Off Topic? Protests, Democracy, and Health Care in Brazil

Off Topic? Protests, Democracy, and Health Care in Brazil

Gilberto Lopes, MD, FASCO, MBA

Jul 11, 2013

The year was 1992. The country’s economy was in turmoil and prices were skyrocketing. As a young medical student, I joined a crowd of hundreds of thousands of protesters demonstrating throughout Brazil. We were claiming for the impeachment of Fernando Collor, our first elected President in 30 years, after the military returned government to civilian hands in the 1980s. Amid the growing popular discontent and an advancing congressional investigation for alleged corruption, he resigned. Lawmakers later made him ineligible for public office for eight years, echoing the ancient Greek democratic institution of ostracism. Brazil eventually defeated hyperinflation and started a process that would lead to the near elimination of extreme poverty in recent years.

Fast forward two decades and Brazilians from all walks of life—students, families, pensioners, and even physicians—are taking to the streets again. With unemployment below 6% (in contrast with the appalling swarms of youth searching for jobs in vain in much of the developed world), with the economy growing at a slow but steady pace, and with the poorest of Brazilians reaping the greatest benefits, a casual observer would be forgiven for asking what my countrymen and women are complaining about. Dig deeper, however, and one finds why.

Small triggers reveal deeper discontent

A small bus fare increase of 20 Brazilian cents, approximately nine U.S. cents, triggered a small movement in the city of Sao Paulo, Brazil’s economic dynamo, emulating a previously successful demonstration in my home town of Porto Alegre, in Southern Brazil. The government, through a poorly paid and trained yet brave police force, which lives its days in fear of being killed by drug dealers and armed gangs, initially responded with unwarranted brutality, waking a sleeping giant. In the days and weeks that followed, millions of people took to the streets across the country, in mostly peaceful protests that have the support of 80% of the population and which have revealed the real grievances.

Brazil has a bloated government, which collects developed-world–level taxes, representing 36% of the country’s GDP, while providing patchy public services of often dubious quality. Corruption is endemic and rampant. Infrastructure is creaking, and we can certainly do a lot better in education and health care. In one of the street demonstrations a sign read: “First world stadiums, third world hospitals and schools,” alluding to the billions of dollars of public money being spent to host the 2014 Football [Soccer] World Cup. Don’t get us wrong, we still love the game and will welcome all those who attend the competition next year with an unforgettable party and the experience of a lifetime, but we were promised that the taxpayers would foot the bill for the infrastructure, which would be the event’s legacy, not the sports venues, which were supposed to be funded from private concessions.

The protests showed that the Brazilian democracy is alive and well. Contrary to decades past, the military is silent and subordinate to civilian government. The demonstrations, which were mostly pacific but did claim a few lives in isolated yet tragic events, shook politicians from their usual lethargy and pork-barrel spending behavior. In a very busy week, the lower House and the Senate passed legislation addressing many of the main popular requests. A project to amend the constitution and decrease the independence of Brazil’s attorney generals in investigating the government was voted out as was another that aimed to make Supreme Court rulings subject to congressional approval [the Supreme Court recently condemned several politicians who had connections with Lula, the former President, and the current ruling party]. Corruption was also deemed to be a serious crime, opening the road for the creation of stiffer penalties.

Calls for greater investment in health care

Finally, the President, Dilma Roussef, after being very publicly booed during the opening of the soccer Confederations’ Cup, a dress rehearsal for next year’s big event, started a process of broad consultation with elected officials in all spheres—federal, state, and municipal government as well as the opposition—and with the society at large for political reform. She proposed that the totality of the administration’s receipts from oil—US$ 6 billion in 2011, a number likely to increase significantly as deep water deposits are explored—should go to education. Congress voted that 75% should go to education and 25% to health care.

Brazil’s unified health care system [SUS in Portuguese]—one of the main popular achievements during the democratization process and enshrined in the 1988 constitution, which protects health care as a right of every citizen and an obligation of the State—desperately needs this boost and more. While covering 75% of the population, public expenditures represent less than 50% of health care expenses. Moreover the system is inequitably concentrated in the most developed regions, and many areas of the country have fewer physicians than needed and working conditions can be far from ideal with a lack of even basic supplies and working conditions.

 In the weeks that followed, in Brasilia, the nation’s capital built in the 1950s in what was then the middle of nowhere, and elsewhere, thousands of our colleagues rallied to voice their views and call for more investment in health care, for the creation of a State career for physicians, and against a government’s plan to allow foreign physicians to practice in Brazil without revalidating their medical credentials locally. While measures to increase the number of health care workers in underserved areas are urgently needed, as a physician who has worked in three different countries, taught in scores of others, and who had to take three different tests and work under supervision for years before being able to obtain full licenses in the United States and in Singapore— and who will need to sit for another exam to be considered an oncologist in Brazil—I can attest to the importance of adequate evaluation in ensuring the quality of the physician workforce, without which we really won’t have any improvement in our medical care.

George Orwell said that if we wanted a picture of the future we should imagine a boot stamping in a human face forever. What my fellow countrymen and women showed this month is more in line with Eleanor Roosevelt’s words: “The future belongs to those who believe in the beauty of their dreams.”

Was I off my usual oncology-related subject in this post? Not really. It is only through public participation and the strengthening of health care systems funding and care provision that low- and middle-income countries can truly improve cancer control in the long run. Countries with less-developed health infrastructure have worse cancer outcomes as patients struggle to have access to preventive, diagnostic, therapeutic, and rehabilitative services. Increasing health care worker training, the creation of cancer centers of excellence, virtual teaching, international support, and other initiatives can help, but a well-funded system with universal coverage is of fundamental importance for conquering cancer in low- and middle-income countries.

Oh, yes, I almost forgot to mention: the transport fare hike in Sao Paulo was cancelled.


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