, he claims that because of the presence of competing views and interests between the military and civic groups during the early formation of his regime, these tensions were perpetuated, and eventually forced Suharto to periodically make concessions to certain groups over others in periods of political instability. This led to a gradual change of authoritarian institutions, thus ushering in stability and adding to the continuation of Suharto’s regime. By focusing on the complex coalitional process going into the formation of Suharto’s regime, Slater argues that we can better understand why Suharto’s subsequent choices were often constrained and why he had to periodically reform institutions in order to broaden his coalition and maintain regime stability. Thus even within what we would normally expect to be a stable and enduring authoritarian regime, sustained through endogenous reproductive processes (Pierson, 2000; Mahoney, 2000), constraints on elite autonomy can lead to political stability.

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We thus have the following accumulation of knowledge when it comes to the unification of theories focused on institutional origins and change: Graph 4.2 – Accumulation of Knowledge Institutional Origins

Institutional Origins and Change

Method Benefits

Theoretical Benefits

Theoretical Benefits

Waldner (1999; 2004)

Doner, Ritchie, Slater (2005)

Slater (2007)

Slater (2006) Slater and Haid (2007) Eisenstadt (1964) While these recent works on institutional origins and change show us the methodological and theoretical benefits associated with focusing on the origins of institutions, what this literature fails to do is show how the coalitional dynamics leading to the formation of institutions also accounts for their subsequent change. More specifically, this literature has fallen short in explaining how the causal mechanisms leading to the formation of institutions, such as the historic formation of bureaucratic and civil societal coalitions based on similar norms and expectations, re-emerges at subsequent points in time, and how contemporary bureaucratic reformers strategically find and reuse these coalitions in order to increase their legitimacy and influence when seeking institutional change. As mentioned earlier, this process is kindled by the rise of new exogenous pressures (such as pressures from international organizations) and from reform bureaucrats’ knowledge of these historic pacts and their prior success. This, in turn, prompts bureaucrats to re-establish and use historically-based informal coalitions

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with civic organizations (as noted earlier in Graph 1.1) and international organizations in order to increase their bargaining power within government. I posit that there are several theoretical and empirical benefits associated with this type of approach. First, it clearly explains the causal mechanisms that link the historical formation of institutions with institutional change at subsequent points in time. By plainly specifying the causal mechanisms involved, this approach adds to the recent literature that seeks to establish theories about institutional change and power resources within organizations (Mahoney, 2004). Observe the following graph:

// Insert Graph 1.3 Here //

As we see here, the rise of international pressures for an effective health system response to epidemics in the historical period leads to the creation of agreed upon norms between globally-integrated civic organizations and federal bureaucrats seeking an immediate institution-building response to epidemics (CM1); this leads to a new coalition for institutional creation and change, comprised of civic organizations, international organizations, and federal bureaucrats (CM2), which in turn leads to further pressures for institutional creation and change (T1,T2). In the more recent period, and in response to similar international pressures for an effective health system response, pro-reform bureaucrats’ (PRB) respond to similar kinds of international pressures. Furthermore, their knowledge of preexisting norms, beliefs, and coalitions with well-organized civic organizations and supportive international actors generates incentives to seek out and work closely with civic organizations that have once again established close relationships

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with international organizations (CM1). Reform bureaucrats then take the lead in resuscitating coalitions with civic organizations and international actors that are similar to those formed in the past, i.e., based on a shared ideological beliefs that institutionbuilding should be an immediate response to health epidemics; denoted by in the graph. This then leads to the rekindling and sharing of norms and beliefs about institution-building, which were established in the past (CM2); which, in turn, leads to a new, historically-based reform coalition (CM3), followed by successful pressures for continued institutional change (T2). The important point here is to clearly explain and illustrate the re-establishment of historically-based coalitions between contemporary reform officials, civic organizations, and international organizations. The above demarcated approach provides a clear causal link between the historic coalitions leading to the formation of institutions and the expansion of institutions at subsequent points in time. The key linkage here is the attempt by contemporary reform bureaucrats to work with civic organizations and international actors in order to re-create coalitions similar to those established in the past. This approach provides motive and causal illustration for why and how contemporary bureaucratic elites establish linkages with institution-building processes in the past. By taking this kind of approach, this work adds to the recent contributions trying to establish connections between the origins of institutions and institutional change. For example, this framework builds on Dan Slater’s (2007) approach because it does not rest upon the assumption that simply understanding the initial conditions and inter-elite conflicts leading to the formation of institutions is sufficient for explaining elite choices and institutional change at subsequent points in time. Through my approach, an

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alternative analysis would require a narrative that explains and illustrates the causal mechanisms linking contemporary choices with individuals from the past. Slater (2007) could have shown Suharto’s strategy for how he later tried to re-build a fragmented coalition with those elites that resisted him in the past, clearly explicating what the precise mechanisms were for doing this - e.g., periodic meetings; this would clearly illustrate attempted negotiation and failure involving old civic and military elites. In addition to forming linkages with the past, this approach may reveal that some segments of the old elite may not have been as hostile to Suharto later on during his reign (when his choices were the most constrained), and that they may have tried to strengthen their relationship with him but decided to do so for reasons other than elite discord with the present situation. Neither Slater’s theoretical framework nor his empirical analysis addresses this issue. But by conducting this kind of approach he may have been able to give us a fuller explanation of how the origins of authoritarian regimes affected subsequent institutional change. With regard to the literature on institutional change, my approach also lends insight into the historical origins and strengths of exogenous resources in civil society that are available to bureaucratic officials seeking institutional change – and therefore addressing the sources of institutional change. To date, the literature on institutional change has failed to establish clear differences in the quality of exogenous resources available to reform bureaucrats in civil society. The quality of these resources is based on the different historical conditions that make up their composition. For example, some civic organizations and their ideas for change are more current, emerging in immediate response to a new crisis (Lieberman, 2002). However,

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other civic organizations, coalitions and ideas are more historically-based, formed by early civil societal and federal bureaucratic elite interests, which can be recycled at subsequent points in time. It is the latter, I argue, that submits a higher quality exogenous resource for contemporary reformers to use. This is because historically based beliefs and norms are perceived as being much more stable, enduring and legitimate than those that are formed in the immediate era at hand – at times seemingly developed out of haste, to support an argument that has little credibility. Contemporary coalitions and ideas are not perceived as enduring and legitimate because of the fact that they still have to pass muster in sustaining coalitions and increasing the legitimacy and influence of bureaucratic officials. Future research needs to make clearer distinctions between the historic differences in shared norms and beliefs and the advantages that they provide to contemporary reformers. Making these distinctions may strengthen our ability to better predict if certain marginalized ‘losers’ within institutions will be successful in relying on and using external resources in civil society for their organizational advantage. In addition, by clearly illustrating the direction and the intended use of civic resources by federal officials, this approach complements James Mahoney’s efforts to establish a new theory out “power” within organizations (Mahoney, 2004). Future studies will need to compare nations based on the availability of civic organizations, ideas, and coalitions that have long-held partnerships with federal officials and international actors. These are highly effective resources in civil society and the international level that contemporary bureaucratic officials at the federal level can draw from. Bureaucrats’ access to these resources also helps us to predict if and when public health agencies can successfully adjust to worsening health conditions and new types of

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health epidemics; furthermore, this process provides insight into what domestic governments and international organizations should do in order to accelerate this process. For instance, they could fund new conferences and programs that help increase public health officials’ awareness of their historic ties with civic organizations that share common interests in institution-building responses to epidemics, as well as those international organizations, non-governmental agencies and even philanthropic organizations that have a historic commitment to strengthening healthy system response to epidemics. Finally, through this theoretical approach, we can better describe the types of public health institutions (such as National AIDS and TB programs) that arise and their capacity to adapt to epidemics. Their ability to adapt is based on an ability to find and draw on historically-based resources in civil society and the international health community. Scholars to date have tended to focus only on the internal bureaucratic resources and the technocratic knowledge needed to respond to health epidemics without considering the importance of bureaucrats resuscitating historically-based coalitions at the domestic and international level in order to help them succeed in convincing the government to continuously allocate more money and political support. As we discussed in Chapter 2, this assumes the legitimacy and influence to continuously persuade the government for additional support. The mere presence of technical resources and resources within an agency will not be sufficient to achieve these ends. Historically-based resources can help achieve this, and future studies focusing on the sources of endogenous capacity of public health agencies will need to examine and compare this process in

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greater detail. Boone and Batsell (2001) have, in fact, suggested that researchers will need to address this issue in the future.

*** In the next chapter, we will start our analysis of the more recent case studies. We begin with a discussion of the United States’ response to AIDS, followed by a discussion of Brazil’s response to the same epidemic. After this, we proceed with a discussion of how these governments responded to non-sexually transmitted epidemics, such as obesity in the U.S. and the resurgence of tuberculosis in Brazil. In the next few chapters, we will see how the emergence of global forces and pressures for reform allowed Brazil to emerge as a more effective institution-builder in response to AIDS and, to some extent, tuberculosis. It suggests that in a new era of globalization, partnerships and communication, being receptive to the institutional and policy recommendations of the global health community, can go far in leading to a successful response to epidemics.

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Illustration 4.1 - Causal Mechanisms linking the Origins of Institutions to their Subsequent Change Historical Period

(similar international pressures)

International Health Community Pressures

International Health Community Pressures

Pro-Reform Bureaucrats

Civil Society

Contemporary Period

Pro-Reform Bureaucrats

T1, T2

Civil Society

T2

CM(1) = Norms and beliefs about the creation and expansion of bureaucratic agencies established between civic elites and pro-reform bureaucrats;

CM (1) = PRB knowledge of preexisting norms and beliefs creates incentives to work closer with civic organizations and international health community;

CM(2) = leads to coalition for agency creation and expansion between civic organizations, international community and bureaucrats

CM (2) = leads to re-establishment of norms and beliefs about the need for institutional change

T1, T2 = leads to coalitional pressure for Institutional creation and change

CM (3) = leads to coalition for agency expansion between civic organizations, international community, and reform bureaucrats T2 = leads to institutional change

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CHAPTER 5 Responding to AIDS in the United States: Elite Contestation, International Pressures, and the Absence of InstitutionBuilding (1980-90) This chapter tells the story of a well-established American democracy that did not immediately respond to the biggest epidemic of our time: AIDS. Divvying up the analysis from the initial period when the virus first emerged and was contested by political elites (i.e., the first phase of the AIDS epidemic), to the period when new international and domestic pressures for institution-building emerged (i.e., the second phase), it shows how in the absence of a direct national security threat the United States continuously failed to respond through new institution-building measures. During the first phase, while competing perceptions and contestation, driven by unique structural conditions at the presidential and legislative level, generated no immediate interest in creating a new federal agency for AIDS and/or modernizing the PHS, 37 the perceptions and interests of the CDC were once again different and in favor of an immediate response. Their views were influenced more by the history of viewing epidemics from a purely secular, scientific perspective. These views motivated them to

37

As noted in Chapter 2, institutional modernization refers to the increased provision of funding for bureaucratic reform, the creation of new programs and congressional adaptation to new bureaucratic needs. Perhaps more importantly, and pertaining mainly to the American context, it also means consolidating (centralizing) responsibility among federal agencies, i.e., reducing agency fragmentation and polarization during the initial stages of an epidemic.

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incessantly pressure the government for additional funding in order to conduct research and devise effective prevention and treatment programs. Nevertheless, the ongoing constraints of agency survival limited its response to bureaucratic embeddedness rather than an increased collaborative relationship with other agencies; as mentioned in Chapter 2, this was a key component of the institution-building process. As you recall from the same chapter, agency survival emerges whenever constraining fiscal conditions and the prospect of agency downsizing prompts directors of federal agencies to use the emergence of newly contested epidemics as opportunities to request additional funding while working independently in order to increase their reputation as agencies worthy of continued funding and expansion. During this period, this motivated the CDC to refrain from immediately work with other health agencies, such as the NIH, for a more coordinated response to AIDS. Thus we take from the first phase of AIDS politics an interesting paradox. Here we see a public health bureaucracy, the CDC, which blunted the influence of puritanical (moral) politics while at the same time blunting institution-building. For in contrast to the White House and the Congress, which was caught up in the maze of puritanical politics, the PHS was isolated from these interests due to its ongoing commitment to objective scientific analysis and professionalism. This made the HHS, CDC, and the NIH eager to immediately respond and to pursue controversial initiatives, such as immediately supporting and working with the stigmatized AIDS community. At the same time, however, the CDC was not willing to work with the NIH for a more timely and aggressive response. The old saw of American bureaucratic politics thus blunted

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institution-building: bureaucracy fragmentation and autonomy continued to generate competition and a lack of inter-agency cooperation, even in a time epidemic crisis. I argue that these outcomes persisted into the second phase, when international pressures for an institution-building (and in general, a more effective policy) response finally emerged. In sharp contrast to Brazil, however, these pressures did not positively influence the perceptions and interests of the President and the Congress. As in the past, the U.S. remained isolated from the global health community, repeatedly unwilling to receive its recommendations. While presidential, legislative, and bureaucratic perceptions of the epidemic gradually started to converge due to the consensus that a real epidemic was finally at hand, in the absence of a clear national security threat this was not sufficient for an aggressive institution-building response. In contrast to the first phase period, during the second phase President George H.W. Bush’s perceptions were influenced more by the prior Reagan administration’s new commitment to AIDS – by 1987. This positively influenced Bush’s interest in responding by passing key funding legislation and anti-discrimination laws, while maintaining a steady stream of funding to the PHS. Nevertheless, given the absence of a national security threat and Bush’s unresponsiveness to international pressures, this policy diffusion was insufficient for him to respond through new institution-building activities. In addition, during this period legislative perceptions changed due to sudden shifts in legislative context, with the democrats taking control of the Congress by 1986. The Congress was now much more committed to responding to AIDS through the passage of key prevention legislation. Nevertheless, there still was no interest in building a new federal agency or modernizing the PHS, notwithstanding incessant recommendations 186

from the Presidents’ National AIDS Commission asking the President and the Congress to create a new “supra-agency” for AIDS. And lastly, notwithstanding this change in the international and domestic environment, the CDC continued to operate on its own: that is, it still did not receive any presidential and/or legislative assistance in modernizing the PHS for a more aggressive response. However, the realization that the epidemic was growing uncontrollably, in addition to the provision of more funding to the CDC and NIH by this point generated more of an interest in inter-agency collaboration. The peril of agency survival finally came to an end. In addition, the PHS continued its tradition of responding to STDs through a secular, unbiased approach to reform. This facilitated its ability to continuously work with the stigmatized AIDS community, one that was evolving to include the intravenous drug and ethnic minority communities. In sum, what we defined in the previous chapter as America’s Globally Isolated Public Health Regime did not immediately respond to the new AIDS epidemic through new institution-building measures. In contrast to what we saw historically, when it came to AIDS the absence of a clear national security threat within our isolated democratic federation generated no interest in even attempting to re-centralize and strengthen its public health administration, notwithstanding the government’s repeated acknowledgement of the fact that local health departments were insolvent an incapable of responding on their own; and what is more, this occurred despite the presence of a presidential- and congressionally-appointed AIDS commission asking for such a response. While the AIDS crisis would eventually begin to gradually subside by the early- to mid-1990s, the absence of an institution-building response suggests that our 187

government was not as responsive to the needs of local governments and more importantly, the needs of civil society during the first few years of the AIDS epidemic.

Graph 5.1 - AIDS Cases and Deaths in the US (1982-2003) 120000 100000 Cases

80000 60000 40000 20000

Deaths 0 82

85

90

95

03

Source: CDC

~ GOVERNMENT RESPONSE (1981-90) ~ In the summer of 1981, a mysterious virus began to emerge in Los Angeles. A few young gay men started becoming fatally ill, first to phenomena, then to a rare form of skin cancer called Kaposi Sarcoma, which was more commonly seen among the elderly. By 1982, scores of gay men in Los Angeles and New York started showing similar symptoms, ultimately dying within months of diagnosis. The new epidemic only hit a few by year-end 1981, followed by a sharp increase in case rates by 1983. In 1984, Luc Montagnier of the Pastuer Institute in France and Robert Gallo of the NIH finally isolated the HIV strain. Official news of a new viral outbreak contributed 188

to growing fears and uncertainty in society. In major cities municipal officials instructed police officers and public health workers to refrain from helping anyone suspected of carrying the virus (US News & World Report, 6/27/83; Altman, 1987). Local health officials were also quick to point the finger and impose a phalanx of laws prohibiting any social activity perceived as contributing to HIV’s spread - such as bathhouses, gay clubs, and restaurants (US News & World Report, 11/4/85; Trafford et. al, 1985). It is important to note, however, that civil society, the media, as well as different aspects of the federal government were responding to AIDS at different points in time. Before the AIDS epidemic was widely accepted as an official health crisis (circa 198586), different segments of civil society and government were responding at different times and with different agendas. This section briefly outlines how and when these actors responded. It then follows up with a more detailed account of how the White House, the Congress, and the U.S. Public Health Service responded, both during the initial AIDS period (1981-87) and after the emergence of new global (and even domestic) pressures and for institution-building (1987-1992). News normally travels fast, so the old adage goes. But the media’s initial response to AIDS was rather slow. The first news coverage of the epidemic emerged in June 5 1981, in Los Angeles, when the LA times followed up on the release of a CDC Morbidity and Mortality Weekly Report (MMWR) discussing the emergence of a rare form of pneumonia, pneumocystis carinii, among 5 young gay men in Lost Angeles. On July 3 of that year, the New York Times published its first article on the CDC report and news of a rare form of skin cancer, Kaposi Sarcoma, which started to emerge in March of that year in New York and Los Angeles among gay men. Initial newspaper coverage of the 189

epidemic was minimal, with the bulk of it covered in small city publications, such as the San Francisco Chronicle. The major newspapers continued to lag behind. The New York Times would proceed to publish only two more articles on AIDS in 1981 (not totaling 3), and only 6 more articles in 1982, all of which did not make front page headlines. In October 1982, major news networks also started addressing the issue. On October 18, for example, ABC World News Tonight featured a show titled “Cause of AIDS Epidemic Still Unknown, Now Present in Many States,” 38 which discussed the mysterious viral outbreak. Media coverage of AIDS gradually started to pick up by 1983. The New York Times went on to publish 126 articles on AIDS in 1983, a sizeable jump from only 6 articles the year before (Nelkin, 1991). Other journals were also starting to address the issue. In May of that year, the Journal of the American Medical Association (JAMA) published an article by the revered young scientist Dr. Anthony Fauci, suggesting that AIDS could be transmissible through daily contact (though this, of course, was later proven to be false). Gradually more and more articles in New York, Los Angeles, and other major cities started to address the epidemic. By 1985, national coverage of the epidemic increased substantially, due in part to the infection of a very famous movie start, Rock Hudson, in August of that year. In response to this event, Nelkin (1991) notes that the New York Times went from reporting only 16 articles in July, to 46 in August and 72 in September of that year (Nelkin, 1991: p. 298). From 1985 to 2001, there was a massive surge in the number of AIDS news, magazine, and journal articles. Burgeoning AIDS cases, and periodic news of famous 38

You may view this news broadcast here: http://abcnews.go.com/Video/playerIndex?id=2033511

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people acquiring the virus, such as “Magic” Johnson of the LA Lakers, contributed to this sudden spurt in news coverage (Mollyann et al, 2004). Nevertheless, researchers found that news coverage of AIDS started to decline since 2001, reflecting the relative success in decreasing the number of AIDS cases and the growing perception in the medical community of it becoming a chronic, treatable disease (Mollyann et al, 2004). In contrast to the news media, civil society’s response to the AIDS was much faster. Because the virus initially manifested itself among young gay men, the gay community was particular concerned and immediately started to mobilize in response. The first community based organization to emerge was the San Francisco AIDS Association in 1982. Though it was initially focused on research, it gradually started to provide prevention and treatment services, especially homecare (Ira and Elder, 1989). Soon thereafter the Gay Men’s Health Crisis was created in New York City. And in 1983, the National Association of People with AIDS (NAPWA), the National AIDS Network, and the Federation of AIDS Related Organizations were formed. These initiatives set the groundwork for the creation of a host of other AIDS NGOs throughout the 1980s and 1990s. Perhaps the most prominent among these was the American Foundation for AIDS Research (amfAR), which was created in 1985 by Dr. Mathilde Krim, Michael Gottleib, and Elizabeth Taylor. AmfAR raised money for treatment and prevention, and soon became one of the largest not-for-profit organizations committed to domestic and international AIDS research and policy. And two years later, in response to escalating prices for the anti-viral drug AZT, ACTUP was created in New York as a not-for-profit organization dedicated to pressuring the government to reduce drug prices. Thanks in part to their efforts, the price for AZT was eventually lowered. In 191

addition to the rise of these two influential NGOs, a host of other grass roots organizations emerged during the 1980s and 1990s. It was a period of unprecedented growth and response by not only the gay community, but eventually scientific researchers, intellectuals, the church and other organizations fighting for human rights (Jonsen and Styker, 1993). The government’s response to AIDS was divided, with the HHS, PHS, and the House taking the lead, mainly with regards to increasing government awareness and the financing of AIDS programs, followed later by the Senate and the White House. As we’ll soon see in greater detail, within a year of the CDC’s MMWR report of June 1981, the HHS responded to the AIDS outbreak by confirming its commitment to tackling the issue and finding the necessary resources to do so. In contrast to the Reagan Administration, by 1983 HHS Secretary Margaret Heckler, Under-Secretary Edward Brandt, and Surgeon General C. Everett Koop publicly declared that the AIDS epidemic was their number one priority. From 1983-85, they incessantly tried to meet with White House officials to inform them of the new epidemic and to obtain more support for their initiatives. At the same time, they were meeting with the Congress to obtain additional funding for bureaucratic expansion. The PHS also immediately responded to AIDS. The first agency to respond was the CDC. The CDC’s MMWR report of June 5, 1981, is considered to be the first official government response to AIDS. The reported discussed the presence of a rare form of pneumonia among 6 gay men in Los Angeles, followed later that summer by several cases of Kaposi Sarcoma (KS). The following year, the CDC responded by creating an official task force on KS and Opportunistic Infections (KSOI); this was later renamed the 192

AIDS Task Force of the CDC in 1984. By 1983, research at the NIH, led by Dr. Robert Gallo, succeeded in containing and defining the virus, while the National Cancer Institute continued to hold conferences on KS. With regards to the Congress, the House was by far the first to respond. In 1982, it held its first open hearing about the epidemic (Kaiser Foundation, 2006; Altman, 1987). A House representative from California, Henry Waxman (D), spearheaded the investigation. Experts from the CDC were called in to testify, while victims were called in to show their scares, describe ailments and their social struggles. The House followed up with several budgetary proposals, starting with $5.6 million in 1982 and increasing to $28.7 million by the following year, in addition to a new proposal for a Public Health Emergency Act, which never passed but would have allocated another $40 million. The House nevertheless continued to hold meetings and press for additional funding, despite its inability to work closely with the Senate on these issues. When compared to the House, the Senate was indeed much slower to respond. Dominated by Republican Party conservatives until 1986, the Senate did not immediately hold public testimonies, nor did they put forth any serious budgetary proposals. Why some more liberally-minded Senators started pressing for additional funding by 1985, they were far less successful than their Democratic colleagues in the House. This was mainly attributed to a large swath of Senators that supported the President and the more conservative establishment’s interests, in addition to the absence of committee hearings that would have allowed AIDS victims to give public testimony. The White House was also delayed in its response. President Reagan and his staff did not immediately respond to the MMWR reports and warnings from the CDC that a 193

new epidemic had emerged. In fact, by 1983, when publicly question about it, the White House admitted to not knowing anything about the epidemic (more on this point soon). In contrast to the HHS and CDC, moreover, from 1983 until Reagan’s first public declaration of the epidemic in 1986, the Reagan Administration did not publicly acknowledge the virus, nor did it warm the public of its spread. By 1986, Reagan finally started to respond. His first response was through public speeches, followed by new budgetary requests for AIDS research and prevention. That year, Reagan also approved the first national screening for blood tests, and by the fall of that year was quoted in several speeches stating that AIDS was a “high priority.” In 1987, Reagan ordered the creation of a new National AIDS Commission. The Commission was an advisory committee providing policy analysis and recommendations. However, it was criticized for failing to appoint HIV/AIDS positive patients and those working in these communities. By October of that year, Reagan also ordered Surgeon General C. Everett Koop to distribute new sex education pamphlets informing Americans about the AIDS virus. By 1988, on the eve of President George Bush’s arrival into office, it was clear to many that Reagan and his staff were finally committed to funding AIDS prevention and treatment policies. President Bush followed Reagan’s lead, shortly thereafter implementing the 1990 Ryan White (Care) Act, which was largest federal commitment to financing anti-AIDS programs at the state and municipal level. These financial and policy initiatives notwithstanding, during this period it is important to note that no effort was taken to either create a new federal agency for AIDS or to consolidate and strengthen those agencies working on it. As we’ll soon see in more detail shortly, neither president took on this initiative, notwithstanding the incessant 194

recommendations of the HHS and the National AIDS Commission insisting that they do so. The end result is that during the first few years of the AIDS epidemic, the states and municipalities were left to their own devices, bereft of funding and incapable of aggressively responding to the new epidemic. In the following sections, I will discuss the government’s response in greater detail. I’ll highlight the structural and ideological factors that shaped initial perceptions and responses at the presidential, legislative, and bureaucratic level, and how ongoing elite contestation led to the absence of an institution-building response during the first and second phase of the AIDS epidemic.

Presidential Perceptions and Response 1600 Pennsylvania was anything but eager to respond to AIDS. Notwithstanding early CDC warnings, the White House took a somewhat cavalier approach to the issue, at times even openly joking about it. Just take a look here at the response of the White House Press Secretary, Mr. Larry Speaks, when questioned by a reporter about AIDS at an official press hearing on October 15, 1983: 39

Q: Larry, does the President have any reaction to the announcement [by] the Centers for Disease Control in Atlanta, that AIDS is now an epidemic and [that we] have over 600 cases? MR. SPEAKES: What's AIDS?

39

This transcript was taken from Jon Cohen's book, Shots in the Dark: The Wayward Search for an AIDS Vaccine, 2001.

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Q: Over a third of them have died. It's known as "gay plague." (Laughter.) No, it is. I mean it's a pretty serious thing that one in every three people that get this have died. And I wondered if the President is aware of it? MR. SPEAKES: I don't have it. Do you? (Laughter.) Q: No, I don't. MR. SPEAKES: You didn't answer my question. Q: Well, I just wondered, does the President MR. SPEAKES: How do you know? (Laughter.) Q: In other words, the White House looks on this as a great joke? MR. SPEAKES: No, I don't know anything about it, Lester. Q: Does the President, does anyone in the White House know about this epidemic, Larry? MR. SPEAKES: I don't think so. I don't think there's been any … Q: Nobody knows? MR. SPEAKES: There has been no personal experience here, Lester. Q: No, I mean, I thought you were keeping … MR. SPEAKES: I checked thoroughly with Dr. Ruge this morning and he's had no (laughter) … no patients suffering from AIDS or whatever it is. Q: The President doesn't have gay plague, is that what you're saying or what? MR. SPEAKES: No, I didn't say that. Q: Didn't say that? 196

This pressroom exchange accurately captured the White House’s perception of the AIDS epidemic: that is, that it was not a priority, and that the President should not immediately respond. And there were several reasons for this. First, the White House believed that there simply was not enough credible evidence suggesting that the epidemic was rapidly unfolding. Despite a quickly escalating rate in the percentage change of the number of AIDS cases reported each year, this was mainly occurring in some select cities, such as NYC and Los Angeles, and mainly among a highly stigmatized, isolated gay community. Despite CDC reports by December of 1983 indicating that the virus had spread to intra-venous drug users and heterosexuals, it was still perceived by the White House as a gay disease and non-threatening to the rest of the nation (Padgug and Oppenheimer, 1992).

Graph 5.2 - HIV/AIDS in the U.S. Military, 1986-2006 (cases) 1400 1200 Marines Navy Army Air Force

1000 800 600 400 200 0 86

95

Source: Navy Environmental Health Center, 2006

197

00

06

Second, unlike the great presidential and bureaucratic response to syphilis during WWII, AIDS did not immediately threaten our military establishment, and thus our national security. For unlike syphilis during the First and Second World War, by the early- to mid-1980s the HIV/AIDS virus was not highly prevalent among military enlistees. In fact, during the first few years of the epidemic President Reagan received briefings from Pentagon officials stating that there was no credible evidence showing that AIDS was quickly spreading among military personal, or that a large percentage of applicants for enlistment were positive (Keller, 1985; Evans, 1988). As Figure 1.2 illustrates above, while case prevalence was initially much higher in the Navy than in other service branches, which was due in large part to a higher enlistment of former drug addicts and alcoholics (Evan, 1988), prevalence rates in other branches was very low. By 1985, the Pentagon officially declared that AIDS was not a threat to the military (Keller, 1985). In addition, it is important to note that the Department of Defense, as well as all of the other military branches, did a very good job of immediately responding to AIDS on their own. By 1985, Secretary of Defense Casper Wienberger required that all applicants and enlistees be tested for the HIV virus (Engel, 1985; Squires, 1988). The official ruling at the time was that all applicants testing positive with HIV or even HIV-antibodies in their blood stream were denied enlistment. Within the military, however, officials were divided over weather or not they should keep HIV+ personnel. After months of deliberation, DOD and Pentagon officials agreed that those that were HIV+ could remain in active duty but were limited to what they could do and were to be very closely monitored (New York Times, 2/7/88; Hilts and Engel, 1985; Engel, 1986; Keller, 1985). 198

On the other hand, those testing positive for AIDS were given an honorable discharge and a bus ticket home. By as early as 1985, the military also had a very impressive sex education program in place. Similar to what we saw in Chapter 3 with the DOD’s response to syphilis among Army enlistees, essentially all of the service branches provided information to their troops about how HIV was contracted. In addition to a spate of educational pamphlets and sex education seminars, recruits were required to watch video tapes about AIDS (Engel, 1985). Condoms were distributed free of charged and encouraged for use (Evans, 1988). They Army was particularly concerned about HIV’s spread after several of its recruits tested positive shortly after being stationed overseas. For instance, in a famous incident in the fall of 1985, several Army enlistees tested positive after confessing to having slept with prostitutes in Western Germany (Engel, 1985). This sparked an immediate effort to scale up sex education programs and to work with government officials to regulate prostitution in countries were the Army had military bases (Engel, 1985). Prevention was followed up with strict enforcement. Early on, all military troops testing positive for HIV were threatened with severe punishment – letters of reprimand, Article Fifteens - if they failed to adhere to their drug regimen (Moore, 1987). Those caught having unprotected sex were court-martialed and quickly discharged. The military’s position was that it had to work harder than civilian agencies in order to ensure that the HIV virus be contained (Boffey, 1985). While the mood was generally to help soldiers rather than to discriminate against them (thus helping maintain solidarity and

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moral, The Advertiser, 10/31/87), officials were nevertheless sternly committed to regulation and discipline. The end result of all this was that there was a consensus among military and pentagon officials that HIV/AIDS was not a national security threat. In contrast to syphilis in the past, there was no sense of urgency to create new health laws and/or agency divisions within DOD to enforce prevention and treatment programs. There was never any recommendation to President Reagan that a new agency be created to regulate HIV/AIDS in the military, or that new funding programs be implemented to provide assistance to those states and communities were HIV prevalence was the highest. Keep in mind that the U.S. Congress provided a lot of money for the states during the syphilis outbreak of WWII. But this never occurred with AIDS. As a consequence of all this, and in sharp contrast to what we saw with syphilis in the past, there was no interest on the part of the military to create a new coalition between military officials, DOD, and the president for an aggressive institution-building response. But more importantly, what all of this meant was that President Reagan’s perception of the AIDS problem was further deteriorating. The absence of a clear national security threat contributed to his general lack of concern about the immediate implications of the AIDS virus. Moreover, one must keep in mind that the U.S. was not engaged in an all-out war during this period, as had been the case with syphilis in the past. All of these factors contributed to Reagan’s already very low threat perception of the HIV/AIDS problem and the need to respond through new institution-building activities.

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And lastly, during the first few years of the AIDS epidemic there was an informal element that perhaps more than anything else ensnared the initial perceptions of the conservative Reagan administration. It was an element that is very well documented in a myriad of books and articles and still rings true to this day: that is, the dark Victorian Christian moral impulse and its seepage throughout the veins of representative government (Morone, 2003; Gusfield, 1986). As in the past with STDs and other vices, such as alcoholism and prostitution, puritanical beliefs shaped the initial perceptions of White House and legislative elites in ways that stymied their ability to immediately respond to AIDS. Morals would be periodically used as a justification for legislative inaction and delay, especially in the White House. And as discussed later in this dissertation, the moral argument would be recycled again and again by future conservative administrations and legislative elites as a justification for delaying their response to the new urban AIDS crisis. This would also help safeguard and maintain the informal institutional tradition of justifying inaction towards STDs. Moral arguments hit the Reagan administration especially hard. During the first 2-3 years of the epidemic, the conservative right immediately tried to influence Reagan and the White Houses’ views on how they should respond to AIDS (Shilts, 1987). They tried to convince Reagan and his staff that AIDS was an immoral act, unworthy of immediate attention. And for the most part, they succeeded in influencing the administration’s views (Herek, 2006; Shilts, 1987; Perrow and Guillen, 1990). In large part this had to do with the fact that there had already existed a burgeoning backlash against the sexual liberalism of the 1960s ad 1970s. The moral conservatives were keen on strategically using this for leverage when trying to convince Reagan and his staff not to respond (Altman, 1987). 201

Moral conservatives were also initially successful at influencing Reagan’s thoughts by holding national conventions and arguing that AIDS was a divine judgment from God, cast upon the immoral sinners from high above (Morganthau et al, Newsweek, 8/8/83; Christian Today, 1985; US News & World Report, 1985). What’s more, reporters at the time noted that conservative Christian organizations were mailing hundreds of pamphlets apparently stating that: “homosexuals and the pro-homosexual politicians have joined together with the liberal, gay-influenced media to cover up the facts concerning AIDS” (Doan, 5/4/87, US News & World Report, p. 12). Their influence was aided by the fact that the moral right was tightly aligned with the increasingly popularized “moral majority,” which was led by a group of Christian evangelicals seeking to re-instill sound Christian morals within government and civil society. Led by charismatic leaders such as Jerry Falwell, the growing popularity of televangelism, coupled with the unwavering support of conservative voters (especially in the south) gave the moral majority greater leverage and influence when working with White House officials (Jonsen and Styker, 1993; Berstein, 2004). Despite having a track record of having supported gay rights as Governor of California, 40 Reagan was very much influenced by the conservative right. Facing congressional elections in 1984, he painted himself into a very tight political corner and quickly found himself essentially forced to support their position (Behrman, 2004). It was the accumulation of these antecedent structural and informal conditions that contributed to Reagan’s initial perception that AIDS was not a national threat and 40

Recall that when Reagan was Governor of California in 1978, he voted in favor of protecting the rights of gay teachers in public schools. Family members have also attested to the fact that he never spoke badly about gay men and respected their choices. Also recall that Rock Hudson was a friend of Reagan, even after he revealed his homosexuality and the fact that he had HIV.

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that it should not immediate respond. . Consequently, it took Reagan a few years to address the issue. While some argue that he often discussed AIDS in the White House and mentioned it at several budgetary meetings (Wise, 2003; Murdock, 2006; Heckler, 2004), the bottom line is that he did not publicly address the issue until 1987. Most consider his famous speech given to the American Foundation for AIDS Research (amfAR) in May, 1987, as the beginning of his campaign against AIDS. In it, Reagan addressed the importance of overcoming unwarranted fears, increasing educational awareness, while calling on all scientists, the bureaucracy, and family members to overcome stigma and find common ground (Reagan, May 3, 1987, amfAR speech). By 1987, Reagan would make it crystal clear that he perceived the AIDS epidemic as a national threat and worthy of a serious response (Boodman, The Washington Post, 6/3/88; Shilts, 1987).

Reagan Takes Action When it came to financing AIIDS initiatives, the Reagan administration was very hesitant. During the first 2-3 years of the epidemic, the White House barely asked for any increase in budget outlays. Reagan received a lot of criticisms from the House for this inaction. For example, Harry Waxman (D-California), chairman of the House Energy and Commerce Health Sub-Committee argued that “the administration’s response to AIDS has been too little and all but too late. … The administration has never asked Congress for money for AIDS and, in fact, has opposed congressional efforts to provide funds to the Centers for Disease Control and the National Institutes of Health,” (Waxman quoted in Christine Russell, The Washington Post, 5/25/83).

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Table 5.1. –

President’s Request

Total Spending for

Presidential

for AIDS Research

AIDS under Reagan

Budget Request

and Education

Fiscal year 1982

0

8

1983

12.6

34

1984

17.6

67

1985

54.1

121

1986

85.6

467

1987

351.1

872

1988

790.9

1525

1989

$1.3 billion

2162

For example, and as Table 5.1 illustrates above, in 1983 Regan asked for a total of $12.6 million in AIDS research and education, which was divided among all of the PHS agencies working on AIDS: the Centers for Disease Control (CDC), the National Institutes of Health (NIH), the National Cancer Institute (NCI), and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). But this request was perceived as insufficient. Agency heads incessantly complained of the need for additional funding. The President’s request for research and education increased to $17.6 million the following year. Funding for AIDS initiatives burgeoned after 1985, from $34 million in 1983, to $67 million in 1984 and $121 million in 1985. Despite this sizable increase in funding, HHS officials were still unsatisfied (Interview with Edward Brandt, former HHS Under-Secretary [1982-85], 11/08/06).

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Advocates for more funding within and outside of Congress (especially the House) argued that this was a lukewarm response at best. The administration countered by arguing that at the time the money was sufficient and that nothing more could be done, even if more money was allocated. These debates went on for years. But the budgetary momentum quickly changed. By 1986, Reagan substantially increased his financial commitment to AIDS. Two key factors contributed to this decision: First, an overwhelming amount of empirical data showing that AIDS was clearly an epidemic. Just take a look at the data (revisit Figure 1.1 above). From 1981 to 1984, the number of AIDS cases and deaths increased from 31 to 7,699, respectively. From 1985-87, this increased from 8, 224, to 13,197 and 21,149, respectively, increasing further to 31,001 confirmed cases by 1988. By 1988, essentially everyone recognized the fact that AIDS was an epidemic. In addition, in 1986 Reagan’s long-time friend, Rock Hudson, was diagnosed and died from AIDS. It sent a clear message to Reagan and everyone else that nobody was immune from the disease. What is more, the fact that Hudson had to travel to France for more effective treatment highlighted the deficiencies in our public health system. These two events, in addition to a host of pressures from the Congress and HHS, persuaded Reagan to increase his financial commitment. Beginning in 1986, he increased his request for AIDS research and education from $86.6 million in 1986 to $351.1 million for 1987 and $790.9 for 1988, followed by an approved increase in overall AIDS funding from $457 million in 1986 to $872 million in 1987 and 1.525 billion in 1989 (see Table 1.1).

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The Failure to Reform the Public Health Bureaucracy But when it came to institution-building, Reagan’s response was not as impressive. That is, his administration never tried to reform the PHS in order to enhance its responsiveness to the AIDS outbreak. Reagan also never expressed any interest in creating an HHS agency that would focus exclusively on AIDS. To senior health officials, he simply appeared apathetic towards the issue (interview with James Mason, former director of the CDC (1981-85), 11/17/06; interview with James Curran, former director of the CDC Task Force for AIDS (1981-85), 11/6/06; interview with Edward Brandt, former HHS Under-Secretary (1982-85), 11/08/06). Needless to say, this also meant that he would not help the HHS, mainly the CDC, manage the fragmentation of research and policy responsibilities between the NIH and the CDC (interview with Edward Brandt, 11/08/06; Engel, The Washington Post, 12/1/87). During the first few years of the epidemic, despite several requests from HHS officials that the White House help the HHS better coordinate with other agencies, the task for managing bureaucratic coordination was delegated to the HHS director, Dr. Margaret Heckler (interview with Edward Brandt, 11/08/96). She then delegated this responsibility to HHS Under-Secretary Edward Brandt (1982-85) and later to acting HHS Under-Secretary Jim Mason (1985-87). Brandt and Mason recall that Reagan and the White House were disengaged from the institution-building process and relied entirely on HHS officials to handle their coordination problems (interview with Mason, 11/17/06;

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interview with Brandt, 11/8/06). Both men knew that Reagan had no plans to meddle in their affairs. To a certain extent this was desired and reinforced by Mason and Brandt’s belief that presidential politics should not interfere with their duties (interview with Brandt, 11/8/06; interview with Mason, 11/17/6). But the problem was that the issue at hand was not scientific research and policy, but rather the absence of inter-agency cooperation and response. On this issue and this issue alone did Mason and Brandt believe that the President should intervene (interview with Brandt, 11/8/06). Indeed, in a recent interview with former HHS Under-Secretary Edward Brandt, Brandt argued that in our decentralized public health system, a more centralized and coordinated bureaucratic response to AIDS would have been much more successful then relying on the decentralization process (interview with Brandt, 11/8/06; Panem, 1986). Despite several complaints from HHS and PHS officials about these issues, the President never intervened (interview with Mason, 11/17/06). Worse still, even after a detailed Presidential AIDS Commission was published in June 1988 informing Reagan of the need to create an official position in the White House that would help increase coordination between the CDC and NIH, Reagan did nothing (Boodman, The Washington Post, 1988). Some accused Reagan of ignoring essentially every policy recommendation from the 200+ page AIDS Commission report (Mellio, 9/24/91). It quickly became apparent to Brandt and Mason that Reagan’s disdain towards the AIDS situation, as something which he considered to be immoral and unworthy of an immediate response, was the major stumbling block (interview with Brandt, 11/8/06). For even as the

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administration began to take AIDS more seriously, it never expressed any interest in helping increase bureaucratic coordination and performance. As noted earlier, by 1987 Reagan was essentially forced to change his views. Nevertheless, it is important to note that in addition to the overwhelming evidence that AIDS cases were increasing, in addition the infection of close personal friends, the institutional landscape within which Reagan operated was also changing. For one must keep in mind that in 1986, Reagan lost the Senate to the Democrats. This new environment could have arguably been just as important of a factor in changing his perception and interest in AIDS. With the Senate was controlled by democrats pressing for a more timely response, and as we’ll see in the next section, with pressures from the House mounting as well, Reagan eventually had now choice but to increase his commitment to AIDS.

Congressional Perceptions and Response AIDS arrived at a time when the Congress was not governed by a party majority. Despite President Ronald Regan’s election into office in 1980, the Democrats controlled the House (having 242 seats versus 192 for the Republicans). The Republicans, on the other hand, controlled the Senate, having 53-46 seats over the Democrats. This led to conflicting ideas and interests in supporting the PHS during the initial years of the AIDS epidemic, with the House showing the most interest. However, during this period neither the House nor the Senate worked hard to help consolidate PHS responsibilities. Furthermore, there was no interest in helping construct a new centralized agency in response to AIDS and the needs of local governments. 208

In the House and Senate, the initial perceptions towards AIDS was somewhat divided. In large part this had to do with the contrasting presence and influence of representative institutions that effectively funneled and voiced the concerns of AIDS victims, couple with the different political composition and tone within each legislature. In the House, the committees responsible for allocating money for AIDS were dominated by representatives from constituent districts most affected by AIDS: New York and Los Angeles, namely House members Ted Weiss (D-NYC) and Henry Waxman (D-CA), respectively. Incessant pressures from the gay community and mayors from these cities helped convince representatives that there was a crisis and that the government should immediately respond (Altman, 1987). As early as 1982, legislative hearings provided by Weiss and Waxman allowed the gay community and city officials to present data showing that case rates and deaths were burgeoning in their districts (Altman, 1987). This kind of institutional representation was important for shaping initial legislative perceptions that the House should allocate more money and support the PHS in its efforts to combat AIDS. The Senate, on the other hand, was dominated by less sympathetic Republican representatives. Despite the presence of some Senators that perceived the situation as a national threat, most of them did not (Talbot and Bush, 1985). Consequently, they did not seek to provide institutional venues for the gay community. Data and cries for help were never heard from the bowels of the Senate floor. This contributed little to the formation of a perception that a national epidemic was at hand and that the government should immediately respond. As a consequence, the Senate closely resembled the White House’s initial perception that AIDS was not a crisis. 209

The first few years of the AIDS epidemic thus marked clear differences in the initial perceptions of Congressional members. As the next section illustrates, this in turn set in motion contrasting responses to AIDS: the House was unwaveringly committed to funding research and prevention programs, while the Senate was not. While the House would go out of its way to obtain information about PHS needs, the Senate would refrain from doing so. But note that during this period there was no interest in both legislatures to create a centralized agency for AIDS. Worse still, there was no interest in consolidating and strengthening the highly fragmented and weak PHS system. Both problems persisted and in the absence of presidential intervention, delayed the PHS’ response. To the surprise of many, when compared to the Senate and the White House, the House was initially much more responsive to the AIDS situation. For unlike the former two institutions, there was no domineering set of perceptions and ideological interests paralyzing the House’s response (Perrow and Guillen, 1990). In addition, some argue that AIDS was never perceived as a partisan issue. Rather, some felt that it had more to do with how one felt as an individual, i.e., if you believed that AIDS was a moral issue, rather than your allegiance to a particular party ideology (Russell, The Washington Post, 5/25/83; interview with Brandt, 9/20/06). As a result, there were various Democrats opposing and Republicans supporting anti-AIDS legislation. Initial congressional perceptions and responses were therefore never pre-determined by party affiliation. In contrast to the White House, the House tried to increase financial disbursements for AIDS research and policy. Yet during the initial few years, it had a very hard time doing so. As we’ll soon see, this was mainly due to the fact that 210

administrative gridlock and lack of clarity and honesty always under-represented the amount of money the PHS actually needed for their AIDS programs. In addition, funding proposals were often rejected by the President and even some House members. Therefore, while their intentions were good, there were some initial administrative problems which precluded the House from providing sufficient funding. For example, even before the epidemic was officially categorized as HIV in 1984, by 1982 the House had earmarked $5.6 million dollars for AIDS activities and $28.7 million in 1983. Though modest in its contributions, this was much more than what the White House initially requested (Perrow and Guillén, 1990; Russell, The Washington Post, 9/27/85). By 1984, the House increased its commitment and authorized $61.5 million to AIDS (54 percent more than the president’s request) and $97.4 million the following year (61 percent more) (Office of Technology Assessment, Review of the Public Health Service’s Response, p. 32; Perrow and Guillén, 1990). By the end of 1985, the House had cleared an appropriations bill that earmarked $190 million for AIDS research, $70 million dollars more than what Reagan requested (US News & World Report, 10/14/85). The House’s supply of funds always out-paced bureaucratic demand. Legislative committees always appeared to be more than willing to allocate additional funds, even more than what the White House and the PHS asked for. And they were often willing to go out of their way to see why this was the case. In fact, various scholars note that the House often suspected the PHS (the CDC and NIH, mainly) of under-reporting the actual amount of money needed to finance AIDS programs (Altman, 1986; Shilts, 1987; Perow and Guillén, 1990). There was, of course, the famous case of two House legislative staffers, Susan Stinmetz and Jim Mitchy, who 211

were asked by House members Henry Waxman (D-California) and Ted Weis (D-New York), co-chairs of the Inter-governmental Relations and Human Resources Subcommittee, to request the director of the CDC, William Foege, for full access to all of his files. This request was made because there was a growing suspicion that Foege may have been under-reporting the actual amount of money he needed in order to avoid angry backlash from the White House. It was even reported at the time that Foege was writing memos to Secretary Heckler and the White House asking for more than what he actually requested at congressional hearings (Altman, 1987; Perrow and Guillén, 1990). Eventually Foege declined the request by House aids for access to his files. Moreover, his decision was supported by HHS Secretary Heckler, who also had incentives not to upset White House officials. Both Foege and Heckler based their justifications on the fact that by disclosing information they would be breaking the law, which mandated that patientdoctor confidentiality be maintained. This action sparked rumors that the White House and CDC were collaborating to obfuscate information. Furthermore, and perhaps what made matters worse, it acknowledged the fact that they were not willing to be openly transparent about their actions. Waxman and Weis also went out of their way to ensure that the voice of AIDS victims was heard. Beginning in August 1982, through their subcommittee on Intergovernmental relations and Human resources, they invited AIDS victims to testify before House. It was the first time that actual victims appeared before the House to voice their concern. It was the first time that they were allowed to publicly discuss and display their physical handicaps and emotional distress. And it was the first time that they were allowed to directly pressure the government (Altman, 1983). 212

A combination of representing constituent interests and personal convictions to get things done were some of the reasons for why the House acted so aggressively. Waxman and Weis represented constituents from the most HIV afflicted regions in the nation, New York and California. A host of Congressmen representing other states with HIV problems were also under pressure. While of course there was some resistance from the more conservative Republican legislators, it so happened that those with the most resources and power – Waxman and Weis – were the ones in charge of committees with the power of the purse. This encouraged other legislators to join them in their cause, notwithstanding resistance from the President and other House members. A good example of this is when Waxman, Weis and 10 other democrats worked together to introduce the Public Health Emergency Act in 1983. The act proposed to establish a $40 million contingency fund “to authorize appropriations to be made available to the Secretary of Health and Human Services for research for the cause, treatment and prevention of public health emergencies” (US House, H.R. 2713; Panem, 1988: p. 88). This fund would not only cover unforeseen expenses but also proposed to finance new initiatives in response to unforeseen events. However, the bill never went anywhere, mainly because Under Secretary for Health and Human Services, Dr. Edward Brandt, argued that he did not need the additional money. Naturally this kindled skepticism, since in 1981 Undersecretary Schweiker proposed a similar amendment and said that he needed the money (Office of Technology Assessment, Review of the Public Health Service’s response to AIDS, US Congress, 1985, p. 40.). Representative Waxman was perplexed. Brandt later argued that politically, he felt (better yet knew) that he had receive too much heat from the appropriations committee and the White House for asking 213

for additional money (interview with Edward Brandt, 11/08/06; Panem, 1988). Eventually the bill went nowhere, despite the fact that it was much needed. Brandt’s assertions were corroborated by the fact that he had to clandestinely reshuffle funds from within his organization in order to make ends meat. For example, Brandt often had to re-allocate funds designated for different health programs to the CDC and other agencies working on AIDS (interview with Brandt, 9/20/06). He later confessed to having done this and was officially warned never to do it again. His only response at the time was that he simply had no choice, that he had to get the money from somewhere (interview with Brandt, 9/20/06). The Senate, on the other hand, was not as receptive to the AIDS situation. Because the Republicans held the majority (until 1986), their initial perception of the epidemic mirrored that of the White House. Nevertheless, there were some senators who perceived the situation as a serious national problem and who wanted more action to be taken; such views were held by Representatives Lowell Weicker (R-Connecticut), Edward Kennedy (D-Massachusetts), and Alan Cranston (D-California) (Russell, The Washington Post, 9/27/85). These Senators consistently made sure that the HHS was spending all the money allocated by the House (Rich, The Washington Post, 3/6/85). Despite this and several successful attempts to join the House to vote in favor of allocating additional money, their proposal of several new programs that could have provided direct aid to gays and other HIV afflicted never passed muster. A good example is provided by Talbot and Bush (1985, p. 35), in which they quote Dr. David Sundwall, then advisor to the Labor and Human Resources Committee, chaired by Senator Orrin Hatch (R-Utah): 214

“Sundwall says that he and Hatch took pains to make sure that their important Senate Health Panel did not get its hands on an AIDS funding bill, because of the intensely homophobic make-up of the committee. Included on the committee are such stalwarts of the Right as Senators John East (Rep., NC) and Jeremiah Denton (Rep., Ala.). When the House sent over an emergency funding proposal to the Senate in 1982, he and Hatch “finessed it” so that the bill bypassed the committee and went directly to the Senate floor “in the quiet of the night.”

Thus in sum, although some members of the Senate were more responsive to the new AIDS epidemic, others were not. In fact, those that were opposed often tried to delay the vote and passage of new AIDS legislation. Our representative Senate was therefore not at all on the same page with the House. In a period of health crisis and uncertainty, stigma and political ideology got in the way. The Senate was divided, paralyzed, and consequently, incapable of reacting as quickly and as boldly as the House.

Bureaucratic Perceptions and Response The way the U.S. Public Health Service responded to AIDS was very different from the White House and the Congress. This was mainly due to the fact that bureaucratic perceptions were influenced by different types of antecedent structural conditions. As I explained in Chapter 3, 41 there were several historical and more contemporary political factors shaping PHS perceptions. First and foremost was the fact that the PHS evolved out of a growing movement for scientific progress and professionalism, breaking away from traditional moral arguments attached to medical research and practice. This led to

41

Note that in contrast to my earlier discussion of the antecedent conditions shaping presidential and legislative perceptions, I have reserved this same discussion – and gone in further detail – for the PHS in the theoretical and historical sections of this manuscript. Therefore, in order to avoid excess repetition, my discussion of its structural antecedent conditions will be very brief in this chapter.

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the rise of a PHS service that was both autonomous and scientifically objective in their views of how to respond to a newly contested epidemic. Second, these conditions encouraged early elite commitments to work closely with stigmatized, at-risk groups. As we saw in Chapter 3, starting in the 1930s and 1940s with the government’s response to syphilis the PHS has always been committed to providing direct assistance to at-risk groups and even racially stigmatized communities, such as prostitutes and African Americans struck with syphilis. These traditions persisted and continued with the CDC’s close involvement with gay communities during the Hepatitis B and C outbreak of the 1960s ad 1970s; these traditions reemerged with the HHS and CDC’s immediate response to the gay AIDS community in the early-1980s. Bureaucracy’s social embeddedness was very strong and praiseworthy, which in turn played an important role in increasing societal perceptions that the government cared and was trying to do something about AIDS. Yet the PHS directors were not as enthused and committed to pursuing inter-agency cooperation; this entailed an entirely different political logic and stream of incentives. Indeed, for as in the past, unexpected epidemic shocks ushered in new bureaucratic opportunities and incentives that failed to complement the PHS’s relationship with civil society. This problem was fueled by a second issue: agency survival, which shaped bureaucratic perceptions and lack of interest in inter-agency coordination. More specifically, agency survival marked the PHS’s tradition of viewing new epidemics as opportunities to increase agency reputation and prestige in order to acquire additional funding in a context of fiscal and bureaucratic retrenchment. As we saw in Chapter 3, this type of response began with the polio epidemic of the early-1950s. This shock to the PHS 216

system ushered in a critical juncture that, in turn, established an on-going tradition of agency directors viewing new epidemics as a means to career survival. This generated to two types of responses: first, the effort to refrain from immediate inter-agency cooperation in order to stand out as notable scientists, winning acclaim and prestige; and second, to use this prestige as leverage for justifying an increases in annual budgetary outlays, thus securing agency survival and expansion. In contrast to the other executive branches, when the AIDS epidemic first emerged it was the directors of the HHS and PHS that viewed it as an urgent crisis, worthy of an immediate response. HHS Secretary Margaret Heckler (1983-85) was one of the first to publicly discuss the AIDS situation. She was quick to publicly announce that AIDS was a genuine epidemic and that she was committed to “conquering AIDS” (Rich, The Washington Post, 10/1/85; Shilts, 1987; Herek, 2006). In 1985, she declared that AIDS was her #1 priority, while trying to increase awareness among political and bureaucratic officials (Rich, The Washington Post, 10/1/85; Gergen, US News & World Report, 11/23/85; Frontline, 5/30/06). Heckler’s second in command was on the same page. Dr. Edward Brandt, HHS Under-Secretary for Health, perceived the AIDS situation as an immanent national threat and was equally as committed to increasing the government’s awareness of the problem (Rusell, The Washington Post, 1983). He frequently testified before the Congress in order to help increase awareness and response. In contrast to the White House, Brandt did not believe that the AIDS situation should be politicized and that it warranted an immediate response (interview with Brandt, 11/8/06; Colburn, The Washington Post, 6/9/87); he once commented: 217

“I consider naming AIDS the number one public health priority to be a symbolic declaration, but also to emphasize to the people working on the problem that in fact they were working on something important to man, that everything else was going to take a back seat, and we were going to sacrifice, if necessary, other efforts to accomplish this major goal … Somehow we weren’t getting that message across, and by that time (spring 1983), I came to figure out that in Washington, you have to have a short phrase to get anybody’s attention. Calling it the number one health priority in the country was something that everyone would listen to. It is also something that would get in the media.”(Edward Brant quoted from an interview with Dr. Sandra Panem, April 5, 1985; see Panem, 1985, p. 15.)

After Brandt left office, Dr. James Curran stepped in as acting assistant secretary for HHS. Like Brandt, he also viewed the AIDS epidemic as a national priority, requiring an immediate response (interview with Curran, 11/8/06). His successor, Dr. William Foege, was on the same page. And lastly, Surgeon General C. Everett Koop agreed with their views. By the mid-1980s, he became a major proponent of HIV prevention and was committed to working closely with the gay and intravenous drug community, emphatically stating that he was the Surgeon General of all, even the so-called “immoral sinners.” For Koop was once quoted as stating: “I am the surgeon general of the heterosexuals and the homosexuals, of the young and the old, of the moral [and] the immoral … I don’t have the luxury of deciding which side I want to be on” (Koop quoted in Whitman, US News & World Report, 5/5/87). This response lends credence to the notion that the moral impulse did not paralyze Koop, nor any another PHS appointees mentioned herein (US News & World Report, 5/5/87). All of these initial responses reflected the fact that in sharp contrast to the White House, the bureaucratic agencies in charge of responding to AIDS were much more open and responsive to the initial AIDS epidemic. Unlike the White House and even the Brazilian government at the time, HHS and PHS directors believed that AIDS was a 218

national priority. Directors and their staffs sought to increase political and societal attention to the etiological and policy consequences of AIDS. They worked hard to secure funding and increase the President and Congresses’ knowledge of the disease. While some would question their commitment to securing funding and increasing awareness, if one considers the context that these directors were operating in, that is, multiple pressures for decentralization, hard budget constraints, and bureaucratic downsizing, especially within the CDC, 42 their response was rather impressive (Sheils, Newsweek, 3/16/81; Meyer and Russell, The Washington Post, 1981; Rich, The Washington Post, 1982). Nevertheless, PHS appointees were limited in their ability to inform and influence policy. In essence, they were operating in what Theda Skocpol once called an isolated “island of efficiency” (Skocpol, 1985). That is, while efficient and dedicated within their own bureaucratic terrain, PHS directors did not have much influence within government. Entrepreneurs at the highest tiers of the HHS and PHS consistently felt constrained in their ability to push forward with their anti-AIDS agenda. Notwithstanding their increase in reputation, both within and especially outside of government, this did nothing to influence the Reagan administration’s policies interests. For example, even at the height of the AIDS epidemic, c. 1985, PHS Surgeon General Koop was consistently denied access to the White House. Reflecting back on those years, he recently stated in an interview that political meddlers in the White House complicated his work on the disease and that “at least a dozen of times I pleaded with my critics in the White House to let me have a meeting with President Reagan” (Koop 42

Keep in mind that the president and congress had already resolved to cut at least 39-50% of the CDC’s funding. The administration’s interest was thus to dramatically downsize the CDC during the first few years of the AIDS outbreak; on this note, see Meyer and Russell, The Washington Post, 1981; Rich, The Washington Post, 1982.

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interviewed by Toner and Peard, New York Times, 6/9/04). HHS Secretary Margaret Heckler and Under-Secretary Edward Brandt faced similar problems. Secretary Heckler had a particularly difficult time communicating with the White House. She was often ridiculed by White House staff for being ideologically “out of step” on the AIDS situation (US News & World Report, 10/14/85). She was sorely criticized for pushing too hard on the issue, as well as other diseases, such as Alzheimer’s (US News & World Report, 10/14/85). Moreover, she was sorely criticized by senior health officials and the White House for her managerial style, specifically her tendency to delegate too much authority (US News & World Report, 10/14/85). Consequently, Heckler and even Undersecretary of Health, Edward Brandt, had a difficult time working with White House staff (interview with Edward Brandt, 9/20/06). In response to increased criticism, Reagan finally responded. Sensing that he needed to incorporate the views of senior bureaucratic officials, in 1987 he created the National AIDS Commission. The Commission was to serve as the president’s main advisory group on AIDS. It was composed of several high level bureaucrats, including the Secretary of HHS at the time, several agency heads and representatives from the private sector and civil society. The Commission was responsible for evaluating the government’s current policies and proposals while constantly surveying the AIDS situation and getting back to Reagan. There were two problems with the Commission, however. First, pundits immediately pointed out that there were no HIV-positive individuals on it. As you can imagine, this triggered an immediate uproar among the gay and HIV positive community. The government was sorely criticized for lacking common sense and for being careless 220

about who was appointed to the commission (The New York Times, 10/11/87). Second, after the Commission’s first review, it received a very low mark across a host of policy and leadership issues (Johnson, 1988). The publishing of this report made it very clear that the administration was sorely divided and that several senior officials were not pleased with the government’s performance. In summation, during the first few years of the AIDS epidemic, the public health bureaucracy was not closely aligned with the White House. What did this mean? Two things: First, the White House was not committed to working with agency branches that were the most knowledgeable and committed to the AIDS situation. And second, the PHS, despite its reputation and responsiveness, could not convince the president to intervene and help strengthen the PHS system. These problems contributed to interagency fragmentation and complicated the PHS’s ability to effectively respond to the AIDS crisis.

Fighting for Money The PHS’s initial perception that AIDS was a national crisis led them to very different types of institution-building initiatives. While agency heads were successful and noteworthy in their efforts to pressure the White House and Congress for additional funding, they neglected to work together in order to learn more about the disease and devise a more effective policy response. When it came to fighting for more money, however, all PHS directors were in agreement. The consensus that AIDS posed an immediate threat in a context of government downsizing led to several noteworthy initiatives. First, HHS secretaries 221

Margaret Heckler and Edward Brandt worked incessant to try and obtain more money for AIDS (Kurtz, The Washington Post, 6/15/83; New York Times, 8/18/83; Frontline, 5/30/06; Wilke, Washington Post, 8/3/83). Brandt was well known for his persistence in trying to get more money from the House (Wilke, Washington Post, 8/3/83). In 1983, for example, he wrote a famous letter to the House sub-committee for health in which he asked for the transfer of $12 million to HHS. As Shilts (1987) notes, at the time this was a significant request, considering the fact that the total budget for AIDS was only $28 million (Shilts, 1987; Perrow and Guillen, 1990). But Brandt wasn’t fazed; he was determined; he worked hard to ensure that the White House quickly responded to the epidemic, seeing it as a national priority and a national call to duty. He also pressed the White House hard for additional money to combat AIDS (interview with Curran, 11/8/06). In September of 1985, he requested that an additional $70 million be tacked onto the White House proposed budget of $126.3 million for fiscal year 1986 (Russell, The Washington Post, 9/27/5). He requested this money because of his “reassessment of the AIDS efforts,” which showed a “need to expand beyond our current request in order to evaluate new drugs and therapies and to gain a better understanding of the prevalence of AIDS” (Russell, The Washington Post, 9/27/85). Curran and other HHS bureaucrats were responding to a very receptive House and a somewhat responsive Senate. “Whatever you ask for, you can get,” said Senator Lowell P. Wicker Jr. (R-Conn), who was chairman of the Senate sub-committee that oversaw the HHS budget. The CDC was also committed to responding quickly. The Director for the CDC (1979-83), Dr. William Foege, was initially very committed to increasing the Reagan 222

administration’s attention to the AIDS problem. Furthermore, he went out of his way to write letters requesting additional money so that the CDC could create a national surveillance program, an initiative that was shelved due to White House resistance (Barringer and Russel, The Washington Post, 4/7/83; Shilts, 1987). He was best known and applauded for continually and successfully opposing OMB budget cuts for the CDC (Barringer and Russel, The Washington Post, 4/7/83). While Foege was not the personality type to make public statements and frequently approach the House, others note that he was nevertheless willing to do this in order to get what he needed (Perrow and Guillen, 1990). Indeed, some stipulate that shortly after Foege testified and asked the House for money, in return the House often gave him more than he requested (Perrow and Guillen, 1990). However, some believe that he often under-reported the amount of money he needed and that he was never open to discussing the matter with House congressional staff (Altman, 1987). Survival Politics While PHS efforts to fight for more money were very impressive, agency directors were not as enthused about working together. Indeed, one must be mindful of the fact that by the time the virus emerged structural bureaucratic conditions were conducive to a high degree of inter-agency competition and lack of cooperation. This was fueled by the need to respond independently in order to increase agency reputation and thus secure money for expansion. But this was also fueled by a high degree of agency overlap in the PHS. Agency overlap helped establish the groundwork for inter-agency competition (Panem, 1988). During the first few years of the AIDS outbreak, the NIH and the CDC were involved in monitoring and reporting the epidemic. The NIH was the first to 223

research and report the epidemic to the CDC in March and April of 1981. It also reported it to the medical community in July of that year (Chabner and Curt, 1984). In addition, it was the NIH that encouraged the academic community to start conducting research on AIDS and held a national symposium at the NCI to initiate this process (Chabner and Curt, 1984). At the same time, the CDC organized an AIDS task force and came out with a description of the new virus in the famous MWWR report of 1981. NCI scientists were also working hard to classify the viral strain. Within the PHS system, there was therefore no interest in working together and responding to AIDS in a timely manner. The main factor contributing to these outcomes was the issue of bureaucratic territoriality. That is, and as we saw with polio in the past, CDC and NIH directors viewed the AIDS epidemic as an opportunity to increase their prestige and influence within government. This reflected not only their genuine interest in containing the disease but also their efforts to survive within a context of hard budget constraints and bureaucratic downsizing. These conditions generated few incentives for the CDC and NIH directors to work together in order to clarify responsibilities, share information, and devise prevention programs that could more effectively provide assistance to state governments. As in the past with polio and other smaller diseases, such as Legionnaire’s, Swine Flu, and toxic shock syndrome, AIDS emerged as a mysterious disease capturing a lot of attention. Within the PHS, both the CDC and NIH viewed the epidemic as a new challenge and opportunity to increase their prestige and influence within government. Both had good reason to be involved; both were committed to eradicating disease and

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protecting society; and both were, as in the past, also very keen on using the virus as a strategic means for agency survival. Given the severe budgetary cutbacks and plans for even more pruning, responding to AIDS provided a new opportunity to ask for and justify an increase in agency funding. Prior to and even throughout the crisis the CDC faced hard budget constraints (Wilke, The Washington Post, 8/3/83; Meyer and Russell, The Washington Post, 1981; Rich, The Washington Post, 1982). As Figure 1.3 illustrates, House budgetary outlays for the CDC barely increased during the first five years of the outbreak. And this occurred despite the CDC’s pressing need for more resources and the administration’s awareness of its needs. The only advice given by the administration at the time was to reshuffle money from other departments. But the problem was that this substantially reduced funding for other programs (interview with Graph 5.3 - Congressional Outlays for the CDC (millions of dollars) 1200

James Mason, 11/17/06). As Figure 1.4 illustrates, yet another

1000 800

problem was staffing. At the

600

height of the epidemic, from

400

1981 to 1986, the CDC did

200

not expand but rather

0 83

84

85

86

87

88

Source: CDC

89

contracted in the size of its staff. From 1985 to 1986,

the CDC lost nearly 500 employees (See Graph 4.3). The situation got so bad that by 1985, the director of the CDC, James Mason, had to impose a hiring freeze and obtain 225

staff from other departments in order to save money (interview with Mason, 11/17/06). This occurred despite Mason’s continued insistence that the White House give him more money (interview with Mason, 11/17/06). But his requests fell on deaf ears, as the administration expressed no interest in increasing its budgetary support (interview with Mason, 11/17/06). The NIH was also experiencing a sizable decrease in funding. Though it was not as extreme as the CDC, projected budgetary outlays were not increasing. While funding for research remained steady, there were no immediate plans to allocate additional money for research (interview with Mason, 11/17/06). Staff size in the NIH also remained steady but did not decrease as suddenly and as markedly as in the CDC. Graph 5.4 - Number of CDC staff (1984-89) 4,200 4,100 4,000 3,900 3,800 3,700 3,600 3,500 3,400 3,300 3,200 3,100 84

85

86

87

88

89

Source: CDC

Although fiscal and human resource conditions would affect both agencies differently, the specter of an AIDS crisis generated new incentives to increase the reputation and prestige of both agencies. The CDC had incentives to do this, especially after the incident with Swine Flu under President Ford, when it inoculated thousands for 226

a flu that never emerged while at the same time creating a new allergic reaction because of the side effects of the drug used for immunization. Lacking resources and in need of rejuvenating its reputation, the CDC had incentives to respond independently and aggressively to the virus. It was, for example, the first to publish an official report on it in 1982, the famous MWWR report. It had to intensify its research and publication on the new virus while at the same time reaching out to the at-risk community. And why did it do this? Bolstering its reputation as an effective disease detective helped justify its need for more money. The CDC director at the time, Jim Mason, strategically used the virus to further justify an increase in his budget (interview with Mason, 11/17/06). When testifying before Congress, he repeatedly mentioned how hard he and his lab technicians worked to define and contain the virus (interview with Mason, 11/17/06). He always made reference to his progress and took advantage of any opportunity to discuss how well his agency was doing (interview with Mason, 11/17/06). Needless to say, this set the ground work for intensive bureaucratic competition. In addition to working around constraining budget constraints, a high degree of policy overlap between the PHS agencies also contributed to a lack of cooperation between them. Competition between the CDC and NIH intensified by 1983. Initially, the main issue was about which agency should be responsible for AIDS research and policy (Russel, The Washington Post, 4/23/84). As the challenge of defining and finding a cure for the disease increased, the NIH insisted that it take the lead. But the CDC resisted this position. It too wanted to be involved in research and discovery (interview with Mason, 11/17/06). After all, in 1981 it had published the famous MWWR report, which described and traced the whereabouts of the disease. Yet 227

as in the past with polio, the NIH was upset with the possibility of the CDC – and any other agency - staking claim over its research mission. The issue at hand was that there was a race to discover and claim credit for the new virus. As noted earlier, there were obvious financial incentives to do this. Indeed, Dr. James Curran, former director of the CDC’s first AIDS Task Force (1981-85), recently argued that the race to claim credit for HIV’s discovery was contributing to a sense of competition and envy between him and Gallo at the NIH (interview with Curran, 11/8/06; “A Viral Competition over AIDS,” New York Times, 4/26/84; Russell, The Washington Post, 4/23/84). This competition had immediate consequences, especially when it came to research. By 1983, the Director of the CDC Task Force for AIDS, Dr. James Curran, and other officials complained that Dr. Gallo of the NIH and his staff were not sharing important information. They were hoping to obtain from Gallo crucial blood tests and samplings that they, in turn, could use to conduct research. But Gallo resisted. The conflict intensified to such an extent that Ed Brandt had to call them into his office. He was tired of hearing individuals in both agencies bicker that they were not helping each other out (interview with Brandt, 11/10/06). The purpose of the meeting was to help clarify matters and to make it very clear to both Gallo and Curran that sharing information was important for progress (interview with Brandt, 11/10/06). But the problem was that Gallo was too prideful and territorial. He didn’t want to share information simply because of the fact that he wanted all the credit for HIV’s discovery and research (interview with Brandt, 11/10/06). Curran was not of the same opinion. Gallo’s race to fame led him to work with other international laboratories. For instance, he was constantly working with French researchers at the Institute Pasteur in 228

Paris. If he was sharing information with anyone, it was the French, not his colleagues at the CDC. Gallo believed that the French were doing the most cutting edge research. In fact, Gallo was working more with his French colleagues than with his colleagues at the CDC and NCI (interview with James Curran, 11/08/06). In fact, Ed Brandt had absolutely no idea that Gallo was involved in these activities and was very surprised to find out about them (interview with Brandt, 11/10/06). Curran of the CDC felt the same (interview with Curran, 11/8/06). Gallo’s activities confirmed his suspicion that it was his race to fame that led to his clandestine, uncooperative activities (interview with Curran, 11/8/06). Apparently Gallo’s only remark at the time was that he had been working with the French before the AIDS crisis and that Curran and others were simply threatened by the quality of his data. They were, as he put it, “sour grapes,” individuals that were jealous of his discoveries (Gallo quoted in Russell, The Washington Post, 4/23/84). To make matter’s worse there was also a sense of competition within the NIH. During the first five years of the outbreak, the NCI (National Cancer Institute) and the NIAD (National Institutes of Allergy and Infections Disease) – both subdivisions of the NIH - were competing to take over HIV research. Directors of the NCI felt that it was their responsibility to take charge because AIDS appeared to be a rare form of cancer. This view contributed to a sense of competition within the NIH. Worse still, the NCI was also not interested in working with Jim Curran or anyone else at the CDC or HHS (interview with Curran, 11/8/06). Gallo was thus facing competition both from within and without his agency. The worst thing about all of this is that despite the “supposed” lessons that the government learned from polio and smaller epidemics in the past, the White House was 229

reluctant to get involved in order to help HHS resolve these territorial disputes. Under Secretary Edward Brandt, who was delegated the task of trying to overcome these problems, Brandt notes that the White House “never” tried to help him bring the NIH, CDC, and the states together to define the problem and establish common ground (interview with Brandt, 11/8/06). While Brandt appreciated the fact he was delegated an enormous amount of autonomy, and issue which he thought was vital for untainted research and analysis, he also felt that Reagan and his domestic staff should have taken the lead in helping him overcome these agency problems (interview with Brandt, 11/6/06).

Vertical Reforms: Working with the Stigmatized, Building Trust In sharp contrast to its complications at strengthening its national bureaucratic response, the PHS was very successful at working closely with at-risk groups. Unlike the White House, the PHS’s isolation from moral interest groups, its unwavering commitment to objective scientific research and analysis and its willingness to work closely with highly stigmatized at-risk groups set the groundwork for impressive vertical assistance during the initial years of the AIDS epidemic. As noted earlier, PHS directors in the HHS and CDC were especially committed to learning more about AIDS and working closely with the gay community. PHS officials were highly autonomous and, since the 1940s, committed to keeping medical science and public health scientifically objective. At the very beginning of the AIDS epidemic, the PHS embedded itself in civil society by working with at-risks groups, mainly the gay community. They approached these communities in ways that went beyond their call to duty. That is, in addition to

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meeting on a one-on-one basis with gay victims, agency directors also met with various gay NGOs in order to learn more about the new virus and the resources that the gay community needed. Shortly thereafter, they also started meeting with other groups, such as drug addicts, heterosexuals, and children, as the virus began to spread. There are several reasons for why the CDC did this. First, these meetings provided the CDC with the information needed to conduct research and create better informed policy. As noted in the theoretical chapter, a bureaucracy’s vertical integration at the beginning of an epidemic is vital for obtaining information about the causes of viral transmission and needs. During the first two years of the AIDS outbreak, CDC officials were clueless about AIDS and desperately needed this kind of information. Immediately meeting with the gay community was the first step in achieving this goal. In addition, these meetings gave CDC officials a better sense of the types of treatment services needed and the types of prevention campaigns best suited for reducing the viral spread. Vertical relationships were thus crucial for CDC learning and adaptation to the new epidemic. Second, and perhaps more importantly, establishing these vertical relationships helped give the impression that the government cared, which was important given the conservative political climate at the time. In addition, CDC outreach gave these groups hope and support. In a context of crisis and uncertainty, this stewardship in clarifying the mode of transmission was important for helping reduce fear that the virus would spread uncontrollably. The CDC’s public statements about the mode of transmission and assurance to civil society that they could not obtain the virus through daily physical contact went far in helping avoid social unrest and hysteria. HHS Director Margaret 231

Heckler played a vital role in this process (The Washington Post, 8/18/83; Kurtz, The Washington Post, 6/14/83; US News & World Report, 6/27/83; Kurtz, The Washington Post, 6/15/83; New York Times, 8/18/83; The Washington Post, 6/14/83). Not surprisingly, the first group that the HHS reached out to was the gay community. Shortly after it was well known that AIDS was mainly associated with this community, Under-Secretary Brandt decided to frequently meet with them. For example, he was constantly on the phone with Virginia Apuzzo, then executive director of the National Gay and Lesbian Task Force (henceforth, the NGLTF, or “Task Force”) in New York (interview with Apuzzo, 9/22/06; interview with Brandt, 9/20/06). In fact, in a recent interview, Brandt noted how he was always willing to talk to her in order to learn more about what was going on and how he could help (Interview with Brandt, 9/20/06). Virginia confirmed this assertion (Interview with Apuzzo, 9/22/06). In addition, Brandt went out of his way to go to California to visit gay communities. He admits that at the time, he had no clue about what the “gay lifestyle” was, its politics, its economics, its philosophy. He was there to learn, and they fed him with tons of information (interview with Brandt, 9/20/06). Brandt also visited a small gay community outside of San Francisco, which had a gay mayor and was trying to become recognized as a gay city. Not only did he meet with several gay leaders, but he also cut the ribbon to a brand new gay medical clinic that focused on helping gay at-risk youth (Interview with Brandt, 9/20/6). Through these efforts and other initiatives, Brandt sent a clear message: that he was open and willing to work with gay leaders, to learn their problems and to see how he could help.

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Virginia Apuzzo was also impressed with Ed Brandt’s commitment to establishing a bridge between the PHS and the gay community. Indeed, she recalls a time when Brandt invited her to go with him to the CDC to meet its new director, Jim Mason, who was rumored to have been a conservative Mormon. Despite this, “Brandt took us and introduced us to Mason, telling him [Mason] how informed and organized we were at the Task Force and that he should work closely with us” (interview with Apuzzo, 9/22/06). Brandt was trying to construct a sense of trust and a stronger working relationship between the CDC and the gay community. Next, Brandt took Apuzzo to meet with Sally Lengal of the CDC in order to learn from the Task Force’s national AIDS hotline and to do the same thing (US News & World Report, 7/18/83). Apuzzo notes that Brandt did a great job of convincing Sally to do this. It was finally achieved, and by 1984 the CDC had created its own national hotline. What is more, Brandt also went out of his way to provide key financial information to the Task Force. In 1983, Brandt submitted (in consultation with the Task Force and other groups) a $91 million dollar budget for AIDS research to Secretary But Heckler was declined this money. Shortly thereafter, he stuffed the budget into a government-issued plain vanilla envelope and mailed it to Apuzzo. “This information was vital,” Apuzzo stated, “because Ed gave us a copy of the rejected budget which highlighted his line-by-line proposed expenditures for the following year” (interview with Apuzzo, 9/22/06). Having this kind of information helped justify her plea for more funding when she used it to testify in front of House. She could now refer to an itemized government budget and ask why the money was not approved. This, in turn, bolstered her credibility and made her all the more persuasive. 233

Other agencies followed suit. In his book titled AIDS in the Mind of America, Dennis Altman (1987) describes how the director of the CDC at the time, Dr. James Mason, went out of his way to establish several meetings with the NGLTF. In a recent interview, Mason confirmed this statement, explaining how he often desired to meet with gay community leaders, to learn more about their situation and what he could do to help (interview with Mason, 11/17/06). He explained how he often desired to give them more money but due to his very tight budget, as explained earlier, he couldn’t (interview with Mason, 11/17/06). It was not until 1987 that he would be able to afford giving the gay community more money (interview with Mason, 11/17/06). A key lesson that emerges from all this is that Victorian morals and the stigma of AIDS did not affect all “parts of the state,” if you will (Migdal, 1992). That is, while ensnaring the presidency and legislatures, it did not affect how the HHS and PHS responded to the crisis. Indeed, the PHS pushed its morals aside and strove to help those in need. The actions by Edward Brandt, Jim Mason, Jim Curran, and Margaret Heckler were vital in increasing the federal bureaucracy and Congress’ information about what the gay community needed, how HIV was spreading among them and why. Furthermore, it established a vital bridge with the HIV (mainly gay) community and government. This was important for demonstrating to civil society that the government did in fact care and that it was doing something in response to AIDS. What is notable about all of these initiatives is that they were initiated by the PHS, not the White House. Indeed, as Brandt notes, Reagan had nothing to do with these initiatives. Rather, Reagan had delegated complete authority to Brandt to do whatever he wanted, a strategy that Brandt says Reagan never received due credit for (Interview with 234

Brandt, 9/20/06). Brandt did not want Reagan involved because the issue was way too complex and he did not want the President to further complicate matters. Brandt was free to do whatever he wanted. Interestingly, the fact that Brandt was given so much autonomy, and the fact that Reagan knew about his activities with the gay community, strongly suggests that the President was not opposed to working with the gay community. If anything, absent Reagan’s resistance to Brandt’s initiatives, it seemed to indirectly endorse what Brandt was doing. What is also interesting to note is that because Brandt was allowed to work autonomously, he was never bothered by any of the morally conservative factions within and outside of government. Brandt was particular surprised never to have received a phone call from the leaders of the moral majority, such as Jerry Falwell (Interview with Brandt, 9/20/06). They left him alone and instead decided to focus on Reagan, White House staff and the Congress. Brandt was therefore able to avoid dealing with the moral majority, a relief that helped him concentrate and achieve what he set out to accomplish.

~ AIDS II: GLOBAL PRESSURES AND REFORM (1988-present) ~ By the end of the Reagan presidency and the rise of the George Bush administration (1988-1992), the global and domestic structural conditions in response to AIDS began to change. By 1987, new global community pressures, mainly from the World Health Organization, for a more aggressive institutional and policy response to AIDS began to emerge. At the same time, President Bush and the Congress became more interested in responding through an increase in their financial commitment to the states.

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Nevertheless, these new global pressures did not elicit a new institution-building response. The PHS remained fragmented and poorly coordinated, notwithstanding incessant pressures from the National AIDS Commission for the creation of a centralized “supra-AIDS agency.” Furthermore, during this period the PHS continued to work on its own. While the agency survival component which hampered inter-agency collaboration substantially decreased by this point, which in part was the result of a decline in political and bureaucratic elite contention over the fact that AIDS was an epidemic, the CDC continued to be committed to working with the AIDS community.

The Rise of Global Pressures The year 1986 marked the beginning of what I referred to earlier as the new global consensus in response to AIDS. Started by the creation of the World Health Organization’s Global AIDS Program (GAP) in 1986, followed shortly thereafter by a flurry of international organizational, NGOs, and conferences, by the late-1980s and early-1990s these international movements began to reach common ground on the need to work together and with other nations for a more aggressive response to AIDS. It was the beginning of what others have called the “Geneva Consensus” for an AIDS policy response (Gauri and Lieberman, 2004). In addition, it was a time when new international health movements began to emerge, mainly in response to the perceived inability of several international organizations to adequately respond (Altman, 1999). By 1987, the United States as well as several other nations (including Brazil) began to be criticized for their delayed response to AIDS. In 1987, for example, Jonathan Mann, the first director of the Global AIDS Program and a Professor from the Harvard

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School of Public Health began to critique President Reagan and Bush for their delayed response. By 1988, he gave explicit warnings to President Bush and his AIDS Commission that they needed to change their approach to the epidemic before any substantial progress could be made against it (The Boston Globe, 11/6/89). Mann’s criticisms were followed up with a flurry of international AIDS activists and conferences alluding to Bush’s lackluster response, especially towards the international health community (Altman, 1991). By 1989, even Bush’s own AIDS Commission began to criticize him for failing to respond to the pandemic (St. Petersburg Times, 7/22/89). At several international AIDS conferences activist from around the world began to censure Bush for his repeated neglect to participate in their meetings (Altman, 1991). In 1990, these tensions heightened when Bush failed to address the 6th International AIDS conference in San Francisco. Not only did he not attend, but he even refused to send in a video tape greeting the conference participants (The San Francisco Chronicle, 2/12/90). Many were also upset with Bush’s decision not to grant visas into the United States for HIV positive foreign nationals (Mesce, 1990; St. Louis PostDispatch, 6/17/91). This was perceived as a direct infringement on individual liberties. But it was also quickly perceived as an effort by Bush to refrain from the global community’s interest in supporting and uplifting those with the disease. And last but not least, in 1991 Bush and the Congress authorized a reduction in the number of research scientists sponsored by the US government to attend international meetings (The Atlanta Journal, 6/14/91). This made it crystal clear to many that Bush was not eager to strengthen his collaborative relationship with the global health community.

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If neither Reagan nor Bush were responding to the global AIDS community, then they were certainly not receptive to international recommendations for strengthening their bureaucratic response to AIDS. These pressures had absolutely no bearing on Reagan and especially Bush’s perception of the need to respond through institutionbuilding and the incorporation of civil society into the policy-making process. The Global AIDS Program made both goals explicit in their recommendations, and only a handful of nations (one of them being Brazil) were receptive to them. Instead, it was politics as usual. That is, despite these new global pressures, and despite President Reagan and Bush’s growing interest in AIDS, both continued to pursue their own reform agenda. This entailed being influenced by domestic structural circumstances and incentives for institutional and policy change, not by global forces. For Bush, this meant being influenced more by the outgoing Reagan administration’s interest in responding to AIDS. Reagan’s commitment to combating AIDS, which he announced in 1987, made it nearly impossible for Bush to avoid the issue. In fact, Bush was widely perceived as a leader that was genuinely sympathetic towards the needs of AIDS victims (Knox, 1990). In addition to publicly declaring a war on AIDS, he also succeeded in introducing new anti-discriminatory legislation protecting the rights of the disabled, which included HIV/AIDS (Hilts, 1990; Knox, 1990). Like Reagan, while Bush did not see the need to build a new federal agency for AIDS, he was nevertheless fully committed to gradually increasing the amount of federal assistance going to the states. In 1990, for example, he authorized the Congress to pass the 1990 Ryan White (CARE) act, which provided $4.5 billion dollars in federal emergency relief to the states. He also worked with the Congress to allocate more money 238

for AIDS spending and continued to support CDC, NIH, and NCI research and policy initiatives. While he was of course criticized for not providing enough money to the states and cities 43 (Hilts, 1990; Perow and Guillan, 1990), Bush did perceive the situation as urgent enough to give more money to the states. Despite this increase in commitment to AIDS policy, this by no means meant that Bush was committed to institution-building. Again similar to Reagan, Bush never hinted at the possibility of expanding and strengthening the PHS. Among Republic Conservatives, downsizing the government was still upheld as a core value. Downsizing the public health bureaucracy seemed more important to him then creating a new agency that could increase policy coordination and direct federal assistance to the states. Nevertheless, this very idea was proposed by Bush’s very own National AIDS Commission in 1990, when it submitted a lengthy recommendation for how the administration could improve its response to AIDS. Among a host of problems outlined in the report, the AIDS Commission critiqued the Bush administration for failing to provide the leadership needed to increase coordination between health agencies for a more timely and efficient response to state needs (Gladwell, 1990; Hilts, 1991). In addition to increasing coordination between the CDC and NIH (which, mind you, is something Secretaries Edward Brandt and Jim Mason were calling for during the Reagan administration), the Commission’s report also called for more leadership in helping the HHS, Veteran’s Affairs administration, and the Department of Housing and Urban Development better coordinate for a more timely response. 43

Keep in mind that Bush never authorized a proposal by Senator Edward Kennedy of Massachusetts and Senator Orrin Hatch of Utah were requesting an additional $600 million a year in 1991 and 1992 to go to the cities and states for emergency help to the hospitals and AIDS clinics, and to pay for drugs and home treatment for patients (see Hilts, 1990).

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In essence, the Commission was calling for a centralized bureaucratic and even somewhat authoritarian approach to AIDS. In fact, the Commission’s Chairman, David E. Rogers, had the following to say: “What is all to evident to the Commission is a critical lack of any top-level federal group- clearly accountable and capable of swift, authoritarian action [author’s emphasis]– to coordinate efforts …” (Rogers quoted in Gladwell, 1990). Up until that point, analysts were referring to the government’s bureaucratic approach to AIDS as an “orchestra without a conductor … a cacophony of musical parts without any kind of coordinative leadership” (Hilts, 4/25/90). In order to achieve this, for the first time the AIDS Commission recommended the creation of a more centralized bureaucratic response to AIDS. The commission felt that such a response was long over due. It was believed that creating a new centralized agency would help increase inter-agency coordination by bringing in relevant policymakers from all of the health agencies, as well as concentrating resources and technical support. The first attempt came with the recommendation of a “cabinet level” group to set up a coordinated national plan for AIDS (St. Petersburg Times, 4/25/90). The next proposal took the cake. The Commission suggested that Bush create a “super-agency” for AIDS (Knox, 4/25/90; Rudavsky, 1992). David Rogers argued that this was needed in order to enhance coordination between various health agencies. It was also needed because PHS bureaucratic fragmentation and a lack of leadership was hampering the nation’s ability to organize medical care for people with AIDS, to train those who care for them, to conduct effective education on AIDS, and to coordinate drug addiction treatment programs (Knox, 4/25/90). In the end, the new proposal was seen as a way to get Bush to “match the rhetoric of his first speech on the subject with his 240

actions” (Knox, 4/25/90). The chairman of the AIDS Commission, Dr. June E. Osborn, said that the creation of an AIDS super-agency “would have been helpful several years ago …” and that “it’s the kind of thing that you would want to do if you saw a big emergency coming” (Osborn quoted in Knox, 4/25/90). These recommendations notwithstanding, the Bush administration still did not respond. What is more, after two years of inaction the AIDS Commission once again approached the White House about the need to create a super-agency, or at a minimum the creation of a new cabinet-level agency for AIDS (Rudavsky, 1992). The chairmen of the AIDS Commission, June E. Osburn, angrily responded and accused the White House of not taking their proposals seriously: “What disappointed me most profoundly was the sense that this was business as usual. This is not business as usual. This is a historic epidemic,” she argued (Osburn quoted in Rudavsky, 1992, p. 2; Hilts, 6/26/92). Thus in sum, as we saw with the government’s initial response to AIDS, even after the emergence of new a new global consensus and domestic pressures for reform, the public acknowledgement by Regan and Bush that AIDS was an epidemic, and what is more, even after the incessant pressures from several National AIDS Commissions, there still was no interest in creating a more centralized bureaucratic response to AIDS. The end result was an increase in direct federal financial assistance to the states, but a repeatedly unwillingness to strengthen the federal government’s bureaucratic response to the epidemic. And this occurred despite common knowledge by that point that the states were having a very difficult time financing and implementing policy.

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Congressional Perceptions and Response During this period, the Congress’ perceptions about the need to respond to AIDS had changed as well. For in contrast to the first few years of the epidemic, there were fewer Congressional disputes over how and when the legislatures should respond. This perception was influenced by the presence of different domestic institutional conditions, as well as the widely held consensus that something urgent was needed to be done. This consensus notwithstanding, institution-building was never on the legislative agenda. Instead, the focus was on increased direct financial assistance to the states. By the arrival of the Bush administration, the legislative context was quite different from the initial years of the epidemic. Keep in mind that since 1986, both the Senate and the House were controlled by the Democrats. With the Democrats unwaveringly interested in responding to AIDS, this facilitated the emergence of a Congressional consensus that funding for AIDS programs needed to increase. The domestic structural conditions shaping legislative perceptions therefore changed from the conflicting perceptions and interests of Victorian morality versus attention to constituent needs, which was present during the first few years of the epidemic, to the absence of moral constraints and a more unanimous consensus for reform. The passage of Ryan White in 1990, in addition to a host of other new prevention and treatment programs and anti-discrimination legislation, demonstrated that the Congress was indeed much more committed during the second phase of AIDS politics. The upshot was that while the Congress was committed to increasing funding for the states and the PHS, it was not interested in institution-building. During the end of the Reagan administration and throughout the Bush presidency, the Congress never proposed 242

the creation of a new “super-agency” for AIDS. While it did nevertheless acknowledge the need to increase funding for the CDC, NIH, and the other agencies involved, at no point did it perceive institution-building and increased federal intervention as a key strategy for increased government intervention. In part, this had to do with the fact that the White House was not interested in bureaucratic reform. On the other hand, it simply was not an urgent issue; getting more money to the states, and making sure that the various PHS agencies could survive, was.

Bureaucratic Perceptions and Response During the second phase period, the PHS sustained its commitment to responding to AIDS. As we saw during the first few years of the crisis, by this period the CDC’s perceptions and interests were once again motivated by the following structural conditions. First, the need to respond based purely on scientific objectivity and professionalism. As in the past, the CDC, NIH, and the other PHS agencies involved continued to see AIDS from a purely secular perspective. For the bureaucrats, AIDS was still perceived as a national health crisis, in need of immediate and sustained government attention. Second, the challenge of agency survival did not play as significant of a role during this period. Instead, by the late-1990s PHS bureaucrats gradually realized that they needed to start working together rather than competing with each other (interview with James Curran, 11/6/06). While this did not translate to the creation of a new agency or inter-agency coordinating mechanism, to some extent it ameliorated tensions between PHS agencies and reduced the need for inter-agency competition (interview with James 243

Curran, 11/6/06). And lastly, key prevention agencies, such as the CDC, continued to work closely with the AIDS community. But this time it had a rather different demographic composition to deal with: a new urban minority and IDU drug community. The PHS tradition of viewing AIDS as a non-moral, purely scientifically objective issue continued during the last few years of the Reagan administration and throughout the Bush administration. As in the past, HHS secretaries, the Surgeon General and high level CDC officials did not view AIDS as a moral issue. Rather, their perceptions were once again guided by the simple need to respond based purely on the scientific evidence at hand. This type of behavior was facilitated, though not necessarily caused by, the fact that there was far less resistance from the White House based on Victorian moral conviction, as we saw during the initial Reagan years. While President Bush was initially perceived as someone who adopted Reagan’s moral stance on AIDS, that is, a view that believed in individual responsibility and immorality as the primary culprit (The Atlanta Journal and constitution, 4/26/90), this view never manifested itself at the policy level. This, in turn, facilitated and encouraged the PHS’ continued, scientifically objective approach to AIDS. With the AIDS epidemic becoming more of an obvious problem during the late1980s and early-1990s, the HHS and the PHS also did not find itself spending a lot of time trying to convince the government that responding to AIDS was a priority. On the other hand, it did continue to press for additional funding. The CDC continued to find itself in need of financial assistance (The Atlanta Journal and Constitution, 4/26/91). And once again, despite the rhetorical commitment by Bush, the CDC continued to see a decline in the number of personnel staff working on AIDS (The Atlanta Journal and 244

Constitution, 4/26/91). In response, HHS and CDC directors continued to pressure the Bush administration and the Congress for additional funding. While the overall budget for the CDC certainly increased, the problem was that most of the money given to the CDC for AIDS was immediately decentralized to state and local community programs, which were still very much in need of financial assistance (The Atlanta Journal and Constitution, 4/26/91). And finally, as we saw during the first few years of the epidemic, the CDC continued to work closely with the AIDS community. This time, however, the demographic composition underwent a significant change, with the majority of AIDS cases now being reported among Black and Hispanic Communities (Okie, 1989; Gladwell, 1991). During this period, moreover, the CDC started funding several Black community initiatives and worked closely with black community leaders to implement new prevention and treatment programs. It also started meeting with several church leaders in black communities, encouraging them to educate their congregations about the spread of AIDS and how to prevent it (Poe, 1991). The CDC also started reaching out to the Hispanic community, drug addicts, and began meeting with groups focused on helping women and children. In closing, as we saw during the initial response to AIDS, the CDC continued to embed itself in civil society. It sustained its unwavering commitment to reaching out to minority communities. As we saw in Chapter 3 and earlier in this chapter, this type of bureaucratic embeddedness is a tradition that goes back to the early-20th century. While a decrease in federal funding for CDC prevention programs continued to challenge its

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efforts, the CDC nevertheless continued to demonstrate its stewardship when working with minority groups.

~ Conclusion ~ In conclusion, it is interesting to note how unresponsive the President and certain segments of the Congress were to the AIDS epidemic. Both during the first and even the second phase of AIDS politics, the government did not immediately respond through new institution-building initiatives. While new policies were certainly implemented, the only initiatives taken during this period was a sustained increase in bureaucratic embeddedness, were the CDC continued to meet with stigmatized AIDS victims, starting with the gay community, then leading to the intra-venous drug users and eventually urban minorities by 1990. This was critical for obtaining new information about the virus while giving the impression that the government cared. Despite these efforts, what this chapter has also shown is the ongoing saw of American bureaucratic politics: that is, the challenge of bureaucratic fragmentation and isolation, and how this breeds competition and a lack of cooperation. Despite the PHS’s repeated ability over the years to brush aside and avoid the influence of puritanical values, several of its agencies were not willing to work with each other for a coherent, immediate response to AIDS. Thus while our public health bureaucracy was able to blunt Puritanism, it also blunted institution-building. Paradoxically, agency survival, which prompted the CDC’s immediate response to AIDS by incessantly lobbying for more money and meeting with civil society, also translated to bureaucratic independence and a lack of cooperation with other agencies. This hampered the PHS’s willingness and ability 246

to increase research and policy coordination while working together to propose new plans for more effective intervention. Another lesson that emerges from this chapter has to do with the political capacity of our PHS system to immediately intervene. For while the PHS certainly had a lot of scientific prestige, and while it had the support of local governments and gay communities, it could never muster a network of support within the Senate and the White House for more inter-agency coordination. And this occurred even after the rise of new international and domestic pressures, and even after the president and the legislatures became more sympathetic and interested in AIDS. This finding suggests that scholars emphasizing the importance of bureaucratic reputation and support networks as necessary and sufficient conditions for agency expansion may not work in a context of epidemic crisis and elite contestation (Carpenter, 2001; Dominguez, 1997). For under these conditions, structural factors decreasing presidential and senatorial perceptions of the urgency of an epidemic, when combined with the capture of moral-based interest groups, can suppress the advantages of scientific reputation and thwart bureaucratic advancement. And finally, perhaps the biggest lesson that we take from this chapter is that even after the emergence of new international pressures and the emergence of a new global consensus for an immediate government response to AIDS, our President and Congress still was not interested in creating a new federal agency for AIDS, and/or even strengthening our PHS system. What is more, this occurred despite the expressed recommendations of a presidential- and legislatively-appointed National AIDS Commission that the government create a centralized AIDS program. As the leader of the 247

free world, especially when it came to science and medicine, President Bush had no interest in incorporating the views of the global health community. The United States was a leader, not a follower. This sent the wrong message and foretold of future difficulties in working with the United States in response to newly contested epidemics – such as obesity, as we’ll see later on in this dissertation. But as we will see in the next chapter, being a follower rather than a leader in the global health arena has its advantages. For as the case of Brazil will show, being receptive to the international health community can create new domestic incentives to engage in institution-building processes whenever new international pressures and incentives for reform emerge. Furthermore, it gives the impression that a nation is willing to work with others in combating the spread of disease, in turn increasing a nation’s reputation as a global partner in the quest to eradicate disease. And yet, during the first and even the second phase of the AIDS crisis our government never displayed this kind of interest, suggesting that the recommendations of other nations and international organizations were simply not good enough for our advanced democracy. But keep in mind that the American public wasn’t good enough either. One would think that if our government was not responding to the international health community, than surely it would respond to our citizens. Wrong again. For as this chapter and previous historical case studies in Chapter 3 illustrated, even within our long consolidated democracy the government never immediately responded to the needs of civil society. Despite the rise of new NGOs, incessant public testimonies in the Congress and picketing in front of the White House, and furthermore, despite the clear need for immediate and

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direct federal assistance to state and municipal health care agencies, our government never responded through institution-building measures. But why did this occur? What critical factor was missing? The crucial ingredient that was absent during this period was the presence of a clear and direct national security threat. Sure, the government re-centralized and acted in a more centralized manner when syphilis and mal-nutrition affected the US Military’s fighting capabilities in WWI and WWII. And this occurred despite a clear and pre-existing (and constitutionally guaranteed) agreement among federal health officials that the public health service was decentralized, controlled by the governors; they were expected to be the first responders, not the federal government. But absent a national security threat during the first few years of the AIDS epidemic, these centrist bureaucratic tendencies were never pursued, no matter how grave the situation was. What this suggests is that as in the past, our government continues to operate as a security-led public health regime, where it only seeks institution-building whenever epidemics are perceived as posing a direct national security threat. As we saw in Chapter 3, this is characteristic of a Globally Isolated Public Health Regime, where domestic political factors play a greater role in determining how governments respond to contested epidemics. In the absence of a national security threat, however, it seems that our government shows this repeated pattern of simply not caring about the immediate needs of civil society whenever a new epidemic emerges. Yet as we saw with AIDS, and as we’ll see again with the recently contested obesity epidemic in Chapter 7, in a democratic setting, where the government is built to represent and serve the needs of civil society, such a 249

response may be inappropriate. What will it take for our government to finally revamp its federal system for a more aggressive institutional (and thus policy) response to these contested epidemics? I’ll return to this issue at the conclusion of this dissertation.

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CHAPTER 6 Responding to AIDS in Brazil: Democratization, International Pressures, and Institution-Building (1980-95) Many are now familiar with the success of the Brazilian AIDS program. For several years now international health officials and scholars have put Brazil’s response on a high pedestal, to be revered and emulated by all. In fact, in 2003 the Bill and Melinda Gates Foundation gave an award to Brazil for having the world’s best model for combating AIDS (US News Wire, 2003), while the World Health Organization publicly supported Gates’ statement (Agnencia Estado, 2003). Despite these prestigious announcements, many are unaware of the fact that before 1992 Brazil’s AIDS program was, like the United States, very poorly managed and ineffective at combating the epidemic. It had a very weak national program, with little presidential and congressional support. And it did essentially nothing to support at-risk groups and insolvent state governments. How, then, did Brazil’s response to AIDS suddenly change? Was it a purely domestic response to burgeoning AIDS cases and deaths? Or were there new international factors that created incentives for improving the AIDS program for more effective intervention? This chapter argues that it was global, not domestic pressures that instigated an institution-building response. Demarking two time periods of analysis AIDS I (1981-92) and AIDS II (1992-present), I argue that in contrast to the United States, Brazil was eventually capable of transforming its National DST/AIDS Program from an insolvent 251

and inefficient agency during the AIDS I period to arguably the world’s biggest, most effective AIDS program during the AIDS II period. While as in the U.S. the first time period exhibited structural conditions that convinced the president and the Ministry of Health that AIDS was not a national priority, there were other DST/AIDS bureaucrats that were not of the same footing. Yet as in the U.S., during the AIDS I period these conflicting perceptual pathways and incentives for institution-building, when combined with the weak positioning of pro-reform DST/AIDS bureaucrats, curtailed efforts to strengthen the DST/AIDS program. Consequently, Brazil closely resembled the U.S.’s lackluster federal institutional response to the newly contested virus. Nevertheless, by 1992 the DST/AIDS program quickly changed. This occurred because of the simultaneous increase in global attention and pressures for a response to AIDS, the opportunity to once again increase Brazil’s global reputation as a modern nation capable of combating disease, and the prospect of receiving a major World Bank loan to achieve this. Brazil’s ability to obtain funding from the World Bank is viewed as a necessary (but not sufficient) condition for an immediate government response, especially in a context of fiscal imbalances. Acquiring resources made it possible for the president and his health ministers to increase their global reputation as effective disease combatants, which was their primary goal; and this was especially important in a context of increased international pressures and criticisms of Brazil’s lackluster response prior to the loan. But it was the president’s concern with his international reputation that I argue contributed to an immediate change in his interest in reforming the DST/AIDS program. At the same time, and more importantly, it also led to the elimination of conflicting perceptual pathways between bureaucrats within the Ministry of Health and the 252

DST/AIDS program. These were dilemmas that, if you recall from Chapter 5, hampered the U.S. government’s immediate response to AIDS. These global structural shifts and pressures also strengthened the position of previously marginalized DST/AIDS bureaucrats, which were always committed to creating more autonomous, centralized agencies for combating disease. In addition, these global pressures also generated new incentives for continued institution-building. While acquiring resources and attention in the immediate is important, this is not sufficient for sustaining long-term administrative and policy spending. What is needed to achieve this is continued pressure from pro-reform bureaucrats, which stems primarily from their personal career incentives to incessantly pressure the President and Congress for continued spending. Doing this adds to their reputation and influence at the international and domestic level, which in turn continues to motivate them to pressure the government for continued reform. But more importantly, these new global pressures also provided new incentives for reform bureaucrats to start working closely with civic organizations, such as AIDS NGOs. Bureaucrats seeking reform had incentives to finally start working closely with previously ignored NGOs, since these organizations now had the backing of international organizations and the President. Because the president was interested in increasing his international reputation, and because international organizations were pressing for the incorporation of civil society into the policy-making process, working closely with civic organizations provided an invaluable resource for bureaucrats to use when bargaining with government for the continued expansion of the AIDS program. At the same time, given this new increase in attention and support, NGOs had new incentives to re253

approach and lobby the government in a more organized manner. In the end, I argue that this inter-active informal partnership, which provided mutual benefit streams for DST/AIDS bureaucrats, NGOs, and international organizations, helped to rejuvenate and sustain a historically-based tripartite partnership between civic organizations, pro-reform bureaucrats, and international organizations seeking an immediate institution-building response to AIDS. By the mid-1990s, Brazil was therefore able to engage in successful institutional change. That is, it was able to quickly break away from the inefficiencies of cosmetic institutionalism 44 and succeed in reforming the DST/AIDS program. DST/AIDS bureaucrats were able to secure additional funding for their projects, obtained more autonomy for policy implementation, while centralizing 45 and increasing their control over sub-national policy. Almost overnight, it emerged as arguably the most effective national AIDS program in the world, far surpassing the United States in its ability to curtail the growth of AIDS. However, in contrast to what some re-democratization and institutional theorists would expect, institutional change within a new context of re-democratization and commitment to human rights did not emerge from presidential and legislative accountability to civic needs (Sen, 1999). Rather, it emerged from global pressures and more closely resembled Kathleen Thelen’s (1999) notion of functional conversion, where major exogenous shifts generated new endogenous opportunities and incentives for 44

As explained in Chapter 2 and in this chapter later, this is when governments initially respond to epidemics by constructing weak federal agencies designed for ‘appeal’, rather than actual efficacy in policy intervention. 45 Keep in mind that all health policies, including TB and malaria, in addition to a spate of other social services were being decentralized during this period. The AIDS program was the only health program to be re-centralized during the early-1990s.

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previously marginalized bureaucratic losers to rise up as winners and lead the way for institutional change. Interestingly, this suggests that democratization (or in the case of Brazil, re-democratization) processes may not guarantee timely and effective institutional change in response to pressing civic needs, and that this may occur in spite of the underlying tenants of human rights and equality that often motivate these transitional processes. In the next section, I’ll run through the government’s initial response to the AIDS epidemic. Note how similar Brazil was to the United States when it came to the government’s first few years of responding to this newly contested disease. . As I address in the conclusion of this chapter, these similar responses suggest that the durability of democratic institutions (the U.S. being far older then Brazil’s) has absolutely no predictive power in how governments will respond to contested epidemics. This further suggests that the less consolidated institutional conditions of nascent democracies (or even non-democracies) may facilitate the rapid expansion of national AIDS programs, especially when there are new global incentives for doing so.

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Graph 6.1 - U.S. and Brazil: AIDS Cases (1981-2004) 120000 100000

US population: 295 Brazil population: 186

80000 60000

U.S.

40000 20000 Brazil 0 81 Source: CDC, 2007; Ministry of Health, Brazil, 2007

04

~ GOVERNMENT RESPONDS (1981-1992) ~ The first cases of HIV emerged in São Paulo, followed shortly thereafter in Rio and some cities in the northeast, such as Salvador and Fortaleza. As in the U.S., the virus ushered in a great deal of uncertainty. The president and government officials were bewildered, trying to understand the causes and the wider ramifications of the disease (interview with former President of Brazil, Fernando H. Cardoso, November 7, 2005). Government and civil society was further shocked to find out that it was most prevalent among young gay men (Veja, 10/14/85; Visao: Revista Semenal de Informacão, 10/16/85; Jornal do Brasil, 6/16/85). In a highly discriminatory setting towards homosexuals (Mott, 2003),

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essentially all of the culpa was put on them, which intensified the already high level of pre-existing stigma towards gays (Laserda, Journal do Brasil, 7/21/85; Veja, 10/14/85).

Graph 6.2: U.S. and Brazil AIDS Deaths (1981-2004) 60000 50000 U.S. 40000 30000 20000 10000 Brazil 0 81

04

Source: CDC, 2007; Ministry of Health, Brazil, 2007

Similar to the U.S., the government did not immediately respond to AIDS (Parker et al., 1999; Da Costa Marques, 2003). And say what you may about Reagan taking 6 years to publicly address the epidemic, it took Brazil’s so-called liberal, carnival, “everything goes” society 10 years for the president to publicly address the issue (Da Costa Marques, 2003). On December 1, 1991, President Fernando do Collor publicly declared that AIDS was a national epidemic (Folha de São Paulo, 1991; Galvão, 2000, p. 125). What is more, the first few years of the AIDS epidemic had a minimal impact on 257

institution-building – that is, while the government created a new agency in charge of responding to the disease, the DST/AIDS Program, it was not well constructed, nor did it work closely with state governments and civil society. This position contrasts from the argument made by Varun Gauri and Evan Lieberman (2004), specifically that the DST/AIDS program was quite effective at implementing AIDS policy by the late-1980s, mainly due to pressures from sub-national governments and civil society. In reality, however, the DST/AIDS program was merely a “cosmetic institution,” built for appeal rather than actual effectiveness in public intervention. Instead, and as seen in the U.S., the states were left to their own devices, expected to finance and implement prevention and educational programs on their own. Government Perceptions and Response Several antecedent structural conditions accounted for the government’s initial perception and response. First and foremost was the belief by the President and his public health appointees that AIDS was not a national health threat. In part this was influenced by the fact that the government was confronting several health problems when the HIV virus emerged. As Figure 1.2 illustrates, officials were dealing with a myriad of health problems, such as tuberculosis, hanseniase, samparo, and especially malaria. The fact that prevalence rates for these diseases were higher than AIDS, save for samparo, contributed to the president and the Ministry of Health’s perceptions that AIDS was not a threat.

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Graph 6.3: Brazil - Cases of Major Disease (1980-93) 700000

AIDS TB Malaria Sarampo Hanseniase Coqueluche

600000 500000 400000 300000

AIDS

200000 100000 0 80

85

90

93

Source: Brazil, Ministry of Health

Notwithstanding burgeoning pressures from civil society and state governments to do something (especially from São Paulo), this perception persisted for the first few years of the epidemic (Teixeira, 1997: p. 50). This was captured most vividly in a public statement issued by the Minister of Health in 1985, Carlos Santa’Anna, in which he claimed that AIDS was not a priority and that the government needed to tend to other more pressing health matters (Folhão de São Paulo, 8/7/85; Jornal do Brasil, 8/25/85). As in the US, the spread and impact of AIDS was much different at the subnational level. While overall trends painted a modest national growth rate (especially when compared to the above mentioned diseases), sub-national growth rates were much higher, particularly in the larger cities. Indeed, as Figure 1.3 illustrates, after looking at the yearly rate of percentage change 46 for each of the diseases depicted above in Figure

46

This growth rate is calculated by the following formula, which I derive from formulas used by macroeconomists to measure rates of yearly inflation, over time: Rate of yearly % ▲= Σ of new cases/ Σ of prior year cases ×100.

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1.2, it is clear that by 1982, AIDS was by far the fastest growing. These facts notwithstanding, this had absolutely no impact on the government’s threat perceptions.

Graph 6.4: Brazil - Rate of Yearly % Change in Case Notification of Major Diseases (1981-93) 1800 1600

AIDS TB Malaria Sarampo Hanseniase Coqueluche

1400 1200 1000 AIDS

800 600 400 200 0

81 Source: Brazil, Ministry of Health

85

90

93

At the sub-national level, São Paulo had by far the fastest growth. During this period, the governor and mayor were incessantly pressuring the government to provide them with the financial resources needed to finance the regulation of blood supplies, increase the number of hospital beds, equipment, and prevention services (Visao, 10/16/85). As in New York, the governor of São Paulo was very committed to financing new heath programs while creating his own AIDS agency, expanding health infrastructure, treatment, and prevention programs. In light of these efforts, many were shocked upon hearing Health Minister Santa’Anna’s comment that AIDS was not of concern. But for the Paulistas, it surely was. Of course there were other factors that contributed to the president and Ministry of Health’s misperceptions. One of them was the simple fact that during the first few 260

years of the AIDS epidemic, it was not perceived as a major social problem. It is important to note that, in contrast to the U.S., not everyone was panicking during this period (Visao, 10/16/85). The fact that AIDS was initially concentrated within small gay communities and shortly thereafter among intra-venous drug users in São Paulo, Rio, and small coastal cities, such as Santos, when combined with the high level of social stigma towards these groups (especially gays), generated very little widespread fear about the disease. As in the U.S., it was mainly viewed as a “disease of luxury,” spreading among young, white middle- and upper-class men and gradually drug addicts. Up till 1985, very few people actually knew precisely what AIDS was and how it was acquired; and this was the case even among young gay men (Jornal do Brasil, 6/16/85). Although the media would start addressing the issue more often, the absence of a great social fear contributed to federal elite perceptions that it was not an urgent health issue. And lastly, intensive global pressures and incentives for reform were absent during this period. Important international financial organizations, such as the World Health Organization (WHO), the World Bank, the Inter-American Development Bank, and the Pan-American Health Organization (PAHO) were not pressuring Brazil to respond to AIDS (Galvão, 2000; Fontes, 1999). Furthermore, AIDS had not yet made the “global limelight,” if you will: that is, the international movement for AIDS, through the creation of new agencies, conferences, and global AIDS NGO-networks, had not yet risen (Fontes, 1999). Consequently, the government had no real incentives for its officials to aggressively respond and prove to the global health community that it was a modern state simultaneously committed to combating disease and developing its economy.

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In contrast to the U.S., it is important to note that during this period executive 47legislative relations were much more tightly aligned. This was due to the absence of fully democratic elections during the last few years of the authoritarian regime. While the military allowed for some degree of representation in the congress and at the state level through the representation of a “militarily approved” opposition party, namely the Democratic Movement of Brazil (MDB), until 1979 the congress was dominated by the pro-military ARENA (Alliance for National Renovation) party. Although in 1980 new and old parties were allowed to be formed, namely the PDS (Democratic Social Party), which splint into the PFL (Liberal Front Party) and the PPB (Brazilian Progressive Party), while the MDB became the PMDB (Brazilian Democratic Movement Party), ARENA’s long-standing rule and close alignment with the president engendered a tradition of strong executive-political party unity, which perpetuated during the first few years of the AIDS epidemic. Initial threat perceptions at the executive-level generated very few incentives to initiate institutional reforms at the federal level. Because the President, the Ministry of Health and their technocrats did not perceive AIDS as a major health threat, there were no immediate incentives to create new agencies or strengthen administrative resources (Interview with Ezio Santos Filho, 6/30/06; interview with Veriano Terto, 6/22/06; Teixeira, 1997). During this period the military was obsessed with the increased decentralization of social services, especially when it came to primary health care to the states. Through the Ministry of Social Welfare (INAMPS), the push was to gradually 47

The term “executive” is commonly used in the comparative politics literature to describe the presidential and/or pseudo-presidential (mainly military) heads in charge of the legislatures. It is more commonly used when referring to leaders that are not fully democratically elected, especially within nascent democracies; see John Carey and Matthew Shugart. 1998. Executive Decree Authority (Cambridge University Press).

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devolve more authority to public hospitals (Heirmann, 2002; Nascimento, 1999). There was no interest centralizing and strengthening the public health bureaucracy. This agency, the Departmento de Saúde Publico (DSP), was in the process of being downsized and incorporated into the Ministry of Health, which was also pushing for decentralization (Arretche and Marques, 2002). The formal incorporation of the DSP was accomplished shortly after the 1988 constitution, which signaled to some – especially to medical historians – that the great federal campaign of the past to eradicate disease was quickly coming to an end. 48 Nevertheless, by 1985 the new José Sarney administration became more interested in responding to the AIDS situation. As seen in the U.S., the growth of administrative and policy reforms at the sub-national level, especially in São Paulo, but also by this point through a vast network of states having crafted their own AIDS projects, such as Alagoas, Bahia, Ceará, Minas Gerais, Paraná, Pernambuco, Santa Catarina, Rio Grande do Norte, Rio Grande do Sul, and Rio, when combined with burgeoning pressures from the gay communities in São Paulo and Rio, gradually changed the government’s perceptions and interest in responding to AIDS. By 1982 most of the political opposition had won state elections, and anti-AIDS programs were implemented as one of several means to democratic deepening. In addition to these reforms, one must keep in mind that the federal government was on the verge of transitioning from an authoritarian government to a fully democratic state, which was, at least in theory, unwaveringly committed to universal rights and access to social services. In fact, the 48

Keep in mind that until 1988, the government had a separate ministerial department for public health, the Departmento de Saúde Publico. As explained in Chapter 4, this institution was created in the 1920s with the Inspectoria Nacional de Doencas and was expanded to include education under the Getúlio Vargas military regime (1930-45); for more on this, see Hochman (1998).

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architects of the 1988 constitution were wholeheartedly committed to universal health coverage as a key component of the new constitution. Thus by 1984, a culmination of factors lead to a gradual change in federal elite perceptions that AIDS was important and that the government needed to do something about it. It is important to note, however, that despite the pressures emanating from what others have defined as favorable “bottom up” pressures for reform, such as federalism and decentralization, (Guari and Lieberman, 2004; Teixeira, 1997), in actuality such pressures did not immediately translate to the creation of an effective AIDS bureaucracy. Of course, it is fair to say that in the case of Brazil, bottom up pressures were not as effective in large part because the first NGO movements for AIDS did not emerge until 1985 and 1986, mainly in Sao Paulo. 49 Nevertheless, there were pressures from state governments prior to the formation of these NGOs (interview with Paulo Teixeira, 11/27/07). And even after the NGOs eventually collectivized and pressured the government, federal institutions such as the National AIDS Program were not strengthened in order to meet the states’ needs. Nor was their any effort to work earnestly with NGOs. While the government’s interest in responding to AIDS certainly changed, their actions and commitments to full-fledged bureaucratic reform did not. Instead, what did emerge was the challenge of cosmetic institutionalism, where new AIDS institutions were created but only for domestic appeal rather than for effective policy implementation. The Challenge of Cosmetic Institutionalism

49

My thanks to James Green, Professor of History at Brown University, for his comments on this issue.

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By 1985, the outgoing president and the Minister of Health, Carlos Santa’Anna, responded to these sub-national pressures by proposing the creation of the Programa Nacional de Controle de DST/AIDS (henceforth, the DST program). This agency fell under the purview of the Ministry of Health and was created with the expressed intent of focusing entirely on AIDS. Composed of a Director, Dra. Lair Guerra Macedo, and a staff of about twenty, the program’s mission was to monitor HIV, disseminate prevention programs, finance medical treatment and establish federal norms for how policy should be implemented at the state- and municipal-level. It was a bold endeavor. For nothing like this had ever emerged in the U.S., notwithstanding the more responsive interests of the PHS and Congress. In Brazil, however, the government realized that only one agency not several, as see in the U.S. - should be in charge of AIDS research, evaluation, and policy. To the extent that the administration was aware of the complications arising from the fragmented system in the U.S. is unknown. Regardless, this new endeavor signaled that the government was finally showing interest in responding to the epidemic (Teixeira, 1997). These institution-building efforts notwithstanding, the degree and quality of commitment to building up the DST program was very half-hearted. For it smacked of a cosmetic impulse that sought to appeal and convince rather than to exhibit policy effectiveness and commitment. It soon became clear to many that the DST was only created to assuage the burgeoning discontent of civil society and some public health officials. It very well could have been perceived as a political ploy intended to support the new democratic movement for greater equality. The program was hastily and fancily designed, as if by Karl Lagerfeld himself, such that it recruited a very famous 265

epidemiological biologist, Dra. Lair Guerra Macedo, who in turn recruited the best medical scientists in the country. Furthermore, Lair made it a point not to enlist the support of political appointees. This was done in order to illustrate that her team was isolated from corruption. It had money, albeit little. It had prestige, albeit domestic. And above all, it had a lot of media attention. But there were problems. First of all, not matter how often and how much money the DST director asked for, she never received nearly enough money to finance her initiatives (Da Costa Marques, 2003, pp. 127-28). The president and congress was simply not interested in insuring that the program was well financed (Da Costa Marques, 2003, pp. 127-23). Similar to the U.S. during this period, because AIDS was not perceived as an immanent national threat, the president had no interest in trying to allocate more money (interview with Veriano Terto, 6/22/06). With Congress acting as essentially a rubber stamp to the president’s needs, it would not authorize any money without him. Second, as was the case with the CDC in the U.S., the DST was very poorly organized (interview with Veriano Terto, 6/22/06; Interview with Ezio Santos Filho, 6/30/06; Teixeira, 1997; Visao: Revista Semenal de Informacão, 10/16/85). There was no interest in trying to re-organize the DST for greater efficiency and responsiveness (Galvão, 2000; Teixeira, 1997). What is more, it received little guidance from the president and even the Ministry of Health on how it should improve (Da Costa Margues, 2003). Within one year of its creation, it seemed as if the DST program was only created to appease the interests of civil society and that there was no substantive “grand strategy” for attacking AIDS (Miguez, Jornal do Brasil, 6/18/89; Daniel, Jornal do Brasil, 6/10/91). The government was more concerned with giving the ‘impression’ that it was 266

doing something in response to AIDS. One must keep in mind that this effort boded well with the times, as the military regime transitioning to democracy stood for human rights, equality, and care for its citizens. Crafting an AIDS bureaucracy thus seemed to fit in nicely with the democratic currents of the day. These intentions notwithstanding, it soon became clear that the DST had very little substance to it. Consequently, it quickly became the focal point of activists arguing that it was, in essence, a purely cosmetic endeavor and that there was no national plan to combat AIDS – or needless to say, help those suffering from it (Miguez, Jornal do Brasil, 6/18/89; Daniel, Jornal do Brasil, 6/10/91). Famous activists such as Herbert Daniel, a writer and also HIV+, often traveled on book tours repeatedly stating that the DST was a scam and that the government needed to build something of substance (Daniel, Jornal do Brasil, 6/10/91; Miguez, 6/18/89). Furthermore, the president and legislature’s perception of the epidemic led to absolutely no interest in helping the DST provide direct vertical assistance to the states, such as providing medical supplies, test kits for blood examinations, and hospital beds (Jornal do Brasil, 8/25/85; Folha de São Paulo, 8/7/85). As noted earlier, the movement was for more decentralization. As in the U.S., the president also believed that the states should be the first responders and that the epidemic provided a good opportunity to test the efficacy of Brazil’s decentralized approach to health care. In summation, even though the President and legislature gradually started to respond to AIDS by creating a new AIDS bureaucracy, it was very, very weak and ineffective. It was poor and highly unorganized, lacking a clear mission and support from the executive. In addition, it did not work closely with the states or with stigmatized 267

victims. Instead, the DST/AIDS program resembled more of a cosmetic institution, such that it looked nice and sounded good but lacked substance and effectiveness in federal intervention. Bureaucratic Perceptions and Response When compared to the U.S., Brazil’s Ministry of Health was not as responsive to the AIDS crisis. Its perception of the epidemic closely mirrored that of the President’s: that is, it was not viewed as a serious national health threat. Instead, it was viewed as a mysterious disease that was affecting the small, stigmatized gay communities of São Paulo and Rio. As noted earlier, in 1985 the Minister of Health, Carlos Santa’Anna, publicly declared that AIDS was not a major threat (Netto, 1985; Jornal do Brasil, 8/25/85). Most of his health ministers were of the same footing and were, like the President, pressing for a decentralization of authority rather than the construction and expansion of a centralized AIDS bureaucracy. In fact, prior to the new constitution in 1988, which consolidated all policy responsibilities under the Ministry of Health, Santa’Anna did not want to be responsible for financing AIDS policy – and mind you, this was 2 years after the National AIDS Program was created (interview with Paulo Teixeira, former Director of the National AIDS Program, 3/22/07). Because the INAMPS (national health insurance system) was still in existence, and because it had more money than the MOH, Santa’Anna wanted INAMPS to pay for it all, to take charge. INAMPS, on the other hand, felt that AIDS was a public health issue, which meant that the MOH should be in charge. INAMPS was after all dedicated to providing health insurance for workers (Brazil by this point still did not

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have universal health care). These disputes went on for months (interview with Paulo Teixeira, 3/22/07). Finally, the MOH decided that it should be responsible for AIDS policy. But the key issue here is that even after the National AIDS Program was created, the MOH still was not fully committed to it. In fact, Minister Santa’Anna wanted another agency to take care of the problem. This smacked of a presidential administration that still did not take the AIDS epidemic seriously, at least not seriously enough to build a more effective AIDS program. But there were other mid-level public health officials in the Ministry of Health and the DST that felt differently. They believed that there was a national health crisis and that the MOH should expand and strengthen the DST program. The structural antecedent conditions shaping these conflicting bureaucratic perceptions between the MOH and DST officials were rather different, leading to different recommendations for institutionbuilding. On one hand, those ministers siding with Minister Santa’Anna were strongly influenced by the same factors that shaped the President and Santa’Anna’s perceptions. That is, that AIDS was not a national health threat and that there were more pressing diseases and health issues at hand. In fact, Teixeira (1997) asserts that these officials were at one point mocking their own colleagues for trying to strengthen the DST program while criticizing AIDS initiatives at the state-level (Teixeira, 1997, p. 55). These officials were also focused on how they should decentralize the health care system, first starting with the states through INAMPS, then quickly moving on to the municipalities with SUDS and SUS. In the absence international and effective domestic pressures, moreover, 269

they were not convinced that there was a national health crisis and that immediate institution-building and policy reforms were needed. Nevertheless, there were reformers in the Ministry of Health and especially the DST that viewed the situation differently. These officials held firmly to the belief that, as in the past, the federal government should take the lead in centralizing its bureaucratic control over disease, even amidst countervailing democratic pressures for redemocratization which, in Brazil, equated to greater decentralization. These reformers were also closely aligned with the sanitarium movement, which, as discussed in Chapter 4, was a historically-based network of federal bureaucrats, intellectuals, and medical scientists committed to working closely with civic organizations for centralizing and strengthening public health administration while insuring the equal distribution of health services. These were the pro-reform bureaucrats, and in contrast to there other bureaucratic counterparts, they sought to centralize and expand the federal bureaucracy, not decentralize it. Pro-reform bureaucrats’ perceptions were strongly influenced by prior histories of building the state through the centralization and expansion of public health bureaucracy in order to curb the spread of disease (Hochman, 1988). It was a historic movement that sought, like to today with the AIDS, to mimic the global community’s - mainly Western Europe’s - highly centralized, state-driven response to plague. Historically, in Brazil, this kind of response was critical for reducing mortality, especially in the more rural areas, and thus safeguarding the economy (Hochman, 1993). This type of response was further consolidated under the supercilious political regime of Getúlio Vargas (1930-45) (Hochman, 1988). It was a tradition that continued through the rest of the authoritarian 270

era (1964-85), which helped to establish a tradition – among some elites, at least – that state expansion through bureaucratic centralization was the only way to eradicate disease. As I explained in more detail in Chapter 3, it is also important to note that there were some key antecedent informal partnerships that shaped the perceptions of these proreforms. That is, they were strongly connected to the historic sanitarium movement, which was a civic movement comprised mainly of intellectuals and doctors that incessantly educated, pressured, and worked with pro-reform bureaucratic elites (who also came from this network) to press for a greater centralization of bureaucratic control over disease while providing public prevention (mainly educational) campaigns; it was a reciprocal partnership that was committed to safeguarding civil society while helping build the state. This informal partnership was nevertheless weakened at the beginning of the epidemic – mainly due to presidential commitment to decentralization – but would nevertheless re-emerge with vigor after major global shifts increased the popularity and influence of pro-reformers in ways that provided new opportunities and incentives for the sanitarium (now the NGO/AIDS) movement to re-emerge with vigor. Therefore, if there was any part of the public health bureaucracy during the initial years of the AIDS outbreak that was committed to responding to civil society, it was these marginalized and often criticized bureaucratic reformers that were connected the sanitarium movement, mainly through their prior work as medical doctors in their respective universities or as lab technicians in federal research centers, such as FIOCRUZ in Rio. These individuals were riddled throughout the Ministry of Health and the DST/AIDS program and would eventually (though not immediately) re-emerge as powerful actors in the reform and expansion of the DST/AIDS Program. 271

If the government was so committed to decentralization, then why did it hire these pro-reform bureaucrats? It’s not clear that it was the intent of the outgoing military to appoint technocrats that were sympathetic to the needs of civil society. More than anything, the recruitment of these reformers lends credence to the notion that the government was not attentive to background of those bureaucrats hired to work on AIDS. Rather, the military was more interested in building a cosmetic institution that looked pretty but lacked substance. The presence of highly skilled technocrats with connections to the sanitarium movement therefore appeared to be the result of unintentional rational designs with the unforeseen affect of establishing the groundwork for subsequent reforms within the DST/AIDS program. The re-emergence of the sanitarium movement, which as we saw in Chapter 3 had its origins in the early-20th century with the Liga de Tuberculose and the Sifilógrafo movement, played a key role in consistently reminding and educating reform bureaucrats that it was their duty, their obligation to remain loyal to the tradition of expanding bureaucracy and providing prevention and treatment programs. Though small, this network served as a periodic reminder of what federal elites had done in the past. But more importantly, this underlying support network was vital for helping these elites perceive of the AIDS situation as a national threat and that something needed to be done. We’ll see this informal movement re-emerge as an influential force generating mutual incentives for civic and bureaucratic elites to further expand and strengthen the DST program. And finally, and interestingly very similar to the U.S., religious morality never influenced how the public health bureaucracy responded to AIDS. That is, essentially all 272

officials in the Ministry of Health and DST program were never captured by moral-based interest groups. Countervailing conservative moral values – aka, dark Victorian morals, as the work of Professor James Morone puts it (Morone, 2003) – never had any influence on the way bureaucrats perceived the AIDS situation, or any other form of sexually transmitted disease (Carrara, 1999; 1997). As discussed in more detail in Chapter 3, this has always been the case in Brazil. Consequently, public health officials have always been committed to scientific progress, objective research, analysis, and direct medical treatment for all, regardless of race and income. The Failure of Institutional Change As seen in the United States, during the AIDS epidemic and the transitional government, the bureaucracy was delegated a very high amount of a policy and administrative autonomy. While of course this was not the case when it came to the financing of administration, it nevertheless was the case when it came to technocratic recruitment, research, policy, and coordination with the Ministry of Health. Before we embark on a discussion of how these different bureaucratic perceptions within the Ministry of Health and eventually the DST played out, it is important to discuss the key structural bureaucratic differences between the U.S. and Brazil. Keep in mind that Brazil’s public health service was not fragmented. Unlike the U.S., there was only one official federal bureaucracy in charge of health epidemics, the Divisão Nacional de Hansenologia e Dermatologia Sanitária (henceforth, NHDS), which initially fell under the auspices of the Ministry of Health but eventually became part of the MOH in 1988. Unlike the CDC and NIH, moreover, the NHDS did not have to compete with other

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agencies. What this meant is that the institutional (inter-agency) conditions for competition and lack of cooperation, as seen in the U.S., were absent. But this did not guarantee that there would not be any competition and friction between public health bureaucrats. For there certainly was. When the DST was initially proposed, it came into direct conflict with the perceptions and interests of officials in the Ministry of Health that did not, as mentioned earlier, view AIDS as a national threat. Instead they were more Reaganisk, if you will, in the sense that they emphasized bureaucratic downsizing and decentralization as the more efficient means of responding to health issues (Da Costa Marques, 2003, p. 124). Da Costa Marques (2003) goes on to argue that the intensive battles between these officials and pro-reform bureaucrats reflected the chaotic political movements of the time (Da Costa Marques, 2003, p. 124). One major consequence was that during the creation and consolidation of the DST program, there was never any clear internal consensus about how, or better yet, if the program should expand. Thus, very much unlike the CDC at the time, there was no interest within the Ministry of Health to ask the President for more funding for the AIDS program. Bureaucratic discord intensified with the arrival of the new DST director, Dr. Lair Guera Macedo. Like her counterpart in the U.S., Secretary Margaret Heckler, Lair was a no-nonsense professional who took the AIDS issue very seriously. After conducting several interviews with high level DST officials, De Costa Margues (2003) claims that she was very committed to increasing the DST’s technical capacity and efficiency (De Costa Marques, 2003, p. 125). She was also criticized by colleagues within the Ministry of Health for constantly pressuring the government for more money, always complaining 274

about the lack of funds, even after receiving an initial grant of Cz30million (Do Nascimento, 2005, p. 100). Officials in the Ministry of Health (including the minister at the time) were not on the same page and were upset with her very stern managerial approach. Unfortunately, an interestingly very similar to her colleague in the U.S. at the time, HHS Secretary Margaret Heckler, Lair was not very well liked. Her managerial style rubbed most health officials the wrong way. Though lauded among reformers for her commitment to DST professionalism and expansion, it came at a time when the government was not yet fully committed to AIDS. Consequently, she never found a strong network of supporters within government. Like Heckler, this severely constrained her ability to build a strong, centralized bureaucratic response to AIDS. Vertical Reforms Contrary to what we would expect, neither the Ministry of Health nor DST/AIDS program paid much attention to the needs of state governments and civil society during the first few years of the AIDS epidemic (Rochel de Camargo Jr., 1999). But what is even more surprising is the fact that the government was in the process of redemocratizing the government, with an emphasis being placed on human rights and equality. Nevertheless, and in sharp contrast to the United States, at the beginning of the epidemic public health officials did not meet with gay victims in São Paulo and Rio. The Minister of Health, Carlos Santa’Anna, and the director of the DST program, Liar Macedo, did not go out of their way to meet with the gay community (interview with Ezio Santos Filho, 6/30/06). Despite the fact that the gay activist community had

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dwindled down in size and almost collapsed by 1984 (the year before the democratic transition), failing to actively meet with the few remaining gay organizations such as Grupo Gay da Bahia smacked of apathy and discrimination, especially in a context of redemocratization and proclaimed government commitment to human rights. Even as the AIDS virus evolved to intra-venous drug users and heterosexuals by the mid- to late-1980s, the national AIDS program still did not try to reach out and work with these groups. Aside from the AIDS activists organizations pressing for their cause, drug-addicts and heterosexuals were poorly organized, small and discriminated against. Despite repeated calls for help, the National AIDS Program very rarely if ever responded to their needs. Thus the fact that the government was not responding to both the initial gay AIDS community and eventually the drug and heterosexual community suggests that despite the transition to democracy and proclaimed commitment to civic rights, equality and social welfare needs, the government was still unresponsive. Brazil’s new democracy was not as representative and responsive as we would have thought, even in a time of health crisis and dire human need (O Globo, 7/13/88; Miguez, 6/18/89, Jornal do Brasil). In reaction to all of this, by the late-1980s several gay NGOs asked for Lair’s immediate resignation (Boletim pela Vidda, 1990). Gay activists referred to her as “the bitch,” mainly because of her disinterest in working with the gay community and her somewhat brusque managerial manner (interview with Ezio Santos Filho, 6/30/06; Galvão, 2000. pp. 125-26). Even after the DST program created the National AIDS Commission (NAC) in 1987, which was designed for the expressed intent of increasing the representation of 276

civil society in the DST through periodic council meetings, Lair was still criticized for failing to invite AIDS victims to discuss their problems and incorporate their views into the policy-making process (interview with Ezio Santos Filho, 6/30/06; Galvão, 2000; Do Nascimento, 2005). In fact, the first few meetings were initially held between state health ministers, academics and representatives from international organizations, such as the WHO and PAHO (Do Nascimento, 2005). What surprised many is that there were no AIDS victims present during the initial NAC meetings (Nascimento, 2005). The closest the government came to meeting with the gay and IDU community was by inviting state and municipal health officials that claimed to be in direct contact with these groups. In addition to not reaching out to the AIDS community, the DST program was surprisingly quite ineffective at AIDS prevention (Rochel de Camargo Jr., 1999). By the mid- to late-1980s, there was a very strong consensus in civil society that the program was ineffective and uncommitted to providing information on how to have safe sex and use condoms. By 1991, a large survey was taken revealing that 95% of those polled said that they were unsatisfied with the information they received from the DST (Jornal do Commercio, 2/26/92). In sharp contrast to the U.S., while the DST did condone the usage of condoms and clean needles as an effective measure to prevent HIV contamination, and while it did televise info commercials about AIDS (Jornal do Brasil, 10/25/85; Jornal do Brasil, 10/1/86), pundits claimed that the quality of information was not very good (Silva, Nacional, 7/8/91; Daniel, Jornal do Brasil, 6/10/91; Jornal do Brasil, 8/21/85). Consequently, because of this lack of clarity, key figures in civil society, such as Betinho, a very famous hemophiliac and the creator of ABIA, argued that the poor quality of information was contributing to a sense of fear and uncertainty (O Globo, 9/24/87). 277

To make matters worse, the DST was sorely criticized for providing very offensive information. During the early-1990s, for example, Dr. Eduardo Cortes, who succeeded Lair as DST director from 1990-92, was chastised for approving prevention campaign slogans such as “Se voce não se cuidar, a AIDS vai te pegar,” (if you don’t take care of yourself, AIDS will take you) and “Eu tenho AIDS e vou morrer,” (I have AIDS, and I’m going to die) (Silva, Nacional, 7/8/91). These slogans were viewed as brusque, harsh, and insensitive, providing little hope for those living with HIV (Galvão, 2000: p. 23; Silva, Nacional, 8/7/91). What AIDS victims wanted to hear was a slogan that not only educated them, but more importantly, one that also gave them hope and a purpose to live (Reis, Revista Afense, 8/1/89; Miguez, 6/8/89, Jornal do Brasil). These social pressures reached an apogee when in 1992, Eduardo Cortes failed to attend the opening of the carnival festivities in Rio. Worse still, he did not send anyone from his staff to go and distribute condoms and provide information. It was an embarrassment to the government. He was immediately made the culprit. The pressure was so extreme that he quickly tendered his resignation. In defense he ended up blaming the overly bureaucratized, burdensome DST program for giving him too much work to do and thus not having the time to go (Folha de Tarde, 3/6/92; Diario Popular, 3/6/92). In addition, during the first few years of its existence, the DST program did very little to help the state health departments cope with AIDS. It virtually did nothing when it found out that most of the public hospitals in São Paulo, Rio, and other major cities were going bankrupt (O Globo, 7/13/88). This occurred despite the continued insistence from governors that they needed help. In addition, there were major shortages of beds in hospitals and tests kits for examining the quality of blood (Jornal do Brasil, 8/16/86; O 278

Globo, 9/27/87). The evidence was mounting that the states needed help and that the DST program was not responding. In closing, during the first few years of the AIDS epidemic the Ministry of Health and DST program provided very little vertical assistance to the states. There was no stern commitment to either meeting with civil society, providing effective public awareness and prevention campaigns and consistent financial and technical assistance. Interestingly, despite its much more morally conservative political environment and problems with inter-agency conflict, it was the PHS service in the U.S. that was far superior to Brazil in helping its initial AIDS victims cope with the crisis. Brazil’s socalled “liberal, everything goes” political and social environment really had no affect on how the DST would respond to the gay community. What is more, apparently Brazil’s long historical legacy of centralized administration for more effective vertical intervention was not strong enough to convince the “democratizing” government to do the same. While there were mid-level reformers that desired to sustain this tradition, they were, unfortunately, out numbered and over-powered by a President, Minister of Health, and bureaucrats that were initially quite apathetic to the AIDS situation and that were pushing for a decentralized response to the epidemic. As the next section explains, it would take a major exogenous shock through changes in the geopolitical attention to AIDS and foreign lending to convince these officials to join their rising pro-bureaucratic reformers in their quest to create a more centralized and effective national AIDS program.

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~ AIDS II: EXPLAIING INSTITUTOINAL CHANGE (1992-present) ~ By the early 1990s, the global and domestic conditions for responding to AIDS radically changed. In contrast to the AIDS I period, during the AIDS II period (1992-present) there were new international conditions that quickly influenced presidential and bureaucratic perceptions of the AIDS crisis, in turn creating new global and domestic incentives for institution-building. First, as the AIDS pandemic drew increased international attention by the late-1980s, mainly through the sudden rise of new international organizations, conferences and policy initiatives, as in the past Brazil’s government desired to join this movement and to gradually lead the global campaign against AIDS. As discussed in Chapter 3, the new opportunity for Brazil to increase its international reputation as a modern nation capable of combating disease helped to transform the perceptions and interests of the President and Ministry of Health in favor of expanding the DST/AIDS program (Interview with former two-term President of Brazil, Fernando H. Cardoso, November 2007). But there were practical challenges to achieving this goal. As is well known, Brazil has always struggled with periodic hyperinflation and fiscal instability. Keep in mind that during the AIDS I period, the government implemented three major fiscal stabilization programs. 50 In desperate need of money, the specter of obtaining a generous World Bank loan helped to increase the President and Ministry of Health’s interest in expanding the DST/AIDS program. By the early 1990s, these new global conditions and 50

These were the Cruzado Plan (1986-90), the Collor Plan (1990-92), and the Real Plan (1993-present); all three were introduced to tame hyperinflation through privatization and tax reform. The Real Plan, created and implemented by then Finance Minister (and former two-term President) Fernando H. Cardoso, finally succeeded in stabilizing the economy by 1994. In 2000, the Chamber of Deputies (Congress) and the Senate passed the Fiscal Responsibility Law, which imposed several hard budget constraints on the state and municipal governments in order to avoid fiscal deficits and debts.

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incentives led to a major perception shift within government: that is, these conditions eliminated the conflicting perceptual pathways and responses of presidential and bureaucratic elites, an issue which, if you recall from Chapter 5, constrained the U.S. government’s ability to respond to AIDS through institution-building. In contrast, in Brazil these new international conditions – especially the World Bank loan and its interest in strengthening the DST program – contributed to the influence of previously marginalized MoH and DST reformers pushing for the centralization of authority. After the World Bank made it clear that it supported bureaucratic centralization and expansion, and after equating the Bank’s loan and support with the opportunity to gain world prominence for AIDS, previously opposing MoH officials started to pay more heed to pro-reform bureaucrats. Then end result was a homogenization of interest and preferences for strengthening the DST/AIDS program. This change in the international environment also provided new incentives for continued institution-building. First, they increased the reputation and influence of DST officials aligned with international actors while creating new career incentives to continuously work together in order to incessantly pressure the President and the Congress for additional funding. Second, these new conditions also allowed reform bureaucrats in the Ministry of Health and the DST to re-emerge with influence and to bolster their position by strengthening their ties with the sanitarium movement favoring, as in the past, a more centralized bureaucratic response to epidemics. The resuscitation of this partnership allowed for the re-emergence and sustainability of historically-based coalitions in favor of institution-building. In short, these new global shifts encouraged

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reformers to find and revive historically-based coalitions that further increased their legitimacy and influence within government. These new structural conditions and incentives also led to new efforts to strengthen the DST program by centralizing its authority over the states, substantially increasing its resources, technical capacity, and more importantly, its autonomy and influence within government. This, in turn, set the groundwork for the creation of the now popularized and highly regarded Brazilian response to AIDS, where the DST/AIDS program now had the political, technical, and social capacity needed to launch a series of successful prevention and treatment programs.

Global Incentives and Opportunity By the late-1980s, global attention to the AIDS epidemic reached a new apogee. Scholars note that 1986 marked the beginning of a new international movement in response to AIDS (Mann, et al., 1993). That year, after being criticized for its delayed response by other international organizations, such as the United Nations, the World Health Organization (WHO) created a special program for AIDS, followed the following year by their creation of the Global Program for AIDS (Altman, 1999). Shortly thereafter, an outpour of international conferences sponsored by several international organizations, such as the World Bank, the WHO, UNAIDS, USAID, and UNICEF, started to address the issue. It is important to note that these efforts reflected a long standing concern for governments to respond to health epidemics in a timely and effective manner. While the World Bank began to prioritize responding to health epidemics during the 1970s in order to avoid poverty and secure economic growth (Ruger, 2005), the World Health 282

Organization also started to apply consistent pressures on governments for a similar response (Kickbusch, 2000). These international conferences thus provided a venue to bring together long-held interests in securing health and equity at the domestic level. In addition, these new movements provided an opportunity for the global health community to critique individual country responses to AIDS. During the early-1990s, Brazil, among many other nations (even the U.S.), was sorely critiqued for its lackluster response to AIDS, as well as TB and malaria (O Globo, 8/11/94; Jornal do Brasil, 3/30/94; Gazette Mercantile, 1/14/94). These meetings held at several international AIDS conferences, in addition to an increase in global media and scholarly attention, provided a new reason and opportunity for Brazil to respond and to increase and maintain its reputation as a global health leader. For in contrast to many developing nations, Brazil had a rich tradition of trying to show the world that it could respond to epidemics in a timely and effective manner. As we saw in Chapter 3, during the First Republic and the later half of the Vargas dictatorship (1940-45) Brazil became world famous for its fight against syphilis, malaria, and yellow fever, in turn generating incentives to respond to any type of global health movement against disease. The criticisms therefore instigated an immediate effort to reclaim Brazil’s reputation as modern nation capable of combating disease. But it is also important to note that these criticisms increased the president and Ministry of Health’s attention to AIDS (Fontes, 1991). Indeed, in a recent interview with the former two-term President of Brazil, Fernando H. Cardoso, he noted that the Itamar Franco and especially his administration was eager to pay more attention to the AIDS situation and to show the world that it could effectively respond to the epidemic. 283

Cardoso noted that this was influenced by the fact that the government had a long-held tradition and reputation of being world leaders in the fight against disease, and his administrations’ interest in maintaining this reputation. Responding to international pressures and criticisms of Brazil’s lackluster response to AIDS provided a new window of opportunity to show the world that it could respond effectively and that it had the capacity to do so (interview with President Fernando H. Cardoso, November 2007). This dramatically changed Cardoso and the rest of his administration’s perceptions of the need the need to immediately respond to AIDS (interview with President Fernando H. Cardoso, November 2007). Thanks in part to these pressures, and as a result of the structural conditions previously mentioned, these elites now had new incentives to give more attention to the epidemic and, more importantly, to move beyond halfhearted interests in institutionbuilding; this entailed supplanting cosmetic institutionalism with increasing the DST/AIDS program’s financial resources, technical capacity, and efforts to work more closely with the global health community and, more importantly, civic organizations. One of the first things Brazil did to achieve this was to increase its attendance and participation at international conferences while inviting international organizations to Brasilia, the nation’s capital, to meet with officials from the Ministry of Health and the DST/AIDS program (De Marques Costa, 2003). International officials from the WHO (the World Health Organization), PAHO (the Pan American Health Organization), and the World Bank were invited in order to reveal Brazil’s commitment to combating AIDS. The goal was to convince the global health community that the government could respond and that it was unwaveringly committed to doing so (De Marques Costa, 2003). 284

From then on, the MOH and the DST were committed to increasing Brazil’s reputation as a global leader in the fight against AIDS. As in the past, it wanted to emphasize the importance of curbing the spread of epidemics and linking this response with commitments to human security and economic modernity (Hochman, 1993; 1998). It had done the same thing with syphilis, yellow fever and malaria in the past and like then, sent international health ambassadors around the world to discuss their achievements (Carrara, 1997; 1999). Moreover, as in the past, government officials wanted to demonstrate through international conferences, meetings, and new program initiatives that they were once again committed to working closely with international health organizations and taking the lead in helping eradicate disease. In sum, by the early-1990s the increased global interests and pressures for Brazil to respond to AIDS had created new interests and incentives by all federal elites – the president and bureaucracy – to aggressively respond in order to, once again, secure Brazil’s reputation as a modern nation capable, if not better, than its more industrialized democratic counterparts in containing the spread of AIDS. What is more, Brazil’s response to AIDS became so successful that it tried to lead the global response against AIDS by being proactive in the fight to secure anti-viral medication for all while providing technical and infrastructural resources for other nations. I’ll come back to this issue later on in this chapter. These new aspirations and incentives notwithstanding, having the economic capacity to achieve these goals was an entirely different matter. For there were a host of fiscal problems. By the late-1980s, the government found itself deluged in debt, imposing, as mentioned earlier, a phalanx of seemingly ineffective fiscal stabilization 285

measures. Hyperinflation burgeoned. By 1988, technocrats predicted that the Ministry of Health and the DST/AIDS program would lose approximately 30% of its budget (Jornal do Brasil, 9/9/88). The DST director at the time, Lair Guerra Macedo, was needless to say very concerned and immediately drafted a budget for additional funding. She needed approximately CZ$600 million to continue financing several of her programs, purchase antiviral medication, and establish blood transfusion banks throughout the country (Jornal do Brasil, 9/9/88). She was allegedly prepared to do whatever it took to get more money, such as seeking alternative funding from private and international sources (Jornal do Brazil, 9/9/88). The DST quickly found itself in a fiscal dilemma. It was an insolvent AIDS program in desperate need of repair (De Costa Marques, 2003; Teixeira, 1997). At the same time, major international lending institutions, such as the World Bank, noticed these problems and how it was hampering the government’s ability to respond to AIDS (Wodtke, Jornal do Brasil, 12/17/89). By 1990, the World Bank was deeply concerned that Brazil would not have the resources needed to avoid a major epidemic (Wodtke, Jornal do Brasil, 12/17/89). (Keep in mind that in 1992, the Bank predicted that Brazil would have 1.2 million AIDS cases by 2000; Brazil never came close to reaching this number.) With this in mind, the prospect of obtaining a major loan from the World Bank enthused DST officials beyond measure. Obtaining a loan from the Bank not only provided a new opportunity to show the world that Brazil could respond, but it also provided a unique opportunity to lead the world in the fight against AIDS. This also had a very strong impact on the President and Ministry of Health’s perception that AIDS was a 286

serious issue, in part because case rates were burgeoning but also because the DST was insolvent and the global health community was beginning to notice. As a result, MOH and DST bureaucrats immediately started to engage in series of negotiations with the World Bank. After several rounds of discussion, in 1991 the Bank offered a very generous loan package of $120 million dollars, with the possibility of being renewed every 5 years. The main objective was to dramatically increase federal prevention programs, medical treatment, regulate the blood supply and fund NGO activities. But more important for our purposes, the new loan clearly stipulated that money was to be used for strengthening the DST program (Galvão, 2000; interview with Maureen Lewis, World Bank official in charge of this loan, 11/9/06). More specifically, the money was to be used for centralizing administration, expanding staff size, increasing salaries, providing technical training, and other related administrative costs (Galvão, 2000; interview with Maureen Lewis, World Bank, 11/9/06). Shortly after the paperwork was signed, World Bank officials and civil society immediately began to notice some changes within the DST/AIDS program. Dr. Maureen Lewis, who was in charge of the first loan, noticed that the DST director, Lair Guera Macedo, became very enthused and excited about getting a loan for her organization (interview with Maureen Lewis, World Bank, 11/9/06). Lair dramatically increased her

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attention to the AIDS problem and became much more committed to working with World Graph 6.5: Brazil: % of Total Investments Provided by International Financial Organizations to the PN DST/AIDS (1992-97) Brazil: MOH

World Bank

32%

58%

USAID 2%

0% Unicef

1% UNDCP 1% CCE

6% PNUD

Source:Fontes, 1999

Bank in order to increase NAP capacity, in a variety of areas (interview with Maureen Lewis, World Bank, 11/9/06). Lewis went on to argue that before the first Bank loan, the DST was an absolute mess and that it had very little support from the President. From what she could see, Lair was the only person committed to transforming the organization. Lewis also explained that as soon as Lair obtained more money, she went on an immediate shopping spree: that is, she hired the best technical and managerial staff that she could find (interview with Maureen Lewis, World Bank, 11/9/06). Others note that this was, indeed, a period of rapid technocratic recruitment and specialization (Gãlvao, 2000; Teixeira, 1997). Others claim that it was the mere prospect of possibly obtaining a World Bank loan that changed the DST program. Jane Galvão, for instance, writes that it was the prospect of obtaining a loan that marked a “new phase” in DST efforts to reform its 288

organization and policies (Galvão, 2000: p. 126). On the eve of the loan, not only was Lair hustling to re-organize the DST, but she also started to meet more frequently with NGOs, something that she had never done before (Galvão, 2000: p. 126). In addition, she started working more with the states, municipalities, and international organizations, such as the WHO’s Global Program for AIDS, in order to start testing vaccines for AIDS (Beloqui, 1992; Grupo Pela VIDDA, 1992). Presidential and legislative views towards AIDS quickly changed as well. The new loan, which finally arrived in 1994 (after on-going negotiations for almost 3 years), was warmly received by President Itamar Franco and his Finance Minister, Fernando H. Cardoso. The new injection of money not only came as a great financial relief (by freeing up money for other programs), but it also helped change presidential and legislative perceptions and interests in increasing their commitment to AIDS (interview with Maureen Lewis, 12/7/06; Galvão, 2000). This meant that for the first time, Lair and her staff at the DST would receive unwavering political support and attention. In sum, the new international loan to combat AIDS injected a new stream of air into the insolvent, poorly organized and ineffective DST/AIDS program. In so doing, it altered the perceptions and interests of president and the DST director to favor reforms that would increase their global reputation. In addition, the new loan provided a unique opportunity for Brazil to become the world leader in the fight against AIDS. But as the next section explains, these global shifts also dramatically changed the perceptions and incentives of bureaucrats in the Ministry of Health and the DST program to engage in new institution-building measures.

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Narrowing Perceptual Pathways, Homogenizing Interests The new exogenous shock of foreign lending, when combined with the new opportunities for global race, also had an immediate impact on the perceptions and response of bureaucrats in the Ministry of Health and the DST/AIDS program. These new structural incentives, when combined with the president’s new commitment to reform, contributed to the homogenization of perceptions and interests in favor of strengthening the DST/AIDS program through administrative centralization and autonomy. In addition, previously opposing officials in the Ministry of Health, who favored decentralization as a response to AIDS during the AIDS I period, quickly began to support previously marginalized bureaucratic reformers favoring a centralization of authority. In part, this was due to the impact that the World Bank loan and its stipulation for centralizing and strengthening the DST had on the popularity and influence of previously marginalized reformers seeking the same outcome (Galvão, 2000: pp. 146151). The fact that the World Bank had similar interests with these reformers gave them more credibility and the resources with which to enhance their position and influence within the DST program. In addition, the World Bank’s expressed interest that the DST use the loan to support NGOs and community organizations further increased the influence of bureaucratic reformers that were, as discussed earlier, connected to the sanitarium movement. The beauty of all this was that because of the increased international and domestic recognition of the pro-reform bureaucrats, officials in the Ministry of Health who previously criticized these reformers now had incentives to join them in their efforts to strengthen the DST program. This had two very important and immediate implications 290

for the program’s transformation and the government’s subsequent ability to successfully respond to AIDS. First, the challenge of contrasting perceptual pathways and incentives were quickly narrowed down to one homogenous set of interests and commitment to continued bureaucratic expansion. Second, by joining previously ignored reformers, both groups now had career incentives to work together in order to centralize and strengthen the DST. These incentives derived from the very high level of prestige associated with being a DST official, or even an affiliate, while earning wages that were much higher than other agencies in the Ministry of Health. Beginning in 1994, the Minister of Health, Jose Sera, the DST Program director, Lair Guera Macedo, and essentially everyone else working on AIDS had interests in reforming the DST program. There were no longer any disputes between the MoH and DST program officials that the program needed to be strengthened; everyone was on the same page (interview with Fabio Moherdai, 7/12/06). Previously criticized bureaucrats in the MoH and DST suggesting an increased centralization of authority, including Lair herself, where now leading the cause for these types of reforms (interview with Fabio Moherdai, 7/12/06; interview with Ezio Santos Filho, 6/30/06). MoH and DST officials immediately agreed that the following bureaucratic reforms needed to take place: first, that the DST become much more centralized and autonomous in its ability to formulate and implement policy (Teixeira, 1997; interview with Fabio Moherdaui); second, that it become more autonomous in its ability to obtain federal and international funding, such as through independent negotiations with

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international financial institutions; and third, that it establish stronger relationships with NGOs and civil society. By the mid-1990s, and in sharp contrast to the AIDS I period, new efforts were made to centralize the DST program. DST centralization increased with the MoH’s delegation of unparalleled autonomy and authority to formulate and implement policy. During this time, the Minster of Health, Jose Serra, and the President, Fernando H. Cardoso, gave the DST authority to conduct policy without having to get any approval from other executive branches (interview with former President of Brazil, Fernando H. Cardoso, 11/20/03; Teixeira, 1997; Galvão, 2000). The President and the Minister of Health entrusted pro-reform bureaucrats with all aspects AIDS policy, believing that they had the technical capacity and international connections necessary to do well. There was thus a new elite consensus, at essentially all levels of government, that the DST should have greater centralized authority, more so than any other health agency. In addition, and in sharp contrast to the other health and social welfare agencies, because of this high level of autonomy the DST did not have to formally apply for funding from the Congress. Starting in the 1990s and even to this day, the DST does not have to fill out reams of paperwork to obtain additional funding from the Congress (interview with Fabio Moherdai, 7/12/06). This has made other agencies, especially the National TB Program, which as the next chapter explains has always needed the extra money, very jealous and upset with the DST and the executive branch (interview with Fabio Moherdai, 7/12/06). With the continued assistance of the World Bank, on one hand, and a very easy way of obtaining additional money, on the other, the DST has had the resources needed to centralize, specialize, and grow. 292

During this period, DST reform bureaucrats also agreed that they needed to recentralize their authority over the states (De Costa Marques, 2003). Teixeira (1997) notes, for example, that the DST believed that all states and municipalities had to implement its policy prescriptions from Brasilia, that they were, in a sense, “calling the shots from above” (Teixeira, 1997). Teixeira also argues that throughout the 1990s, the DST created the “Comissões Municipais de AIDS” (Municipal AIDS Commissions), which worked with the DST in Brasilia to monitor and implement AIDS prevention and treatment programs. And this occurred despite the expressed discontent of state and municipal health agencies that already had their own programs in place, such as São Paulo’s (Teixeira, 1997: p. 63). This suggested that the DST was becoming too powerful and arrogant and that the DST was starting to overawe federalism and impose its policies onto the states. This does not mean that the DST became a completely isolated, despotic agency. Although it maintains its centralized character, since the early-1990s it has been simultaneously committed to consulting and representing the interests of civil society through NGOs while working in cooperation with other federal agencies. While the DST started to work with other agencies before the first World Bank loan, after the loan it started working more closely with other agency secretaries, especially from education and law. As I discuss in the next chapter, although the DST was reluctant to work with the National TB Program (out of fear of losing its political influence and authority), it did nevertheless start to work more closely with these other agencies in order to ensure that World Bank-prescribed prevention and treatment programs were being implemented effectively (Galvão, 2000). 293

For the first time, the DST also started to work very closely with civil society. As noted earlier, this movement started on the eve of the first World Bank loan. As soon as the loan was approved by the Bank in late-1992, DST officials started working even more closely with AIDS NGOs and community organizations. Through the already established National AIDS Commission (created in 1987), DST officials began to meet more frequently with key AIDS NGOs, such as ABIA (Associacão Brasileira Interdisciplinar de AIDS), Pela VIDDA, SomoS, and ABGLT (Associacão Brasileira de Gays, Lésbicas e Travestis), just to name a few (there were by this point close to one hundred NGOs involved in the AIDS movement) (Villela, 1999). These efforts continued over the years (Villela, 1999; Parker, 1997). Keep in mind that these activities were new for Lair, who did not, as mentioned earlier, believe in the efficacy of community activism. Suddenly, Liar and her technocrats, and essentially the entire Ministry of Health changed their minds and started to work more closely with civic organizations (interview with Ezio Santo Filho, 6/30/06). She now had the money to work with these groups, and the World Bank expected her to do so (interview with Maureen Lewis, 11/9/06). What is surprising to note is how quickly support from within the Ministry of Health and DST program changed shortly after the loan. Prior to the loan, previous health officials ridiculed those in the DST in favor of working more closely with the states (Teixeira, 1997). The Minister of Health, moreover, was not supporting any kind of work with civil society. But this all changed shortly after the World Bank loan arrived and as global interests in responding to AIDS increased. As Galvão notes (2000), by 1992-93 everyone was on board; everyone in the DST agreed that it needed to work more closely 294

with civil society in order to make sure that prevention and treatment programs were being implemented in an effective, timely manner (Galvão, 2000). But why did this happen? Was it only the World Bank loan and other forms of technical assistance that sparked this sudden interest in working with civic organizations? Or was there more to it than that? The Civic Sources of Institutional Change Although the homogenization of preferences and interests in reforming the DST/AIDS program was necessary for reform, there were also important bureaucratic incentives that were equally as necessary in order to sustain this commitment. Somewhat similar to the United States, one issue that created incentives for DST officials to continue building the AIDS program was the simple fact that it was very prestigious to be affiliated with it. While DST officials have of course shared a sense of mission and commitment to safeguarding society, there has always been an element of pride and prestige associated with working for the DST (interview with Veriano Terto, 6/22/06). The prestige has come in the fact that beginning in the mid-1990s, the public visibility and reputation of the DST program grew tremendously. Especially when the DST started increasing its visibility through several new public awareness campaigns and its aggressive assault on international pharmaceutical corporations to lower prices, DST officials – and those working with them in the MOH and other agencies – became even more proud to be working for the agency and pursuing its mission. This, in turn, has always contributed to a sense of mission, an unwavering team spirit and personal career incentives to work hard in order to further increase and sustain the visibility of the DST program.

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As mentioned earlier, the new international structural opportunities to raise the visibility and prestige of Brazil as effective disease combatants have also provided incentives for its technicians to be proud of working with the DST and to work even harder for greater prestige and notoriety. The DST has certainly increased its visibility and reputation throughout the world. Note, for example, the recent award by Bill Gates recognizing the National AIDS program (US News Wire, 2003), coupled with the WHO’s recent declaration of it being such a successful world model (Agencia Estado, 2003). These accomplishments along with the wide array of public praises that the DST started to receive since the mid- to late-1990s generated even more incentive for its officials to remain loyal to the organization. And lastly, as is always the case, money talks. Since the early-1990s, the high salaries that DST officials have received through the World Bank has helped to maintain high moral, commitment, and more importantly, the retention of DST staff. And because of their continued good performance and acclaim, these officials continue to be paid very well. The average salary of DST program officials is much higher than their counterparts in other public health agencies, such as TB and Malaria. As Figure 1.5 illustrates below, the government continues to commit much more money to AIDS when compared to other health agencies, such as TB and malaria. This has created even more incentives for DST officials to remain committed to the program.

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Graph 6.6: Government Spending for AIDS, TB, and Malaria (2003-06)

1,400,000.00 1,200,000.00 AIDS

1,000,000.00 800,000.00 600,000.00

TB

400,000.00 200,000.00 0.00

Malaria

2003

2004

2005

2006

Source: Ministry of Health, 2006

In part because of their hard work, the World Bank has renewed their loan package three times and is in the process of finishing “AIDS IV (2007-2012),” which is the acronym that DST officials use when referring to the loan. DST officials claim that they continue to be paid high salaries because of their continued progress in expanding program effectiveness through increased technical recruitment, program development, and the successful enforcement of prevention and treatment programs (interview with Fabio Moherdai, 7/12/06). Therefore, there are serious monetary incentives for DST bureaucrats to stay the course and to further develop the agency. In summation, since the first World Bank loan and the new incentives to prove muster as global leaders in the fight against AIDS, there have been several domestic incentives for bureaucrats to support and continue working for the DST program. The

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popularity and reputation of being associated with it, when combined with increased global recognition and high salaries have retained a cohesive staff that is committed to maintaining and expanding the AIDS program. There are thus several formal tangible incentives that perpetuate the institution-building process. But these are not the only motivation forces explaining this outcome. For as we saw in Chapter 4 with the government’s response to syphilis and TB in the past, there are also very strong informal institutional mechanisms bolstering and supporting these formal incentives. It is, as I see it, an invisible force that keeps the momentum and spirit alive for continued institution-building in response to AIDS. Informal Means to InstitutionBuilding Indeed, one of the keys to

Illustration 6.1 – Informal Means to Institution-Building

understanding Brazil’s continued

Endogenous Bureaucratic Incentives for Institutional Reform

institutional success is how shifts in

B*

the international environment lead to

High

the resuscitation of informal

Low

B C* C

partnerships between historically-

Low

High

(* denotes post-1994 actors)

based civic movements in favor of

International Finance And Global Health Shift

bureaucratic reform and newly empowered pro-reform bureaucrats.

These informal reunions generate benefits for both parties and lead to a continued commitment to institution-building.

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The logic is simple. Recall from Chapter 2 that there are informal 51 reciprocal relationships (denoted as

in the graph to the right) and incentives that derive from

historically constructed pacts between civic organizations (C) and pro-reform public health bureaucrats (B). On one hand, civic organizations have incentives to take advantage of new global structural changes (i.e., increased global awareness to AIDS and foreign aid, as mentioned earlier) and to re-approach 52 bureaucracy with more vigor, all the while making sure to take advantage of pre-existing open institutions 53 guaranteeing their representation within bureaucracy 54 . In turn, reform bureaucrats benefit from using their historic connections with civil society in order to enhance their position within the Ministry of Health and government in general. Their relationship with influential civic organizations also enhances their global reputation (recall the World Bank’s recommendation to support NGOs), thus generating further incentives to continue working with civic organizations and building the AIDS program. But note that civil society’s success rests entirely on pro-reform bureaucratic interests in working with them, which was absent during the first phase of the AIDS epidemic. This time, however, the emergence of civic organizations that are well connected with a new global health movement, in addition to new presidential interests in reform, has created new incentives for these bureaucrats to work closer with civil society; doing so brings them institutionbuilding influence and career benefits. 51

I define informal institutions as preexisting historical and contemporary elite-civil societal consensus over approaches to federal institution building (centralization) in response to epidemics. 52 I use the term “re-approach” here because of the fact that civil society was not successful in influencing AIDS policy during the first phase of reform. 53 “Open institutions” are federal bureaucratic guarantees that civil societal interests are heard; these usually take the form of official AID Commissions or in the case of the congress, legislative hearings that guarantee civic representation. 54 It could indeed be the case that pre-existing open institutions generate further incentives to re-approach bureaucracy in a more organized, professional manner. This issue is explored in further detail in Chapter 2.

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The assumption is that this reform process continues as long as everyone receives the benefits that they expect. Civic movements receive the benefit of inspiring bureaucrats to build a stronger, more centralized AIDS program that is more effective at delivering prevention and treatment services; bureaucrats get more domestic and international prestige; they make more money, get more political support, and thus are able to achieve their goal of strengthening the AIDS program; everyone’s happy; reforms continue. As discussed at length in Chapter 3, which explains the formal and informal institutional origins of public health bureaucracies, the informal institutional element discussed here is the formation of an early consensus between public heath bureaucrats and civic organizations that the central government always take the appropriate institutional course of action in response to a new epidemic, such as bureaucratic recentralization. The contemporary sanitarium movement was born out of historicallybased agreements and expectations that bureaucratic elites continue to strength public health agencies while working closely with like-minded civic organizations, academics, and medical scientists. As we saw in Chapter 4, to achieve this, civic organizations established informal partnerships – through “Ligas”- with bureaucratic elites promising to respond to epidemics through greater bureaucratic centralization and efficiency in providing health prevention and treatment services in a racially unbiased, equitably efficient manner (Frey, 1963; De Castro Santos, 1985). Several decades later, the emergence of the sanitarium movement was born out of this very historical pact and similarly sought the implementation of more equitable and effective health system, as well as centralized (and where appropriate, decentralized) approaches to public health. 300

I argue that the new structural changes in the global environment provided for the resurgence, strengthening, and more importantly, the survivability of these historicallybased partnerships, this time manifested through the sanitarium movement. This provided incentives reform bureaucrats to work with the sanitarium movement to achieve concrete institution-building. The sanitarium movement was composed of a host of AIDS NGOs and other health organizations committed to responding to AIDS. The new pact between this movement and DST reform bureaucrats was based on the assurance from the later that AIDS would get on the “national” agenda and that reformers would, as in the past, strengthen public health bureaucracy (through centralization) while ensuring that the voice and influence of the sanitarium movement would continue to be heard. Moreover, these elites had incentives to do this, as reaching out and reconstituting their partnership with civil society added to their global and domestic credibility (especially with World Bank lenders), in turn increasing their influence within the DST, ability to obtain resources for agency expansion, while creating more career incentives for them to remain committed to bureaucratic reform. Shortly after the World Bank loan, the sanitarium movement re-emerged as a more organized, wealthier, globally-connected group of AIDS NGOs working together to strengthen the DST program and its policies (Villela, 1999). By the late-1990s, the number of AIDS NGO increased from a mere handful – 4 or 5 – in the earlier 1980s to well over 100. Further, Villela (1999) writes that within a year or two after the loan in 1994, at the second national meeting called the VI Encontro Nacional de ONGs/AIDS, more than 400 civic organizations (mainly composed of gay rights, human rights, racial and social equality groups) signed up to work with AIDS NGOs (Villela, 1999: p. 195). 301

With the realization that AIDS NGOs were now supported through the World Bank, there emerged a sudden spurt of NGO activity that continued to expand and provide new – and quite lucrative – employment opportunities for anyone working on AIDS. 55 Their realization that the World Bank loan(s) guaranteed them funding, when combined with their evolutionary growth in domestic and international influence, induced this new sanitarium movement to approach the DST program more aggressively. These incentives created new opportunities for AIDS NGOs to work more closely with previously marginalized pro-reform bureaucrats in the DST/AIDS program that had always supported their cause (Villela, 1999; Parker, 1997). During the 1990s, these pro-reform bureaucrats used their new status within the DST program and the global health community to strengthen their connections and commitment to the sanitarium movement. Motivating them to do this was the knowledge that key reformers had of the successful partnerships that had emerged between civic organizations and federal health officials during the early 20th century, mainly through the Liga do tuberculosis and the Sifilógrafo movement, as we saw in Chapter 3 (interview with Paulo Teixeira, 11/29/07). When Paulo Tiexiera was director of the national AIDS program, for example, he recently stated in an interview how working on AIDS often reminded him of the historic Liga movements and the strong history partnership that public health reformers had with these civic organizations (interview with Paulo Teixeira, 11/29/07). In addition to acquiring this knowledge through their own studies and work experience, NGOs through the sanitarium movement also helped to continually remind 55

My thanks to Professor James Green of Brown University for informing me about the new employment opportunities that burgeoned with the sudden resurgence of AIDS NGOs in the 1990s.

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AIDS officials about the success of these historic partnerships and the rich history of working together through common ideals and interests in institution-building responses to epidemics (interview with Paulo Teixeira, 11/29/07). This knowledge inspired DST AIDS directors to resuscitate these historic partnerships with civic organizations. It was believed that doing so would add to their credibility and influence within government (interview with Paulo Teixeira, 11/29/07). Indeed, Wilza Villela (1999) writes that after the World Bank loan these bureaucrats tried to resuscitate and strengthen their ties with the burgeoning network of AIDS NGOs (Villela, 1999). In addition to adding credibility to their ideas about centralizing and expanding the AIDS program, it was believed that reviving these historic partnerships also provided career benefits because health officials were supporting the World Bank (and the global AIDS movement’s) interest in strengthening their partnerships with civil society. Consequently, this meant that reform bureaucrats could potentially receive more projects and thus funding, while adding more to their resume and ability to move up within the MOH. Because of this, Parker (1997) writes that these reformers had interests in continuously strengthening their ties with the quickly expanding sanitarium movement (Parker, 1997: 8-14). Throughout the 1990s, bureaucratic reformers’ efforts to resuscitate their relationship with a globally-integrated civil society also added greatly to their bargaining power and influence within the Ministry of Health (interview with Paulo Teixeira, 3/22/07). By supporting a civil society that was supported by major multilateral institutions, such as the World Bank, and by supporting a movement that the president was now fully committed to, DST reformers now had the leverage needed to press for a 303

continued expansion of the AIDS program (interview with Paulo Teixeira, 3/22/07). They now had the civic and global support base needed to amplify their influence (interview with Paulo Teixeira, 3/22/07). Furthermore, this provided reformers with incentives to keep working closely with civil society, since this meant more support from multi-lateral organizations and the president and, thus, more influence and leverage going forward. Maintaining and increasing their ties with the sanitarium network also continued to uphold the reputation of DST reformers. For in a new context of increased World Bank and global health community commitments to funding and incorporating the participation of civil society, sustaining and strengthening these partnerships bolstered their reputation both within and outside of government. This also helped to further homogenize bureaucratic perceptions and interests within the DST and Ministry of Health. In addition, re-connecting with civil society allowed these reformers to maintain and strengthen their relations with the World Bank. These relations persist to this day and have led to the steady employment and increased reputation of DST officials. But more importantly, the new inter-dependent relationship between the sanitarium movement and the DST reformers helped to safeguard and enhance the longheld informal partnerships between bureaucratic elites seeking to re-centralize and build the federal bureaucracy in response to epidemics with the sanitarium movement desiring the same thing. In addition to providing immediate, tangible benefits for both parties, i.e., the reputation, career advancement, and the ability to expand the DST program, while on the other hand providing money, prevention, and treatment services for AIDS NGOs movement, this relationship also helped to rejuvenate and sustain rich, historically wellbased partnerships between civil society and government. This would set the 304

groundwork for a stronger partnership in the future and a more effective response to AIDS. ~ Conclusion ~ The reform of Brazil’s national AIDS program has taught us several important lessons about the politics of government response to epidemics. First is the notion that even though governments may create a national program in response to AIDS, as recently seen in Vietnam, Cambodia, and India, unless presidents and bureaucratic elites are fully committed to supporting these agencies they will not be very effective at rendering prevention and treatment services. Nor will they be very effective at working with state governments. What this case study has shown is that democracies may instead create cosmetic institutions, where national AIDS programs are crafted for domestic appeal rather than successful policy implementation. The creation of Brazil’s national DST/AIDS program in 1985 was created in order to assuage domestic interests and to give the impression that the government cared, rather than to render services in a timely and effective manner. Moreover, and sharp contrast to the United States, it did not immediately meet with gay at-risk groups in order to provide information and learn more about their problems. This was particularly damaging since it gave the impression that the government simply did not care. This leads us to the issue of the durability of democracy and its predictive affects on institution-building in response to epidemics. Re-democratization theorists would have us believe that governments are more accountable and responsive to citizens when transitioning from a repressive military regime to a more electorally accountable democracy (Haggard and Kaufman, forthcoming; Gerring, 2005). Presumably this should 305

lead us to expect that nations grounding their democratic transitions on principles of human rights, universal access to social services, and political inclusion should be even more responsive to citizen needs when health epidemics emerge (Sen, 1999). But unfortunately, this was not the case in Brazil. Despite the fact that the government was transitioning away from a military dictatorship that was not committed to human rights and electoral representation, prior to and during the transition to democracy in 1985 the government was not responsive to the immediate needs of AIDS victims. Recall that it took 10 years before the president officially recognized the epidemic; and it would be another 8 to 9 years before the gay community was officially integrated into the National AIDS Commission. Furthermore, the new democracy did not immediately respond to the needs of insolvent state governments and NGOs, relying instead on a poorly plan decentralization process that did not yield effective policy results. Brazil’s newly democratized government would not respond until two major structural shifts occurred in the international environment: first, the importance of responding to a global health community that began prioritizing the response to AIDS, on one hand, and the prospect of foreign lending that would help Brazil maintain its reputation as a nation capable of combating disease. It was only after these two structural shifts occurred that Brazil’s president began to support and help transform the national AIDS program. Furthermore, in more recent years this has motivated the government to lead the new global fight against AIDS. I think it is safe to induct from these findings the notion that nascent democracies, no matter how socially liberal and friendly they are, no matter how verbally committed 306

they are to human rights and equality, may still refrain from constructing effective AIDS programs unless there are strong global incentives for doing so. In the absence of global incentives, democracies may only succeed in constructing cosmetic institutions that fail to adequately intervene whenever new epidemics emerge. Nevertheless, successful institution-building in Brazil has shown that when these global shifts do occur, national AIDS programs can be transformed in more effective ways. Global structural shifts dramatically change presidential and bureaucratic perceptions in favor of bureaucratic reform. But more importantly, these shifts also increase the prestige and influence of previously marginalized pro-reform bureaucrats when their ideas – such as centralizing and strengthening the national AIDS programs – bode well with international pressures for reform. Both of these factors allowed Brazil to overcome a dilemma that hampered the United State’s institutional response to AIDS: that is, the challenge of conflicting perceptual pathways and interests within government. Instead, in Brazil new global incentives and pressures quickly homogenized presidential and bureaucratic elite perceptions and interests in ways that led to the increased centralization and expansion of the DST/AIDS program, on one hand, and greater vertical assistance to the states and HIV afflicted groups, on the other. Perhaps even more important is the fact that global pressures may set in motion new domestic incentives that lead to the continued expansion and strengthening of an AIDS program. First is how the increased popularity of a federal agency can increase the pride and fame of working for it. As we saw in Brazil, the growing popularity of the AIDS program generated incentives for its bureaucrats to remain committed and

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supportive of its mission. Second, the higher pay relative to other health departments of course added to bureaucratic retention and appealed to the best and brightest. And finally, changes in the global context allowed for the re-emergence and survivability of informal pacts between pro-reform DST bureaucrats and civil society in ways that not only provided new incentives for the latter to approach the former in a more organized, assertive manner, but also in ways that generated incentives for bureaucrats to re-kindle their relationship with civil society and to continue working with them in order to increase their influence and ability to strengthen the AIDS program. More importantly, these informal pacts led to the re-emergence and survivability of a traditional belief held by reformers in bureaucracy and civil society that it is the government’s responsibility to create centralized bureaucratic agencies that are not only capable of implementing policy effectively, but that are also committed to working closely with civil society. While the resurgence of this legacy ultimately depended on the impact of global structural shifts, not on domestic re-democratization processes, the old adage “better late than never” certainly rings true. For the revival of this legacy, when combined with the massive institutional changes that occurred, continue to inspire political and bureaucratic elites to press forward with new institutional and policy reforms that help to maintain and advance Brazil’s reputation as being the world leader in the fight against AIDS.

~ post script ~ Allow me to conclude with just a brief post script on the potential future of Brazil’s DST/AIDS program. While I’m certainly an optimist, there are several possible scenarios

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that worry government officials, including myself. First, as with everything in life, good things come to an end. The World Bank loans are just that, loans, and they do not last forever. What’s going to happen when the Bank finally cuts the umbilical chord? And God forbid, what’s going to happen if Brazil undergoes a serious macroeconomic crisis and defaults on its loans? Keep in mind that AIDS is not going anywhere. The virus is still mutating and there are certain genetic “mega-strands” that – though rare - are resistant to all forms of anti-viral medication. Furthermore, because the government currently guarantees antiviral mediation through the SUS medical network (which is decentralized to the municipalities), at-risk youth are becoming less careful in their sexual relations and drug habits, mainly because it is becoming common knowledge that drugs are free, easily accessible, and that people are living a normal life expectancy on full anti-viral medication. However, the recent resurgence of HIV among young homosexual males and drug addicts, for example, worries many, and for one simple reason. That is, the government may not be able to continue financing anti-viral medications and finding international pharmaceutical companies willing to continuously lower prices (interview with former President of Brazil, Fernando H. Cardoso, 11/20/05). Providing drug cocktails free of charge is becoming way too expensive for the government. Given the inevitable situation where the Bank will some day stop funding Brazil, what will happen then? Under these conditions, the government may not be able to afford providing free medical treatment; it may not be able to afford expanding the DST/AIDS Program; and it may, in turn, lose its global popularity and influence as the world leader to combat AIDS, a reputation that Brazilian elites cherish more than 309

anything else. (Interview with former President of Brazil, Fernando H. Cardoso, 11/20/05).

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CHAPTER 7 Responding to Obesity in the United States: International Pressures, Personalism, and the Absence of InstitutionBuilding Right around the time that AIDS started to emerge as an epidemic in the United States, obesity began to be recognized as a serious threat as well. For several decades, overweight and obesity problems gradually arose as a serious health problem. By the early-1990s, the number of obesity cases burgeoned, especially among children. By 2001, case rates were so high that Surgeon General David Satcher publicly declared obesity to be an epidemic in his famous Call to Action report, in which he stated: “overweight and obesity may not be infectious diseases, but they have reached epidemic proportions in the United States.” Many were on the same page. For as Professors Rogan Kersh and James Morone (2002) argued at the time: “Academics, federal officials, medical experts, journalists, and public interest groups have begun to echo the alarm” (Kersh and Morone, 2002: p.1). That same year, President Bush declared a national war on fat (Vulliamy, 6/23/02, The Observer), dovetailing nicely with a new call to national security, strength, and unity. But other scholars have had problems with these assertions. Researchers such as J. Eric Oliver (2006) and Paul Campos (2004) have argued that obesity never emerged as an epidemic. They were quick to point out that the techniques used to measure obesity, such 311

as the BMI (Body Mass Index), were erroneous, and that analysis generated from these findings were skewed to fit the government’s biased interpretation. While these and other researchers nevertheless acknowledged the fact that overweight and obesity emerged as serious chronic conditions, they contend that it never emerged as an epidemic. But the findings in this chapter reveal a rather different story. For in contrast to Oliver and Campos’ views, it claims that obesity has indeed emerged as an epidemic, and that in contrast to the views of government officials and academics, it emerged well before the Surgeon General’s Call to Action in 2001. In fact, it was the PHS, namely the CDC, which once again took the lead in defining and responding to an epidemic. This began with the director of the CDC, then Dr. David Satcher’s, public declaration in 1997 that an obesity epidemic had emerged. Satcher’s response was a result of the culmination of several CDC reports and discussions calling obesity an epidemic since the mid-1990s. Satcher’s assertions continued when he became Surgeon General in 1998. By 1999, the CDC further substantiated this claim by incessantly testifying before the Congress, the HHS, and the media about the epidemic, while repeatedly asking the government for a more aggressive response. As in the past, the CDC once again took the lead in defining an epidemic and trying to respond to it. Despite these efforts, this chapter shows that the government never responded to these declarations by creating new agencies, sub-divisions, and/or modernizing the PHS for a more effective response. Moreover, this outcome occurred during the first and the second phase of the obesity crisis: that is, in response to the CDC’s early declarations in 1997 and even after the emergence in 2001 of a new global consensus and pressures for

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reform, respectively. Moreover, during the later period even the Surgeon General’s Call to Action had no affect on the institution-building process. During the first phase period, it is argued that President Clinton’s failure to perceive obesity as a serious national threat and his lack of response was motivated by the following conditions: first, the failure of obesity to pose a clear threat to our national security, mainly its threat to U.S. military soldiers’ fighting capabilities in war (as we saw with syphilis and malnutrition during the Second World War). 56 Second, the absence of personalism in epidemic politics: that is, the personal threat that weight gain posed for the president and how this failed to motivate Clinton to pursue institution-building and/or place obesity on the national agenda. In the absence of presidential leadership, the PHS was once again left alone, devoid of resources for it various prevention campaigns. In contrast, personalism’s emergence during the second phase led to new discussions and warnings about the epidemic. President George W. Bush’s personal concern with weight gain motivated him to place obesity on the national agenda by incessantly discussing his commitment to physical fitness, weight loss, and exercise. This inspired him to not only consider new policy initiatives but also to proactively warn and inspire others to take better care of themselves. Personalism also positively influenced the views and actions of HHS directors and even sub-national politicians, leading to new warnings, policy advice and institution-building initiatives at the sub-national level mainly through the implementation of new municipal laws and regulations. Nevertheless, despite all of this talk personalism has never led to federal institutional reforms. In the presence of an administration that is continuously hostile 56

Though recently, this view has started to change. The current administration is very concerned about the growing overweight problem in the military. I’ll come back to this issue at the conclusion of this chapter.

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towards the recommendations and advice of the international health community, there has never been any incentive for the government to strengthen its top-down administrative and policy response. And despite the continued challenge of inter-agency fragmentation and lack of cooperation, once again neither the President nor the Congress has tried to help consolidate inter-agency responsibility within the PHS for a more timely response. The end result has been a lot of talk but no administrative action. In this context, the PHS has once again been forced to work on its own. This has led to two problems. First, the ongoing challenge of agency survival, which has once again emerged to hamper a more collaborative response to obesity between the CDC, NIH, and other health agencies, such as the USDA. The challenge of agency survival has re-emerged because of the increased attention given by the government and the media to the obesity epidemic, which in turn has provided an opportunity for the CDC to strategically use the epidemic as a means to garner additional resources, survive and expand in yet another context of fiscal and bureaucratic retrenchment - this time triggered by the war in Iraq. This has led to the continued problem of bureaucratic territoriality, where the CDC has again tried to work independently in order to increase its reputation and justification for acquiring additional resources. These constraints notwithstanding, the CDC and other agencies, such as the USDA, have remained committed to working with the states for the implementation of new prevention programs. As in the past, the CDC has maintained its commitment to bureaucratic embeddedness in periods of health crisis, which in turn has helped to increase the perception in civil society that the government cares. However, recent cutbacks by the Congress for financial assistance to the states suggest that the 314

government is still not fully committed to combating obesity, especially among our youth. In the next section, I’ll briefly discuss the emergence of the obesity epidemic. This is followed up with an analysis of the first and the second phase of obesity politics. In both time phases the government did not immediately respond to obesity through new institution-building initiatives, notwithstanding the HHS and PHS’s repeated suggestions of the need to do so.

Graph 7.1 - Obesity and Overweight Data (1990-2002) 40 35 Overweight

30 25 20 15

Obese 10 5 0

90

95

00

02

Source: CDC, 2007

~ GOVERNMENT RESPONSE (1980-2001) ~ The obesity epidemic did not arise as mysteriously and as suddenly as the AIDS virus did. Instead, the number of overweight and people started to gradually increase throughout the 1980s and 1990s, burgeoning in case notification rates by the mid- to late1990s. From 1960 to 1980, CDC researchers using NHANES survey estimates (National 315

Health and Nutrition Examination Surveys) noted that the number of obese Americans, measured in terms of the BMI (Body Mass Index), increased by 8%. This percentage increased to 22% from 1988 to 1994 (Flegal, et.al, 2002). As Figure 1.1 illustrates above, by 2002 the CDC reported that approximately 30% of the U.S. population was obese. The numbers were just as staggering for children. As Figure 1.2 illustrates, the number of overweight cases (again measured in terms of BMI) for children increased Graph 7.2 - Childhood Overweight National 60

from 15.1% between 197174 to 50.1% from 2003-04.

Trends (1974-2004) (ages 2-19)

50

Cases of childhood obesity

40

continued to increase. And

30

as we’ll discuss in more

20

detail shortly, these trends 10

convinced PHS officials

0 71-74

76-80

88-94

03-04

well before the 2001

Source: CDC, 2007

Surgeon General’s Call to Action that childhood obesity was indeed a national epidemic. But was obesity really an epidemic? And if so, who was calling it one and why? As we saw in earlier chapters, during the initial years of an epidemic outbreak the term “epidemic” is highly contested and used by only a handful of government officials, mainly bureaucrats. For example, while CDC researchers refrained from going public with the term “obesity epidemic” until 1997, they nevertheless started to use the term when conducting research as early as 1994 (interview with Katherine Flagal, senior CDC researcher, 7/6/07). The CDC had its own standard definition of what an epidemic was. It was basically defined as an “unexpected increase in the amount of obesity cases in a short 316

period of time” (interview with Katherine Flagal, 7/6/07). There were no fancy formulas or magic numbers. It was based purely on individual interpretation (interview with Dr. Bob Kuczmarksi, 7/6/07; interview with Dr. Katherine Flagal, 7/5/07). In addition to contributing to a host of physical ailments, such as type-two diabetes, high blood pressure, and heart disease, obesity has also contributed to psychological problems. Throughout the 1980 and 1990s, the psychological depression associated with being overweight and obese increased tremendously (Salinsky and Scott, 2005; Rovner, 1985; Epstein, 1991; Veciana-Suarez, 1993). This was a particularly big problem for our youth (Squires, 1998; Salinsky and Scott, 2003; interview with Sheila Ramsey, MD, George Washington University, Weight Management Program, GW School of Medicine, 1/17/07). Several studies emerged showing that weight loss was the only way to help kids build confidence and self-esteem (Raeburn, 1994). The psychological impact of obesity among children will surely continue as the epidemic progresses. Presidential Perceptions and Response Scholars nevertheless assert that it wasn’t until recently that presidents have paid sufficient attention to the overweight and obesity problem (Kersh and Morone, 2005). But a closer look at the evidence suggests otherwise. Concern about overweight and obesity issues began with the Johnson and Carter administrations (Nestle and Jacobson, 2000). While Johnson indirectly addressed the issue through the formation of his Presidential Commissions for Exercise, Carter would go further by making weight loss 1 of 17 new national health initiatives, others including the consumption of less salt, less

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alcohol, and more exercise (Booth, 1991). Carter made it a goal to cut the overweight rate to 10 percent for men and 17 percent for women by 1990, goals which drew much skepticism from government officials (Booth, 1991). Carter’s interest was just that, “an interest,” and no substantive effort was made to propose a new federal program (Nestle and Jacobson, 2000). More than anything it reflected a growing concern in civil society about better fitness and health. While the PHS was warning about America’s growing overweight problem since the 1970s, this reflected the general mood that people should be taking better care of themselves. Yet these bureaucratic warnings were not enough to convince Carter that he should respond through a more aggressive federal campaign. While Carter may have been aware of the emerging overweight and obesity problem, the PHS was not yet yelling “crisis!” Graph 7.3: Content Analysis of News Paper Articles Discussing General Overweight and Obesity Issues (1988-1995)

60 50

Southern news

40

Northeastern news

30

Western news

Midwestern news

20 10 0

88

89

90

91

92

Source: Lexis-Nexis news service

318

93

94

95

The general concern for fitness and weight loss was also reflected in the media. Overweight and obesity issues were periodically discussed in major newspapers throughout the 1980s, quickly increasing after 1991 (see Figure 1.3). By 1993, there was a sizeable increase in newspaper coverage, suggesting rapid surge in government and civil societal attention. By 1994, moreover, the media started to use the terms “national obesity epidemic” (see Figure 1.4). The increased usage of these terms suggested yet another change in the general perception that obesity had reached epidemic proportions. What is interesting about this discussion in the media was that it occurred prior to the Surgeon General’s Call to Action in 2001. The increase in attention was being led by PHS officials and acclaimed medical scientists. What is further surprising to note is that despite this increase in media attention, the president and the Congress was still not paying sufficient attention to the issue. Graph 7.4: Content Analysis of News Paper Articles Discussing Obesity as a National Epidemic (1980-2001)

70 60 Southern news

50

Northeastern news

40

Midwestern news Western news

30 20 10 0

80

90

01

Source: Lexis-Nexis news service

319

Indeed, it was the Clinton administration that received most of the criticism for failing to respond. While the CDC was by the mid-1990s frequently testifying before the Congress and asking it and the HHS for additional funding (interview with former CDC director Dr. Jeffrey Koplan, 7/6/07), and while the CDC was starting to publish reports about the epidemic in 1994, special interest groups in civil society were arguing that Clinton was failing to address the rights of overweight and obese people. The National Association for Fat Acceptance (NAFA) in particular was concerned that Clinton was not passing legislation for anti-discrimination in the labor force and making obesity related medical costs covered by health insurance companies (Rosin, 9/11/94, Pittsburg Post Gazette, p. D1). Graph 7.5: Number of Military Personnel Separated from Failure to Meet Weight and Body Composition Standards 2500

of course limited in

Navy

2000

While the CDC was

its ability to meet

Army 1500

directly with the 1000

Air Force

White House (it 500 Marines 0

1999

always has to work up 2000

2001

2002

Source: National Institutes of Medicine, 2003

the chain of command

by first meeting with HHS directors and then the Congress, unless there is a public health emergency, which would then allow it to bypass these two institutions and go directly to the president), it did nevertheless indirectly inform the Clinton administration of the problem. By 1994, the media started to write about a president that was not taking any action towards the emerging obesity epidemic (Price, 8/25/94, The Washington Times;

320

Rosin, 9/11/94, Pittsburg Post Gazette, p. D1). But why was this occurring? And what structural and/or ideological conditions were contributing to this kind of response? There were several structural conditions that were contributing to Clinton’s misperceptions and lack of response. First, and again similar to what we saw with AIDS and syphilis in the past, the absence of obesity’s threat to the U.S. national security contributed to a general belief within government that obesity did not pose a serious national security threat: more specifically, its direct threat to military enlistees and their ability to fight in war. Despite the fact that Presidents George Bush (senior) and Bill Clinton were at war when overweight and obesity trends were increasing (1980-2001), the first Gulf War (Desserts Storm and Sheild) and Samalia, respectively, obesity never affected the military’s fighting capabilities. As Figure 1.5 illustrates above, the number of military personnel having to separate from active duty due to weight problems has actually declined in recent years. 57 On the other hand, historically, and as we saw in Chapter 3, malnutrition did prompt an immediate institution-building response, beginning with the creation of the War Food Administration during World War (II) (Levenstein, 1993). Yet another factor contributing to President Bush and Clinton’s lack of interest in the problem was the fact that Clinton did not take his personal health seriously. What I referred to in Chapter 2 as personalism in health politics, this is when the personal fear of being affected by an epidemic generates incentives for presidents to place an epidemic on the national agenda, propose new policies and encourage others to take the necessary precautions. Clinton’s lack of concern and fear about his own health did not allow for this 57

Please note that I am still working on getting more data for the years prior to 1999.

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personalistic element to emerge. With the exception of perhaps Jimmy Carter and his unwavering interest in physical fitness, weight loss, and nutrition, Presidents Bush (senior) and Clinton were never personally challenged by their weight problem. Clinton was rather well known for not taking his weight problem seriously. He never believed that it warranted a new personal commitment to exercise and better nutrition. Indeed, as the content analysis later reveals in Figure 1.7, this is supported by the fact that he very rarely if ever spoke in public about his personal commitment to exercise and weight loss. Perhaps the biggest upshot was the fact that personalism’s absence under Clinton did not elevate obesity onto the national policy agenda. Clinton did not incessantly talk about the issue in public, nor did he warn his staff and other officials about the need to lose weight and stay in shape. This stalled any interest in making obesity a national policy priority. And finally, yet another consequence of the absence of Clinton’s personal interest in obesity was the fact that he did nothing to strengthen the PHS’s response to it. As a high level official at the CDC once told me, obesity “simply wasn’t an issue” during his administration; consequently, none of the PHS agencies benefited from direct presidential assistance in bureaucratic expansion, agency consolidation (i.e., reducing fragmentation), and funding (interview with William Bietz, Director of Nutrition and Physical Activity, CDC, 1/25/07). The same thing could be said for presidential interest in supporting state-led initiatives. There simply was no interest in increasing the OMB budget for state programs. While there was support for programs geared towards better nutrition within public schools, the budget was meager, with the lion’s share being financed by the states. 322

Moreover, neither administration increased the budget for physical fitness in schools (McCall, 9/15/91, The Washington Times, p. E1). 58 Legislative Perceptions and Response When it came to the House and the Senate, the structural conditions affecting their threat perceptions and response were different from what we saw during the initial years of the AIDS epidemic. First, legislative perceptions were influenced by the fact that throughout the 1980s and 1990s, obesity was not perceived by civil society as a major health threat. It was not killing thousands of people each year. While more and more cases were being reported, it was not perceived as a new life threatening disease but rather as a slowly emerging chronic condition that most people believed could be defeated through individual will-power. Because of this, and in sharp contrast to AIDS, there never emerged well-organized civic organizations and pressures for reform. The only obesityrelated NGO that existed during this period was the National Association for Fat Acceptance (NAFA), which was very small and ineffective in mustering sufficient pressures for change. In this climate, political parties (especially within a Republican dominated House and Senate) were not eager to respond. This was reflected by the fact that there were no bills or proposed legislation to address obesity. While there were hearings every now and then (led by concerned congressional members), they were scarce and parcel, never leading to any initiatives (Nestle and Jacobson, 2000).

58

Keep in mind that during this period, the number of school kids failing the president’s national physical fitness test was at an all time high. In 1955, when the tests were first administered, about 55 percent of the children failed. By 1991, 85 percent to 90 percent failed; see McCall, 9/15/91, The Washington Times, p. E1; and Scarton, 3/31/93, Pittsburg Post-Gazette, p. C5.

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Second, and again similar to what we saw with the issue of mal-nutrition in Chapter 3, the ongoing influence of the private food industry and their interest and opposing any type of regulatory policy delayed legislative action (interview with Dr. Michael Jacobson, Center for the Study of Science in the Public Interest, 2/16/07; interview with Kelly Brownell, Professor of Psychology and Director of the Rude Center for Food Policy and Obesity, Yale University, 2/19/07). Time and time again, major private corporations successfully lobbied the Congress and Senate at even the mere hint of an interest in federal regulation. Because of the fact that major food corporations, such as Craft, General Mills, Coca-Cola, and Pepsi are one of the biggest contributors to political campaigns, Republicans in both legislatures have repeatedly refrained from imposing regulatory measures on the fast food industry (interview with Kelly Brownell, 2/19/07). If the private sector had the Republicans, the agricultural sector had the Democrats. Democrats linked to major agricultural industries (in the mid-west, especially) were wedded to protecting their interests. Fearful of imposing regulations on a weakening 59 yet crucial constituent base contributed enormously to the lack of interest in tackling obesity (Tillotson, 2004; interview with Michael Jacobson, 2/16/07). Keep in mind that from 1900 to 2000, the house passed more than 70 acts protecting the agricultural food industry (Tillotson, 2004). With the exception of some congressional hearings and an eventual “threat” of imposing regulations on the Coke and Pepsi corporations in 1999, both the House and the

59

Recall for a minute how much money the agricultural sector lost under Reagan and the amount of lobbying needed to finally obtain assistance in the form of direct subsidies. Going into the obesity issue of the 1990s, there was therefore a prior tradition of the federal government short-changing agriculture.

324

Senate did not initiate new anti-obesity legislation during the Clinton administration (Kersh and Morone, 2005). This reflected the fact that in the absence of open institutional representation, the weakness of civic movements and the pre-emptive pressures of the private and agriculture sector were too influential. The end result was a decreased perception and lack of response by the House and Senate. What is more, and again similar to what occurred during the first few years of the AIDS epidemic, there were no efforts to increase the budgetary size of the HHS and especially the CDC. Yet again he House and Senate (especially under Republican rule) had no interest in strengthening those agencies responsible for tackling a new public heath threat. Furthermore, during this period essentially no money was given to the states for implementing anti-obesity programs (interview with Michael Jacobson, 2/16/07).

Bureaucratic Perceptions and Response The same conditions shaping bureaucratic elite perceptions of AIDS also emerged for overweight and obesity issues during the first phase period. Bureaucratic perceptions were influenced by the following informal and formal conditions: first, the ongoing tradition of viewing health epidemics from a purely scientific, secular perspective and, though not as prominent during this period, the ongoing perception of viewing epidemics as a means to agency survival within a context of increased fiscal retrenchment. As we saw in Chapter 3, this kind of response dates back to the 1950s, re-emerged with AIDS in the 1980s and yet again with obesity today. Morals would once again not be an issue when it came to influencing the perceptions of PHS bureaucrats. For although the case could be made that obesity was a 325

moral issue, based of course on the puritanical principles of sloth and gluttony, for the PHS it never was (interview with William Bietz, Director of Nutrition and Physical Activity, CDC, 1/25/07). As noted earlier, the PHS was constantly writing reports and warning the government and civil society about the health related problems associated with excess weight. Second, money matters and the need to survive within a constricting fiscal environment once again contributed to an increase in the CDC’s perception of obesity as an epidemic. It also increased its interest in requesting additional funding from the Congress. It was therefore always very responsive to the new data revealing an emerging obesity problem and strategically used this data to justify an increase in budgetary outlays. But it is important to note that the CDC was not socially constructing an epidemic in order to garner more resources, as some scholars contend (Oliver, 2006). . The CDC was instead simply reporting concrete obesity trends that had existed for years, trends that they were writing and publishing about since the mid-1990s. It is also very important to emphasize here that the challenge of agency survival did not really begin to emerge until after the Surgeon General’s Call to Action in 2001. As we will see shortly, this problem only began to emerge as the president and the Congress started to pay more attention to the obesity issue, especially after the Surgeon General’s call to action in 2001.

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Table 7.1. Examples of Policy Guidelines for Obesity and General Nutrition published by the HHS and NIH in the 1970s and 1980s 1974

National Institutes of Health: Obesity in Perspective

1977

National Institutes of Health: Obesity in America

1977

US Senate Select Committee on Nutrition and Human Needs: Dietary Goals for the United States, 2nd Edition

1979

US Department of Health, Education and Welfare: Healthy People: The Surgeon General’s Report on Health Promotion and Disease

1980

US Department of Health and US Department of Agriculture: Dietary Guidelines for Americans, 2nd Edition

1988

US Department of Health and Human Services: The Surgeon General’s Report on Nutrition and Health

Source: Nestle and Jacobson, 2000

The PHS and the HHS were the first to perceive the obesity problem as an “epidemic.” By 1997, the director of the CDC, Dr. David Satcher, started to publicly address obesity as such, which was also done the following year by the new CDC director, Dr. Jeffrey Koplan, and yet again by Dr. David Satcher as the new Surgeon General in 1998. Nevertheless, it is important to note that up till that point the PHS was simply warning the government that an obesity epidemic was at hand. Because of this, I have divided up the PHS’s response into two time periods: public warnings and declarations. Warnings By 1974, well before the general public became aware of the obesity problem, the NIH started holding meetings and writing reports warning the government that rates of overweight and obesity were increasing throughout the nation. As Table 1.1 illustrates, since 1974 several reports were published by the NIH and the HHS providing strict 327

policy guidelines for the prevention of obesity through diet and exercise (Nestle and Jacobson, 2000). On February 13, 1985, the NIH even held a public symposium in which it described obesity is a “killer disease” and that people who are “even five pounds” overweight should have cause for concern (Rovner, 1985). The panel of experts provided evidence showing that about 34 million Americans weighed 20 percent or more above their desirable body weight, the point at which physicians should be treating the problem. The report also argued that obesity should get the same attention as smoking, high blood pressure, and other acknowledged health risks (Gustaitis, 2005). One must of course keep in mind that all the hype about overweight and obesity boded well with the times. The 1980s was an era of increased public consciousness and interest in being in shape, eating “lo-cal” foods, feeling good. People frequently tuned in to see Richard Simmons and Jane Fonda shake their buns on TV. Weight loss programs – Slim Fast got its start in the ‘80s - and lo-fat snacks were selling by the droves. These PHS reports thus boded well with the times. But it is important to understand that these reports were to a large extent reflecting the general health craze in society. They were not yet emblematic of what the PHS believed to be a genuine obesity epidemic. 60 By the early-1990s, the CDC started becoming more concerned with obesity. By 1991, it published reports illustrating how Americans were getting heavier and failing to see the health consequences of it (Booth, 1991). By 1994, the CDC warned that if the government did not address the issue, especially for children, a national epidemic would surely arise (Russell, 1994; Elder, 1999). According to Dr. William Bietz, Director of the CDC’s Division on Nutrition and Physical Activity, the CDC had been warning the Bush 60

I’d like to thank Jim Morone for pointing this out to me.

328

(I) and Clinton administration that obesity was going to be the next big epidemic if the government didn’t respond (interview with William Bietz, 1/25/07). Even before coming to the CDC, Bietz was warning President Clinton about the problem in his position as Director of Clinical Nutrition at the New England Medical Center in Boston (Capital Times, 7/19/94; McMurrie, 1994). But keep in mind that all of this was now occurring in a different social context. The in shape, “lo-cal” years of the 1980s were quickly coming to an end. By 1991, CDC researchers showed that data on self-reported leisure time for physical activity indicated that 58.1% of adults reported irregular or no leisure time physical activity (Kuczmarksi, et al 1994). The NIHS (National Institutes of Health Survey) also found that the percentage of adults who exercised on a regular basis declined from 1985 to 1990, especially among Black, Hispanic, low income and unemployed individuals (Kuczmarksi, et al 1994; Piani, 1990). More and more kids were failing presidential fitness exams (McCall, 1991). The fitness craze that swept across America started to become a “class bound phenomenon” (Ahmad, 1997). The arrival of home computers, video games, and by the late-1990s the internet motivated people to stay home. The sedentary life style that Americans have quickly grown accustomed to (and well known for around the world) began to emerge (Schnurr, 1992). From then on, PHS reports would take on a different tune, address a different audience. These reports were no longer writing to appease a health-conscious society. They were now trying to seriously warn the government that it needed to respond. In addition to this change in the health-conscious climate, two additional factors contributed to the PHS’s increased concern with obesity. First, AIDS was no longer 329

usurping most of the resources and attention within the PHS. By the early- to mid-1990s, it was being perceived as a controllable (yet still chronic) condition, far from a crisis. At the same time, overweight and obesity among children was growing at a heartening pace. These two conditions provided a new opportunity for the HHS and CDC to start focusing more on obesity in addition to a host of other public health matters, such as tobacco and alcohol (interview with Michael McGinnis, former Assistant Secretary and Director of Disease Prevention and Health Promotion, Department of Health & Human Services (1977-1995), 7/12/07). In essence these two conditions provided the PHS with more time to focus on the issue and to warn the government and the public about it (interview with Michael McGinnis, 7/12/07). And so it did. “We are going to reap what we sow,” said CDC health officials at the time (Russell, 1994). Research at the CDC showed that obesity cases, especially among children, were increasing at an alarming speed (Russell, 1994). Conferences organized by the CDC, such as the one held in Miami in fall of 1995, snatched immediate headlines. Findings discussed at the conference revealed that the number of obese children and teens (ages 6 through 17) jumped from 6 to 11 percent nationwide (Somerson, 10/3/95, Columbus Dispatch, p. 1B). Furthermore, the report unmasked the growing racial disparity among children, highlighting the fact that black females were, for example, the most obese and the least active, with 60% reporting that they watched at least three hours of TV a day. Amidst this backdrop, government officials in other agencies started to become more critical of the government’s inaction. In 1994, Dr. Philip R. Lee, then UnderSecretary for HHS, argued that the Clinton administration had no national campaign or 330

plan to address the issue (Burros, 7/17/94, New York Times). In a New York Times article published on July 7, 1994, Lee was quoted as stating: “the Government is not doing enough. It is not focused. We don’t have a coherent across-the-board policy (Burros, 7/17/94, New York Times, p. 1, Column 5). He went on record to criticize the White House for only giving $50,000 on average to the states for programs focused on nutritional education (Burros, 7/17/94). While Dr. Lee was not yet declaring an obesity “epidemic,” he was nevertheless committed to creating a more aggressive national campaign (interview with Dr. Philip R. Lee, former Assistant Secretary for Health, Department of Health & Human Services [1993-98], 7/ 3/07). HHS director Donna Shalala also started to express concern. By January 1995, she proposed “10 Health Resolutions,” of which losing weight (through diet and exercise) was one of them (Washington Post, 1/3/95, p. 27). The second New Year’s resolution she proposed was called “Get off of the couch!” (Washington Post, 1/3/95, p. 27). She made a clear connection between poor diet and exercise, which at the time she claimed was associated with 300,000 deaths a year (Shalala, 1/3/95). Shalala also worked closely with Surgeon General David Satcher to educate Americans about physical fitness and nutrition. In addition, she was the master mind behind Healthy Vision 2010, which encouraged Americas to eat better, exercise, and to have more pro-active lifestyles (Strumpf, 2004). Declarations While these official warnings from the HHS were important for increasing the government’s attention to the issue, other agency officials were taking a more assertive approach. Although the CDC was starting to declare obesity as an “epidemic” within the 331

confines of their research corridors in Atlanta, they were not yet going public. But by the fall of 1997, all of this changed. That year, the Director of the CDC, Dr. David Satcher, started publicly declaring obesity as an epidemic. This reflected the burgeoning consensus since the mid-1990s among CDC researchers that obesity had reached epidemic proportions. Satcher’s declarations, both as CDC director and later as Surgeon General in 1998, were also supported by the views of Dr. Jeffrey Koplan, CDC director from 1998 to 2002. Led by Dr. Bob Kuczmarksi and Dr. Katherine Flagal of the CDC, in 1994 these researchers wrote an article titled “Increasing Prevalence of Overweight among U.S. Adults,” published by the Journal of the American Medical Association (JAMA) in July of that year (Kuczmarksi, 1994). According to the authors of this article, it was the first time that the CDC published data revealing a clear epidemic-like spread among overweight adults in the U.S. Based on the arrival of new survey estimates that measured prevalence rates up through 1991 (the NHANES II [1976-80] and NHANES III [198891], which were estimates based on individually reported surveys of height and weight throughout the U.S.), the article essentially marked the beginning of what its authors and others at the CDC began to refer to as a genuine obesity epidemic (interview with Dr. Bob Kuczmarksi, Director of the Obesity and Prevention Treatment Program, National Institutes of Health, 7/6/07; interview with Dr. Katherine Flagal, CDC researcher, 7/5/07). Indeed, the article actually stated that: “Increased physical activity is an important candidate for intervention in the overweight epidemic that currently exists in the United States and is consistent with recommendations and goals established by the US Public Health Service” (Kuczmarksi et al 1994, p.). These findings were soon 332

followed up with a host of other articles and CDC reports confirming Kuczmarksi and Flagal’s claims. But why does all this matter? Why should we care that CDC researchers were calling obesity an epidemic since the mid-1990s? It matters because while they were not going public with this information, they were nevertheless beginning to create a consensus within the CDC that an epidemic was at hand. And this consensus was needed in order to eventually motivate the CDC director to go public. Indeed, by the fall of 1997, then CDC director, Dr. David Satcher, decided to start publicly declaring obesity a national “epidemic.” It was the first time that the PHS had ever done so. His main venue for making this declaration was the media. For example, when speaking to newspaper columnists about the issue he often referred to obesity (especially childhood obesity) as a “national epidemic,” emphasizing how our daily lifestyles were contributing to its spread (Krucoff, 9/16/97). The following year, as the newly appointed U.S. Surgeon General, Dr. Satcher raised the ante in his leadership and public declarations. In several newspapers he was once again quoted as stating that a new epidemic was at hand: “childhood obesity is at epidemic levels in the U.S.,” he argued (Squires, 11/3/98, Washington Post, p. Z07; The Associated Press, 11/17/98). He went on to state that: “We have been remiss in shedding light on this problem, which leads to so many other health problems, particularly when we consider the threats that this disease imposes on our children. Today, we see a nation of young people seriously at risk of starting out obese and dooming themselves to the difficult tasks of overcoming a couch illness” (Satcher quoted in Squires, 11/3/98, Washington Post, p. Z07). That same year Dr. Satcher also took his message to several 333

televised news stations. In several news interviews he again referred to obesity as an “epidemic.” He was not at all shy about making these televised declarations (WAGMTV, show: “Ag Day,” November 12, 1998, 5:30pm; WCNC-TV, show: “6 News at 6,” October 27, 1998; KING-TV, show: “King Five News at Five,” October 27, 1998, at 5pm; WCBS-AM, show: “Newsradio 88”). 61 By November 1998, the media began to refer to Surgeon General Satcher’s announcements as official government declarations (Thompson, New York Times, 12/14/98). While Satcher had already been making these statements as CDC director, he continued to do so as Surgeon General. Because of this he quickly earned the reputation of being more aggressive and committed to combating obesity, much more so than any other agency director, even Secretary Shalala (Marchione, 6/15/98). His public declarations continued throughout 1999 (Lasalandra, 6/11/99), setting the stage for his “Healthy People 2000” report and eventually the Surgeon General’s Call to Action report in 2001. By the fall 1999, Satcher felt compelled to begin criticizing President Clinton for his inattentiveness to the epidemic (The Hill, 10/6/99, p. 19). In addition to confronting the issue, he wanted Clinton to push for the implementation of more obesity prevention polices, especially those focused on health promotion at the community level (The Hill, 10/6/99). He also wanted the administration to provide more funds for nutritional education and exercise, especially in schools (Krucoff, 9/16/97, The Washington Post, p. Z14). Despite these requests, it quickly became apparent that nothing was being done;

61

In all transcripts to all of thee televised news interviews, Satcher was quoted as referring to childhood obesity as an “epidemic.”

334

Satcher’s requests were falling on deaf ears (McFeaters, 10/19/99, The Washington Times, p. B4; Ahmad, 12/29/97, US News & World Report; McMurtrie, 1994). Satcher’s rhetoric was soon matched by yet another colleague at the CDC: CDC Director Dr. Jeffrey Koplan. Entering in 1998, when Satcher became Surgeon General, Koplan was equally as vocal about the epidemic. But for Koplan, this was nothing new. For he had been writing about the issue since the mid-1990s (interview with Dr. Jeffrey Koplan, 7/6/07). An advocate for an aggressive government response, Koplan’s declarations about an obesity epidemic were quoted in several newspapers and congressional testimonials (The Gazette, 10/26/99, p.D17;The Atlanta Journal and Constitution, 9/27/99; Cox News Service, 10/26/99; The Australian, p. 11, 10/28/99; Jackson, 12/8/99, The Boston Globe, p. A27). When it came to government response, Koplan did not hesitate to recommend the creation of a new federal campaign. Like HHS Under-Secretary Phil Lee before him, he realized that no administration up that point had devised a coherent national plan. Koplan once commented: “It’s time to create a national obesity-control policy …” and that a new “national effort is needed to control it” (Rubinowitz, 10/27/99, The New York Post, p.009; Romei, 10/28/99, The Australian, p.11). As CDC director Koplan incessantly complained and took his argument to HHS. Because the White House believed that obesity was a chronic disease and because it did not pose an imminent national security threat, Koplan was not advised to go directly to the White House (interview with Dr. Jeffrey Koplan, 7/6/07). Instead, he approached HHS and the Congress for additional support. Unfortunately, his requests were often ignored (interview with Dr. Jeffrey Koplan, 7/6/07). With the exception of a handful of 335

Congressmen, neither the Congress nor HHS was ever wiling to provide him with the additional resources needed to finance his prevention campaign (interview with Dr. Jeffrey Koplan, 7/06/07). In closing, I once asked Dr. Jeffrey Koplan if he believed, like most academics today, that the Surgeon General’s Call to Action report in 2001 was the first public declaration that the government issued about the obesity epidemic. He laughed and said that that view was “totally bogus” (interview with Dr. Jeffrey Koplan, 7/06/07). Instead, he emphasized to me that CDC researchers were calling it an epidemic well before then; and that by the mid-1990s they were incessantly writing reports, testifying before Congress, informing HHS that obesity was an epidemic. For the CDC bureaucrats, it was an old issue. They were simply reporting the facts. They were not making up numbers. They were, as always, pressing for an immediate government response. Up to that point the lack of government attentiveness to the issue not only concerned CDC officials, but it also motivated former officials to try and take action. For instance, in 1995 Surgeon General C. Ever Koop re-emerged to publicly declare obesity the “the No. 2 killer [next to alcohol]” and even added that “If I had stayed as Surgeon General, it would have been the first thing I tackled!” (Dreyfuss, 3/5/95, Chicago-Sun Times, p. 58). That year, he devised a new program through the C. Everett Koop Foundation called “Shape Up America!” It was the first national crusade to combat obesity; its absence up to that point frustrated him beyond measure and motivated him to not only work with Hillary Clinton but also with HHS officials, the AMA, private corporations, such as the Kellogg Corporation, and a host of activists and researchers(Strumpf, 2004; Meisner, 6/12/95, Chicago-Sun Times, p. 61). The goal was 336

to work with various organizations to increase prevention information, encourage physical fitness in schools and the workplace (Dreyfuss, 3/5/95, Chicago-Sun Times, p. 58). It was also intended to be a motivational catalyst, that is, to get citizens more informed, enthused, and interested in defeating obesity (Kuss, 5/12/95, Post-Standard). By the late-1990s Koop rushed to broaden his coalition. Through his new program, he worked closely with the American Cancer Society and the Center for Science in the Public Interest (CSPI) to pressure Clinton for a response and, more importantly, to build a new institution: the President’s Council on Diet and Health (Ahmad, 12/29/97, US News & World Report), which unfortunately never materialized. Like his former colleagues in the CDC and NIH, Koop realized that an immediate institution-building response was needed, and as he had done with AIDS before, he did all that he could to get the ball rolling.

The Absence of an Institution-Building Response In contrast to the first few years of the AIDS epidemic, what is surprising about this time period is that there was an interest on the part of the U.S. Public Health Service to work with other agencies in response to obesity. Intra-PHS (CDC/NIH) and inter-agency (USDA/CDC/NIH) collaboration was focused mainly on research and reporting. Over time, inter-agency collaboration would focus on research, prevention, and new policy initiatives, generated primarily through the creation of new inter-agency initiatives. During the first few years of the obesity epidemic, however, because the PHS was still learning about the problem, these inter-agency initiatives were few and parcel.

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The impetus for engaging in inter-agency cooperation stemmed primarily from the fact that there was no race to find a biological cure for obesity. That is, there was no mysterious, unknown virus that, as we saw with AIDS, immediately generated interagency competition to find a cure and the appropriate policy response. The relative absence of the media’s discussion and the president’s lack of interest in the issue also failed to place obesity on the national agenda, which in turn created fewer incentives for agency heads to compete with one another. This would soon change, however, and reintroduce the on-going challenge of agency survival. When it came to providing financial and technical assistance to the states, because neither the president nor the Congress viewed obesity as a national threat, there was no interest in increasing the amount of grant assistance going to the states. During the 1990s, the amount of money allocated from the Congress to the states for obesity prevention programs – especially for health education – was meager. In 1994, for example, only $50,000 was given to the CDC to work with the states for obesity programs (Burros, 7/17/94, The New York Times, p.1, Col. 5). On its own, the CDC could not afford to provide more assistance. As a result, a substantial decline in the number of nutritional educational programs and physical fitness standards emerged. In sum, as we saw with the initial response to AIDS in the mid-1980s, it was the US public health service that once again took charge in its response to a burgeoning new epidemic. While everyone else was ignoring the issue, the PHS was not; the latter immediately responded through new research, public warnings and pressures for a federal response. The evidence cited here suggests that the CDC and NIH took charge much earlier than what others have suggested (Kersh and Morone, 2002; Oliver, 2006). 338

~ OBESITY II: GLOBAL FAT, PERSONALISM AND REFORM (2001-present) ~ 2001 marked a critical juncture in American politics. The events of 9/11 led to a massive transformation of our political structure. Amidst the chaos of trying to recover from the worst terrorist attack ever on American soil, impressively the president started to address the obesity issue. In contrast to what we will see in Brazil, however, the President’s response came not as a result of increased international pressures and incentives for change. For while they did exist, President Bush not only ignored but even attacked the WHO’s recommendations for how to respond to growing obesity problem. Post-2001 obesity politics ushered in a new era of what I call personalism in epidemic politics. As discussed in Chapter 2, and as we saw with FDR and the fight against polio in Chapter 3, personalistic responses occur when epidemics directly affect influential politicians and bureaucrats. These can be Presidents,, directors of national and sub-national health agencies, governors, and even former presidents. Personalism is an individual motivational force that is instigated by personal fear and the resulting commitment to weight loss in order to avoid fattening and possibly even death, first and foremost, followed by empathy and hope that others will do the same. As I explain shortly, illustrates this personalistic rationale is what finally motivated George W. Bush and his Secretary for Health and Human Services, Tommy Thompson, to respond to the obesity epidemic; moreover, it also explains recent sub-national initiatives to combat the epidemic. This is not to say that other structural conditions failed to influence the President’s perceptions. By the early-2000s, burgeoning domestic pressures from the media, civil society, and again, the US Public Health Service, contributed to President 339

Bush’s decision to initiate “the war on fat.” While new initiatives were proposed, they have only focused on prevention and education, not institution-building: that is, the creation of a new government agency to combat obesity, the president’s leadership and direct involvement in helping the PHS and other agencies better coordinate in response, as well as direct transfers to the states. While some level of inter-agency collaboration has finally been achieved between the USDA, CDC, and NIH, bureaucratic change has only occurred within the CDC, and once again without the President’s support. New vertical initiatives have also been implemented for obesity; yet neither the President nor the Congress has been fully committed to them. While institution-building has not occurred at the federal level, it has nevertheless started to develop at the sub-national level. Since 2001, a flurry of new laws and health agency divisions has emerged. The tenants of federalism persist, as the states and municipalities have once again been left to their own devises, expected, as always, to be the first responders to a new epidemic threat. Nevertheless, and as we’ll soon see in greater detail, the influence of personalism as seen through the recent initiatives of former Governor Huckabee provides a ray of hope. Global Fat Politics: The World Health Organization and the United States Before we delve into the domestic politics of obesity, it is important to take a minute to understand the U.S.’s position on obesity vise-a-vise the global health community. As we saw in Brazil, the global health community can have a profound influence on the domestic politics of government response to epidemics. In order for this to occur,, reform bureaucrats within ministries of health and civic organizations must have mutual re-

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enforcing incentives to pursue institution-building, driven by pre-existing informal relationships and historic ties with the global health community. While Brazil was receptive to the international health community, the United States has repeatedly been hostile towards it. As we saw in Chapter 3, the historic absence of informal civic organizationalbureaucratic relationships, grounded in long-standing traditions of working closely Illustration 7.1 – America Feeds the World

with the international health community, engendered a government that has never responded well to external criticism. Instead, as with essentially every other policy and security issue, the United States has tried to lead the international health community rather than being led by it (Kickbush, 2002; Yach and Bettcher, 1998). The upshot is that even when a new global epidemic emerges, such as AIDS in the 1980s, obesity and the mere specter of avian flu and bioterrorism today, the United States will once again prefer to work on its own. In sharp contrast to Brazil and the government’s fight against AIDS and more recently TB, the global health community’s ability to effectively pressure the US for an immediate response to obesity never emerged. While the global movement for combating 341

obesity emerged by the late-1990s, it had no influence either on Clinton, Bush, or the PHS’s perceptions of the epidemic. What is more, when it did finally emerge in 2003, the Bush administration’s response was more hostile than receptive. That is, it initially opposed every recommendation that the World Health Organization (WHO) proposed for combating obesity. The end result has been a government that views obesity as a purely domestic issue, unwilling to collaborate with international organizations for an aggressive response. The global movement for obesity began in the early-1990s. Beginning mainly in response to burgeoning growth trends in the South Pacific (such as Fuji and Samoa, which to this day ranks in the top three for the highest prevalence of obesity), a major international health conference was organized in 1992 to draw awareness to the emerging pandemic and to enlist the support of international organizations and governments. This occurred at the joint FAO/WHO International Conference on Nutrition when 159 countries recommended the development of National Plans of Action on Nutrition (NPAN) (World Health Organization, 2003). In 2002, the WHO responded by creating, together with the FAO, a Global Forum for Food Safety Regulators. This was followed up by a joint WHO/FAO expert consultation on diet, nutrition, and the prevention of chronic disease. It officially endorsed a new set of rules and guidelines for all nations to abide by. Since then, the WHO, in addition to other international organizations, has resolved to increase awareness of the obesity pandemic. By the late-1990s, the United States became one of the world leaders with regards to per-capita obesity prevalence. Consequently, it became one of the WHO’s main targets for action. Well before the Surgeon General’s call to action in 2001, the WHO began to 342

criticize the US and other nations for its lack of response to obesity. The WHO’s criticisms increased dramatically shortly after the Surgeon General’s call to action in 2001. By the fall 2003, the WHO drafted a report titled the 2004 “Global Strategy on Diet, Physical Activity, and Health.” In this report, the WHO provided a “toolbox” of options for nations on how to respond to obesity. These included: tight regulation of food advertisements, especially those aimed at children; adoption of a “fat tax” on junk food and soft drinks; and several other regulatory and educational programs (World Health Organization, 2003; Vastag, 2004; Buckley, 4/20/04, The Financial Times, p. 8). The report also suggested that there should be some fiscal incentives for citizens to eat healthier and to refrain from purchasing fatty foods (Buckley, 4/20/04, The Financial Times, p. 8). But the WHO stepped out of bounds when it started suggesting that the U.S. pick up the ante in its regulation of fatty foods (especially foods containing artificial sweaters) because of their linkage to obesity. The WHO report also stated that fast foods directly contributed to childhood obesity, and that governments, especially the U.S., should limit the marketing of these foods to children. The Department of Health and Human Services, as well as several sugar industries, immediately attacked this statement, 62 vehemently asserting that it had no merit and that the scientific evidence was inconclusive (Simon, 2004; 2/10/04, BBC News; Vastag, 2004). The HHS issued a line-by-line critique of the draft, which some say 62

And attack it did. For as Simon (2004) argues, the HHS was accused of: “(1) at least 52 times, weakening existing language, adding qualifying statements, or substituting voluntary language such as “encourage” for the stronger word “should;” (2) inserting the term “personal” or “individual” nine times (to reflect the food industry’s mantra that personal responsibility is the key to solving obesity, not regulation); and (3) striking language calling for the production and marketing of “fruit, vegetables and legumes and other health produce” (Simon, 2004: p. 406).

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read as if it came from the food industry itself (Simon, 2004). HHS, as well as the Grocery Manufacturers of America (GMA), demanded immediate changes to the document, or supplant it with a message advocating more personal responsibility without government intervention (Doyle, 5/4/05; Stein, 1/16/04, The Washington Post). In addition, pundits argue that Secretary Thompson had clandestinely written a letter to the WHO executive board indicating that the scientific evidence was inconclusive and that it did not support the notion that fatty foods directly contributed to obesity (Jacobson, 2004; Ruskin, 1/15/04, Commercial Alert). Others chastised members of the Bush administration for traveling to Geneva to meet with WHO directors to persuade them to refrain from making any further “unscientifically valid” comments (1/16/04, Center for Science in the Public Interest). This effort was perceived as just another example of how the Bush administration has re-acted negatively to international interference in domestic health issues, and how ideology and corporate interests continue to shape Bush’s international and domestic health policies (Waxman, 2004). Of course, it didn’t take long for the WHO to complain (1/15/04, The Guardian; Ruskin, 1/15/05, Commercial Alert). It immediately suggested that Bush was siding with lobbyists from the sugar industry and other corporations producing fatty foods (Simon, 2004). The U.S. government’s rejection of the WHO’s criticisms reached an apogee when the Bush administration made public the fact that it would not officially endorse the WHO’s recommendations (4/28/06, Consumer Affairs). This sent a clear message to the global health community that the United States was going to tackle the obesity issue on its own, and that it discounted (better yet, ignored) the WHO’s recommendations. While the European Community and even Brazil responded to the WHO’s criticisms and 344

recommendations for responding to obesity (Fleck, 2004), the United States did not. Despite the U.S.’s immediate resistance, the Bush administration eventually acquiesced and signed off on the WHO report. However, the Bush administration still has not adopted the WHO’s recommendations, which now include not only regulating the fat food industry but also providing more direct assistance to states. If this is not enough, in 2004 Bush instituted a new rule that CDC officials were not allowed to accept invitations to visit the WHO without obtaining his expressed permission. The czarist edict states very clearly that CDC officials working on obesity are not allowed to freely visit the WHO, and that the oval office would have to first review who was going and what they intend to discuss (McKenna, 7/1/04, Ventura County Star, p. 14; McKenna, 6/30/04, Cox News Service). This further confirmed widely held suspicions that Bush was not interested in collaborating with the WHO, neither for research nor to explore various policy options. Incensed government officials called this a clear travesty, better yet “antithetical to the scientific process … [that] is political control in both directions … it limits the WHO’s opportunities to get the best people and it suppresses the domestic health agency’s opportunity to provide the best people,” said Dr. Jeffrey Koplan, former CDC director and now Professor at the Emory University School of Medicine (Koplan quoted in McKenna, 7/1/04, Ventura County Star, p. 14). In response to these criticisms, the Bush administration has recently had to show some interest in working with the global health community. While Bush is willing to send the appropriate people to the WHO for policy discussions, he still does not want to be told what to do. Two years ago, in an effort to ameliorate tensions, Bush sent the Under Secretary for Health and Human Services, Alex Azar, to meetings at the European 345

Commission for Health and Consumer Protection in Brussels to discuss policy options for combating obesity (4/28/06, Consumer Affairs). The effort comes in response to growing international criticisms and perceptions that the US is still apathetic about WHO guidelines. Only time will tell if the rest of the world will take the US seriously in its contributions to the global war on fat. Presidential Perceptions and Response Since entering office, President Bush appeared to be quite committed to addressing the obesity issue. While of course this does not mean that it has been first and foremost on his policy agenda, when compared to his father and especially Clinton, there is no question that the issue has been important.. Shortly after 9/11, the president was noted as immediately perceiving the obesity issue as a national threat and was quoted as declaring a new “war on obesity” (Vulliamy, 6/23/02, The Observer; Kiefer, 2002; New York Times, 10/3/02). To demonstrate how committed he was to the problem, he immediately appointed a new Secretary for Health and Human Services, Tommy Thompson. Thompson was the former Governor of Wisconsin and just as concerned about the obesity issue – keep in mind that he was rather corpulent at the time. Despite Bush’s new commitment to the war on terrorism, which as expected usurped much of his attention in the fall of 2001 (Washington Post, 2002), he remained committed to obesity and pursued initiatives that reflected his concern.

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Graph 7.6 - Number of Presidential Appointments to the President's Council on Physical Fitness & Sports (1917-present)

40

Bush I (32)

35

Bush II (35)

30 25

Carter (15) Kennedy (13)

20

Nixon (16)

Clinton (27) Reagan (26)

15 10 5

Johnson (17)Ford (16) Eisenhower (12)

0 Source: Author's calculations

Take for instance what he did in the spring of 2002. Shortly after the Surgeon General’s call to action, Bush “re-invigorated” the President’s Council on Physical Fitness and Sports (Washington Post, 2002). Created by Dwight Eisenhower in 1956 and maintained under the Johnson and Carter administrations, the Council was essentially dormant under Clinton (Washington Post, 2002). Bush revived it by appointing 20 officials and launching an exercise-more-and-eat-right initiative called “HealthierUS: The President’s Health and Fitness Initiative” (Washington Post, 2002). As Figure 1.6 illustrates above, moreover, Bush (II) was more pro-active in the number of members (including directors) appointed to the Presidential Council. This increase suggests that the current administration is much more concerned about physical fitness than prior administrations. Instead of focusing on sports and dieting, as prior Councils did, Bush’s fitness council focused on encouraging Americans to become more physically active; it emphasized activities like daily walking and alluded to studies that showed how regular 347

exercise can help ward off obesity (Washington Post, 2002). It also encouraged a gradual, “small steps” weight loss plan, which emphasized setting aside 30 and 60 minutes a day for adults and children to exercise, respectively. Yet another initiative that Bush undertook was to sign an executive order in July 2002 mandating all health agencies to encourage physical fitness activities within their agency. Specifically, the executive order mandates all federal agencies to review policies, programs and regulations for physical activity, nutrition, and screening (The Nation’s Health, 2002). Bush’s bureaucrats were to be fit and ready for service! What motivated Bush to make obesity such an important issue? Was it an explosion of civil societal interest and pressures for change? Not necessarily. Professor J. Eric Oliver of the University of Chicago and Taeku Lee conducted a poll in the spring of 2002 and found that obesity was not of major concern for citizens (Oliver, 2006; Nagourney, 6/4/02, New York Times, p.8). Of those polled, out of 900 across the U.S., only 1/3 found obesity to be a problem (Nagourney, 6/4/02, New York Times, p.8; Oliver, 2006). Well then how about the Congress? Was it pressuring Bush to lead the war on fat? No. Evidence suggests that the Congress was inactive during this period, that there was no bi-partisan consensus for pressuring Bush for an increase in funding and implementing new prevention programs (Brownlee and Walter, 2001; Nestle and Jacobson, 2000; Kersh and Morone, 2005). And finally, did the global health community have any influence? Negative.. As mentioned earlier, the Bush administration was not receptive to the WHO’s call for

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action. Instead, it was rather reactionary, questioning and out right rejecting their recommendations for an increase in supply-side 63 regulation. Personalism in Presidential Perceptions If it wasn’t domestic and international pressures, then what was it? I argue that it was personal. It was President Bush’s personal fear of gaining weight, when combined with increasing empirical evidence from the scientific community, which motivated him to perceive obesity as an urgent matter. Moreover, and in sharp contrast to former President Clinton, the fact that Bush had a prior history of staying in shape made the threat of gaining weight all the more effective (Kiefer, 6/20/02). More specifically, it was the fear of being overweight and his commitment to good health and exercise that motivated him to make it both a personal and public health issue. Indeed, reporters note that shortly after Bush came into office, he confessed in an interview to telling one of his friends that he feared the possibility of gaining weight due to a busy work schedule and that this was the main reason for why he was so committed to exercise (Dowd, 6/23/02, The New York Times, p. 13). For he had experienced what it was to be overweight, sick, and often told reporters of his stern belief that running kept him healthy and safe: “I am convinced that running helped me quit drinking and smoking … I quickly realized what it felt like to be healthy, and I already knew what it felt like to be unhealthy” (Bush quoted in Sweet, 8/29/02, Chicago Sun Times, p. 33).

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“Supply-side” regulation refers to policies aimed at attacking those industries that produce and sell fatty foods; such policies can include increased taxes on fat food consumption, regulation, and fines on industry, restaurants, and schools. “Demand side” regulation, on the other hand, refers to prevention and education policies, an approach which the Bush administration has continued to take; on this note, see James E. Tillotson. 2004. “America’s Obesity: Conflicting Public Policies, Industrial Economic Development, and Unintended Human Consequences,” Annual Review of Nutrition. Vol. 24: 617-643.

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Graph 7.7: Content Analysis of Clinton and Bush's Personal Commitment to Exercise and Obesity 30 Bush (00-07)

25 20

Exercise 15 10 Obesity 5

Clinton (92-00)

0 92 93 94

95 96

97 98

99 00

01 02 03 04

05

06

07

Source: Lexis Nexis; this graph measures the number of times Clinton and Bush were “quoted” in the news media as discussing their personal commitment to exercise, addressing the obesity issue and calling for a communal response to the problem. The following key words were used for this analysis: “Clinton” “Bush” and “exercise” “fitness” “obesity” “overweight” and “fat” for hundreds of news papers and magazines throughout all regions of the US.

Yet, personalism in and of itself did not cause Bush to respond; for while it certainly increased his attention to the epidemic, equally as important was the flurry of epidemiological information that he received upon entering office (Pittsburg Gazette, 3/31/02, p. C-3). In addition to spates of information obtained from the CDC, there was also a sudden surge of information from the media leading up to the Surgeon General’s call to action in 2001 (Kersh and Morone, 2006). As Figure 1.4 illustrates above, the number of newspapers addressing the national obesity “epidemic” increased substantially by the time Bush was elected into office. Personalism had wide ranging implications. Spanning from Bush’s daily contact with White House staff to the broader health of the nation, Bush’s commitment to 350

defeating obesity inspired him to ensure that others were doing the same. At home on 1600 Pennsylvania, Bush expected his staff to engage in daily exercise and to watch their diet (Milbank, 6/17/02, The Washington Post, p. C01). “It’s really important for the White House team to exercise on a regular basis … I hope you understand that’s how the boss thinks,” Bush once said (Bush quoted in Jackson, 6/23/02, The Seattle Times, p. A6.) Close aids report that Bush’s addiction to exercise has inspired the creation of new White House sports clubs, such as “Girls with Gloves” (i.e., weight lifting gloves), the “Dixie Chicks,” and daily personal exercise routines and new dietary habits. “I lost 17 pounds on the Bush plan,” said Bush’s Deputy Director for Communications, James Wilkinson (Wilkinson quoted in Milbank, 6/17/02, The Washington Post, p. C01). Other White House employees now feel obligated to become more physically fit. In a sense Bush created a new “culture of fitness” and nutrition in the White House, which in turn won him the honor of being named as the fittest president in American history (Dobin, 1/8/03, McClatchy Newspapers, p. F1), working with a staff that was just as committed to exercise and health Bush’s concern about obesity drove him to go beyond the personal. During his first few weeks in office, he often drew a direct connection between individual health and the nation’s broader health. “If you’re interested in improving America,” Bush once said, “you can do so by taking care of your own body” (Hawkes, 6/25/02, Intelligencer Journal, p. B-1). He also remarked that: “the doc and I are going to encourage all our country to either run or walk or swim or bicycle for the good of their families, for the good of their own health, and for the good of the health of the nation” (Pittsburgh PostGazette, 3/31/02, p. C-3). Bush was making it clear that being fit also meant being 351

patriotic, and that a real American should always be in shape, hard workin,’ always ready to go (6/24/02, Deseret News, p. A06).

All Talk, No Action … In sum, for a Republican administration focused on the war and institution-building in other nations, it is surprising to see how responsive Bush has been to the obesity epidemic. Of course, this does not mean that he has gone out of his way to help create a new federal agency for combating weight problems, as we saw with the War Food Administration of the 1940s and its response to mal-nourishment among U.S. troops. Remember: Bush’s Army warriors are not getting any fatter, so there is no need to build a new federal agency for combating obesity (revisit Figure1.5). While Bush’s personal interest in obesity has surely helped increase attention to the epidemic, unfortunately he has not taken the extra step in creating and/or strengthening the PHS for a more effective response. Furthermore, he has not pressed the Congress and Senate to implement new legislation increasing the regulation of the fatty food industry. These shortcomings have prompted analysts to view Bush as all talk but no action. Indeed, for as Margo Wootan, director of nutrition policy at the Center for Science in the Public Interest has previously stated: “The administration gets an A-plus for talk but a D for action” (Wootan quoted in Conolly, 8/10/03, The Washington Post, p. A01). Does this mean that personalism is all together ineffective in prompting reform? Absolutely not! For it is much better than nothing, and we must give President Bush some credit. We cannot dispute the fact that he has done a lot more than any previous administration for putting obesity on the national agenda. Personalism has led to a

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massive increase in political and bureaucratic attention to obesity, as well as a host of new studies, increased media attention, and citizen awareness of the problem. That in itself is a major accomplishment.

Personalism at the State Level Within our large, highly decentralized democratic federation, it is both interesting and encouraging to see personalism also operates at the state national level. Similar to what we saw at the national level, the fear of weight loss and a personal commitment to losing weight has also shaped the perceptions and interests of state leaders. In addition, and as seen at the Presidential-level, personalism has lead to an increased sense of empathy for others and a growing gubernational commitment to working with society for a more aggressive response to obesity. The anti-obesity initiatives pursued by Governor Michael Huckabee (R) of Arkansas provide a good example. Like many of his constituents, Governor Huckabee was personally affected by the consequences of excess weight. During the early part of his administration, he was very overweight and suffered from several associated psychological and physical handicaps. The Governor finally decided to take action when on a particular evening an incident occurred which made him realize how embarrassing and challenging his situation was. At the state capital meeting in Arkansas in 2003, in front of a large gathering of supporters, he broke an old wooden chair that he was sitting on. He initially shrugged it off, laughed and jokingly said: “They sure don’t build them like they use to!” But later in his book, Quit digging your Grave with a Knife and Fork (Huckabee, 2005), Huckabee admits: “Deep down, I knew it wasn’t the chair that needed 353

rebuilding – it was me that needed a major overhaul” (Huckabee quoted in Barrett, 5/5/05, Newsweek). He immediately embarked on a personal weight loss program, which he called the “12-stop” plan, 64 and within a few months lost 110 lbs. In addition to his psychological issues, Huckabee also had a fear of the physical aspects of obesity. He was probably most concerned with the possibility that he was going to die from a sudden heart attack. Prior to starting his successful weight loss plan, he was diagnosed with a minor – though potentially severe – heart condition. This problem, when combined with the loss of a dear overweight friend from a sudden heart attack, magnified his concern about overweight and obesity issues (Barrett, 5/5/05, Newsweek). For as Huckabee once said: “There was [a good friend] Gov. Frank White’s death from a heart attack, my own diagnosis with type 2 diabetes and a heart catheterization, which scared the daylights out of me – though [the test came out] clear, thank God. I was at my heaviest in the spring of 2003, at least 280 pounds at the time. I knew I was unhealthy and I didn’t want to be this way” (Huckabee quoted in Barrett, 5/5/05, Newsweek). Like President Bush, for Governor Huckabee personalism soon transformed into a hybrid of both personal and public health concern. Soon after he started his weight loss program, he began a major intra- and inter-state campaign to address the issue. As Chairman of the National Governors Association, he took that opportunity to encourage other governors to implement prevention programs and policies geared toward weight reduction and better health (Dewan, 9/10/06, The New York Times, p. 22; Tanner, 64

Huckabee’s “12-stop” plan encourages readers to stop the following habits: 1) procrastination; 2) making excuses; 3) sitting on the couch; 4) ignoring signals from your body; 5) listening to destructive criticism; 6) expecting immediate success; 7) whining; 8) making exceptions; 9) storing provisions for failure; 10) fueling with contaminated food; 11) allowing food to be a reward; and 12) neglecting your spiritual life.

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2/25/06, The Associated Press). He vehemently believed that the governors, mayors, an all citizens needed to work together, to combat a disease that he was also experiencing. Through these actions, he made it clear to many that he didn’t want anyone going through what he experienced, and that the only way to combat the problem was not only individualistic effort and responsibility, but also by working together as a community. Huckabee did such a good job that former President Bill Clinton congratulated him and proposed to work with him on several new initiatives. Like Huckabee, Clinton was also personally affected by the physical ramifications associated with weight gain and decided to join Huckabee in his plight against the epidemic (6/6/06, Obesity & Diabetes Week, p. 113). Similar to Huckabee, and FDR years before him, Clinton’s personal (and near death) experience from being overweight finally convinced him that he needed to respond: “I’m more sensitive to it [obesity] because of my recent heart problems and because I had come to terms with the fact that they came about not only because of my predisposition to high cholesterol but because of decades of poor eating habits,” Clinton once said on ABC’s Good Morning America (Clinton quoted in Buss, 2005). Huckabee started working with Clinton on developing programs that help monitor and reduce childhood obesity and type-II diabetes (Balz, 3/1/06, The Washington Post, p. A04). Since starting to work together, both are very concerned with attacking the “culture” of overeating in America and instilling new personal goals and incentives to moderate food consumption and eat better foods (Barrett, 5/5/05, Newsweek; Balz, 3/1/06, The Washington Post, p. A04). The momentum in Arkansas in favor of tackling obesity decreased substantially after Huckabee lost to Mike Bebee (D). Key Government officials are concerned because 355

they noticed that under Huckabee, there was a tremendous amount of formal requests for both national and state level policy initiatives for obesity. In a recent interview with the Director of Nutrition at the USDA, Steve Carlson, he explained that when Huckabee was in office Carlson got a ton of requests for financing several of his new anti-obesity initiatives (interview with Steve Carlson, 2/22/07). But immediately after Huckabee left office, Carlson stated that the number of requests substantially declined. This convinced Carlson that Huckabee was taking the obesity issue personally (interview with Steve Carlson, 2/22/07). In sum, personalism in epidemic politics also thrived at the sub-national level. Under Huckabee, it led to new initiatives to combat obesity in Arkansas. But it also led to a diffusion of new policy initiatives and even inspired a former president to join the cause. For example, Governor Sonny Purdue of Georgia and Governor Haley Barbour of Mississippi stated that they were inspired by Huckabee to lose weight and to pursue similar policy measures; this gives us hope that personalism can lead to policy diffusion at the state and municipal level (Dewan, 9/10/06, The New York Times, p. 22). As the next section explains, moreover, personalism has also affected reforms at the federal bureaucratic level. This gives us even more hope that personalism will radiate within government and lead to a host of new initiatives and commitment to reform.

~ OBESITY II: THE BUREAUCRACY RESPONDS – YET AGAIN! (2001-present)~ It was not surprising to see the HHS and the US Public Health Service once again eager to respond to a new epidemic. As discussed earlier, these agencies had been warning about the obesity issue for several years, incessantly informing Bush (senior) and the

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Clinton administration that they needed to respond. It did not take long for these agencies to realize that new types of institution-building were needed for an aggressive response to obesity, and that the President and the Congress should help take the lead in achieving these objectives. Personalism and Bureaucratic Perceptions It is important to note that unlike AIDS, personalism had a dramatic impact on HHS leadership and its interest in working closely with the PHS. While HHS director Margaret Heckler immediately responded to AIDS mainly out of empathy and care for the gay community, Secretary Tommy Thompson’s perceptions stemmed mainly from his own experience of being overweight and his perception that the government and civil society was not responding to the issue in a timely manner. Like Bush, Thompson also felt threatened with the prospect of gaining weight. This motivated him to respond and to motivate others to do the same (1/12/02, Obesity Fitness & Wellness Week; 3/15/04, The Boston Globe, p. A14).

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Graph 7.8: Content Analysis of the Number of Times Shalala, Thompson, and Leavitt Publicly Discussed their Personal Commitment to Exercise, Fighting Obesity and Individual/Civic Responsibility (1993-2005)

25 20 Thompson

15 10 5

Leavitt

Shalala

0

92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 00 of times all HHS secretaries since Source: Lexis Nexis & Google; this graph measures the number the Clinton administration were "quoted" in the media as discussing their personal commitment to exercise, obesity and a communal response to the issue; the following key word terms were used: "Donna Shalala" "Tommy Thompson" "Michael Leavitt" "exercise" "fitness" "obesity" "overweight" and "fat" for hundreds of newspaper and magazine articles in all regions of the US

Indeed, for similar to what we saw with President Bush, Thompson’s personal concern with gaining wait motivated him to started calling on others to take better care of themselves. He first started by focusing on his own staff and other agencies. Following Bush’s executive orders for an increased attention to fitness within agencies, Thompson started asking his staff to get in better shape (Leonard, 3/10/04, Boston Globe; Connolly, 3/12/04, The Washington Post, p. A21). In an interview with Washington Post writer Ceci Connolly, Thompson once remarked about how he chastised his own staff and praised others for their progress in losing weight (Ceci Connolly, 3/12/04, The Washington Post, p. A21).

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Next, Thompson looked to civil society and started critiquing those that were apathetic about their health. “We’re too darn fat!” he once commented (Leonard, 3/10/04, The Boston Globe), lambasting Americans for not doing anything about their weight. “We are not very healthy in America;” “Americans are eating themselves to death;” “Americans need to understand that obesity is killing us,” he stated (Pear, 2003; Thompson quoted in CNN news, 11/19/03; Milloy, 9/10/04, The Washington Times; Milloy, 3/10/04, The Washington Times). As an approach to the issue, Thompson also called on a collective, communal response to obesity: "We must take responsibility both as individuals and working together to reduce the health toll associated with obesity”(Thompson quoted in Wahlberg, 2/22/04, Atlanta Journal Constitution, p. 1a; again in Wahlberg, 1/21/04, Cox News Service). As we’ll soon see, this perception, this desire, emanating from the personal, manifested to an unwavering effort to coordinate with other federal agencies for greater coordination while working with the states for policy reform. PHS Perceptions However, personalism did not affect all the other health agencies as strongly as the White House and HHS. For one thing, the president and the HHS Secretary were much more accountable to the electorate; they were the “symbols of power,” an image that they had to uphold; and this set the groundwork for personalism to thrive and influence reforms. Although personalism did not affect all of the PHS branches, the agencies still continued to perceive obesity as a serious issue. Similar to what we saw earlier, the CDC, NIH, and the USDA’s perception of the epidemic was clearly influenced by the

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burgeoning growth of evidence showing that obesity was on the rise. Recall from my discussion earlier that the NIH and CDC was warning Bush (senior) and Clinton about the epidemic and that they should respond. These agencies continued to deliver the same message, but this time to a more concerned president. As was the case with AIDS, the PHS’s reluctance to make obesity into a moral issue contributed to its ongoing perception of the need to urgently respond. Obesity and the diseases associated with it were always analyzed from an objective scientific perspective. Morality could have easily been employed as a justification for inaction based on the puritanical principles of slothfulness and laziness (see Mathew 2:14, for example), which as discussed earlier are sedentary lifestyles contributing to obesity. But the commitment to scientific objectivity remained. In addition, the Surgeon General’s Call to Action in 2001 did not change the CDC’s perception of the epidemic. As discussed earlier, well before this CDC directors were warning and even admonishing prior administrations for not doing anything about it. After 2001, the new director, Julie Gerberding, continued to perceive the situation as urgent (Chakraborty, 7/3/02, The Associated Press; Dobbs, 10/13/02, The Associated Press). Later she would add that “the problem of obesity is really an epidemic, and [that] we need to apply the same tools to combat it as if it were an infectious disease” (Leonard, 3/10/04, The Boston Globe, p. A1). She would frequent universities, even her own alma matter, UC Berkeley, and after being asked by students what she felt the biggest health threats were to the nation, she would say: “As far as I’m concerned, if asked to identify the two most important health issues in the country today, I would say obesity and the consequences of obesity” (Gerberding quoted in Sanders, 4/9/03, UC Berkeley News). 360

The NIH was on the same page. After all, they started viewing obesity as an emerging health issue back in the 1970s (revisit Table 1.1). In charge of researching the growing obesity trend and reporting it to the president, they were persistent in arguing that it was a problem and that an urgent response was needed (Leonard, 3/10/04, Boston Globe). The data was there and as always, they were not at all influenced by any kind of moral issue. As we saw prior to 2001, they continued to generate reports and warn the government and civil society about the problem, while providing policy recommendations for greater prevention and healthy lifestyles. Other federal agencies involved in the response to obesity, such as the USDA, also perceived the epidemic as urgent (Price, 1/30/00, The Washington Times). “The USDA and the CDC are taking lead roles in the anti-obesity crusade, and many nonprofit and private groups may soon join them in their battle,” Joyce Price of the Washington Times once reported (Price, 1/30/00, The Washington Times, p. C1; interview with Steve Carlson, Director of Nutrition, USDA, 2/21/07). As a matter related to the nutritional policies and guidelines that they provide, even before the Surgeon General’s call the USDA has been very proactive in its response (Price, 1/30/00, The Washington Post, p. C1; interview with Steve Carlson, 2/21/07). Survival Politics These bureaucratic perceptions were also influenced by an element that dates back to the days of polio: that is, agency survival. As we saw with polio in Chapter 3, and again in Chapter 5 with the response to AIDS, the perceptions and response of the CDC were once again influenced by the burgeoning epidemic and their ability to strategically use it as a means for agency survival. While I argue that they did not try to construct the epidemic 361

into a national issue (mind you, they had been calling obesity an epidemic since the mid1990s, with reports and articles published by CDC researchers), they were nevertheless alluding to it and reinforcing its problem in order to maintain their legitimacy and ability to obtain more money for CDC operations. By doing so, they could survive as an agency while responding to a new health threat. Since 2001, the CDC has been the biggest proponent of addressing the growing obesity epidemic. They’ve gone as far as to put it on the same plane with terrorism (Balko, 2005). Naturally, many researchers and reporters have become suspect of the CDC’s motives. And some scholars even blame other scholars for making an academic career out of doubting the CDC’s recent claims about obesity (e.g., Oliver, 2006; interview with Kelly Brownell, 2/19/07). These doubting Thomas’ assert that the CDC has socially constructed an epidemic and that they have delved into an issue that they have no prior experience with (interview with David Boaz, Cato Institute, 3/2/07; Milloy, 9/10/04, The Washington Times, p. A16; Washington Times, 5/2/05, p. A18). Professor J. Eric Oliver, for example, has recently argued that since 2001, the CDC used epidemiological data (mainly impressive slides showing burgeoning prevalence rates throughout the states) to convince the government and the medical establishment that there is a credible threat, when there really isn’t. In 2005, moreover, Oliver argued that the CDC was criticized for publicizing data that was wholly inaccurate in order to give the impression that there was an epidemic (Oliver, 2006). The CDC report stated that obesity was the culprit for approximately 400,000 deaths a year, slightly above tobacco. After correcting for methodological errors, the estimate dropped to approximately 250,000 (Washington Times, 5/2/05, p. A18). The CDC was quickly accused of tossing a 362

“fat lie” (Raniszewski Herrera, 7/5/05, The Washington Times, P. A16; Milloy, 5/10/05, The Washington Times, p. A16; 2/28/05, The Washington Times, p. A20; 11/29/04, The San Francisco Chronicle, p. B6). Furthermore, others believe that the CDC has far exceeded its role as “disease detectives” concerned with real viral threats – such as influenza, malaria, cholera, and the like (Boaz, 7/21/04, The Washington Times, p. A16). While it could easily be perceived that the CDC has socially constructed an epidemic, I ague that this is not the case and that it has been using a pre-existing, credible threat for its own organizational advantage. As noted earlier, one must keep in mind that the CDC and the NIH were warning the government of an obesity epidemic since the 1980s. Researchers within the CDC started to view obesity as a genuine epidemic back in 1994 through various research reports and JAMA publications, followed shortly thereafter by CDC director David Satcher’s public declaration in 1997. For the PHS there was nothing new about the obesity epidemic, and regardless of what the particular numbers revealed in 2005, however wrongly interpreted they were, the fact is that the CDC was calling obesity an epidemic for more than a decade (interview with Dr. Jeffrey Koplan, former CDC director, 7/6/07; interview with Kelly Brownell, 2/19/07). The commitment by Director Gerberding to keep calling obesity an epidemic and to continue working hard on the issue despite these allegations lends further credence to the fact that obesity is a genuine epidemic. She has no problem admitting her errors and for possibly over-exaggerating the issue. If anything, this little peccadillo has generated big positive externalities, in the sense that it got state and municipal health departments thinking more about the problem (5/2/05, The Washington Times, p. A18). For if it was the case that the CDC “suddenly” created this epidemic in the past few years, as Oliver 363

(2006) contends, then it would have refrained from further addressing obesity as an “epidemic;” but the simple fact is that it hasn’t (Raniszewski Herrera, 7/5/05, The Washington Times, p. A16; Milloy, 5/10/05, The Washington Times, p. A16). Similar to what occurred with AIDS in 1985 (as well as the polio and influenza epidemics of the past), the CDC once again viewed and more importantly used the obesity epidemic as a means for agency survival. In a context of increased fiscal retrenchment, thanks in part to the War in Iraq, the CDC has used obesity as a defensive mechanism of survivability 65 in order to once again justify it existence within a constrained bureaucratic environment. Indeed, for as Eric Oliver even points out himself, the CDC has used the epidemic in order to sustain its legitimacy, to maintain sufficient funding, and to maintain its political agenda (Oliver, 2006). Others have made a similar assertion, explaining how the CDC has responded in order to increase its legitimacy and justification for existence (Boaz, 7/21/04, The Washington Times, p. A16). Some have also argued that the CDC has responded just so that it can remain in the spotlight. The years of combating malaria, yellow fever, and influenza are over (at least for the moment). Because of this some argue that responding to obesity has helped maintain the CDC’s legitimacy and survival (Milloy, 3/14/04, The Washington Times, p. B1). Prompting this effort was the fact that, once again, the CDC had money problems. During the 1990s and early-2000s, the CDC received very little funding from the Congress or the White House for combating obesity (Thompson, Associated Press News Wire, 3/2/02; Tumiel, 1/24/03, San Antonio News Express, p. 3B). Even after the Surgeon 65

As discussed in Chapter 2, and empirically illustrated in Chapter 3 (with polio and the Asian influenza scare of 1957) and Chapter 5 (with AIDS), these defensive mechanisms based on survivability and territoriality provide public health bureaucrats with the opportunity to increase and maintain their prestige and relevance within a context of bureaucratic retrenchment.

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General’s call in 2001, the CDC managed to squeeze out of the Congress a mere $100 million for obesity research and prevention activities, while the NIH received a whopping $226 (Brownlee and Wolter, 12/15/01, The Washington Post, p. A29). As an organization in general, and especially when compared to the NIH, the CDC’s budget has been extremely tight (interview with William Bietz, 1/25/07). The division within the CDC focusing on nutrition has had to fight tooth-and-nail for more money, and thankfully, it started to receive some during the first few months of 2001 (Jacobson, 2004; Kersh and Morone, 2005). Recently, however, the division working on obesity within the CDC has lost money, due in part to hard budget constraints across all federal agencies (Trust for America’s Health Reports, 2006; interview with William Bietz, 1/25/07). Recent estimates suggest that the agency will lose approximately $500 million in the next few years (Pear and Schmit, 2/5/05, The New York Times, Section A, Column 1, p. 10; Stein, 3/6/05, The Washington Post, p. A9). As a result, CDC officials have had to re-shuffle funds from other departments to the department of nutrition (Raniszewski Herrera. 7/5/05, The Washington Post, A16). In fact, the only division within the CDC that continues to receive an increase in funding is bioterrorism (interview with Dr. William Bietz, 1/25/07). In the past few years the CDC has also experienced several internal problems. For example, in the past twenty years, and more recently, the CDC has had difficulty retaining and recruiting staff. Since 2003, after a “Futures Initiative” for internal reorganization was launched (which entailed endless mergers and downsizing for greater efficiency), roughly 40 top level managers left the CDC (Stein, 3/6/05, The Washington Post, p. A9). They left because they were upset with the organization and did not see any 365

change in organizational efficiency. What is more, the CDC in recent years has repeatedly neglected to promote bureaucrats within the organization to senior level offices. As a result, there is now a spate of temporary appointments. These organizational problems provide propitious conditions and incentives for the CDC to use obesity as a justification for increased financial and political support. As we saw with AIDS in Chapter 5, once again the CDC has found itself financially and institutionally constrained, incessantly working hard to push for a response to obesity in order to survive. While of course the CDC’s intentions are genuine (note, again, that they have been concerned with the obesity problem since the 1980s), the recent surge in obesity case rates and related diseases and deaths continues to provide incentives to keep using the epidemic for a justification for more money and political support. And lastly, as we saw with AIDS, it is important to note that the need to use the obesity epidemic as a means for agency survival has dramatically increased the CDC’s perception of the importance of responding to obesity. While PHS bureaucrats continue the tradition of responding to health epidemics from a professional, non-moralistic perspective, when combined with the burgeoning evidence suggesting crisis, the plain meat and potato needs of the agency has once again contributed to its perception of obesity as a critical issue worthy of an immediate response. Thus as we aw in the past, the same bureaucratic response to epidemics continues to ring true: aggressively tackle the epidemic, ignore the moral argument, but at the same time watch your back and use the epidemic for your own survival. Same politics, different epidemic.

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Attempted Administrative Reforms in the Second Phase These organizational constraints notwithstanding, it is interesting to note that as discussed earlier the challenge of institutional territoriality did not complicate the willingness of federal agencies to immediately engage in inter-agency collaboration. As you recall from Chapter 5, territoriality hampered the PHS’s ability to immediately respond to AIDS. Shortly after the Surgeon General’s call in 2001, however, those federal agencies responsible for crafting obesity policy, such as the CDC, USDA, and NIH, started working together. For example, the Surgeon General’s speech in 2001 was actually coauthored by CDC and NIH officials, suggesting that since the very beginning they were willing to coordinate in response to the epidemic (Interview with William Bietz, CDC, 1/25/07; interview with Steve Carlson, USDA, 2/22/07). Shortly after the Surgeon General’s announcement, moreover, these agencies started working together on a host of new prevention programs with the states. While the CDC and NIH maintained their distinctive roles (the CDC providing more direct service to the states, while the NIH conducts research), since 2001 they have been co-sponsoring several initiatives. Bureaucratic adaptation to the growing disease has also occurred. Last year the CDC worked with the NIH to create a new inter-agency working group, called the IWGOOR (Internal Working Group on Obesity Research). The main reason for creating this working group is to increase research and collaboration between the agencies on obesity, to find common ground and policy solutions that will lead to more effective policy implementation (Interview with Steve Carlson, USDA, 2/22/07).

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The USDA has also been very active in collaborating with other agencies in response to mal-nutrition. Recall in Chapter 3 the USDA’s immediate response to children’s mal-nutrition by working with the Children’s Bureau to create new health clinics in major cities. Almost a century later, the USDA has responded in a similar manner. Shortly after the Surgeon General’s announcement in 2001, the USDA began to work with the CDC (a mutual initiative, with the CDC also initiating the joint operation) on a new food labeling program and food nutritional services (Interview with William Bietz, 1/25/07). With the help of the CDC, the USDA provides, for example, a Women’s Income and Children’s Feeding Program. In addition, they have been working on new programs to monitor and measure children’s weight in schools and to provide schools with a host of educational pamphlets, guidelines, and recommendations (Interview with William Bietz, 1/25/07). Personalism Breeds Inter-Agency Collaboration As HHS Secretary, Tommy Thompson was also very much committed to working with the USDA on a host of new prevention programs. His personal conviction, as noted earlier, in addition to his unwavering support for President Bush’s new HealthierUS initiative, motivated him to start working with the USDA on joint programs aimed at working more closely with the private sector, such as food restaurants. In 2002, for example, Thompson and USDA Secretary Ann M. Venemamn met with officials from the National Restaurant Association and the National Council of Chain Restaurants to initiate dialogue about how food and beverage industries can help Americans combat

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obesity, which has reached epidemic proportions (Department of Health and Human Services news release, 10/15/02). Through this joint initiative with the USDA, Thompson’s personalism radiated and added gusto to his work with the USDA: “I am calling on leaders from the food and beverage industry to aid us in our fight against obesity,” Thompson sad. “Overweight and obesity are at an all-time high in America and the public health consequences are enormous. At HHS, we aim to lead by example. We must act now, and act together, in order to improve the health of our country’s adults and children” (Thompson quoted in HHS news release, 10/15/02). Secretary Venemamn appreciated Thompson’s commitment. She was more than willing to work with him and other sectors in a new partnership to win the war on fat. “At USDA, our goal is to work together in partnership with all sectors to strengthen our ability to reach consumers about these important lifestyle decisions,” Venemamn said (Venemamn quoted in HHS news release, 10/15/02).

The Resurgence of Agency Survival: Terrible Territoriality Persists! All of this may sound a bit too peachy. The bureaucracies are working together?; they agree that obesity is a national epidemic; they notice the deficiencies at the state-level and they have, it seems, been more than willing to go out of their way to intervene and find results. And for the first time since FDR, personalism has motivated the Health secretary to work with other agencies and even sub-national governments. But as always with American epidemic politics, bureaucratic fragmentation persists and threatens to become a serious problem going forward (Salinsky and Wakina, 369

2003). Similar to what we saw with AIDS, the fragmented nature of federal bureaucracies has complicated policy coordination. In a recent JAMA report, the director of the Center for Food Safety and Applied Nutrition at the US Food and Drug Administration (FDA), Alan Rulis, characterized government efforts to combat obesity as “dangerously disjointed …There are a lot of different [agencies] doing a lot of different things that aren’t very coordinated,” he went on to say. “There’s a lot of dissipated energy” (Rulis quoted in Vastag, 2004, p. 2). One element that continues to cause problems is the issue of agency territoriality and its repeated tendency to impede inter-agency collaboration. As we saw in Chapter 3 with polio and again with AIDS in Chapter 5, territoriality is a defensive mechanism that bureaucrats often use to increase their prestige and to distinguish themselves within government. Yet terrible territoriality persists! For even though there was some initial collaboration at the federal level, CDC officials still allude to the fact that they are in the middle of a turf war with the NIH over which agency should be responsible for responding to obesity. Ironically, although both the CDC and NIH recognize their distinctive roles in federal intervention and research (as we saw in Chapter 3, a mutual understanding that dates back to the CDC’s creation), as we saw with AIDS there is still an element of inter-agency competition that has delayed agency cooperation for policy reform (interview with William Bietz, 1/25/07). The CDC believes that it should take the lead, since the problem is a sub-national issue and the states are financially incapable of responding on their own (interview with William Bietz, 1/25/07). The NIH, on the other hand, still believes that more research needs to go into the precise causal linkage between obesity and mortality, given the fact that there is no scientific proof that such a 370

relationship exists. The result is that even though both agencies want to work together, inter-agency tensions persist (interview with William Bietz, 1/25/07). The fact of the matter is that territoriality is beginning to re-emerge precisely because obesity is quickly emerging as a very popular health epidemic. Unlike the first phase of the epidemic, when fewer people (even the president) knew about the problem, recently obesity has garnered a lot more scientific, academic, media, and now even political attention, thanks in part to President Bush and Tommy Thompson’s personal interest in the issue. The problem is that this spurt in attention to obesity has created a new level of competition between the NIH and CDC over who is going to be responsible for obesity policy (interview with William Bietz, 1/25/07). This has contributed to the resurgence of territoriality and may unfortunately complicate inter-agency coordination going forward. Once again, neither the president nor the congress is anywhere to be found. Why aren’t they intervening to help ameliorate this problem? Did the government not learn anything from AIDS? As discussed earlier, while Bush has done a great job of elevating obesity to a national issue through his verbal commitment to exercise and nutrition, neither he nor the Congress have taken the extra step in helping the PHS better coordinate. PHS fragmentation persists. Again, different epidemic, same politics. The one element saving these agencies is the fact that there is no race to find a cure for a mysterious “viral” disease. To some extent, this has helped ameliorate the challenges of inter-agency territoriality and competition. Recall that this competition was a major stumbling block to the PHS’s response to AIDS in the 1980s. Thus, while turf wars persist, it is no where as extreme and as inhibiting as we saw with AIDS. 371

Personalism Ameliorates Territoriality But there is hope. Personalism may once again save the day. For one of the benefits associated with personalism is the fact that it can help ameliorate the territoriality problem. Personalism radiates urgency, an immediate need, and a direct order from presidents or agency secretaries to other agency directors to increase inter-agency collaboration for a more unified response. And this is precisely what occurred under Tommy Thompson’s reign. Indeed, for in sharp contrast to HHS Secretary Margaret Heckler during the first few years of the AIDS crisis, shortly after entering office Secretary Thompson noticed that inter-agency fragmentation and territoriality might complicate his ability to address the obesity epidemic. In response, and in anticipation of a bureaucratic mess, Thompson tried to create a more centralized HHS agency that could respond more effectively (interview with William Bietz, 1/25/07). As someone personally affected and committed to the issue, Thompson was dedicated to ensuring that all bureaucratic agencies were on the same page and that they were working together for an immediate response (interview with William Bietz, 1/25/07). While Thompson could never be 100% sure that his PHS directors were behaving accordingly, as discussed earlier his watchful eye and frequent interaction with staff certainly helped. For it is very possible that in the absence of this leadership, territoriality could have been far worse than what it actually was.

Fighting for Money As we saw during the AIDS crisis, the HHS and CDC continued to press for additional funding to meet their growing organizational needs. Yet similar to what we saw during 372

the first wave of obesity reforms (pre-2001), the Congress was very hesitant to respond to such requests. Despite an enthused and charismatic Tommy Thompson screaming for additional funds, the Congress wouldn’t budge: “I tell Congress to set aside dollars for prevention. They're all very encouraging, but they don't give me the dollars for it!" he once argued (Thompson quoted in The Associated Press News Wire, 3/2/02). He often complained that he wasn’t getting enough money: “Currently, just 5 percent to 7 percent of federal health care dollars are channeled into prevention … We have to change that paradigm to get more money into preventative medicine, and that is what I've got to figure out how to do," he said in an interview (Thompson quoted in Tumiel, 1/24/03, San Antonio Express-News, p. 3B). The new HHS Secretary, Michael Leavitt, faces a similar battle. Thanks in part to the war and other agency needs, like Thompson he has had a very difficult time trying to obtain additional funding from the Congress (Granger and Koplan, 2005). As noted earlier, the budget for the CDC is expected to decline in the near future. And reports indicate that neither the White House nor the Congress is requesting an increase in PHS budgetary allocations for next year. As we saw with AIDS in Chapter 6, it is nevertheless encouraging to see that the HHS and PHS are fighting hard to secure additional funding. While the White House, the House and Senate may be hesitant, this bureaucratic tradition is nevertheless essential for future efforts to successfully combat obesity and other emerging epidemics, such as typeII diabetes and heart disease.

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Vertical Assistance to the States Compared to what occurred before the Surgeon General’s announcement in 2001, the vertical reforms that emerged afterwards are quite impressive. Two issues stand out and resemble what occurred during the first few years of the AIDS epidemic. First, Thompson and his directors worked very closely with the states to learn more about the obesity problem and to craft the appropriate policy response. And second, a host of new federal prevention programs, jointly sponsored by the USDA and PHS, were implemented. Moreover, and in sharp contrast to AIDS, these initiatives have emerged with the president’s full blessing. This support, when combined with Thompson’s (and Bush’s) personal conviction to fight obesity has generated even more impetus for concerned USDA and CDC officials to intervene at the local level. As we saw with the HHS’ initial response to AIDS, the CDC once again took the lead in working closely with the states and municipalities in order to learn more about the obesity problem. In an interview with the Director for Nutritional Science at the CDC, Dr. William Bietz, he stated that since 2001 the CDC has continued to work very closely with the states in order to learn more about their needs. Bietz and his staff have been particularly concerned with, and have reached out to low income families and minorities suffering from obesity, while providing new educational and nutritional programs in schools (interview with William Bietz, 1/25/07). Dr. Kelly Brownell, Professor of Psychology, Director of the Rude Center for Food Policy and Obesity at Yale, and a long-time critic of obesity policy supported Bietz’s position (interview with Kelly Brownell, 2/19/07). Not only that, Brownell praised their activities and argued that of all the federal agencies under the current administration, the CDC is the only one doing 374

something constructive about the problem (interview with Kelly Brownell, 2/19/07). Working through the Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases (NPAO), which was created in 1998 and is now operating in 28 states, the CDC continues to meet with obese individuals and provides financial support for several programs (Centers for Disease Control, 2007). Furthermore, within three years of the Surgeon General’s call in 2001, the CDC obtained the support needed to implement over twenty additional state programs, all of which are geared towards improving nutrition and physical activity (Rodgers, 4/19/04, The Boston Globe, p. A. 13). After the Surgeon General’s call in 2001, the CDC also became more committed to targeting and providing the bulk of their assistance to the largest at risk groups in society. Noticing a spurt in the number of obesity cases among children, mainly between the ages of 10 and 16 (see again Figure 1.2 above), or what the CDC calls the “Tweens” (Ten going on fifteen), in 2002, with the support of Secretary Thompson, the CDC created the VERB (It’s what you do) national obesity campaign (8/24/02, Obesity, Fitness, & Wellness Week, p. 11). The mission of this campaign was to increase the CDC’s collaboration with state, municipal governments, and families to address the growing obesity problem among Tweens. The goal is prevention. The VERB campaign unleashes a myriad of innovative media ads. There are, for example, several colorful informational posters, riddled throughout various bus-stops and metro trains, that target Tweens; furthermore, they are carefully designed in order to appeal to the interests of several different minority groups, such as Hispanics, Blacks, and South Asians. One of my favorites is the “Hip-Hop Scotch”! initiative, which encourages inner city Tweens of

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color to play Hop Scotch on the street to Hip Hop music. The goal is to try and make physical activity more socially acceptable and “hip” for inner city youth. And lastly, the HHS has created a new website, which provides a fun, easy to follow inter-active game that Tweens can play (you can find the website here: verbnow.com). Through this game, Tweens learn the importance of remaining active and having fun. They also learn about nutrition and the importance of staying healthy. These types of initiatives continue to this day. Despite HHS director Tommy Thompson’s resignation from office in 2004, his predecessor, Secretary Michael Leavitt, continues to work with state governments and local communities. For example, in 2005 Leavitt created an officially sponsored HHS national forum on obesity, called the National Obesity Action Forum. The goal was to bring together state and local health officials, community leaders, the private sector, health nutritionists, and parents to develop new plans for addressing obesity (Obesity, Fitness & Wellness Week, 2005). The forum also identified lessons learned in implementing change at the family and community levels, showcased various successful community models, and provided tools for local leaders to develop their own collaborations, as well as to sustain and evaluate those programs (Obesity, Fitness & Wellness Week, 2005). The Forum discussed the possibility of using technology, such as the website, for reaching out to kids. The HHS and CDC have also been quite committed to targeting at-risk groups. Noticing that obesity rates among African American children are especially quite high, in 2005 the HHS created new initiatives for the black community. That year Secretary Levitt announced an award of $1.2 million to improve efforts to reduce obesity in this population through various African American community organizations (5/2/05, Obesity 376

& Diabetes Week). “The obesity epidemic is one of the major health challenges facing our nation, and the African-American community is highly affected by this disease and its health consequences,” Leavitt said. “The initiative … will mobilize three of the nation’s premier academic and civic organizations to join us in a new partnership to mount critical prevention efforts in the African-American community” (5/2/05, Obesity & Diabetes Week). This initiative stems from a growing realization, supported by empirical data, that obesity (like AIDS) disproportionately affects poor urban minority groups. Leavitt and his Deputy Assistant Secretary for Minority Health, Dr. Garth Graham, have been fully committed to working with state health agencies to target the Black and Hispanic communities, which have seen the highest rates of childhood overweight and obesity in the nation (5/2/05, Obesity & Diabetes Week).

~ Conclusion ~ This chapter has looked at the two phases of obesity politics. The first phase saw the emergence of a new epidemic proclaimed by the CDC in 1997 and the government’s lack of response. The second phase saw the emergence of new global pressures from the World Health Organization, the government’s formal acknowledgement of the epidemic by the Surgeon General in 2001, and a personal commitment by the president to address the issue. One would assume that given this radical shift in the environment and the president’s personal interest in obesity that our government would have responded through new institution-building initiatives. But this, in fact, never occurred. During the first and the second phase of obesity politics, it was the federal bureaucracy that once again emerged as the first and only responder. However, during

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this period the CDC did not obtain a steady increase in funding for its programs. During these two periods, moreover, the CDC worked alone when trying to increase awareness of the obesity epidemic through published research, legislative hearings, government criticism and warnings while working with the states for a more effective policy response. In addition, and as we saw with polio, influenza, and AIDS in the past, the CDC used the emergence of a new epidemic for agency survival. The CDC shows this repeated pattern of simultaneously achieving two objectives: immediately responding to an epidemic as soon as it emerges while at the same time using epidemiological data to acquire additional funding. While viewing the obesity epidemic as a means for agency survival certainly reinforced the CDC’s perception of its need to respond, its public declaration of escalating prevalence rates were also strategically used to justify requests for additional funding and political support while at the same time kindling new levels of inter-agency competition, especially as the media and the government began to pay more attention to the problem.

Should We Take Things Personally? In the second phase of obesity politics, the emergence of one key causal factor gives us hope that obesity can transform into a national issue, kindling new interest in concrete institutional and policy reforms: personalism. As we saw with FDR and polio in the past, and today with President Bush, Secretary Thompson, Governor Huckabee, and even former President Clinton, personalism has the potential of convincing political and bureaucratic elites of placing obesity on the national agenda while eliciting a more 378

effective policy response. By instigating personal fear among political leaders and empathy for others, personalism can lead to a marked increase in attention to the epidemic, while in some instances leading to policy change, as we saw with Governor Huckabee in Arkansas. Yet in and of itself personalism has not led to concrete institution-building. It has not motivated President Bush to take the extra step in providing more funding for the PHS while helping consolidate agency responsibility and possibly create a new agency and/or subdivision for obesity. While personalism at the federal level still has to prove itself as an effective catalyst for reform, it has to some extent proven itself at the subnational level. As we saw in Arkansas, Governor Huckabee’s personal commitment to losing weight led to new policy proposals and incessant demands on the USDA to finance several new policy initiatives. What is more, and this is key, personalism has instigated policy diffusion. Huckabee’s response has inspired other governors to pursue similar reforms. For example, recent attempts by the Governors of Georgia and Mississippi to mimic Huckabee through personal weight loss and similar policy innovations gives us hope that other governors and mayors will do the same. Perhaps the only benefit of a highly decentralized, federal system in this regard is that it allows sub-national politicians to use personalism as a successful reform strategy. For while federalism has certainly constrained the United States’ ability to immediately respond to obesity, personalism may help overcome federalism’s ongoing constraints: that is, in the absence of consistent and increased federal support, it may provide state and community leaders with the personal conviction needed to work harder at mobilizing resources; it may motivate them to incessantly pressure the USDA, CDC, the Congress 379

and other government branches for additional resources and even inspire other governors and mayors to do the same. Given the dire fiscal circumstances in which the states currently find themselves, in the future personal inspiration and conviction may be the only hope for effective leadership in response to obesity. For those of us interested in agency theory and the forces that motivate politicians to pursue reforms, it behooves us to take the personalism issue seriously. This is because of all the potential variables influencing executive decisions to enact reforms during a health epidemic, personalism directly and immediately threatens their survival, which in turn prompts their interest. This is important because political executives are often not threatened by epidemics and health conditions that lay people (especially the poor) are exposed to, such as AIDS, tuberculosis, malaria, and the like. Rather, in most instances executives are often quite wealthy, influential, and isolated from the socio-economic factors leading to these ailments. Nevertheless, there are some ailments that even the most affluent of politicians cannot escape from: weight gain and obesity, as well as airborne (influenza) viruses and other epidemics that usually emerge by chance, such as polio. These personalistic epidemics, if you will, can threaten political leaders and motivate them to address an otherwise ignored health problem. Personalistic epidemics are thus unique in that they force executives to relinquish their esteemed, pious social status in order to join common folks in their plight against disease. In most instances this may lead to new levels of executive empathy and commitment to helping others. Future work will need to further test this hypothesis, measuring the number of presidents that are either overweight or obese and if they are more likely to respond through new policy and institutional reforms. 380

The politics of epidemics are often very unique when nations decide to completely isolate themselves from the global health community. As we saw with AIDS and yet again with obesity, governments that respond to epidemics on their own are often more prone to respond due to factors that are unique to their domestic situations. As seen in the United States, this often includes an epidemic’s affect on the national security situation. The fact that even a personal threat to the president did not prompt reforms further reinforces the notion that national security plays a prominent role in prompting a government response. In addition, unlike nascent, middle-income democracies, such as Brazil, advanced democracies like the United States often have fewer reputational incentives for responding to criticisms from international organizations and suggestions for reform. However, this kind isolation and out right arrogance can have dire institutional and policy consequences, as it often stalls institution-building. When it comes to health epidemics, political isolation and delay may not be the best course of action to pursue. It is time that the U.S. and other industrialized nations humble themselves and join the new global movement to combat obesity. I’ll come back to this issue at the conclusion of this dissertation. In closing, I want to emphasize again that obesity is an epidemic and that it is not going anywhere. It requires a bigger role for the U.S. government. It requires an expansion and strengthening of the PHS so that it can create more nutritional programs, advice families on how they can eat better, exercise more while providing state governments with the resources needed to implement innovative programs. It is entirely ludicrous to argue, as Eric Oliver (2006) so eloquently does, that just because there is no direct scientific causal linkage between obesity and death that the government should not 381

expand its activities and intervene through innovative policy measures; 66 that government policy does nothing to address the root cause of fatness in America: that is, our liberties, wealth, time and our unique culture of snacking on fatty foods to make us feel better. Sure, Oliver is correct in stating that the “Progress Paradox” has made snacking and our inactive lifestyles a problem, and that this in turn has contributed to obesity’s spread. But this does not mean that the government should refrain from tackling the issue and provide its citizens with sound advice. Obesity is a serious epidemic. The CDC has been arguing this for years. And while there is no scientific evidence that it directly contributes to death (nor is there any for smoking), it does nevertheless lead to a host of other ailments, such as depression and anxiety, which are often much more traumatizing then the illnesses directly attributed to obesity. Because of the great American “Progress Paradox,” because of our deeply ingrained tradition of consuming in abundance, enjoying a leisurely lifestyle and snacking to feel good, I can guarantee you that the obesity epidemic will not be going anywhere any time soon. Because of this, it is time that our government raise the ante in its commitment to strengthening the PHS and its ability to intervene, especially at the lowest tiers of government and especially within our poor urban communities. It is time that our government take the obesity epidemic just as seriously as any other kind of infectious disease threatening our livelihood and national security. In other words, it’s time to invest more in those bureaucratic institutions that serve and help to protect our citizens through sound policy innovations. Given our highly fragmented, decentralized

66

Indeed, Eric Oliver closes his book Fat Politics with the following statement: “The best way we can begin to solve the obesity epidemic is not by trying to get everyone to lose weight, but by no longer making weight a subject of official concern” (Oliver, 2006: p. 189).

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political context, where state and local governments are often incapable of adequately responding on their own, effective institution-building can work at helping to protect the livelihood of our children and future leaders.

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CHAPTER 8 Responding to Tuberculosis in Brazil: International Pressures and Institutional Collapse (1980-present) In an era of increased globalization, democratization, and economic growth, why has tuberculosis (TB) resurfaced around the world in epidemic proportions? Tuberculosis should have been permanently eradicated with the introduction of successful chemotherapeutic treatments in the 1950s; and yet, it lingers. Brazil, as well as the United States, succeeded in arresting the growth of TB by the 1950s. Nevertheless, the government has recently entered into a second bout with the disease, challenging its ability to secure healthy standards of living and a vibrant workforce for development. Notwithstanding Brazil’s long history of successfully responding to tuberculosis through massive state-building campaigns (as we saw in Chapter 3), by the early-1980s TB resurfaced in tandem – many would say as a direct consequence of – the new HIV/AIDS virus. However, few scholars have explained why the government failed to immediately respond to TB’s resurgence, especially when compared to the government’s successful – albeit delayed – response to TB in the past. More importantly, few have explained why the government’s recent response to TB pales in comparison to its highly effective (and revered) response to AIDS. This chapter submits an explanation and concludes with broader lessons for why nascent democracies are often biased in the types of epidemics they respond to. 384

In this chapter, I argue that as we saw with the initial years as of the AIDS outbreak, the government did not immediately respond to TB. The main problem lied with the president, bureaucracy, and civic elites’ perceptions that tuberculosis had not reemerged as a national health threat. The AIDS and TB epidemic therefore started off along similar paths, such that most federal elites, with the exception of some health officials, did not initially view both epidemics as serious national threats. As was the case with AIDS, it was only after a major global structural shift occurred, that is, an increase in the global health community’s attention to TB and their criticisms of Brazil’s response that the government and civil society finally emerged to pursue institution-building. While recent horizontal and vertical 67 reforms have been implemented, this chapter argues that in contrast to the recent response to AIDS, the nature of these institutions is purely cosmetic, such that the president has not been entirely committed to funding and supporting these initiatives. Similar to my discussion of AIDS in Chapter 6, the argument in this chapter is divided into two reform periods: the First Phase of TB Politics (1980-94), which witnessed the collapse of a historically based National TB Program through hasty policy decentralization, followed by the more recent Second Phase of TB Politics (1994present), where an increase in global attentiveness to tuberculosis, international pressures for institution-building, mainly through the re-centralization (or rather, re-birth) of Brazil’s National TB Program and their coordination with the municipalities, finally occurred. 67

As noted in Chapter 2, horizontal institutional reforms refers to executive support for bureaucratic expansion and inter-agency cooperation in response to epidemics; vertical institutional reforms, on the other hand, refers to the efforts by federal public health bureaucracies to work worth civil society and to help municipal governments, both through finance and technical assistance, respond to epidemics.

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During the first phase period, I argue that two antecedent structural conditions accounted for the president and Ministry of Health’s perception that TB was not a new health threat. This accounted for its initial unwillingness to pursue institution-building. First, the president and most health officials’ perceptions of TB were negatively influenced by the presence of multiple diseases, which made it difficult for the president and most health officials to consider TB’s resurgence as a genuinely distinctive health threat – notwithstanding reports from pro-reform health officials stating that it was. In addition, these perceptions were also influenced by the rich historical legacy of successfully responding to TB through aggressive institution-building (as we saw in Chapter 3) and how this, in turn, lead to a dramatic decline in TB cases since the 1940s. When combined, these antecedent structural conditions contributed to initial presidential and bureaucratic elite perceptions that tuberculosis was no longer a health problem and that the government should not respond through new institution-building activities. In addition, during this period the absence of a pro-active civil society fighting for the rights of the TB-HIV/AIDS co-infected and the poor allowed for a precocious 68 form of decentralization 69 to emerge and quickly dismantle years of institution-building responses to tuberculosis. Pro-reform bureaucrats in the National TB Program (NTBP) could not use their connections with a well organized civic movement to justify the survival and expansion of the NTBP; this gave them little leverage when trying to thwart

68

A precocious form of decentralization occurs when the federal government decentralizes fiscal and administrative policy too quickly, without ensuring that municipalities are adequately prepared to handle new health policy responsibilities; on this note, see Paul J. Smoke, Eduardo J. Gómez, and George E. Peterson (Eds). 2007. Decentralization in Asia and Latin America: Towards a Comparative Interdisciplinary Perspective (Edward Elgar Press). 69 Again, note that the military had been pushing for decentralization for a very long time and that most elites viewed this as the most efficient way to render social services. Recall that in Chapter 6, this movement for decentralization hampered the Ministry of Health’s ability to immediately respond to AIDS.

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the President and Congress’ unwavering commitment to decentralization. Unlike the case of the successful Liga movements for tuberculosis in the early-20th century, by the early21st century democratic civic elites (mainly doctors) found few career incentives to respond to tuberculosis. Consequently, their absence, when combined with the federal elite’s lack of interest in immediately responding, made the momentum in favor of decentralization too overwhelming to bear. Under these circumstances, pro-reform bureaucrats could by no means justify NTBP survival and expansion. This allowed precocious decentralization to thrive and dismantle the National TB Program. During this initial period, the third causal factor explaining the reluctance of the NTBP to engage in bureaucratic reform had to do with the dilemma of agency survival, which stemmed from the President and other health officials’ decision by the early-1980s to completely disregard the input of NTBP bureaucrats and instead focus on AIDS. This immediately suggested to NTBP bureaucrats that it was on a very short leash and that it could be dismantled at any minute. In a context where the NTBP was historically revered for its successful respond to TB, as you can imagine this generated a lot of fear and envy towards other new health agencies, such as the national DST/AIDS Program, especially when the TB-AIDS co-infection problem became more evident by the mid0-1980s. And yet, in the absence of presidential interests in responding to TB, as well the absence of a supportive network of NGOs that the NTBP could use to justify its position, NTBP reforms were marginalized and ignored, gradually supplanted with a more decentralized approach TB policy by the late-1990s. In this context, it tried its best to survive by incessantly discussing the rising TB epidemic and by trying to obtain more funding from the Congress. But the President and the rest of the national health 387

ministry’s attention to decentralization was too overwhelming. These requests fell on deaf ears. The end result was predictable: due to envy and in an effort to work independently in order to distinguish itself, the NTBP had a lack of interest in working closely with the new national AIDS program in response to not only TB, but also to a new TB-AIDS co-infection problem, especially within congested urban centers. This stymied any prospect for institution-building. The last period under consideration, the second phase of TB Politics (1994present), focuses on the government’s recent realization of these problems and its efforts to rebuild the National TB Program. In contrast to the past, however, recent institutional reforms did not emerge in response to increased civil society pressures as a product of redemocratization, nor from a genuine, altruistic federal commitment to citizen needs. Rather, and as was we saw with the government’s response to AIDS, it emerged from a sudden increase in the global health community’s interest in cracking down on tuberculosis and pressuring Brazil to strengthen its commitment to institution-building. By the early 1990s the global pressures to respond to tuberculosis reached a new apogee. As with AIDS, direct pressures on Brazil to respond to the TB problem heightened by the late-1990s. Again similar to AIDS, these new global pressures radically altered the perceptions of presidential and bureaucratic elites in the Ministry of Health, motivating them to finally respond by re-centralizing the National TB Program, giving it more resources and political attention. In addition, with TB case prevalence increasing in tandem with AIDS, a new co-infection problem was finally noticed, as well as the emergence of other strands of TB, such as multi-drug-resistance TB (MDR-TB). By this point the government was simply embarrassed by the fact that it had ignored TB 388

and instead focused all of its resources on AIDS; the global health community, especially multi-lateral lending institutions, such as the World Bank, picked up on this as well. By 1998, these global shifts led to the re-creation of the National TB Program and ushered in a new era of attempted bureaucratic reform. For the first time, the President and the Minister of Health became much more committed to helping establish a new cooperative relationship between the NTBP and DST/AIDS Program, an initiative that was fully supported by health officials in both agencies. The Ministry of Health and the NTBP also became much more committed to providing financial and technical assistance to the states, especially to insolvent, distant municipalities, in order to improve access to medicine and preventive care. Nevertheless, despite the NTBP’s new commitment to helping the municipalities, during the 1990s the fast paced timing of decentralization made policy efficiency at the local level very difficult to achieve. In most instances municipal health agencies were quickly decentralized new TB policy responsibilities without any supportive financial and technical resources. Despite the emergence of a new national campaign and the recentralization of the NTBP, in recent years political elites still have not been 100% committed to providing financial and technical assistance to the states. With the recent provision of a generous grant from the Global Fund to Fight AIDS, TB, and Malaria, there is new hope that the NTBP will nevertheless increase its commitment to making decentralization work. For in addition to providing a new opportunity for Brazil to once again show the global health community that it can defeat yet another health epidemic, the Global Fund has established what I call a unique institutional conditionality: that is, where it has forced the government to formally 389

institutionalize the needs of civil society while working more closely with municipal health agencies to implement policy. Only time will tell if this new kind of foreign aid assistance will motivate the government to finally respond to TB – and hopefully just as well as it has responded to AIDS.

Graph 8.1: Brazil - National TB Trends (1980-2002)

100,000 90,000 80,000 70,000

Cases

60,000 50,000 40,000 30,000 20,000 Deaths

10,000 0 80

85

90

95

00

Source: Ministry of Health, 2005

~ TB I: GOVERNMENT RESPONDS (1981-1994) ~ Tuberculosis did not re-emerge in Brazil as suddenly and mysteriously as the AIDS virus. It did not trigger immediate fear and uncertainty – nor did AIDS, really. The gradual spread of TB in the 1970s and 1980s was attributed mainly to urbanization, free market reforms, economic crisis, and unemployment (Barrozo, 11/8/93, Diario Popular; Adeodato, 8/19/91, Jornal do Brasil; Marques, 3/24/92, A Trabuna; Jornal do Brasil, 390

9/7/93). The inefficiencies of decentralization stemming from the military’s SUDS (Sistema Unico de Sáude) program and its repeated inability to adequately monitor and respond to TB also contributed to its resurgence (Adeodato, 8/19/91, Jornal do Brasil; Santos Filho, 2006). TB also re-emerged because of the HIV/AIDS virus (Jornal do Brasil, 6/27/89; Folha de São Paulo, 11/29/91). As the strength of human immune systems was radically depleted because of HIV, TB’s resurgence quickly spread among the HIV infected. This was most commonly seen within tightly concentrated urban centers, such as in Rio and São

Graph 8.2: Brazil - Rio: Number of TB and AIDS Cases (1983-2004)

12000 10000 TB

8000 6000 4000 AIDS

2000 0 83

90

95

2000

2004

Source: Boletim DST/AIDS, 2005, Rio Secretaria de Estado de Saude

Paulo. As Figure 1.2 illustrates, in the city of Rio the number of TB cases essentially ran parallel to the surge in AIDS cases throughout the 1980s and 1990s. During the 1980s especially, a TB-AIDS co-infection problem emerged, due in part to the difficulty of 391

diagnosing AIDS patients with TB. For instance, the incessant coughing, vomiting of blood, and rapid weight loss commonly seen with TB patients is not present with the TBHIV infected (interview with Ezio Santos Filho, 6/30/06; interview with Dr. Margareth Delcalmo, 7/18/06). As a result, those that were TB-HIV positive did not realize that they had TB (nor HIV, in some instances, since it takes approximately 5-10 years before the physical symptoms manifest) and consequently did not seek immediate medical attention; this contributed to TB’s further spread.

Graph 8.3: Brazil - Sao Paul: Number of TB and AIDS Cases (1987-2005)

25,000 TB

20,000

15,000

10,000 AIDS

5,000

0

87

95

2000

2005

Source: Boletim Epidemiologico, Destado de Sao Paulo

Similar to AIDS, during this period there was also a relatively high level of social stigma towards those with tuberculosis. As in the past, it was – and still is – a disease that is mainly seen among the poor. Many times, having TB also reveals one’s low income and thus social status, which in Brazil often conjures up racism and discrimination. While AIDS attacked the gays, TB attacked the poor and the gays, as a consequence of HIV. As 392

we’ll soon see, one key difference between the two was that AIDS dovetailed nicely with the pre-existing movement for gay and human rights throughout the re-democratization period. But this was not the case for TB. For the poor had no pre-existing “pro-poor” or “pro-TB/HIV” movement that they could draw from and use to pressure the government for reform. Instead, and as explained in more detail shortly, it would take an increase in global attention to TB and pressures for institution-building, coupled with the fact that it had reemerged as a health crisis, to generate a pro-active civic movement.

Graph 8.4: Brazil - Number of Cases and Deaths from HIV/AIDS and TB (1980-2003)

100,000 90,000 80,000 70,000

TB (cases)

60,000 50,000 40,000

AIDS (cases)

30,000 20,000

TB (deaths)

AIDS (deaths)

10,000 0

1980

2003

Source: Ministry of Health, 2006

These factors weighed heavily on military (1980-85) and presidential (1985-94) perceptions. For as the next section explains, the history of Brazil’s successful institutionbuilding response to TB, when combined with the weight of empirical evidence suggesting that TB was no longer a health threat, convinced the transitioning military 393

regime that TB was no longer a problem and that it did not have to respond through new institution-building initiatives.

Presidential Perceptions and Response Prior to the reemergence of tuberculosis in the 1980s, neither the president nor the congress was convinced that TB had re-emerged as a major health threat. Rather, they perceived it as a disease of the past, permanently eliminated and controlled through the highly centralized vertical programs created during the Getúlio Vargas presidential and eventually military government (1930-45). As in the past, the government’s focus was instead on taking care of what they perceived to be more imminent health threats, such as samparo, dengue, and malaria. The President and the Ministry of Health believed that there were too many health problems in Brazil and that TB did not warrant any special attention. This perception was crystallized when Brazil’s new democratic president, Jose Sarney, publicly announced in 1985 that TB was no longer a problem, that there was nothing to worry about, and that there were other, more pressing health issues that the government needed to worry about (interview with Ezio Santos Fihlo, 6/30/06).

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Graph 8.5: Brazil-Rio: % Change in Yearly TB and AIDS Cases (1988-2004)

160 140

AIDS

120 100 80 TB

60 40 20 0 88

95

2004

Source: Department of Health, Rio de Janiero

As we saw in Chapter 3, and similar to what occurred during the post-colonization period (1900-1930), the President and the Congress had to be convinced by the medical community that tuberculosis was a national health threat before deciding to respond. As we will soon see, however, and in sharp contrast to the past, this civic movement was not present during the contemporary TB period. Furthermore, because of the president’s perception that it was under control, the government did not feel compelled to immediately pursue reforms that would increase the NTBP’s ability to both monitor and control the spread of TB.

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Graph 8.6: Brazil-Sao Paulo: Yearly % Change in TB and AIDS Cases (1987-2005)

180 160

AIDS

140 120 100 80 60

TB

40 20 0 87

95

2005

Source: Department of Health, Sao Paulo

There were also several structural factors that contributed to the president’s perceptions. The first was the well known history of successfully controlling TB under prior military regimes. During the re-democratization period (1980-85), government officials recalled prior regime success at eradicating TB. As we saw in Chapter 3, beginning with the Ministerio de Educacão e Saúde Publico in 1931 and the creation of the National Tuberculosis Program (NTBP) under Vargas in 1941, the government was fully committed to financing and expanding the NTBP in order to curb TB’s spread. International philanthropic organizations, such as the David Rockefeller Foundation, also contributed to the NTBP’s expansion. These centralized institutional responses, when combined with the introduction of Streptomycin in 1944, Para-aminosalicylic, and Isoniazid in 1952, and the resulting decline in case and death rates attributed to TB contributed to the general perception in government that TB was under control and that it would never re-emerge (Santos Fihlo, 2006). 396

Historical quantitative evidence also revealed a precipitous decline in TB case and death rates. In Rio, the nation’s capital - and at the time the most populated city (with a very high concentration of poor urban agricultural works), case and death rates plummeted by the 1950s (see Figure 1.7 and 1.8). São Paulo showed similar trends. This evidence also weighed heavily on the president and Ministry of Health’s perception that TB was no longer a problem.

Graph 8.7: Rio - TB Cases and Deaths (1930-1953) 9000 8000 7000 Cases

6000 5000 4000 3000 2000 Deaths

1000 0 1903

1930

1940

1953

Source: Ministerio de Saude, Brasil

Decentralization Proof of the president’s perception that TB was no longer a problem came with the government’s decision to quickly decentralize the management and implementation of 397

TB policy to the municipalities in 1990. As was the case with AIDS, by the early 1980s pressures from below, mainly from the governors and mayors, for greater control over health management and policy where to overwhelming to ignore. Believing TB to be a relic of the past, in 1990 the President and the Congress decided to devolve all aspects of TB management, policy, and treatment to the municipalities. The only responsibilities retained at the federal level was the creation of technocratic norms for TB treatment from the Ministry of Health and the financing of mediations provided through the National Reference Centers, which are now located in Rio and São Paulo.

Graph 8.8: Rio - Total number of Deaths Attributed to TB (1855 to 1953) 1400 1200 1000 800 600 400 200 0

1855

1953

Source: Ministerio de Saude, Brasil

However, with decentralization came the death of the infamous National TB Program. While some may argue that decentralization could have easily been perceived as a more efficient institutional response (on the grounds of policy efficiency through increased local accountability), the problem was that it was very poorly planed: that is, it

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occurred at a very fast pace, without the government ensuring that municipal heath agencies were administratively prepared to manage and enforce policy (Franco, 1991). Unfortunately, this smacked of government apathy in insuring that municipal health agencies had the administrative and technical capacity needed to implement policy. The municipalities were simply unprepared, administratively, medically, and especially financially to render treatment services, such as DOTS, in an efficient manner (Ruffino-Netto and Figuerido de Souza, 2001; Franco, 1991). As a result the quality of TB policy suffered tremendously; and unfortunately, this trend continues to this day (Antunes and Waldman, 1999; O Globo, 3/20/98). As I have argued elsewhere, this was a direct consequence of the fast-paced timing of decentralization and the state governments’ reluctance to work with municipal health agencies; or what I and others have called a precocious form of decentralization (Smoke, Gómez, and Peterson, 2007; Gómez, 2008). A major factor allowing for this kind of decentralization to unfold was the absence of a proactive civic movement that could incessantly remind the government of the need to respond through the creation of a new federal program. As we saw in Chapter 6, the response from civil society was a necessary – though not sufficient – condition for altering presidential perceptions and interests in strengthening the national DST/AIDS program. But since there existed no such civic movement for TB during the 1980s, these pressures were absent. This facilitated and in fact encouraged precocious decentralization to unfold. As we’ll soon see, it would take major global shifts and pressures to convince the government and civil society that it needed to respond to TB through institution building and modernization. 399

Bureaucratic Perceptions and Response Similar to what had occurred during the initial years of the AIDS epidemic, officials in the Ministry of Health were initially divided over whether or not a new TB crisis had emerged. During this period, Health Minister Carlos Santa’Anna and his technocrats did not believe TB was going to resurface as an epidemic (Serra, 4/20/00). For although they may have seen and heard otherwise, they initially sided with the President’s views and perception that TB was under control and that strengthening the NTBP was not necessary. In addition, prior to 1990 NTBP technocrats did not agree that the program should be dismantled via decentralization. For they all agreed that the NTBP should be strengthened and remain at the national level (Interview with Dr. Margareth Delcalmo, 7/18/06). As a waning government agency bereft of money and confronting massive pressures for decentralization, they also agreed that the NTBP program needed additional funding and that the executive should give them more support. Therefore, similar to the CDC and the NIH in the United States during the initial AIDS outbreak, there were immediate financial incentives to use the TB problem as a justification for asking for additional funding and, therefore, surviving. Of course, a balance had to be struck: that is, these technocrats were, as in the CDC, first and foremost genuinely committed to addressing the TB problem. But quite frankly, they also needed money. What is more, and once again similar to the CDC, they were willing to use TB’s resurgence in order to obtain more political support.

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The Challenge of Institution-Building While NTBP officials were committed to institutional change and responding to TB, they were not as enthused about the possibility of working with other health agencies. Paradoxically, the vast administrative expansion and federal campaign to eradicate TB under Vargas established the foundations for subsequent NTBP pride and territoriality decades later. This prohibited horizontal bureaucratic reform and influence through greater cooperation with other agencies. What is more, this further contributed to the NTBP’s waning popularity, decreased influence, and eventual downfall (via decentralization) by 1990. Keep in mind that consecutive years of political and financial attention to the NTBP established a cadre of TB technocrats that were highly revered and respected in government. While this facilitated the government’s response to TB during the 1950s, the upshot is that this historically high level of bureaucratic attention set the stage for NTBP resistance to anything or anyone that would challenge its authority. Better understanding this dilemma requires that we recall for a minute my discussion in Chapter 3: specifically, recall my discussion of the unwavering support that the Vargas government (1930-45) had for the creation and maintenance of the National TB Program. Furthermore, recall the strong inter-ministerial support under subsequent military regimes from the Ministry of Health, Social Security, and even the governors, for financing and modernizing the NTBP (Ruffino-Neto and Figueiredo de Souza, 2001). And lastly, recall the high amount of pride and prestige that TB officials had during this period. The 1950s was their heyday. For they were not only popular within government

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and civil society but they also managed to run away with nearly 50% of the annual budget allocated for public health spending (Barreira, 2000)! Given this backdrop, consider for a minute how these technocrats felt when they realized that: a) TB was no longer perceived both within government and civil society as a major health threat; and b) that the NTBP would be completely dismantled within the next few years. Needless to say, this upset TB technocrats and contributed to their opposition to decentralization. Moreover, these realizations had serious consequences for the creation and continuation of inter-ministerial cooperation for combating TB. It would especially be problematic when a new bureaucratic threat emerged – i.e., the national DST/AIDS program - that quickly reduced the prestige and amount of attention that the NTBP would get from the president and the Minister of Health. Because HIV/AIDS case rates were surging, and because the government was becoming increasingly attentive to this situation by the mid-1980s, TB bureaucrats started to become very territorial and fearful that they would gradually lose their influence within government. They feared that AIDS and the newly created DST/AIDS program was obtaining too much attention and that because of the new TB-HIV co-infection problem, the government would end up focusing on them and forgetting about the NTBP. Of course, this prospect did not bode well for an agency that was historically revered for its success at curbing the spread of tuberculosis. These territorial tensions heightened as NTBP officials realized that the specter of a TB-AIDS co-infection problem increased and that they were not being consulted about it (interview with Dr. Margareth Delcalmo, 7/18/06). Especially problematic for them was the fact that the media and the medical community were incessantly publishing 402

reports showing that TB was quickly resurfacing and that there was a serious co-infection problem. In essence, what all of this meant was that years of TB bureaucratic pride, tradition, and respect was quickly deteriorating. And it was deteriorating at a point when we should have expected their reputation and influence to be increasing. What consequences did this spell out for the much needed inter-ministerial support to modernize the NATB? A lot. First, because of their anger and perception that they were being ignored, initially there was no interest on the part of NTBP officials to work with the DST/AIDS program (interview with Dr. Germano Gerhardt, 7/19/06). They had no interest in seeking new funds from a financially better off AIDS program, both for helping support and maintain the NTBP, which was on the verge of collapse, and for enhancing their response to the TB-HIV co-infection problem (interview with Germano Gerhardt, 7/19/06). They also had no interest in seeking technical assistance about how to disseminate information to doctors and civil society on how to prevent from getting tuberculosis. This suggested to some that bureaucratic pride had finally caught up with these officials, which in turn contributed to their sense of independence and envy towards the DST/AIDS program (interview with Dr. Afrânio Kritski, 7/20/06). This created few incentives to initially work with DST/AIDS officials. They were not only upset that they were not receiving enough attention, but they were also jealous of the fact that the new AIDS program was obtaining more domestic and international recognition (interview with Dr. Margareth Delcalmo, 10/20/06). This angered them all the more as it became increasingly apparent that TB had re-emerged as a public health threat. Nevertheless, they

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did not realize at the time that this territorial pride and arrogance hampered their efforts to maintain and centralize the NTBP. Compounding this problem was the DST/AIDS bureaucracy’s staff. As the government started giving them more attention, they were becoming increasingly pompous and selfish. Although there were one or two NTBP officials (in an office of about 20) that were seeking technical assistance from the DST/AIDS program, such as Dr. Margareth Delcalmo, they were often denied this assistance. This was mainly due to the fact that AIDS officials thought that AIDS was a greater priority and that they could not – or rather, should not – spend any additional time worrying about anything else, especially TB (interview with Dr. Margareth Delcalmo, 7/18/06). AIDS officials were of the opinion that NTBP staff already had their own bureaucracy and that AIDS officials should not worry about anything else other than AIDS. The DST/AIDS program’s autonomy further complicated matters. AIDS officials were very cognizant of the fact that they had a lot of autonomy and could do essentially whatever they wanted; this contributed greatly to their lack of interest in helping out the NTBP (interview with Dr. Fabio Moherdaui, 7/12/06). Furthermore, the DST’s autonomy and influence within government allowed it to do things that the NTBP (or any other social welfare agency) could never do, such as directly applying for funding from the Ministry of Health and congress without having to fill out reams paperwork (interview with Dr. Fabio Moherdaui, 7/12/06). As you can imagine, this incensed TB officials beyond measure, since they had to follow regular procedures and for a lot less money (interview with Dr. Fabio Moherdaui, 7/12/06). Naturally, this contributed greatly to the

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sense of envy and hostility that the NTBP had for the DST/AIDS program (interview with Dr. Fabio Moherdaui, 7/12/06). Yet another problem was the fact that although the DST/AIDS program was receiving more money each year, it still was not enough. Keep in mind during the late1980s, Brazil had once again slipped into a major fiscal and macroeconomic crisis. This substantially reduced the amount of money that the federal government could allocate for social spending. Consequently, the DST/AIDS program had to do whatever it could to distinguish itself from other agencies. This distinction translated to working independently in the hopes of obtaining more domestic and international recognition. As noted in Chapter 6, recall that it was not until the first World Bank loan of 1994 that the DST/AIDS program started to obtain enough money for its initiatives. Needless to say, these conditions generated few incentives for the AIDS program to work with the NTBP. Lack of Presidential Support This decrease in federal attention to NTBP officials had serious consequences for the expansion of the NTBP during the first few years of the AIDS epidemic. While TB officials appealed to President Sarney, Collor, and Franco for additional funding and technical support, the President and the Congress never responded to their requests. As mentioned earlier, they did not see TB as an urgent situation. Because of this, institutionbuilding was not pursued. Instead, the government relied completely on the decentralization process. Indeed, keep in mind that while the decentralization of TB administration and policy did not occur until 1990, interest and commitment to it increased during the early-

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to mid-1980s, precisely when the AIDS crisis emerged. Because of this, the President and the Congress did not initially take very seriously the NTBP’s requests for additional funding; all of it was going to the states, mainly through the SUDS and later the SUS health decentralization program of 1988. This made it clear to many that the National TB Program was losing the interest and support of the executive branch. Without this support, and in the absence of an executive perceiving the TB situation as a serious problem, the NTBP would not succeed in securing additional political and financial support.

Vertical Assistance During the 1980s, because the momentum in favor of decentralization was so overwhelming, and because the NTBP’s influence within government had substantially decreased, there were no efforts to increase direct vertical assistance to the states. Government misperceptions, a product of the historical institutional and structural conditions mentioned earlier, also contributed to this problem. Instead, the redemocratizing government was committed to decentralizing TB and a host of other health policy issues, including – albeit briefly – the response to AIDS. What is more, and in sharp contrast to AIDS, one must keep in mind that there was no civic movement in response to tuberculosis during this period. There were no NGOs or civic organizations fighting for the poor and HIV+ gays afflicted with TB. People were still learning about AIDS. And the fact that the strain of TB accompanied with HIV was much more difficult to detect complicated the NTBP’s ability to pin down and understand which groups in civil society were suffering from the disease. As a result, 406

the NTBP and the Ministry of Health had no TB network to work with, which was a problem when it came to learning more about the co-infection problem. Due mainly do these problems, during the first few years of TB’s resurgence the federal government did not support the introduction of new vertical health programs. Similar to AIDS, and as explained in greater detail shortly, it would take new global pressures and incentives for the government to finally perceive the TB situation as something worthy of vertical response. As was the case with AIDS, moreover, it was only after a major global shift in attention towards TB emerged that the government finally tried to introduce new vertical reforms. In sum, by the time tuberculosis reemerged as a national health threat along with HIV/AIDS and, eventually, on its own, the massive institution-building campaign that occurred in the past left in place a horizontal territorial dimension that hampered the willingness of the NTBP to work with other health agencies, such as the DST/AIDS program, for more technical assistance, research, and policy. This decreased the NTBP’s developmental capacity and the government’s ability to immediately respond to TB (Interview with Ezio Santos Filho, 6/30/06). At the same time, the DST/AIDS program was too focused on itself and unwilling to support the NTBP. This was mainly due to the fact that it was trying to work independently in order to distinguish itself and increase its domestic and international recognition. The government’s perception that TB was no longer a health problem, when combined with its growing interest in the AIDS situation by the mid-1980s, also contributed to a lack of support for the NTBP’s efforts to expand and modernize. This problem, when combined with the latter’s waning reputation and influence (due in part to 407

the pressures for decentralization), contributed to a rapid decline in support from the president and the Ministry of Health. By 1990, the NTBP completely collapsed, as a result of decentralization, while the DST/AIDS program survived, thrived, and in contrast to the NTBP, remained at the federal level, expanding and eventually becoming highly autonomous and influential. Unfortunately, the need for federal NTBP expansion came at a time when the pressures for decentralization were simply too overwhelming to bare; this was heavily influenced by a pre-existing elite consensus in favor of decentralization and, of course, the absence of a pro-active civic movement supporting a more centralized administrative response to tuberculosis. Furthermore, it was a time when the government was still not convinced that TB was a problem. But why did this happen? Why wasn’t civil society as proactive as it had been in the past? Recall in Chapter 3 how the famous Liga movement in São Paulo and Rio emerged during the early-20th century to incessantly pressure the government for a more centralized institutional response to TB. Unfortunately, however, this movement never reemerged with tuberculosis in the 1980s. Instead, and as the next section explains, this movement died off with the rapid decline in TB case and death rates by the 1950s, only to re-emerge through an increase in global attention to the new TB pandemic. The Absence of Civil Society In sharp contrast to AIDS, the resurgence of democrat tuberculosis never benefited from the presence of a new civic movement incessantly pressuring the government for an immediate response to TB. More importantly, and in sharp contrast to AIDS, it never

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benefited from the presence of a unified, burgeoning civic movement, such as the historic Liga movement, which fervently believed that the federal government should respond to TB through the increased centralization and expansion of the NTBP. However, by the time tuberculosis had resurfaced as a problem, this movement no longer existed. By the early-1980s, the medical and academic elites of old that were passionately unified to confront a lackluster governmental response to TB while inciting broader patriotic appeals for action were long gone, focusing instead on other more impending health issues, such as AIDS (Raimundo do Nascimento, 2005; interview with Carlos Basilia, 7/26/06). During this period, civic elites, that is, medical and academic elites, perceived the new TB situation differently from how they had perceived it in the past. At first they viewed its resurgence as lingering remnants of the past, a problem that had already been controlled through federal programs and treatment (Interview with Carlos Basilia, 10/17/06). To a certain extent, this viewed mirrored the president’s initial perception of the problem. TB was also perceived by these elites as something that only the poor received. Consequently, Brazil’s civic elites did not initially perceive TB as an urgent national threat (interview with Carlos Basilia, 10/17/06). And in sharp contrast to the past, this also meant that there was no effort to transform the TB situation into a new patriotic movement calling on everyone in civil society, the private sector and government to work together. Another major issue that precluded the rise of a new civic movement for TB was the fact that TB simply did not have the same “sex appeal” that AIDS did. This perception among civic elites had several consequences. First, when confronted with the 409

choice to work on TB or AIDS, few medical elites had incentives to work on the former. Most of the talent and impulse was going to AIDS, which was a new, mysterious, unexplored virus that could literally make someone’s career over night. TB was old. It had not appeal. A cure had already been found for it. It therefore offered no immediate career incentives. Obviously it had nothing near the kind of appeal and immediate career benefits that the new AIDS virus had (Interview with Carlos Basilia, 10/17/06; 7/26/06). There were also some structural challenges. By the time TB and AIDS reemerged, it came at a time when, like in the United States, chronic disease and research took most of the laboratories’ attention. Because of this the medical and academic community was not very well equipped – nor did they have the experience – to establish a strong connection with civil society in response to TB (interview with Carlos Basilia, 10/17/06). Partly because of the dire financial situation of these establishments, there also seemed to be no need to establish this kind of lab-tech/civil societal network, since many doctors were not convinced that there was a TB problem (Interview with Dr. Margareth Delcalmo, 10/17/06). The biggest upshot to all of this was that, in sharp contrast to AIDS, there never emerged a distinctive TB NGO network during the initial years of TB’s resurgence. Indeed, during this period there never existed one single NGO for TB. This contrasted sharply with the multitude of AIDS NGOs that existed by this time, which jumped from about 5 in 1985 to over 100 by 1990. For AIDS activists, NGOs were vital for increasing awareness of the disease, providing prevention education and above all incessantly pressuring the government to respond. AIDS NGOs were also needed to establish what Katherine Sikkink and Margaret Keck once (1999) referred to as international 410

“triangular” networks with other human rights NGOs and international organizations; these networks worked together to apply incessant pressure on governments to respond to humanitarian needs. Yet, the TB problem never benefited from this kind of activity. During this period, there were no domestic and international networks of NGOs fighting for greater attention to TB. There simply was no representation and needless to say interest in establishing such a network for TB victims, which now included those with HIV and the poor. Rather, civil society’s response only emerged after the global community starting paying attention to TB. This is similar to what we saw historically in Chapter 3 with the emergence of the Liga do Tuberculoses in respond to international pressures, and comports with my overall hypothesis that well organized civic movements only emerge in tandem with new global health pressures on government to respond. This lack of civic responsiveness is quite interesting, especially after one considers the fact that by the late-1980s and early-1990s it was becoming well known in government circles that the TB co-infection problem was worsening (Lux Jornal, Diario do Grande ABC, Santo Andre-SP, 6/2/94; Lux Jornal, Tribuna da Impresa, Rio de Janeiro-RJ, 6/17/94). What is even more alarming is the fact that the federal government was becoming increasingly aware that HIV+ carriers were the ones contributing to TB’s spread (Jornal do Brasil, 6/27/89; Folha de São Paulo, 11/29/91; O Globo. 11/22/91). And yet despite this information, no well organized civic movement emerged to take advantage of the government’s knowledge of this problem. Despite efforts by the National TB Program to increase awareness of the co-infection problem, moreover, no effort was made by medical and academic elites in civil society to take advantage of this new opportunity space and to create new NGOs for TB victims. 411

This led to several problems. First and foremost, and in sharp contrast to AIDS, the absence of a well-organized civic movement meant that there were no “bottom up” pressures for institutional and policy reform. More specifically, there were no civic institutions that could mobilize the expertise and resources needed to force the Ministry of Health and the National TB Program to enhance its direct vertical assistance to the municipal health agencies in charge of providing medical treatment. Second, and in sharp contrast to AIDS, this meant that pro-reform TB officials in the Ministry of Health and the NATB did not have the civic network and support needed to increase the president and government’s perception that institutional change was of paramount importance. This meant that they had no civic resource to use, build upon and justify in their pleas for a centralized expansion of the NATB. There was thus little substance and justification for the NTBP’s request to maintain and expand their organization. As you recall from Chapter 6, these civic-based resources were necessary for the increased influence of pro-reform DST/AIDS bureaucrats and the expansion of their agency shortly after the first World Bank loan. The presence of a pro-active civic movement equating centralized institution-building with responses to epidemics was important for giving pro-reform DST/AIDS bureaucrats the justification for pressuring the government for a more centralized administrative response to AIDS. Although these reforms did not take place until after the World Bank loan, this partnership with civil society added to the pro-reform movement’s bureaucratic prestige and set the groundwork for the national DST/AIDS program’s subsequent growth and expansion. Third, the absence of an initial civic movement meant that there were no organizations that could increase TB awareness and education for the poor. While AIDS 412

would of course benefit from not only a well-organized gay movement by the late-1980s but also a host of new AIDS NGOs that were increasing by the minute, TB had no such experience, nor any kind of NGO network that could disseminate information on TB prevention and treatment. And lastly, this also meant that the TB community had no way of effectively presenting its case both domestically and internationally for the acquisition of more resources and support. At the time, municipal health agencies were in need of money to finance not only the acquisition of TB medication (6/27/89, Jornal do Brasil; Franco, Jornal do Brasil, 11/19/91), which was not received from the federal government in a timely manner, but also for the implementation of TB awareness and prevention programs. Of course, more money was also needed to finance groups of individuals and even possibly civic organizations that could directly assist the poor. Despite these challenges, by the late-1990s pressures emanating from the global health community appeared to be necessary and sufficient to convince the government that it needed to reform its institutional approach to tuberculosis. Indeed, for as the next section explains, although the anti-TB civic movement did not emerge until the 21st century, the government did start to reform the NTBP in response to these global pressures – albeit, in a very cosmetic manner.

~TB II: (1994-present): GOVERMEN RESPONSE AND THE CHALLENGE OF COSMETIC INSTITUTIONALISM ~ As was the case with AIDS, by the late-1980s the global health community was becoming increasingly attentive and responsive to the resurgence of tuberculosis (Jornal do Commercio, 3/20/98). The problem could no longer be ignored. And it was becoming 413

increasing obvious to the global health community, as well as the media and academia, that TB was closely associated with the HIV virus (Tarantino, Jornal do Brasil, 12/12/94; Neto and Pasternak, O Estado do São Paulo, 6/5/95; Jornal do Brasil, 11/4/95; O Fluminense/RJ, 4/4/97). It was, if you will, piggy-backing off of a burgeoning new epidemic, AIDS, while at the same time reemerging through domestic structural changes, such as decentralization, economic crisis, and unemployment. By 1993, these happenings in Brazil and in other nations motivated the World Health Organization (WHO) to officially declare TB a new global health threat (Revista Global Cienca, 1993; Tribuna da Impresna, 3/20/98). By 1996, moreover, the new Global Stop TB Alliance was formed, further increasing the global momentum in response to TB. Of course, the Brazilians noticed (Freitas, Jornal do Brasil, 4/12/00). Shortly after the WHO’s declaration in 1993, the global health community started critiquing national government responses to tuberculosis. Keep in mind that even before the official declaration, the World Bank was already critiquing Brazil for its biased attention to AIDS at the expense of a worsening TB situation (Wodtke, Jornal do Brasil, 12/17/89; Santos Filho, 2006; Jornal do Brasil, 3/30/94). These antecedent pressures added to direct criticisms that Brazil would receive shortly after the WHO declaration. For example, at the 10th annual International AIDS Conference held in Japan in 1994, the WHO pointed out that government officials in Brazil and other nations were not recognizing the HIV-TB co-infection problem and that it would kill an estimated 3.5 million people by the year 2000 (O Globo, 8/11/94; Jornal do Brasil, 3/30/94; Gazeta Mercantil, 1/14/94). In 1998, the WHO followed up with another public critique of Brazil’s lackluster response to TB (Tribuna de Impresa, 3/20/98; O Globo, 3/20/98). 414

Academics from the U.S. and abroad began meeting with Brazilian health officials to discuss why the government and civil society was not responding (Biancarelli, Folha de São Paulo, 8/28/96). Some officials in the Ministry of Health were becoming increasing concerned with their inability to adequately monitor and respond to the problem (Jornal do Commercio, 7/14/94). The pressures from above and from below helped to change the government’s perception about the TB problem. By the mid-1990s, the government finally responded. For the first time since the Vargas dictatorship, in 1994 the government officially recognized TB as a national health threat (Santos Filho, 2006). Officials in the Ministry of Health admitted that they had overlooked TB, that they had not taken it seriously and that they needed to respond (Serra, Folha do São Paulo, 4/20/00). Thanks in part to these global pressures, the federal government finally started to aggressively respond to TB, which as noted earlier boded well with former NTBP officials that had always pleaded for a re-centralization of NTBP authority, not its decentralization and collapse (Interview with Dr. Germano Gerhardt, 7/6/06). But note that, as in the past, and as was the case with HIV/AIDS more recently, this change in government perception was not instigated by domestic re-democratization processes. It was thus not an endogenous response to the demands of concerned NTBP officials and segments of civil society calling for a new institution-building response. Instead, and as had been the case with diseases in the past (and especially with AIDS), the government’s response mimicked the new global movement and response to TB. By 1994, the TB growth rate was so high that the government could no longer avoid the situation. Avoiding TB would have sent an obvious message to increasingly alarmed 415

international health community that the federal government was apathetic about the situation and that it was too fixated on the AIDS problem. In response to increased global criticism, in 1994 the government created the “Emergency Plan for TB Control,” which fell under the auspices of the Ministry of Health (Junqueira, O Estado de São Paulo, 3/2/98). The Plan included a monetary transfer of approximately $R100 for each individual case of TB to municipal health agencies (Ruffino-Netto and Figuerido de Souza, 2001). Any additional allocation of money would be based on agreements between the municipalities and the National Foundation of Health, which was part of the Ministry of Health. In addition, government scientists, mainly in the federal Instituto de Oswaldo Cruz, started to conduct studies on the HIV-TB co-infection problem (Gazeta Mercantil, 8/1/94; Jornal do Brasil, 5/5/94). In response to increased global community pressures and its criticisms of the Emergency Plan, in 1998 the National Council of Health re-created the National TB Program (NTBP). As it had done with AIDS in 1985, the government responded to a worsening public health issue by creating a new institution, or this time, resurrecting an old one that had been completely dismantled through decentralization in 1990 (Cioccari, O Globo, 8/4/99). Ministry of Health officials, and even the director of the DST/AIDS program at the time, Dr. Pedro Chequer, noted that in 1998 the Ministry officially declared a new fight against TB (Leali, Jornal do Brasil, 7/23/99). The revival of the National TB Program was thus the first major step that the federal government took in its public display of its commitment to combating TB (Serra, Folha de São Paulo, 4/2/00). Note, however, that the creation of this program came rather late, especially when compared to the creation of the DST/AIDS program in 1985. Consider the fact that it 416

took the government 9 years (!) to create a centralized institutional response to the burgeoning TB problem, notwithstanding its concomitant resurgence with AIDS in the 1980s, especially in Rio (see Figures 1.2 and 1.3). This further confirms the fact that, as noted earlier, the government did not perceive the TB situation as a national health threat until much later and that AIDS was garnering most of the government’s attention. The goal of the new program was to detect, by 2001, 92% of all cases and to cure at least 85% of them (Leali, Jornal do Brasil, 7/24/99). In addition to striving to decrease incidence through DOTS to 50% by 2007 and decrease mortality rates by 2/3, under the NTBP the Ministry of Health was responsible “for establishing official standards for TB control, procuring and providing drugs, developing laboratory and treatment guidelines, coordinating the surveillance system, furnishing technical support to the states and municipalities, and providing inter-sectoral coordination. It [was also] keen on trying to insure inter-sectoral harmony between the federal, state, and municipal level for TB while advocating increased community participation in policy-making” (Ruffino-Netto and Giguerido de Souza, 2001). Further initiatives would be taken by the Lula administration. In 2003, the government mobilized a new federal and social coalition to intensify its commitment to TB. The new goal was to reach and maintain a detection rate above 70%, to cure at least 85% of all new cases, continue to implement DOTS treatment, and maintain a decentralized form of health treatment. By 2004, the administration appeared to have met its goals: detections rates were indeed above 70%, cure rates above 73%, and 30 new public health professionals were hired and approximately 9,000 new ones trained (Basília and Santos, 2005). 417

To further insure a government commitment to TB, in November 2004 the Lula administration created the National Stop-TB Campaign. Comprised of Ministry of Health officials, the business sector and NGOs, this initiative mimicked the Global Stop-TB Alliance which, as noted earlier, was created in 1996. So far it has been very successful at marketing TB as a new national health threat. It has done so by enlisting the support of famous television and movie stars. In fact, at a national TB awareness day in Brasilia that year, a famous movie star was named the national “TB Ambassador” (Basília and Santos, 2005). Moreover, this dovetailed nicely with President Lula’s commitment to his ongoing war against poverty, ushering in a host of new family-based programs among the poor. These types of initiatives are vital for increasing TB awareness and drawing more attention to the problem. Timing and Cosmetic Institutionalism Notwithstanding these new initiatives, there are several problems with the more recent TB campaign. The first has to do with the timing of the government’s response, while the second has to do with its quality. When it came to the timing of institutional change, it became more apparent by the late-1990s that the government’s response was very late. It should have happened as soon as TB resurfaced as a serious threat – that is, by the mid-1980s. As noted earlier, during the 1980s the media and several government officials were cognizant of the fact that TB had resurfaced because of HIV and new socio-economic environment (Jornal do Brasil, 6/27/89; Folhã do São Paulo, 11/29/91; O Globo, 11/22/91; Safatle, Gazeta Mercantil, 1/14/94). Nevertheless, as had been the case with AIDS in the early-1990s, it

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was not until the global health community, specifically the WHO, declared TB as an official epidemic that the Brazilian government started to respond through the resurrection of the NTBP and the creation of new a federal campaign. The government’s response was thus not the product of increased democratic pressures and commitment to social equity, an issue which it had campaigned on throughout the democratic transition. Rather, it was a direct response that was, like AIDS, instigated by new global shifts in attention to TB and pressures for reform. Second, the government was criticized for the quality of the institutions it had created. As had been the case with the national DST/AIDS program during the first few years of the AIDS epidemic (1981-92), the challenge of cosmetic institutionalism once again emerged, prompting international criticism and pressures for continued reform. Indeed, by the year 2000 officials from the World Health Organization (WHO) and the Pan-American Health Organization (PAHO) declared that the resurrected National TB Program was very poorly implemented and inefficient in its response to TB (Ruffino-Netto and Giguerido de Souza, 2001). The NTBP was critiqued for having no long term strategy, having few technical and financial resources and for being incapable of working with the states and municipalities (Ruffino-Netto and Giguerido de Souza, 2001). Furthermore, it relied on financial assistance from the Congress that to this day prioritizes giving money to the DST/AIDS program (interview with Ezio Santos Fihlo, 6/30/06; Santos Fihlo, 2006). What is more, and in sharp contrast to the DST/AIDS program, the NTBP has had to use standard bureaucratic procedures for obtaining additional money. This entails filling out a myriad of government forms and attending countless congressional hearings, which often delays and delimits the acquisition and 419

usage of money, respectively. The DST/AIDS program, on the other hand, is allowed to avoid this red tape and directly apply and receive money, without delay. As noted earlier, this has contributed to DST/AIDS-NTBP conflict and lack of cooperation (Interview with Dr. Fabio Moherdaui, 7/12/06). To get around this problem, the NTBP had to find an alternative means of finance. As was the case with the DST/AIDS program in 1992, this meant going to the international lending community. In 2003, the NATB and the Ministry of Health skipped the World Bank (the DST/AIDS program’s main funder) and instead applied to the newly formed Global Fund to fight AIDS, Tuberculosis, and Malaria (the Global Fund). 70 In 2005, the National TB Program applied for grants (not loans) to expand the program and its technical assistance to the municipalities. Although the NTBP was not approved for a grant the first time around, apparently due to the fact that the Global Fund was not convinced that the interests of civil society were adequately represented in the grant proposal (interview with Ezio Santos Fihlo, 6/30/06), it re-applied in 2006 and was finally awarded a grant of $11 million dollars. Table 8.1 – Global Fund Grant for Brazilian TB Program, Phase 1 & 2 Year 1 Human Resources Infrastructure & Equipment Training Commodities & Products

Year 2 1,271,850

185,000

Total Phase 1 1,271,850 185,000

708,450

1,901,625

2,610,075

960,850

326,320

1,287,170

70

Established in 2001, the Global Fund to fight AIDS, Tuberculosis, and Malaria is a non-governmental organization located in Geneva, Switzerland. It provides grant assistance to nations in need of funding their response to these diseases. The Global Fund does not fall under the United Nations and thus is not accountable to anyone accept its Board of Governors. The Board is composed of representatives from a variety of nation states that contribute money to the Fund.

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Drugs Planning & 1,149,578 Administration Technical Assistance Other 300,402 Total 3,304,280 Source: Global Fund, 2006

1,425,352

2,574,930

555,000 5,480,147

855,402 8,784,427

The government does not, however, get all of the money as once. As Table 1.1 indicates below, the $11 million dollars are divided in to 5 phases, with the first and second phases provided for the first 2 years. The remaining 3 phases are contingent on how well the government uses the money. Ever year beginning after the 2nd phase, a local auditing firm, hired by the Global Fund, conducts an evaluation and reports this back to the Global Fund’s headquarters in Geneva. In summation, the receipt of new international funding notwithstanding, one must keep in mind that as it had done with the DST/AIDS program in the past, the government created a purely cosmetic institution for tuberculosis. That is, while the NTBP program was resurrected in 1994, it was very poorly funded, lacking long-term vision and coordination with the states. The World Health Organization, among others, noticed and critiqued the government for its lackluster response. In addition, its lack of political and technical support from the government, especially when compared to the newly empowered DST/AIDS program, suggested that it was created for the mere signaling of its commitment to change, rather than a genuine commitment to bureaucratic reform (interview with Ezio Santos Filho, 6/30/06).

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~ TB II: THE BUREAUCRACY “FINALLY” RESPONDS (1998-PRESENT) ~ By the turn to the 21st century, an increase in global pressures finally motivated the Ministry of Health to pursue horizontal reforms in order to strengthen the NTBP and its coordination with the DST/AIDS agency. In addition, civil society finally emerged to pressure the Ministry of Health and the NTBP for bureaucratic and policy change. As had been the case with AIDS, and TB in the past, civil society once again responded to the new global shift in attention to TB, prospects for international funding, and used these new opportunities to organize, expand, and pressure the government for reform. Despite these reforms, the government still has not been committed to increasing funding for the NTBP. This suggests that in the absence of a major financial loan, as had been the case with AIDS, the government will not have incentives to fully commit to bureaucratic reform. As the conclusion of this chapter discusses, however, the recent approval of a major grant through the Global Fund to fight AIDS, TB, and Malaria provides a new ray of hope. However, given the new level of support that the NTBP has received from the Lula administration, the NTBP has pressed forward with new vertical reforms. Recent evidence nevertheless suggests that it has not been entirely committed to following through with these new initiatives. As this section illustrates, this has contributed to municipal perceptions that the government is still not fully committed to helping municipal governments eradicate TB at the grass-roots level. This, in turn, suggests that as was the case with institutional designs during the AIDS I period, recent reforms have been introduced for purely cosmetic purposes, such that they were introduced for the

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main purpose of assuaging growing discontent in civil society, not for effectively intervening. Again, and similar to what is occurring at the federal bureaucratic level, the recent emergence of a Global Fund grant and its unique mandate that Brazil (and other nations) create new institutions formally incorporating the views of civil society and municipal governments provides hope that the NTBP will be much more committed to providing consistent financial and technical assistance to municipalities in the future. Because of this new type of institutional conditionality, recent evidence suggests that the NTBP is becoming more committed to following through with its vertical assistance to the states. As we’ll discuss in the conclusion, however, note that this institutional initiative has emerged not from within government, but from the international health community. The Rise of Civil Society and Pressures for Institutional Change In contrast to the initial years of the TB crisis (1980-94), by the early-2000s civil society had finally emerged as an important player in the institution-building process. By the early-2000, civic associations and NGOs finally started to mobilize in response to TB. Recall that prior to this period there existed no civic movement for TB. Nevertheless, and similar to what had occurred during the AIDS II period (1992-present), the global health community’s new interest in TB and pressures for reform also generated incentives for the rise of new civic movements in response to tuberculosis. The civic movement that died out with the decline of TB cases and death rates by the 1950s was quickly resurrected due to new global pressures for change. These pressures also dovetailed nicely with the burgeoning fear in civil society about TB’s resurgence. What is more, and

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again somewhat similar to the AIDS II period, the prospect of obtaining new streams of funding from the international donor community to assist civil society, this time coming from the Global Fund and other international philanthropists, such as the George Soros Foundation (Open Society Institute), created new incentives for the rise of TB activism. It is important to note, however, that this civic movement is new, and only time will tell if it is indeed capable of effectively pressuring the government for reform. While the new TB movement finally emerged, it arrived very late. It was only in 2003 that the first official TB network, or what activists have called the new State Forum in the Fight against TB (henceforth, the Forum), emerged in Brazil. The Forum is dedicated to increasing awareness of the TB problem, promoting access to information, and defending the human rights of those afflicted by the disease (Basilia, 2006). The first Forum of activists emerged in Rio, followed by São Paulo in 2005. In 2003, Rio’s NGOs focusing on community nutrition, human rights, academic researchers, health professionals and TB victims/activists came together to form the Rio Forum. In addition, activists from famous and well endowed AIDS NGOs, such as PellaVida, ABIA, and a host of others came together to provide advice and support. Ever since its inception in 2003, the Forum has been committed to working with the government to obtain more direct vertical assistance from the National TB Program, for a host of prevention and treatment programs. As with AIDS in the past, moreover, the Forum has worked diligently to convince the NATB and the government in general that responding to TB is a fundamental component of human rights. Forum leaders made frequent reference to the 1988 constitution, which is grounded in these very principles (interview with Carlos Basilia, 7/26/06). 424

A similar Forum network was created in 2005, in São Paulo. In addition to a host of community based NGOs focusing on nutrition, human rights, TB victims/activists and researchers, the religious community has also been involved. Pastors from large evangelical churches and the Catholic Church have helped the new Forum network (interview with Carlos Basilia, 7/26/06). Church leaders, activists and researchers frequently come together to strategize on how they are going to respond to TB. São Paulo’s Forum has frequently met to have cafezinho and discuss the TB-AIDS coinfection problem. As we saw with AIDS NGOs on the eve of the AIDS II period, the sudden surge in global attention to TB, when combined with new global pressures for reform, led to the Forum’s rapid growth. Within just three years, from 2003 to 2006, Rio’s Forum grew from 32 to 117 organizations involved in the TB movement (interview with Carlos Basilia, 7/26/06). Rio’s Forum has grown a lot faster than São Paulo’s, with the latter showing a sizable – though not as extreme – increase in size. While NGOs and civil society have finally re-emerged in response to the TB problem, as was the case with AIDS, the prospect of obtaining international funding and support (this time from the Global Fund), when combined with increased criticisms of the federal government’s approach to TB, provided a new opportunity space for civil society to re-emerge and pressure the government for reform. The new civic movement has emerged because of a new opportunity that the global health community has provided, not the NTBP. Indeed, the Global Fund mandates that governments applying for grants formally represent the interests of civil society through the creation of national representative 425

institutions. For the Global Fund, this means the creation of a Country Coordinating Mechanism (CCM). CCMs are a governing body of representatives from civil society, NGOs, government, and the private sector that convene at the Ministry of Health to write a grant proposal. Shortly after its creation in 2001, activists in the TB Forum began to strategically mobilize and grow in order to take advantage of this new funding opportunity (interview with Dr. Afrânio Kritski, 7/17/06; interview with Dr. Germano Gerhardt, 7/6/06). It is important to note that the Global Fund’s mandate that grant recipients create these CCMs also creates incentives for civil society to mobilize; and this has occurred precisely because CCMs guarantee civil societal representation at the federal level. It is thus an internationally-led initiative for federal institutional representation, not a domestic initiative that we typically assume sympathetic parts of the government (such as political parties) create in order to institutionalize the interests of civil society. Furthermore, the Global Fund requires that grant recipients, in this case the NTBP, work closely with civil society, state, and especially municipal health agencies in order to ensure that the grant money is being used effectively (interview with Dr. Margareth Delcalmo, 7/14/06; interview with Dr. Germano Gerhardt, 7/6/06). Before the Global Fund’s emergence, these representative and state-civil societal mechanisms were not guaranteed. Consequently, although the Forum still continued to mobilize (mainly in response to increased international pressures and concern with burgeoning TB growth rates), there were fewer incentives for the Forum to expand and to pressure the government for reform.

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But the ball has certainly started rolling. Now the Forum is starting to work together with other highly experienced, influential AIDS NGOs to pressure the government for reform. Indeed, since 2005 several influential AIDS NGOs and Forum activists have started working together to strengthen the NTBP and enhance its responsiveness to their needs. The primary goal has been to convince NTBP officials that they should start working more closely with the DST/AIDS program in order to stymie the TB-HIV co-infection problem, while at the same time strengthening their relationships with municipal health agencies. These reforms have required that previously hesitant TB bureaucrats push their territorial pride aside (which, as noted earlier, previously precluded them from collaborating with the DST program) and start working more closely with the DST/AIDS program. These pressures from civil society have dovetailed nicely – and indeed, have reinforced – the global pressures for the NTBP and the DST/AIDS program to start working together. Rebuilding the National TB Program And so they have. After extensive international and domestic criticism, the Ministry of Health finally realized that it needed to change its approach to the TB situation and show that it was, for the first time, equally as committed to helping contain its spread (Santos Filho, 2006). By this point, government officials were frankly quite embarrassed with how much attention and support they were giving the DST/AIDS program, especially when little – if any – attention was given to the NTBP. Officials from the Ministry of Health could not afford to see this go on and new horizontal reforms were immediately

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proposed to strengthen the NTBP’s responsiveness and coordination with the DST/AIDS program (Santos Filho, 2006). For instance, in 2004 the DST/AIDS program, in consultation with the NTBP, took the initiative to create a new position that focused exclusively on enhancing its coordination with the NTBP. Lead by Dr. Fabio Moherdaui, a physician with extensive domestic and international experience and who has worked in the DST/AIDS program since its inception in 1985, he has been responsible for not only providing financial support to the NTBP, but also for co-sponsoring new initiatives, such as increased technical training, while proposing jointly sponsored conferences with the NTBP. Since it’s inception a couple of years ago, Dr. Moherdaui has been unwaveringly committed to achieving these goals and establishing a new partnership with the NTBP (Interview with Dr. Fabio Moherdaui, July 12, 2006). In sharp contrast to the past, since 2004 the relationships between both programs have been very cooperative. Through Dr. Moherdaui, both the DST/AIDS program and the NTBP have expressed a new commitment to working together. And in contrast to prior years, TB staff are now actively seeking the counsel and assistance of DST/AIDS officials (Interview with Dr. Fabio Moherdaui, July 12, 2006). TB officials have incessantly asked Dr. Moherdaui for help and guidance on implementing several of their prevention and treatment programs, thus revealing humility and a willingness to work in a team-like manner. The DST has reciprocated and gone out of its way to provide support. For the first time, since the creation and co-existence of these programs in the Ministry of Health, the DST/AIDS and the NTBP program have been committed to working together to achieve their goals. 428

Adding to this movement has been the provision of new international streams of funding and opportunities to continue working together. The recent approval of a Global Fund grant, for example, provides a good example. As noted earlier, last year Brazil was awarded a grant from the Global Fund totally $11 million dollars, over five years, to fund new prevention and treatment programs. The NTBP is the main recipient, or in Global Fund terms, the PR (Principle Recipient), of the money. The states and, especially, the municipal health agencies are the co-recipients. The grant allows for the DST and the NTBP to work together on creating new programs increasing the HIV-AIDS co-infection problem. This has led to the proposal of new meetings and a conference organized by Dr. Mohrdaui (which mind you, is the first ever conference on this issue) to discuss how these agencies can use this money and the types of programs and policies that they can both work on. In addition to financing new TB initiatives, both agencies are proposing joint programs for increasing prevention and treatment services for co-infected victims. Vertical Assistance As discussed earlier, prior to the 2004 initiate the NTBP did not provide any direct assistance to the municipalities for the monitoring and implementation of TB policies. As noted earlier, in 1990 the president and congress decided to completely decentralize all aspects of TB prevention and treatment policy. However, these programs landed into the laps of mayors that were all but technically and administratively prepared to handle these responsibilities (8/28/96, Folha de São Paulo). At the time, the mayors were juggling a myriad of health policy tasks that were hastily devolved to them through the 1988 constitutional reforms. These tasks included the creation of policy programs, the direct

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provision of primary health care, the hiring and training of new staff, hospital management, and the financing of these initiatives. 71 Such tasks, when combined with the receipt of an inadequate amount of financial and technical support from the states had, by the late-1990s, made it nearly impossible for the municipalities to adequately implement TB programs (Almeida, 1999; Ramminger; 1997; Gómez, 2008). Nevertheless, the combination of several different types of political pressures from international organizations (mainly), politicians, and civil society convinced the government that it needed to start directly assisting the states and, especially, the municipalities. While civil society had not yet mustered an influential group of NGOs to sufficiently exert enough bottom-up pressures on their own, direct pressures from international organizations convinced the government that it needed to implement new vertical programs. Furthermore, and as noted earlier, by the early-2000s the government was quite frankly embarrassed with its response to TB, especially when compared to its stellar response to AIDS (Santos Fihlo, 2006). Many blamed decentralization, as it became increasingly evident that the poorly planned decentralization process – that is, the absence of direct and persistent federal and state technical assistance – along with its fastpace timing was limiting the municipalities’ ability to effectively implement and modernize TB programs. 72 In response, in 2004 the government introduced new initiatives that would increase direct vertical assistance to the municipalities. First, it announced that it would 71

Note that the municipalities also rely on the federal government for financial transfers, mainly through the SUS program. However, these transfers have provided an insufficient amount of money to cover escalating expenditures. 72 Of course, one must take into account the fact that there has been wide variation in municipalities’ ability to implement policy. Not all cities lack sufficient technical and financial resources. Yet, by this point it was quite clear that the largest cities with the worst TB problems, namely Rio and São Paulo, were lacking resources.

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hold regional meetings, twice a year, with all municipal health secretariats. To formally consolidate this process, that year the government created the Brazilian Partnership Against TB (which is, as mentioned earlier, the domestic equivalent of the Global StopTB Partnership). In addition to incorporating the views of civil society and better coordinating with the DST/AIDS program and other ministries, through the Partnership the government sought to engage in a persistent dialogue with the mayors while providing more technical and administrative assistance. For those municipalities with the biggest TB problems, such as São Paulo and Rio, these regional meetings have been very important for obtaining more information about what these municipalities need in order to respond more effectively to the TB situation (Interview with Dr. Vera Galesi, Director of the TB Program, São Paulo, July 12, 2006). There were several immediate benefits to holding these regional meetings. First, meeting with the mayors continued to reinforce the need for more effective DOTS training and implementation. Through these meetings bureaucrats and doctors working in the NTBP meet with local TB managers in order to insure that they are adhering to the DOTS program (Santo Fihlo, 2006). These meetings provide the technical and normative assistance needed to help TB mangers (especially in the more rural, hard to reach areas, such as the Amazons) learn and understand how the DOTS treatment program works and the various strategies they can take to make sure that they are adhering to their medical regiment. In 2004, the NTBP also implemented a host of new guidelines on how to administer DOTS treatment. The NTBP provides technical guideless as to how DOTS should be administered, the type of treatment given and what municipal health 431

secretariats need to do in order to ensure that the poor have access. It has also established new goals, such as promising to assist 315 municipalities with 80 percent of the TB problem by 2007, diagnosing 70% of all pulmonary TB infections with bacillary TB diagnostic tests (sputum tests), while continuing to maintain TB treatment and cure rates above 80%. There is thus a new technical and normative commitment at the federal level, which in turn makes sub-national governments reliant on their advice when in need. Since 2004, the government has also repeatedly stated that it would finance and disseminate all TB medical treatments free of charge. Obviously, in a context where many state and municipal governments are starved of fiscal resources, this support is important for ensuring that TB programs are consistently and properly administered. The government currently finances the manufacturing and distribution of all TB drugs, including MDR-TB, and works through the Centro de Referencia Profesor Helio Fraga (the Brazil National TB Reference Center, henceforth CRPHF) to provide these drugs. Neither the states nor municipalities are allowed to purchase and provide these drugs on their own. The only time they are allowed to do this is when infection rates are spiraling out of control and the federal government cannot distribute the medications on time. Furthermore, the NTBP makes sure that all drugs are provided through public municipal hospitals falling under SUS guidelines. Everyone, rich or poor, has to go to the same local SUS hospital to receive their medications. There are no exceptions. This, in turn, not only reflects a strong federal government presence, but it also establishes a sense of equality and fairness in drug distribution (Interview with Dr. Margaret Dalcalmo, July 18, 2006).

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In addition to providing drugs free of charge, the NATB also provides money for training programs, information, and the procurement of equipment. Such assistance has been critical for the larger cities where there are hundreds of poor neighborhoods. In São Paulo, for example, which next to Rio has the highest number of TB cases, municipal officials believe that this assistance has been important for helping them respond to TB, especially among the HIV co-infected (Interview with Dr. Vera Galesi, Director of the Division of TB, State Ministry of Health, São Paulo, July 12, 2006.) And finally, as a consequence of the arrival of the new Global Fund grant, the government further increased its commitment to directly assisting the municipalities. Such assistance is encouraged by the fact that the Global Fund explicitly dictates as a condition for the loan that the Principal Recipient (PR), in this case, the NTBP, to work directly with municipal health agencies, NGOs, and philanthropic organizations. Consequently, more meetings between the NTBP and the latter have been scheduled for this year and the following, for the duration of the grant, which is for five years. Since the NTBP will be periodically reviewed by local auditing agencies assigned by and working through the Country Coordinating Mechanism (CCM), the NTBP will have more incentives to continually work with the co-recipients of the grant. Some municipal officials have already noted a marked increase in the NTBP’s commitment to meeting with them, mainly as a result of the new grant’s arrival. In Rio, for instance, the Global Fund has forced the government to listen more to the needs of previously stigmatized, ignored TB victims (Interview with Dr. Bettina Durovni, Director of the Division of AIDS, TB, and Lepracy, Department of Health, Municipality of Rio, July 18, 2006). The director of Rio’s municipal health program on TB, AIDS, and 433

Lepracy states that the Global Fund has allowed her to better communicate with the NTBP. She claims that the later has also sought her advice on issues and that they have been committed to working with her for more financial assistance for training programs and policies (Interview with Dr. Bettina Durovni, Director of the Division of AIDS, TB, and Lepracy, Department of Health, Municipality of Rio, July 18, 2006). Other health officials have confirmed this trend, noting that the Global Fund grant has helped to increase direct lines of communication and assistance between the NTBP and various other states and municipalities (Interview with Dr. Germano Gerhardt, July 19, 2006; interview with Dr. Magareth DelCalmo, July 18, 2006.)

~ The Challenge of Committing to Vertical Reform ~ Despite all of these new initiatives, unfortunately since 2004 the NTBP has not completely lived up to its promises. While there is no question that the government and the NTBP is far more committed then it has ever been to vertical assistance, further investigation suggests that it is still not 100% committed to following through and that it needs to improve in the following areas: 1) regularity in the number of times NTBP staff meet with state and municipal health officials; 2) ensuring that municipal governments have adequate financial resources for technical training, staff build up and general administrative capacity; and 3) the development and distribution of free drugs. When it comes to regularly meeting with sub-national health officials, both pundits of the government and government officials themselves have noticed that the NTBP has not remained committed to meeting with municipal health secretariats on a regular basis. Dr. Vera Gelasi, the Director of the São Paulo TB program, stated in an

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interview that the regional meetings held in 2004, which were originally held twice a year with state and municipal health secretariats, are no longer done (Interview with Dr. Vera Gelasi, 7/12/06). Furthermore, she notes that direct NTBP assistance is sporadic and unpredictable. So what’s the problem? Why has the NTBP failed to sustain its commitment to vertical intervention? “It’s Politics,” Gelasi said. She claims that the NTBP only meet with her when the agency director and the president feel that TB is a politically salient issue. If the Lula administration feels on any given day that it’s important, then the NTBP meets with her and continues to press forward with these regional meetings; but when the administration doesn’t, for reasons that she could not provide in detail, it doesn’t. Thus, the NTBP’s response has nothing to do with party allegiance and electoral competition – mind you, both the governor and mayor of Rio hail from the same governing party. Rather, these meetings are influenced by the president and the NTBP’s perception of what’s going on, which is fickle and inconsistent. TB activists have also noted a lack of NTBP commitment to meeting regularly with them. In contrast to what the government claims to have done since 2004, it still does not reach out to the new TB Forums in Rio or São Paulo. Carlos Basilia, director of the Brazil Stop TB Alliance, recently argued in an interview that the NTBP sill does not try to engage in a consistent dialogue with the Forums in Rio and São Paulo (Interview with Carlos Basilia, July 26, 2006). Furthermore, Carlos has as sense that NTBP officials are still not entirely committed to working closely with the Forum, that they often refrain from sharing important information and that they are often apathetic to learning more about what the Forum needs and has to say. This, in turn, makes it difficult for the Forum 435

to know when and how they can meet with NTBP officials (interview with Carlos Basilia, 7/26/06). When it comes to vertical financing, some are also of the opinion that the NTBP still has not been as committed as it should be. Some municipal health officials that I interviewed stated that they are still very much in need of money. For example, São Paulo’s director of the municipal TB program notes that despite all the recent bureaucratic and policy reforms, she still does not have enough money for her prevention and treatment programs (Interview with Dr. Vera Galesi, Director of the Division of TB, State Ministry of Health, São Paulo, 7/12/06). Worse still, she argued that the state government is not providing any financial support. Consequently, she’s had to find additional funding on her own, such as working with the international donor community, e.g., the USAID and PAHO (the Pan American Health Organization), for smaller projects in remote municipalities were access to medicine and DOTS supervision is difficult to achieve (Interview with Dr. Vera Galesi, Director of TB, State Ministry of Health, July 12, 2006). The same situation has occurred in Rio. There, the director of the TB program has also complained that the NTBP is very sporadic in providing financial assistance. Some years it’s great, some years it isn’t (Interview with Dr. Bettina Durovni, Head of the Division for AIDS, TB, and Lepracy, July 18, 2006). As noted earlier, Bettina claims that it all had to do with politics: when TB is perceived as important and where there’s sufficient international and domestic pressure, she gets money; but in the absence of such pressures, she does not (Interview with Dr. Bettina Durovni, Head of the Division for AIDS, TB, and Lepracy, July 18, 2006). 436

Furthermore, despite all the recent efforts to provide TB medication free of charge (which in most places the NTBP has achieved), ironically it’s the most troubled cities where TB incidence rates are the highest that still do not receive enough medicine for DOTS treatment. Again, in Rio, the most problematic area, Dr. Durovni asserts that the NTBP has not provided enough medicine and that the government has been behind in the manufacturing and distribution of certain types of medications (Interview with Dr. Bettina Durovni, Head of the Division for AIDS, TB, and Lepracy, July 18, 2006). As a consequence, she has been forced to obtain medication from other countries, going as far as Bolivia! Keep in mind that the Ministry of Health and NTBP do allow municipalities to procure medication from abroad. As noted earlier, the law permits municipal health departments to purchase foreign medication when TB case rates are increasing at an alarming rate. But the critical issue here is why Dr. Durovni has to do this, especially when medications for AIDS have always been produced on time and in ample amounts. But perhaps the better question to ask is why the city with the highest TB prevalence and growth rate is having this difficulty in the first place? This seems to suggest that while the government has created a generous medication plan, it still has not been fully committed to ensuring that the most afflicted areas have the medications that they need. And lastly, in addition to these sporadic meetings, financing, and in some instances, lack of medication, keep in mind that even after 18 years of administrative decentralization (which began in 1988), most municipalities still lack the human resources needed to launch a successful campaign against TB. While the government has recently provided money for training, it is very sporadic and insufficient, leaving many municipal hospitals understaffed and poorly paid (Santos Fihlo, 2006; Interview with Dr. 437

Afranio Kritski, 7/20/06). Salaries for TB health care workers are still very low and have not increased. In Rio, for example, Ezio Santos Fihlo (2006) notes that a TB health care worker only receives R$1,200 a month (approximately $580), and that this is similar for most other states. Such low pay provides few incentives to remain in the health care industry. In the future, the NTBP will need to focus on increasing the salaries of municipal health care workers in order to retain staff and motivate them to work harder. Some analysts are optimistic that the recent Global Fund grant for Brazil will help full in these lacuna. But this raises a key issue: why has the government waited on external funding to do accomplish these tasks? What is it waiting for? While the argument can be made that it’s simply a lack of resources and that the government has had to wait for additional money, and while this may certainly help to explain the delay in the financing and production of much needed mediations, it still cannot explain why the NTBP has neglected to meet with municipal health officials on a regular basis. Furthermore, it still cannot explain why the NTBP is not fully committed to working closely with civil society, especially when compared to the DST/AIDS program’s persistent interaction with them. Thus in sum, although the Ministry of Health and the NTBP has introduced an impressive array of vertical reforms since 2004, it still seems that they are not 100% committed to them. While the absence of the federal government may be easily justified based on federalism and increased efficiency through decentralization, when compared to how the government responded to AIDS, such an argument can easily lose merit, especially when many municipalities are still undergoing a serious TB and general health care crisis. As seen with AIDS, under these emergency conditions federal intervention 438

can be easily justified. Note that the federal government did not hesitate for a second when it came to responding to yellow fever and tuberculosis in the past (Houchman, 1996; Filho, 2001; Nascimento, 2005). Indeed, and as we saw with AIDS, the federal government could just have easily intervened at the municipal level for TB. But it still hasn’t done this, which suggests – at least to me - that either that the current Lula administration is still apathetic about the TB situation or that it is more committed to safeguarding the tenants of democratic federalism and decentralization. Nice, but not really that nice.

~ Conclusion ~ In closing, when compared to the government’s response to AIDS, the findings in this chapter clearly indicate that there was no concrete institution-building when it came to TB. Despite the fact that tuberculosis reemerged and increased along with HIV and other changes in the socio-economic environment, initially the President, the Congress, and the Ministry of Health did not try to create a centralized institutional response to the epidemic. Instead, during the first few years of TB’s resurgence, the absence of global pressures and the absence of a well organized civic movement allowed for the overawing pressures of decentralization to completely dismantle Brazil’s long history of combating TB through its highly centralized, autonomous National TB Program. The incentives to decentralization were further reinforced with the lack of executive and ministerial perceptions that TB was a problem. As with other social welfare and fiscal policies during this period, TB control was hastily decentralized, landing into the laps of

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municipal health agencies that had very little experience and few resources to adequately implement policy. Initially, the NTBP technocrats were also rather ineffective in their response to TB. For while they perceived the TB situation as an urgent matter, and although they worked together to pressure the president for maintaining and expanding the NTBP, when it came to institutional change, that is, working with other agencies in response to TB, their unique history and pride precluded them from doing this. As the most highly revered disease combatants in Brazilian history, NTBP technocrats never felt compelled to immediately work with the newer, more pompous national AIDS bureaucrats, especially when the AIDS bureaucrats were receiving much more attention. The fear that they were being ignored by the President and the Ministry of Health, which suggested that their national program could be quickly dismantled, created disincentives to immediately work with the AIDS bureaucrats. NTBP officials reasoned that working independently, in addition to incessantly reporting about the surge in TB cases and requesting additional funding in response, could help to justify their continued existence. But working independently also derived from their anger and jealousy, especially when TB was re-emerging as a co-infection problem and they were not being consulted on the matter. Under these conditions, the NTBP had no incentive to try and work with the AIDS program. Territorial pride and the absence of a pro-active civic movement supporting their reform efforts would in the end add nothing to their efforts to maintain and strengthen the centralized NTBP. This, in turn, provided the conditions for precocious decentralization to overawe their institution-building preferences and completely dismantle the NTBP by 1990. 440

Similar to what had occurred during the AIDS II period (1992-present), executive interests and efforts to centralize the government’s response to tuberculosis occurred only after the emergence of new global shifts in the global health community’s attention to TB and their increased criticisms of Brazil’s response. While the race to international fame and the immediate global financial incentives to win were absent for tuberculosis, incessant criticism and pressures from the international community did nevertheless convince the executive that institutional reforms were necessary. By the late-1990s, the government finally responded by resurrecting the previously dismantled NTBP while engaging in new vertical relationships with municipal health agencies and civil society. Moreover, NTBP technocrats finally pushed their pride aside and started working with DST/AIDS bureaucrats for a more coordinated response to TB. New institutions were created; new horizontal collaborative schemes established; new vertical ones, too; … for a moment, it seemed as if effective institutional reformers were going to occur. But sadly, it didn’t. The government would in the end confront the same institutional problem that emerged during the AIDS II period: that is, the challenge of cosmetic institutionalism, where centralized response and institution-building was conducted mainly for assuaging an increasingly restless global health community, rather than effectively intervening to save lives. In addition, in the absence of global and thus domestic career incentives, coupled with the absence of a well-organized civic movement, there were still no sufficient incentives for the president to press forward with concrete reforms. In the end, despite new presidential interests in supporting the NTBP, by 2004 it was still lacking money and political support. As you recall from Chapter 6,

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the same problem occurred with the national DST/AIDS program during the AIDS I (First World) period (1981-92). This unfortunate toll of events leads me to conclude that as was the case with AIDS, the incentives for institution-building derived not from the democratic transition process and its grounding in the tenants of human rights and social equality, but rather from new global structural shifts and pressures for change. As was the case during the second phase of AIDS politics period, notwithstanding the government’s increased awareness of the TB problem, despite the incessant pressures from TNBP technocrats for reform, and despite the well know inefficiencies of precocious decentralization, the government would not respond until the global health community recognized TB as a new health threat. Global perceptions and response therefore emerged well before the Brazilian government’s did. This finding therefore suggests that we can in now way presume that democracies transitioning from suppressive military regimes unwaveringly espoused to the principles of human rights and social equality will be committed to immediately responding to the needs of civil society whenever a new (or even old) epidemic emerges. It is only when epidemics are first perceived by the global health community as genuine threats that nascent democracies, such as Brazil, will respond to them. It is only when global pressures highlight lackluster domestic institutional responses (or no responses at all) that new democracies, such as Brazil, respond. This seems to suggest that we can in no way presume that nascent democracies will always put the needs of civil society above and beyond the immediate perceptions and interests of democratic elites.

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Brazil’s response to tuberculosis also confirms the fact that democracies – both old and new – can be quite biased in the types of epidemics they respond to. Just because they are democratic does not mean that they will respond equally to all types of diseases. For example, although AIDS and TB encountered similar global pressures, the incentives for institution-building were radically different: the immediate prospect of obtaining a financial loan from a major lender, the World Bank, and thus the opportunity for Brazil to increase its recognition as the global leader in response to AIDS induced federal elites to prioritize AIDS over any other health issue, including TB. Tuberculosis did not have these same initial opportunities, which was clearly reflected through the government’s lackluster institutional response to its reemergence. Note that it is only recently with the grant from the Global Fund to fight AIDS, TB, and Malaria that the federal government has started to respond through strengthening the NTBP and engaging in new vertical relationships with the municipalities. However, if the Global Fund had emerged earlier, that is, in tandem with the first World Bank loan in 1992, then perhaps the government’s response to AIDS and TB would have been similar. Time will only tell if the Global Fund has the same impact that the World Bank loans have had in strengthening the government’s commitment to institutional change. And lastly, just a brief note on the reemergence of civil societal response to TB. What is most striking about civil society’s response to tuberculosis is that it mirrored the virus’ evolution: that is, the civic movement died out along with the disease by the 1950s and then suddenly re-emerged later with the resurgence of TB by the 1980s. What is surprising is that, in contrast to AIDS, there was never a strong civic movement for TB during the initial stages of TB’s resurgence, especially during the re-democratization 443

period – a landmark era when civil society was fighting for greater human rights, social equality, representation, and universal access to health care. Unlike AIDS, there were no NGOs or civic organizations fighting for those suffering from tuberculosis, no civic association that fought for the rights of the poor and the HIV-TB co-infected. Why? In large part, this had to do with the neglect of civic elites in society, that is, medical doctors, lab technicians and academics who for the most part did not initially perceive TB’s resurgence as a new threat. Despite alarming growth rates, especially in the larger cities of Rio and São Paulo, these elite perceptions, which closely resembled the President and Ministry of Health’s initial reactions, generated no efforts to organize a new civic movement in response to TB. But recall from Chapter 4 that these were the types of civic elites that created the successful Liga do Tuberculose in the past. What happened? In essence, it was the absence of career advancement and prestige through the discovery of a new vaccine for TB, when combined with insufficient technical infrastructure, resources, and weak linkages with the poor that generated few incentives for these so-called “democratic civic elites” to mobilize. (This says something about the empathy and care of democracy’s new civic elites, an issue that I will return to in the conclusion of this dissertation.) However, this clearly was not the case with AIDS, where the prospect of vaccine discovery, prestige, and money was more than abundant. Thus, in sharp contrast to the pro-active Liga movement in response to tuberculosis in the past, which emerged during the country’s first bout with TB in the early 20th century, by the early-21st century there were no incentives and efforts to immediately respond and enact new “bottom up” pressures for reform. Interestingly enough, despite a growing co444

infection problem during the initial years of the TB crisis, moreover, there were no positive externalities and diffusion effects between the pro-active AIDS NGOs, which were growing by the minute. Note, however, that the TB community did eventually respond. But in sharp contrast to the past, these new civic movements were prompted not from the bowels of an increasingly disenchanted civil society but rather from the emergence of a new global shift in response to the emerging TB pandemic. Civil society really did not respond until the WHO and other international organizations started pressing Brazil for a more effective response to TB. These new civic movements emerged because it was the global health community, not the domestic government – e.g., parties, bureaucracy – that created new opportunities for the resurgence of civil society and pressures for reform. But keep in mind that even after the emergence of these new civic movements, the federal government still did not immediately respond. Even after the arrival of the new Global Fund money, remember that Brazil failed to initially qualify for a grant because of the fact that the Global Fund believed that the government still had not committed to adequately representing the interests of civil society on CCMs. Indeed, in the end it was the Global Fund to fight AIDS, TB, and Malaria that provided the domestic institutional mechanisms and opportunities needed for civil society to reemerge and to have federal officials finally respond to their needs. More specifically, it was the Global Fund’s mandate for the creation of Country Coordinating Mechanisms that forced NTBP officials to formally institutionalize the interests of civil society through CCM meetings in the Ministry of Health. It was, in essence, an institutional conditionality, such that if the federal government did not create the CCM, no grant 445

money would be provided. The interests of the Global Fund comported nicely with the interests of a new civic movement, the TB Forum, in Rio and São Paulo, to ensure that the needs of TB victims were represented. The CCM has thus provided a new domestic institutional mechanism that generates the motivation and incentives for civil society to continually mobilize and respond. It is important to note the different structural origins of these institutional mechanisms; for they emerged not from within government, as some comparativists would have us believe. For instance, Theda Skocpol (1993) notes that the presence of sympathetic federal bureaucratic officials is a necessary condition for the creation of bureaucratic committees that formally represent the interests of civil society (in her case, mothers and children). The origin of institutional mechanisms is thus the federal government. But note that the origins of institutional representation may also emerge from the global level. In the case of Brazil, the Global Fund forced the National TB Program to formally represent the interests of civil society through the mandated creation of the CCM. This, in turn, has not only motivated TB technocrats to support and uphold this institutional mechanism, but it continues to motivate civil society to mobilize and pressure the NTBP and the Ministry of Health for reform. The potential consequence of this institutional mechanism is very positive. For as was the case with the sanitarium movement for AIDS and their formal representation in the National AIDS Commission, the resurgence and institutionalization of the TB Forum will now create new informal relationships between civil society and those NTBP bureaucrats committed to state-building; this is an informal pool of resources that these bureaucrats can use to justify an increase in the expansion and autonomy of the NTBP. 446

As we saw with the pro-reform bureaucrats in the national DST/AIDS program, this pool of resources is vital for not only justifying bureaucratic expansion, but also for increasing the recognition and influence of pro-reform bureaucrats. As we saw with AIDS, this, in turn, engenders a two-way reciprocal relationship, where the bureaucratic prestige associated with supporting the TB community (and the international lending community, such as the Global Fund, which supports these initiatives) generates career incentives to consistently work closer with civil society, while the latter, through the TB Forum, have further incentives to voice their needs through new representative channels in CCMs. Only time will tell if this type of two-way reciprocal relationship emerges and if it creates self-generating bureaucratic and civil societal incentives for state-building – the recipe of success behind Brazil’s successful state-building response to AIDS. In closing, it is surprising to see just how biased the Brazilian government has been in its response to epidemics. While it has done wonders and has become the world leader in response to AIDS, it has not done the same for TB. It is only recently that the government has decided to respond through new state-building initiatives. While new global pressures and financial incentives have recently emerged, mainly due to the Global Fund, more time is needed to see if the federal government will use this money effectively. In other words, as it did with AIDS, we have to wait and see if the government will use this money to become the world leader in response to TB. Based on what we saw in Chapter 4, and given the rich history of Brazil’s plight to become the world leader in combating disease, I remain optimistic and hopeful that it will do the same for TB and other recent health threats, such as obesity and chronic heart disease.

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CHAPTER 9 Conclusion I conclude with a simple message, captured by the rich historical and contemporary case studies in this dissertation: that democracies, no matter how old and advanced they are in the consolidation of their presidential and electoral systems, do not immediately respond to epidemics and the needs of civil society. The theorized benefits associated with electoral accountability, a free press, and the bottom up pressures of federalism and decentralization as catalysts for an immediate government response does not appear to be an important factor in motivating governments to respond. More broadly, what this suggests is that Amartya Sen’s (1999) thesis that democracy and development safeguards society from the peril of health epidemics is incorrect, indicating that, at least when it comes to institution-building for public health, democracies can be initially unresponsive to the immediate needs of civil society. If, indeed, democratic elites behave in this manner, then going forward it is important that we focus on the federal elites themselves, more specifically the factors that motivate their threat perceptions and the structural and/or ideological conditions underpinning them and leading to their change. By doing this, we can gain a better sense of how committed democratic elites are to the needs of civil society and the conditions that motivate their decisions to finally respond.

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As we saw in this dissertation, however, democratic elites – even those harboring promises of social equality and equity in social welfare redistribution – often perceive health threats differently from civil society and those public health officials supporting their cause. The emergence of new epidemics is often contested between presidents, congressmen, and reform bureaucrats; their perceptions of a health threat are influenced by antecedent structural conditions and legacies that are unique to each of these levels of government. During what I call this first phase of epidemic politics, federal elites cannot agree to an immediate institution-building response, notwithstanding their knowledge of the fact that a decentralized approach to containing disease has not yielded effective policy results. Instead, what the findings in this dissertation show is that political elites often wait several years before they respond to epidemics through institution-building processes, and that when they do eventually respond it is done for reasons other than meeting the needs of civil society. An epidemic’s threat to the national security or the emergence of new global pressures and the incentives they provide for aspiring political leaders to increase their reputation are instead shown to be more important factors shaping the perceptions and interests of politicians to pursue reform. The extent to which one of these two conditions motivates elites to respond depends on a nation’s relationship with the global health community. Within more isolated democracies, such as the United States, this dissertation has shown that reforms tend to reflect the interests of politicians and bureaucrats, not the international community. As we saw historically, our government has only responded to epidemics when they are seen to pose a direct national security threat, specifically the ability of 449

military soldiers to fight in war. An epidemic’s personal threat to the president, such as polio’s effects on FDR, has also made reforms a priority. In this context, PHS officials throughout history and up to the present day have tended to work on their own, repeatedly incapable of obtaining support for institution-building and creating a civic and international coalition for reform. This, in turn, has reflected the U.S.’s relationship with the international health community, where it has continuously sought to lead through international financial assistance and technical support, rather than allow international organizations to penetrate and influence domestic policy. In contrast, for those nations that have been more open and cooperative in working with the international health community, such as Brazil, reforms have tended to reflect the interests and pressures of the international health community and their interest in revamping domestic institutions and policy. In this context, politicians responding to international criticism by supporting institution-building in order to increase their reputation, in addition to taking advantage of international lending to achieve these ends, have provided an opportunity space for the emergence of historically-based tripartite partnerships between the international health community, public health bureaucrats and civic organizations seeking a centralized institution-building response. This, in turn, has allowed for continued incentives and the ability of reform bureaucrats to motivate the president and the congress for continued administrative and policy reform. These differences in a nation’s receptivity to the international health community also account for differences in institution-building outcomes. That is, Brazil’s receptivity to the international community has led to a more aggressive institution-building response to AIDS when compared to the United States. Brazil’s ongoing interest in increasing its 450

international reputation, when combined with its willingness to readily accept international financial and technical assistance from organizations such as the World Bank, has created a government that has been consistently committed to strengthening its National AIDS Program. However, the international community’s delay in pressuring the government to respond to TB, and the resulting lack of incentives for politicians to increase their international reputation and acquire resources has generated few incentives to re-build an effective National TB Program (which was dismantled through decentralization processes in 1990) while providing assistance to the states. With the recent arrival of funding from the Global Fund to Fight AIDS, TB, and Malaria, we can only hope that this will increase the government’s commitment to combating TB in the future. Nevertheless, Brazil’s centralized institutional response to AIDS has shown that within large democratic federations, creating strong federal agencies is important for helping local governments respond to the needs of civil society. And this is especially important in a context where the decentralization of health policy management has occurred in a rapid and poorly designed manner. The United States initially shared with Brazil the fact that both governments relied on poorly designed decentralization programs to respond to AIDS and other non-sexually transmitted diseases, such as TB and obesity. Yet unlike Brazil, eventually the U.S. did NOT create new federal agencies or strengthen pre-existing bureaucracies in order to provide direct assistance to the states. This has led to acute differences in the types of prevention and treatment policies being implemented, while at the same time suggesting that our government was apathetic to the needs of local governments and more importantly, the needs of civil society. 451

But this raises a key question. Why have I been arguing all along for a centralized institutional response to epidemics when, in fact, the literature and health policy community has advocated a more decentralized approach to controlling diseases (Bossert and Beauvis, 2001; Donaldson, 1994; Khaleghian, 2004)? While I do not dispute the fact that decentralization has helped governments respond to epidemics in nations where the geographic size of the country is small and where decentralization was pursued in a gradual manner (such as in Asia; see Smoke, Gómez, and Peterson, 2007), centralization has been important within larger geographic federations and where decentralization was quickly implemented and poorly designed. In this context, and as we saw in the detailed case studies in this dissertation, municipalities often lack the resources needed to respond to epidemics in a timely and effective manner. In addition, a delayed local response contributes to a viruses’ spread and the belief that the federal government is apathetic to citizens’ needs. Centralized institution-building is thus not only perceived as important for policy implementation within large federations, as others have argued (Nathanson, 1996; Gauri and Khaleghian, 2002; Gómez, 2007), but in this context it has also been important for helping build trust in government more generally. Trust in government comes not only from politicians’ commitment to institutional-building, but also in the understanding that it takes considerably more commitment and resources to create and/or reform of public health institutions than to create and implement policy. Institution-building is a complex process, requiring new degrees of political, bureaucratic, civic, and international support. It is a much more complicated process than crafting health prevention and clinical treatment policies. Because of this, I argue that institution-building provides a better indicator of government 452

commitment to containing the spread of disease, and that in the future it should be established as a new indicator and benchmark for adjudicating weather or not nations are indeed committed to responding to epidemics and the needs of civil society. Because of this, future scholars and policy-makers should pay more attention to the endogenous and exogenous conditions leading to successful institution-building, or more precisely, the creation and/or adaptation of public health agencies. Until now, this is a topic that has not been addressed in those studies examining the quality of government response to health epidemics. Instead, most scholarship has tended to focus on the political conditions leading to more effective policy implementation (with a biased emphasis on AIDS), without considering the conditions leading to successful institutional change for public health. Alternatively, an approach that I have introduced in this dissertation is focusing on the civic sources of institutional change. Here, the focus is more on the exogenous (domestic) resources that public health bureaucrats have at their disposal when seeking institution-building processes. The civic sources mentioned here refer to the rich history of partnerships between civic organizations that are closely aligned with international health movements and those public health bureaucrats seeking centralized institutionbuilding. As we saw in Chapters 3, 4, and 6 with Brazil’s response to syphilis, AIDS, and TB, the history of these partnerships, and contemporary bureaucrats’ efforts to resuscitate them, provide contemporary bureaucrats with the legitimacy and influence needed to consistently pressure the government for a sustained commitment to institution-building. Thus, I argue that what is necessary for effective institutional responses is the availability of these historic partnerships, as well as contemporary bureaucrats’ interest and ability to 453

resuscitate them in response to new health threats. Finally, as we saw with the case of Brazil, this process is aided by the fact that reform bureaucrats have personal career incentives to once again reach out to civil society, and to work with them in forging a historically-based tripartite partnership with international organizations. While this approach submits new insight into theories focusing on institutional change, it also establishes a bridge between theories focusing on the origins of institutions and institutional change. This is an issue that has not been addressed in the comparative politics literature. However, as I outlined in Chapter 4, by clearly establishing the causal mechanisms that link the formation of institution-building coalitions in the past with contemporary efforts to resuscitate and use them in the future, not only do we learn more about the institutional change process but this also enhances our ability to describe, understand, and predict the quality of exogenous resources available to previously marginalized reformers within bureaucracy. In addition, through this approach we can begin to compare the strengths of different types of exogenous (civic-based) resources based on the unique history underpinning their reform ideas and beliefs. This helps us to better understand the types of ideas – e.g., decentralization versus centralization – that have greater credibility with the president, the congress, and the international health community. Finally, I argue that this approach provides us with a more effective tool for predicting if and when public health agencies are capable of adapting to the emergence of new health epidemics. Specifically, it enhances our ability to detect if bureaucrats within government have had a rich history of forging partnerships with civic organizations and international organizations; this, in turn, can provide us with a better understanding of the 454

civic resources that bureaucratic reformers have at their disposal and, thus, their capacity to engage in effective (and consistent) institution-building. In the future, academic scholars and policy practitioners will need to work harder at coding nations based on the availability and quality of these civic resources while explaining how and why reformers use these resources for their organizational advantage. When it comes to policy, this study further suggests that in the future, international organizations, such as the World Bank or the Global Fund to Fight AIDS, TB, and Malaria, should begin to invest more in helping reform bureaucrats find and resuscitate institution-building partnerships between civic organizations and government, rather than focusing exclusively on funding civic organizations directly. Likewise, governments need to invest more in resuscitating partnerships with civic organizations, especially those that have had a long history in working with federal officials for institution-building. International organizations and domestic governments can achieve this by sponsoring conferences, workshops, and partnerships that educate bureaucratic officials of their history of working with civic organizations and the benefits associated with doing so. On the other hand, as we saw in this study with the Global Fund’s work on TB policy in Brazil, international organizations can motivate governments to resuscitate their ties with civil society by imposing new institutional conditionalities for grant assistance. This occurs when governments are forced to re-connect with civic organizations through their representation on national grant committees. This is done in order to insure that the needs of civil society are represented, and that the grant money is used effectively. By doing this, international organizations can help – rather, force – governments to 455

reestablish linkages with civic organizations when seeking reforms. This suggests that the availability of international resources and pressures introduce benefits to those nations that have been perceived as being on the periphery and negatively affected by volatilities in the international market. Indeed, while globalization appears to have threatened the sovereignty of many nations and contributed to an increase in income inequality, poverty, and illness around the world, it has also provided the benefit of reconnecting government with civil society. An increase in international criticism and pressures for reform has led to the reemergence of long-forgotten partnerships between government and civil society. For example, the imposition of aid conditionality from the Global Fund, in addition to ongoing criticisms from the World Bank and the World Health Organization, has motivated bureaucrats to reestablish long-lasting traditions of working closely with those civic networks and organizations that have a long history of working with federal health officials for institution-building. As we saw in Brazil, this has helped to strengthen government ties with civil society, while helping build more trust and confidence in the government’s commitment to meeting civic needs.

The Way Forward: Working with the International Health Community In closing, it is interesting to see how Brazil has been able to outpace the United States in its response to epidemics, especially HIV/AIDS. But how could this be? How could a nascent democracy like Brazil, which has far fewer resources and a weaker public health system, surpass the United States when it comes to institution-building for public health?

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As we saw in this dissertation, the answer is rather simple. As I have indicated, this comparison with Brazil has once again highlighted the fact that it is our government’s repeated arrogance and unwillingness to respond to international criticisms, in addition to its prideful disdain towards obtaining financial resources and technical support from the international lending community, which has provided few incentives for our government to pursue institution-building for public health. And this has occurred even when domestic health officials have incessantly pressured the government for this kind of response. The government’s belief that it has nothing to prove to the world, itself fostered by our superpower status, has reinforced this mindset. Why does our government continue to behave in this manner, and what can future leaders do to change this? In the future, I believe that our political leaders will have to humble themselves and work more closely with international organizations for a more effective institutional and policy response to ongoing health problems, such as our persistent (and often forgotten) struggles to contain the spread of AIDS within our inner-cities as well as burgeoning overweight and obesity patterns among children. Our citizens can no longer afford to have a government that is repeatedly too arrogant to take advantage of ample foreign aid and technical assistance. While our government should nevertheless try to maintain its commitment to providing funding to international organizations, such as the World Health Organization, the World Bank and the Global Fund to Fight AIDS, TB, and Malaria, perhaps it is time that we start joining others in becoming a recipient of donor aid as well. Brazil, for example, is both a donor for AIDS funding and a recipient for TB funding from the Global Fund. Should our government do the same? Or are we too concerned with our superpower status to try such a bold maneuver? These are questions 457

that future administrations will have to consider, especially as we seek to work closely with the international health community in striving to contain the spread of disease and growing health inequalities both within our country and throughout the rest of the world.

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