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THE POLITICS OF GOVERNMENT RESPONSE TO HIV/AIDS IN RUSSIA AND BRAZIL: HISTORICAL INSTITUTIONS, CULTURE, AND STATE CAPACITY Eduardo J. Gómez Working Paper No. 4

June 2006 http://www.globalhealth.harvard.edu/WorkingPapers.aspx The views expressed in this paper are those of the author(s) and not necessarily those of the Harvard Initiative for Global Health. 20o6 by Eduardo J. Gómez. All rights reserved.

Eduardo J. Gómez Politics and Governance Group Department of Population and International Health Harvard School of Public Health Building 1-1210 Boston, MA 02115 Department of Political Science Brown University 36 Prospect Street Providence, RI 02912 Email: [email protected]

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I.

INTRODUCTION

This paper presents a cross-regional analysis of the politics of government response to HIV/AIDS in Russia and Brazil. It elaborates on an alternative interdisciplinary approach to understanding the politics of government response, emphasizing a combination of historical institutionalism, cultural analysis, and state bureaucratic capacity for implementing AIDS prevention and treatment programs. This approach argues that Brazil responded more aggressively to the AIDS epidemic than Russia because of a series of antecedent historical institutional differences which engendered by the early-1980s a federal elite commitment to building an autonomous, highly centralized bureaucracy controlling the spread of disease while working with civil society for more effective policy implementation. In addition, the relative absence of an early institutionalization of Christian moral values contributed to the emergence of a responsive federal elite facilitating and encouraging collective action among homosexuals at the outset of the AIDS epidemic. Hence, a persistent federal government commitment to state building in response to epidemics, coupled with the state’s willingness to respond to civil society, has led to the implementation of successful anti-AIDS programs. In contrast, Russia’s recent failure to build strong, centrally governed federal agencies committed to AIDS policy implementation is attributed to the historical absence of federal elite commitments towards these types of state-building activities, with a corresponding reliance on decentralization and communal health care instead. Moreover, and in sharp contrast to Brazil, the early historical institutionalization of Christian morality and conservative socialist values led to the emergence of federal elites and institutions that were condemnatory towards those engaged in immoral sexual and narcotic behaviour, in turn complicating the capacity of civil society to mobilize in response to the government at the early stages of the AIDS crisis. It is shown that these historical trends persist today and go far in explaining the current administration’s lackluster response to the enduring AIDS problem.

II.

RE-APPRISING THE POLITICS OF GOVERNMENT RESPONSE TO HIV/AIDS

Comparing the politics of government response to health epidemics has been of recent interest to political scientists. In the area of HIV/AIDS policy, while much has been written on the politics of government response in the United States (Shilts, 1982; Altman, 1985; Fox, 1990; Johnsen and Styker, 1993; Quam, 1994), less has been done on comparing government response in middle- and low-income nations, especially from a cross-regional perspective. Nevertheless, the existing studies tend to focus on the following independent variables: politicians’ electoral incentives, the design of political institutions such as federalism, and the role of civil society. Following is a brief

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examination of these approaches which highlights their strengths and weaknesses and concludes by proposing a more interdisciplinary approach combining historical institutionalism, cultural (moral) analysis, and state (bureaucratic) capacity as an alternative for explaining differences in the politics of government response to AIDS. Recent studies on the politics of AIDS in the developing world have focused on the issue of politicians’ incentives for reform. The argument here is that in order to better understand how and why presidents respond to epidemics, we need to first consider the electoral, cost/benefit rationales for policy intervention. Scholars such as Alan Whiteside (1999) have argued that politicians intervene with aggressive prevention and treatment programs in order to enhance their chances of winning elections. AIDS policy is thus considered a key electoral strategy. Nevertheless, others find that electoral accountability often instigates fear in proposing bold AIDS (especially prevention) programs as they challenge individual liberties by recommending radical changes to behavioural lifestyles; consequently policy is never implemented (Boone and Batsell, 1993; Fassin and Dozon, 1998). Thus the point emphasized by these scholars is that electoral incentives shape the response of government leaders and that, as Anthony Downs once put it, “policy” is often crafted for winning elections rather than trying to win elections in order to implement policy (Downs, 1955). The problem with these studies, however, is that they assume that government leaders are never influenced by other variables, such as historical legacies, altruism, benevolence, and legitimacy. We are simply led to assume that AIDS policy is treated as any other kind of policy, shaped and molded to suit politicians’ electoral interests. As seen in the cases of Brazil and some African countries such as Senegal and Uganda, politicians strive to implement AIDS policies prior to and after elections, even when such policies are unpopular with electoral constituents. Indeed, as James Putzel (2003) argues, the gravity of the AIDS epidemic often moves AIDS beyond the electoral realm, forcing presidents to respond in order to maintain their political legitimacy before and after elections. Putzel concludes that there is nothing inherently “political” about AIDS policy. An alternative approach that places greater stock in politics and institutions but has yet to fully emerge in the AIDS policy literature is the impact of federalism on the policy reform process. Referred to mainly by political scientists when discussing economic (especially fiscal) policy, the general concept of federalism implies that sub-national governments (state and municipal) are politically and economically independent from the center. This, in turn, often increases the national policy-making influence of sub-national politicians for the following reasons: first, the design of electoral institutions: that is, openversus closed-list electoral systems1 within federations usually generate incentives for national politicians to amplify the policy interests of powerful governors and mayors (Samuels, 2003; Samuels and Mainwaring and Samuels, 2004; Gómez, 2003); second, the

1

An open-list electoral system implies that candidates within a party vote for intra-party nomination for federal elections. This increases intra-party competition and makes office holders much more attentive to the needs of local constituents and politicians. On the other hand, a closed-list party system is where candidates for office are chosen by the party leadership. In this case, intra-party competition is low and party stability is much higher.

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economic and political importance of sub-national governments (Rodden et al. 2003; Montero, 2001; Smoke, Gómez, and Peterson, 2006); and finally, the problems of geography and central government coordination with a plethora of sub-national agencies riddled throughout the country. The latter complicates the center’s ability to sustain its autonomy and bureaucratic capacity when implementing policy from above (Migdal, 1998; Evans et al. 1985). Certainly, a necessary but not sufficient condition for federalism’s constraint on federal policy-making is the depth of policy decentralization. When governments devolve2 complete fiscal and social policy-making autonomy, state governors and mayors have an immense amount of policy-making influence because of their possession of resources and thus capacity to influence future re-elections and administrative appointments. Such influence is then effectively channelled through an open-list electoral system design, as mentioned above. Conversely, when the center de-concentrates these responsibilities, that is, when it decentralizes administrative but no financial responsibility and autonomy, the center may more easily retain its authority and is much more capable of autonomously implementing policy (Eaton and Dickovick, 2006; Smoke, Gómez, and Peterson, 2006). Therefore, the extent to which federalism constrains federal policy-making is heavily influenced by the depth of decentralization. But what does all this mean for AIDS politics? As this paper illustrates, this framework can, and should, be applied to the politics of implementing AIDS policies within large, highly decentralized federations, such as Russia, Brazil, South Africa, India, and China. For example, in the Russia/Brazil analysis conducted here, two large, highly decentralized federations striving to overcome the AIDS problem are compared. These two cases are also similar because both decentralized the financing and administration of health policy throughout the 1990s. Nevertheless, the Brazilian experience shows that the government successfully overcame federalism’s constraints on AIDS policy. Indeed, the governors and mayors were ill-equipped to finance and administer AIDS policy on their own (perhaps with the exception of São Paulo, as discussed later), as in the past the central government aggressively intervened to finance and administer prevention and treatment programs. At the same time, the governors and mayors acquiesced and allowed for government intervention mainly because of their awareness that they could not implement and modernize policy on their own (which, of course, contrasts sharply with other policy areas, such as finance and education).3 Therefore, in contrast to the aforementioned theories discussing federalism’s constraints on policy-making, responding to AIDS was such a high priority that no matter how decentralized the federation was, the states never resisted the center’s efforts to intervene in order to implement new anti-AIDS policies.

2

Here, devolve derives from the commonly used term of policy “devolution,” where sub-national governments are given complete fiscal, administrative, and policy-making autonomy. This is distinguished from the more typically seen form of policy “de-concentration,” where the center decentralizes administrative and policy-making autonomy but without fiscal and financial autonomy. 3 As discussed below, this was always the case in the past. That is, since the early 20th century the only policy area in which the states allowed for the center to interfere in their affairs was the area of public health (on this note, see Hochman, 1998).

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In contrast, the case of Russia demonstrates to what extent federalism and decentralization can hamper the federal government’s response to AIDS, especially when the government (in this case, the President and his health ministers) is unresponsive to local needs. Sub-national representation is sorely hampered by leadership that is essentially apathetic to constituent needs. This, of course, is aided by the absence of an open-list electoral system, which normally generates incentives for central party leaders to represent and press for local needs. Then what is it about federalism in Russia that impedes successful state intervention? The biggest problem is territorial fragmentation and decentralized health ministry responsibility, where health agencies in distant states and municipalities are responsible for financing and directly administering anti-AIDS polices. The center has not been capable to effectively coordinate with these sub-national health agencies; rather, the latter are left to fend on their own, without any increased financial and technical support from the federal Ministry of Health. Therefore the geographic complexity of federalism, combined with lack of executive stewardship for reform, has complicated successful policy innovations. It is important to note that other scholars have also begun to examine the importance of federalism and decentralization in the politics of AIDS policy reform. A good example is the recent work of Varun Gauri and Evan Lieberman (2004). In their paper AIDS and the state: the politics of government response to the epidemic in Brazil and South Africa, they posit that federalism and decentralization generate sufficient incentives for an early response to AIDS. Critical here is the importance of federalism and the decentralization of health policy as catalysts for early sub-national policy innovations. Comparing Brazil to South Africa, they noticed that Brazil’s decentralization of authority allowed for a high degree of government response to take place at the state-level, which in turn eventually incited federal politicians to follow the states’ example. Early sub-national reforms in Brazil (especially in São Paulo) were possible because of the rich history of health policy autonomy and independence from the center, which generated incentives to respond quickly to the AIDS epidemic. While providing an excellent account of how federalism may facilitate (Brazil) or not (South Africa) AIDS policy reforms, the problem with this approach is that it assumes that within highly decentralized democratic federations, early sub-national reforms instigate enough bottom-up pressures for presidents to mimic these reforms. Another issue with the currently presented approach is that focusing exclusively on the role of federalism overlooks the deep historical and cultural factors that motivate subnational and eventually federal politicians to respond to AIDS in the first place, and thus the historical legacies that would have inevitably led to an aggressive state response. As already noted above and discussed in greater detail below, Brazil has a long tradition of federal executive and bureaucratic commitment to responding to health epidemics, motivated, since colonialism, by elite beliefs that state modernization must go hand in hand with curbing the growth of epidemics. Over the years this concern motivated subsequent elites, even under the military, to pass down this tradition of aggressive state intervention (Stepan, 1981; Hochman, 1998, 1993). Therefore one can easily argue, as I do in this paper, that the government’s recent response to AIDS would have occurred anyways, no matter how federal and decentralized institutions were.

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Of course this is not to say that scholars examining reforms in giants like Brazil, Russia, India, and China should not consider federalism and decentralization as constraints to policy reform. Federalism has certainly had a negative effect on Russia, China, and India. Moreover, poorly implemented decentralization policies and lack of policy coordination between the central and local health ministries have complicated policy implementation, but this was not the case in Brazil. Consequently, we should also consider the fact that there are other institutional and non-institutional (cultural) factors that account for Brazil’s success. Yet another problem that emerges in the Gauri and Lieberman (2004) piece is that they have absolutely no explanation for why federal and state-level elites were so quick to respond to what would appear a highly controversial moral issue, that is, a sexually transmitted disease, especially within such a religious (Roman Catholic) environment. Other nations, such as Russia and the United States have seen these types of moral constraints delay government response to syphilis and AIDS. But why were Brazil’s political elites so open and willing to work with the “sinners”? We cannot tell from Gauri and Lieberman’s analysis. Finally, a lot of research has emphasized the role of civil society in generating sufficient pressure for government response. The general argument in this camp is that a proactive civil society (associations and NGOs) can have a positive effect on AIDS policy implementation by working together to constantly urge the government for reforms. When effective, Samantha Willian (2000) and Alan Whiteside (1999) have argued that a proactive civil society can safeguard a country from experiencing a full-blown AIDS epidemic where the virus spreads uncontrollably, as seen in several African states. Willian (2000) and Whiteside (1999) state that because a well-organized civil society incessantly pressures the government for policy reforms, society will never have to worry about an unstoppable epidemic but rather a challenging disease. Barnett and Whiteside (1999) took the debate further by making distinctions between different types of civil societies and their capacity to avoid an epidemic. The most successful were societies with high levels of social cohesion and income; the second most successful were societies with high levels of social cohesion but low income, experiencing a very slow moving epidemic with infection checked by social controls. Third came societies with low levels of social cohesion and low incomes which experience epidemics that develop slowly but accelerate quickly; and last was the worst case scenario of highly divided societies with low levels of social cohesion and high income (Barnett and Whiteside, 1999). In this literature, moreover, scholars argue that NGOs play a vital role in funneling the interests of civil society. For as Boone and Batsell (2001) put it, NGOs help society by becoming partners with the state, i.e. they step in to provide much needed, recently privatized health care services (Boone and Batsell, 2001: p.14). The pervading assumption in this literature, however, is that a proactive, cohesive civil society (especially, though not necessarily) within democracies will always exert enough bottomup pressure to force elites to aggressively respond to the AIDS epidemic. The problem with this literature emerges when we conduct a simple test of necessary and sufficient conditions. That is, is a proactive civil society a necessary and sufficient condition for government response? Or is it, rather, a necessary but insufficient condition? As I argue in this paper and as illustrated in the Brazilian case, a well7

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organized civil society represents a necessary but insufficient condition. For equally as necessary is the presence of a “responsive elite” that comprises presidents and senior health officials willing to listen and address the needs of the civil society. Thus, much of this literature tends to focus on the bottom-up process of reform without considering that civil societal success really hinges on the willingness of federal elites to be receptive to the society’s needs. Therefore the best solution is both a top-down and bottom-up reciprocal, two-way relationship, not a one way, bottom-up relationship, as this pluralist literature tends to emphasize. The theoretical approach presented in this paper is thus an attempt to see how much leverage we may obtain by adopting a more reciprocal approach that nevertheless places greater stock in federal elite response to AIDS. The analysis is tilted in favour of federal elites because it is the elites that devise federal agencies in response to epidemics and decide whether or not to maintain them over time, whereas civil society’s role always depends on the elites’ willingness to respond to society’s needs. Certainly, the presence of a pro-active civil society is seen as a necessary condition because without it there may not be sufficient pressures for the federal government to respond to epidemics. Therefore, and in contrast to the literature noted above, I argue that a better understanding of the contemporary politics of AIDS policy may require a deep historical institutional and cultural analysis accounting for the rise of receptive political elites that progressively respond to civil society’s needs. Indeed, recent political scientists are starting to gravitate in this direction, arguing that authors of contemporary AIDS politics have overlooked key historical lessons and legacies shaping current day legislation (Da Costa Marques, 2003). The historical approach adopted in this paper focuses on the institutionalization of Christian and socialist conservative moral tenants, on one hand, and the persistent tradition of federal elite commitment to building centralized health agencies in response to epidemics (Brazil, not Russia) while addressing civil societal needs (Brazil, not Russia), on the other. Both of these historical institutional and non-institutional movements are mutually dependent, such that the degree of moral institutionalization will constantly influence federal elite commitment to building centralized public health agencies. Regarding the institutionalization of morality, this paper explores and builds on James Morone’s (2004) recent work on how the Christian moral impulse throughout American history shaped the way political elites viewed immoral sinners and the way this view in turn influenced the design of federal institutions and policy. In brief, Morone (2004) asserts that throughout American history two types of moral politics can be observed: the dark Victorian politics where elites devised institutions and polices in ways that discriminated against immoral sinners, versus the less discriminatory “Social Gospel” approach that blamed the political economy conditions of the day rather than individual behaviour. As argued in this paper, in some countries such as Russia, the Victorian impulse dominates, continually shaping legislation, institutions, and policy response to AIDS, whereas in Brazil, the “Social Gospel” approach dominates. According to Morone, the Victorian politics of government response to sin, as seen in the Russian case, is the reflection of a long winded history of the institutionalization of these discriminatory moral convictions, periodically inculcated through the incessant interaction of morally inspired elites with great Christian (or in the case of Russia, Christian and communist socialist) “revivals.” That is, periodic public gatherings that generate moral “shocks,” 8

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“awakenings,” which continually remind elites of who they are, what they believe, and from where they draw their political inspirations and thus politics. As Michael Ross (1997) argues, these moral “tipping points” periodically emerge throughout history, explaining how morality often influences the creation of sustainability of institutions. This is a realm of comparative political analysis that he claims is often overlooked by political scientists. The persistence of a Victorian discriminatory outlook towards sinners in Russia helps to explain the reason why political elites have not responded to civil society and why, consequently, few if any efforts have been made to implement federally sponsored anti-AIDS legislation. Yet the Russian case also shows that while Christian morality has a deep historical institutional presence, the conservative moral impulse of Soviet communism was also deeply institutionalized, beginning with Stalin, which led to a unique Victorian impulse combining Christian morality with conservative tenants of communism. I argue that the institutionalization of these moral outlooks entered the public sphere and continues to shape the way recent administrations and health officials respond to civil society: that is, with open discrimination and distaste, using their moral convictions as excuses to both avoid the implementation and enforcement of key anti-AIDS prevention (especially) and treatment programs, while openly discriminating against the so-called immoral sinners, such as intravenous drug users and homosexuals. In contrast, as seen with the Brazilian case, early historical absence of morality in the political realm led to the absence of a morally discriminatory outlook towards civil society. Rather, political elites’ perennial commitment to secularism in medical science and policy has led to the emergence of more responsive elite, one that seeks to help the so-called sinners through state building and anti-AIDS legislation. Equally as important for understanding current government response is a consideration of how the historical commitment to state building arose and persisted. Scholars of AIDS politics have overlooked the importance of understanding the contemporary influence of historical efforts to construct highly centralized, autonomous public health agencies in response to epidemics and their direct association with state building and modernization. As the case of Brazil in this paper illustrates, the federal government’s response to the AIDS epidemic in 1985 very much reflected the government’s long held tradition of creating a centralized public health agency that could contain epidemics. The government’s similar recent response to AIDS thus suggested a continued federal political elite interest in controlling health epidemics from above, rather than, as seen in Russia, completely decentralizing policy and implementation to subnational governments. Indeed, Russia’s inability to construct a highly centralized, permanent federal agency responsible for AIDS prevention and treatment mirrored its long history of a highly decentralized form of medical coverage and response to epidemics, on one hand, and the weak nature of centralized federal health infrastructure under the Soviet system, on the other. Such patterns persist to this day, which suggests that there is a high degree of path dependency and institutional continuity in the area of public health policy. Understanding historical institutions and their legacies also enhances our understanding of the reasons why some democracies exhibit far more propitious social conditions for the emergence of a proactive civil society versus others. In this paper I introduce the distinction between the historical institutions generating conflictive civil 9

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societal response to AIDS versus those that allow for, and indeed facilitate, effective collective mobilization. As in the Russian case, a long history of institutionalized discrimination, codified through public law and policy towards homosexuality and drug addicts, generated an immediate conflict regarding how society should react to the government’s AIDS policies: respond aggressively – oppose the state, or passively - work with the state. These differences in opinion generated conflicting views among homosexuals and consequently, collective paralysis, that is, an inability to effectively pressure the state from below. Key here is the idea that the presence of harsh discriminatory laws generated immediate differences in individual and collective fear, which in turn led to differences in opinion on how the government would respond to collective action. In contrast, the absence of condemnatory institutions throughout Brazilian history, coupled with the outgoing military government’s interest in gravitating towards individual rights and universal health care, both facilitated and encouraged collective action. Thus, the absence of historical institutional condemnation (through military law and institutions) of immoral behaviour (influenced, as mentioned earlier, by the absence of sexuality in the public sphere) motivated the gay community to work together and with NGOs and the church for an aggressive response to the government’s AIDS policies. However, it is important to note that the success of civil society was in large part determined by the presence of a receptive military and eventually democratic presidential elite, which unlike Russia’s elite, was not openly discriminatory towards sinners. The point to be emphasized here is that in contrast to the recent literature on the politics of government response to HIV/AIDS, more work needs to be done on the historical non-institutional and institutional factors influencing the rise of a responsive political elite, one that equates state building with combating health epidemics, and that is consistently responsive to the needs of civil society, on one hand, and the historical emergence of the institutional conditions leading to effective civil societal response, on the other. Therefore I elaborate on the key issue raised by Cathy Boone and Jake Batsell on the origins of “good governance” for AIDS that research should be “aimed at better understanding where state strength and effectiveness comes from … [which can] contribute to broader and more general understandings of what it takes to generate state capacity …” (Boone and Batsell, 2001: p.13). I argue that this approach requires a deep historical institutional and cultural analysis, explaining the sources of present state capacity and the political will for reform. However, most of the current literature on the politics of government response to AIDS is, as noted earlier, highly static and focusing on the immediate (contemporary) politics of reform. Future work will need to concentrate more on historical institutional and cultural issues in order to explain why federal elite interests and institutions are so path dependent, and whether or not such patterns are also present with other types of epidemics, such as malaria and TB. There are several limitations of the argument as presented here. For I have omitted a discussion of the types of endogenous reproductive mechanisms that both lead to and sustain the presence of a responsive federal elite. These reproductive mechanisms may take the form of inter-elite learning, institutional tradition/norms, and/or sunk costs (Pierson, 2000). Discussions of endogenous reproductive mechanisms and their interaction with exogenous shocks, such as democratic breakdown and economic crisis, are 10

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required in order to test for the continual presence and efficacy of these endogenous mechanisms. Future work will therefore need to explore precisely what these mechanisms are, how they originate, and how they sustain themselves over time.

III. RESEARCH METHODOLOGY The purpose of this cross-regional comparative analysis between Russia and Brazil is not to devise a generalizable theory about the politics of government response to HIV/AIDS, but rather to compare two complex sets of historical institutional, cultural, and contemporary political processes in order to accentuate and better understand the unique response in each case (Katznelson, 1997). The selection of these countries was also motivated by the following reasons: first and foremost, Russia and Brazil happen to be respectively the worst and arguably the best cases of government response to HIV/AIDS among the larger, highly decentralized federations. Therefore I have intentionally chosen on the dependent variable in order to better understand and explain the dramatic differences in government response (Collier an Mahoney, 1996). Second, there are many structural similarities between the two countries: both are large federations covering thousands of miles of territory; both have over 20 state and municipal governments; and within the past twenty years both have decentralized new fiscal and social policy responsibilities, in turn generating similarities in the politics of policy reform (Gómez, 2003). Both governments also transitioned from an authoritarian style of governance to democracy at roughly the same time and at the height of the AIDS outbreak. Moreover, during the initial outbreak federal elites in both cases were somewhat unresponsive. Yet as discussed below, when the government finally decided to respond, Brazil’s political elites responded much faster and more aggressively than Russia’s. Understanding these differences in outcomes requires that we look back into history, unraveling the differences in elite response to health epidemics, the role of morality, and as the next section explains, the radically different patterns of government commitment to state building in times of health crisis.

IV. THE HISTORICAL ORIGINS OF PUBLIC HEALTH BUREAUCRACY RUSSIA Pre-revolutionary Russia was marked by a one step forward, two step backward process of state building in response to epidemics. While under Catherine I the state initially supported decentralized institutions for public health provision, later under Alexander II, it did not. Catherine I was by far the most progressive social welfare reformer when compared to her predecessor Peter I and her successor Alexander I (Hartley, 1999). In 1760 she founded medical colleges in Moscow and St. Petersburg while establishing in 11

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each of the provinces new public health boards through the Statute of Provincial Administration in 1775. In addition, she amply financed these boards and was always directly involved in their operations (Hartley, 1999). These efforts were short-lived, however, as Alexander II, despite his emancipation of the slaves, decided to completely decentralize the provision of health services to provincial governments. Though decentralization in this case had the potential to increase the efficiency of health service provision, in practice, it did not. Rather, a decrease in federal financial support and federal assistance for sub-national administrative reforms directly led to the deterioration of public health conditions. By the beginning of the 19th century the Tsars’ commitment to decentralization generated new divisions between the bureaucratic and medical elites, which hampered efforts to establish a centralized Ministry of Health. James Hutchinson (1990) writes that the Tsar’s medical bureaucrats and their interests in centralizing control over public health issues clashed with the interests of provincial doctors who had been practising direct, hands-on community treatment since the devolution of authority under Catherine I (Hutchinson, 1990). This clash is exemplified by the fact that although several of the Tsar’s bureaucrats proposed the creation of a Ministry of Health in 1864, and again in 1886, both times the local zemstvo physicians resisted these efforts. After several years of central government’s apathy and corruption, the zemstvo members were convinced that the center could never render public health services efficiently (Hutchinson, 1990). The zemstvo also believed that such an important responsibility required a very carefully planed effort, not an immediate re-centralization of authority. Thus inter-elite conflict over who should be in charge of responding to epidemics precluded the establishment of a centralized public health agency. This historical institutional context set the tone for future government response to health epidemics. As in the past, the post-1917 revolution response to epidemics continued with the practice of decentralized care. After the revolution, the socialist government constructed 7 People’s Commissariats of Public Health for each of the republics. These Commissariats had the responsibility of providing health services, pharmacology and medical training (Newsholme and Kingsbury, 1933: p.196-197), while supervising the workings of the district and city level public health commissariats. Each of the 7 Commissariats were autonomous, falling under the directorship of the regional Commissariat for Public Health, which was appointed by the central party leadership. Appointees were apolitical, that is, they were medical doctors with no prior political experience, nor were they formally affiliated with a political party (Newsholme and Kingsbury, 1933). The problem was that these reforms generated few incentives for the central government to create a federal public health ministry that would periodically intervene to insure that the 7 regional and district level Commissariats were working effectively. This “hands off” approach mentioned above continued throughout the Soviet era, which contributed to an ongoing tradition of little to no direct federal assistance in the area of public health. Thus, by the fall of communism in the late 20th century, the new democracy had absolutely no tradition of centralized public health governance upon which to draw. Reformers had to start from scratch. Oblasts by the dozen were forced to undertake reforms on their own. This historical context contrasted sharply with the Brazilian case 12

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and continues to complicate the government’s ability to effectively respond to Russia’s current and future (or maybe “pending”) HIV/AIDS crisis. BRAZIL In contrast to Russia, there was a rich history of government response to health epidemics in Brazil. Throughout colonialism and up through the 1920s, Brazilian political elites equated state building with government response and control of health epidemics (Hochman, 2004; Hochman, 1993). Colonial and newly independent elites, located mainly in Brazil’s coastal ports, believed that overcoming disease was vital not only for safeguarding the burgeoning agricultural economy, but also for spurning economic development and advancing political nationalism. Since colonialism, government response to epidemics was considered crucial for state-building - building a modern state that could compete with its European counterparts. Two years prior to political independence, the Brazilian emperor and his medical elites responded to a host of epidemics, such as yellow fever, malaria, and smallpox by creating a strong, centralized bureaucracy: the Departmento Geral de Saúde Público (DGSP), which was linked with the Minister of Justice in the Interior. This institution was established with the purpose to monitor and curb the rise of epidemics. From 1902 through 1920, the DGSP acted as a highly centralized administration freely penetrating state boundaries to eradicate various kinds of epidemics. What is important to note here is that state elites, namely the emperor and his medical staff, were highly autonomous from civil society. Because epidemics posed a tremendous threat to the economic and political modernization of Brazil, and thus to its sense of nationalism and pride, elites did not want either the DGSP or its policies to be influenced by powerful governors, land and agricultural elites (Hochman, 1993; Hochman, 2004). Civil society did not play a role in federal policy-making (Vascondelos, 2004). The only types of civil societal actors that could to some extent influence legislation through informal meetings with the president and medical bureaucrats were the medical doctors and some intellectuals (Lima and Britto, 1996). Yet their influence was very limited, relegated only to suggestions of how to improve medical access and treatment. They were not physically represented in the DGSP, nor did they directly influence policy legislation. Even with the arrival of an authoritarian government in 1930, led by Getúlio Vargas, this pattern of centralized control over health epidemics continued and even expanded. Vargas increased the amount of fiscal resources going to the Ministry of Health, bolstered its centralized managerial authority, and in 1942 created the Servicio Especial de Saude Publico to provide health services to all workers (Acurcio, 2004). Thus, like his predecessors, Vargas sought to maintain and strengthen the federal campaign to curb the growth of epidemics. The center’s commitment to centralized bureaucratic control over epidemics did not end with the downfall of Vargas (1930-1945). Rather, it persisted, spanning across a series of future democratic (1945-1964) and military (1964-1985) regimes (Hochman, 1998; Hochman, 1993). This commitment dovetailed nicely with the outgoing authoritarian 13

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government’s efforts to create a more universal health care system, one which did not discriminate based on race, social status, and income. These twin fronts, i.e. the persistent, progressive federal elite’s commitment to containing health epidemics through centralized bureaucratic institutions, coupled with a commitment to universal health care access established by the outgoing military (Weyland, 1996), set the stage for an aggressive government response to HIV/AIDS.

V.

VICTORIAN POLITICS

RUSSIA The early Orthodox Christian church in pre-revolutionary Russia had a substantial impact on politics and society. While Christian Orthodoxy was not the only form of religious practice, it was the most dominant in the region. By the 16th century, Moscow was considered the “Third Rome” of Eastern Europe, following the fall of Constantinople in 1453. A poll taken in the 19th century recorded the presence of 36,314,000 Christians (including Russian and Greek Orthodox, united Catholics and Protestants), 2,830,000 Muslims, 200,000 Jews, 305,000 Buddhists, and 635,000 pagan shamanists within the Russian Empire (Hardley, 1999). While at no point did the state impose any type of religion, especially in the educational system, the overwhelming presence of the Christian Orthodox faith, which held biblically-based conservative views towards sexuality, had a strong influence on shaping the moral values of the nation, especially since, by the 18th century nearly 30% of the Christian clergy were appointed to high level civil administrative posts in the government (Hardley, 1999). In addition to the early presence of Christian moral values, during the post-1917 revolutionary period we see the institutionalization of conservative socialist values, harbored by socialists who believed that there was only one accepted cultural and especially socio-economic standard of life for the true communist. Socialism’s teachings to refrain from any form of capitalism boded well with, and very much reinforced, the heavily ensconced Christian moral impulse of non-indulgence, humbleness, equality, and respect for the community. What is more, like Christianity, socialist communism promoted a certain way of life, one which focused on the family as well as proper individual and social behaviour. Like Christianity, socialism approved of love between a man and woman, not between homosexual men; like Christianity, it chastised and punished those engaged in immoral activity, such as drug abuse and alcoholism. Any deviation from these norms was seen as a sin, an offence to the community and hence, to the state. Consequently, during the pre- and post-Soviet revolutionary period, there emerged a very strong dark Victorian impulse, one which vehemently opposed and punished any individual engaged in immoral activity. This dark Victorianism set the stage for several laws that would openly discriminate against homosexuals and drug addicts. With regards to homosexuality, although there were no formal laws banning homosexual activity from October 1917 till Stalin’s revision of the Soviet legal code in 1934, scholars maintain that there was a very 14

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heavy dose of social discrimination towards homosexuals in civil society (Schluter, 2002). Under Stalin, however, the state aggressively persecuted homosexuals on the grounds that their behaviour, according to Stalin, was “immoral” in nature and that it was a plain “bourgeoisie aberration” (Williams, 1995: p.121). Article 154 of the Penal Code explicitly stated that sexual behaviour between men was prohibited, subject to “deprivation of freedom” for a term of 5 to 8 years. Although later N. Khrushchov would successfully reduce the amount of time spent in jail, political and social persecutions nevertheless continued, even under the reform government of M. Gorbachov (1985-1991). Despite Gorbachov’s intentions to repeal anti-gay laws, the economic disparities associated with his market reforms and the future uncertainty of Russia compelled government leaders to temporarily suspend efforts in that direction. A new ray of hope emerged with the democratic Boris Yeltsin administration (1992-2000). On April 29, 1993, Yeltsin signed a bill that eliminated the law against consensual sex between men. In addition, the punishment for sex with a minor was reduced from 8 to 7 years. And in 1997, Yeltsin amended the constitution to abolish all legal prosecutions for adult homosexual acts. Despite these impressive efforts, scholars argue that the dark Victorian spirit persisted, and that to this day anti-gay legislation still discriminates against homosexuals by making a clear distinction between heterosexual and homosexual activity. For instance, heterosexual sex with a 17 year old is legal, while it is illegal between homosexuals. Moreover, homosexuals are required by law to be tested for HIV/AIDS; those who fail to comply are subject to imprisonment. Table 1 Number of homosexual men convicted under Article 121 in the RSFSR, 1987-1991 Year 1987 1988 1989 1990 1991

Total 831 800 538 497 462**

Sources: Schluter (2002): p. 123, originally taken from Gessen (1994:11) and Kon (1995:246). **Kon reports 482 convictions for 1991.

Compared to homosexual activity, the state’s discrimination towards the personal usage of drugs was never as extreme. Rather, before the 1960s, the state only penalized individuals that were either involved in the manufacture of drugs, mainly opium, or engaged in trade activities undermining the state’s monopoly over drug production (Butler, 2004), as enforced through Article 140 of the 1925 RSFSR criminal code. Those engaging in such activities were either imprisoned for several months or required to pay a large fine. In contrast, individual consumption of narcotics was not punishable by law at the time.

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During the Soviet era, the state did make clear, however, that those citizens afflicted with drug addition also suffered from a severe “moral” problem. Indeed, they were labelled as “morally defective” (Butler, 2003). By the 1960s, this prompted the Soviet leadership to take seriously the burgeoning drug addiction problem, the attention to which continued and increased throughout the 1980s, forcing the center to issue a decree titled On serious shortcomings in the organization of the struggle against narcotics addiction. Yet with the perestroika reforms taking place, the state paid scant attention towards insuring that the decree would be enforced; it was not. Consequently, rates of drug addiction became higher, doubling in number from 35,254 in 1984 to 67,622 by 1990 (Butler, 2003). The problem, as Butler argues, was that the legislation opposed to the manufacture and usage of drugs did not consider the implications it would have for the implementation of harm reduction programs. For instance, the 1998 Federal Law on Narcotic Means and Psychotropic Substances contained clauses that prohibited certain types of drug usage, which made it difficult to enforce harm reduction programs in the future. Such programs were seen as indirectly contributing to the drug problem. BRAZIL In addition to the strong tradition of centralized public health institutions and the emerging commitment to universal health care prior to the transition to democracy, the historical absence of dark Victorianism since the colonial period provided the groundwork necessary for a deeply institutionalized and socially embedded tradition of secularism towards sexual behaviour in the public sphere. In contrast to Russia, in the case of Brazil there was not a highly committed Christian clergy that sought to codify conservative Christian moral principles within governing institutions. Instead, the colonizing Catholics never set out to convert the natives, the Portuguese or any other western Europeans, nor did the Catholics have in mind to instill Christian biblical teachings within federal institutions. Rather, it was political centralization, service to the crown, and economic decentralization that proved to be the key driving forces during the colonial period (De Abreu, 1997). The absence of dark Victorianism in Brazil helps to explain the political and social acceptance of moral taboos, such as sex to the subsequent benefit of the homosexual community. To better understand this, one must first realize that sexual activity was socially constructed into a topic socially and scientifically acceptable to discuss. In his book titled Bodies, pleasures, and passions, Richard Parker (1991) notes that Portuguese Catholicism was rich with what he called “hidden morals,” i.e. Catholic ideals that were understood to be present in the family and the community, but never surfaced into the political and economic spheres. Portuguese-style Catholicism, moreover, was very open to sexuality, to the point of even believing in saints that gave spiritual advice about good and proper sex (Parker, 1991: p.68; Freyre, 1956). Parker agues that this led to the discovery of the personal self and individual bodily pleasures, unmasking the truth about what sex actually meant for the person, without any fear of social and political repercussion. With this background, political modernizers of the 20th century allowed for the concomitant transformation of economy, society, and sexuality. That is, the European movement 16

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towards the scientification of sexual activity, viz., discussing and analyzing sex in a scientifically objective manner, was embraced by the government and civil society (Parker, 1991: p.86). Thus by the 20th century one detects the absence of dark Victorianism in Brazilian sexual politics. The movement towards the rational scientific and social acceptability of different types of sexual activity, as seen in Western Europe, paved the way for a different type of political economy of federal commitment towards STDs, such as HIV/AIDS. Indeed, by the early-1980s scholars allude to the fact that the federal government in Brazil did not immediately associate HIV/AIDS with the immoral, sexual nature of homosexuals, prostitutes, and drug abusers, as had been the case both in Russia and America. Rather, the socio-economic status of gay men and their fancy bourgeois lifestyle and habits were to blame (Bastos, 1999). Bastos argues that associating the HIV/AIDS epidemic with the affluent lifestyles of homosexuals provided a good excuse for the government not to immediately intervene, and to rely instead on the affected individuals’ ability to pay for their AV treatment on their own (Bastos, 1999: p.70). Underpinning the association between wealth and disease, moreover, was the prevailing ideology, denying the existence of homophobia, akin to the denial of racial discrimination (Bastos, 1999: p. 75). Safeguarding society and politics from the possible emergence of dark Victorianism were annual festive activities openly embracing sexuality. In Sex, drugs, and HIV/AIDS in Brazil, James Inciardi et al. (2000) state that the yearly carnival festivities held in Rio help to suppress any potential movement towards sexuality as a social and hence, political taboo: “Carnival, an annual three day pre-Lenten festival, is a ritual reversal in that every form of pleasure is possible – there are no prohibitions that temper sexual practice or desire. It is a time when Brazilians momentarily suspend their moral categories and undertake “dangerous,” prohibited practices. In this way, Carnival momentarily serves to both suspend and challenge dominant social structures like religion and the genre hierarchy” (Inciardi et al. 2000: p.35). Thus in Brazil, colonial history, modernization, and contemporary activities all contributed towards sustaining the anti-Victorian drive that kept stern, potentially sexually discriminatory Christian moral principles at bay. This in turn influenced the government’s view about who was responsible for this disease. But more importantly, it also elided any possibility of openly discriminatory discourse and action on the part of the federal government towards the gay community.

VI. POLITICS OF GOVERNMENT RESPONSE IN RUSSIA Like most countries, Russia’s initial response to the AIDS epidemic was one of disbelief and denial. Worse still for Mother Russia as her pride and unwavering nationalism convinced the government that such an epidemic could never fester from within. As a consequence the blame immediately went to a foreign “them”: initially, this category included African immigrants having sex with Russians and even a conspiracy theory that 17

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the disease was planted by the CIA. The idea that AIDS was a ploy devised by the CIA boded well with the times, as the virus was used by the Soviets as evidence that the US government was trying to undermine the Russian authorities. Consequently, some scholars contend that the government did not immediately respond to the virus and that it took years until it finally realized around 1987 that the epidemic was not a strategic attack planned by the Americans (Williams, 1995b). With the conspiracy theory ruled out, the government turned to the other potential conspirators against the state, that is, the immoral “them.” But who were these immoral traitors? They were the homosexuals, drug users, the prostitutes. Because of their peccadillos the government did not feel compelled to immediately intervene on their behalf (Powell, 2000). Rather, it was “their” problem, officials argued, and a direct consequence of their immoral lifestyles. Thus, as to be expected, the dark Victorian tone, well-grounded in a deep sense of Christian and Soviet communist morality, immediately influenced the government’s response to the epidemic. During the first few years of the AIDS crisis, strong political opposition from various parties and pressure from the church led to an initial legislative stalemate, delaying the passage of anti-AIDS legislation. As Valeriy Chervyakov and Igor Kon (1998) argue, most of the opposition against AIDS policy stemmed from the parties and churches staunchly against any form of government assistance for those participating in immoral behaviour. The Communist majority in the Duma, various Pro-Life Organizations, and the Russian Orthodox church opposed these prevention and treatment programs on the grounds that it was “improving the sexual culture” of Russia (Chervyakov and Kon, 1998: p.51). These forces succeeded in not only voting against the law on reproductive rights, but also in pushing through a reduction in state financing for family-planning programs. Chervyakov and Kon note that consequently, the so-called UNESCO project on sex education for Russian schools was cancelled, while the anti-AIDS propaganda campaign in Moscow organized by Médecins sans frontiers was also blocked. Needless to say, the phrase “safe sex” had virtually become a taboo (Cherkvyakov and Kon, 1998: p.51). Two types of dark Victorian spirits were driving this sense of opposition: the Christian moral principles of a pious “we” versus an immoral “them” and the conservative Communist socialist principles stemming from Stalin’s belief that Russia needed to rejuvenate its moral character. As Chervyakov and Kon (1998) note, the “official soviet communist morality was as afraid of and hostile to sex just as any form of Christian fundamentalism, including Russian Orthodoxy.” This wedding in moral philosophies between those harboring Christian conservatism and those harboring socialist conservatism facilitated and encouraged the unification of organizations that were historically hostile towards one another, such as the Pro-Life organization and the Communist party, and the latter with the Russian Orthodox church (recall that the Communist party was historically atheistic in its views) (Chervyakov and Kon, 1998). Thus, the ongoing Christian and especially Communist conservative tenants engendered by the late 1980s a lackluster government response to the HIV/AIDS epidemic. Unfortunately, even under the newly democratic and capitalist Russian state, these slow-moving trends continued. The responsiveness of the president and bureaucratic elite throughout the 1990s was equally ineffective. One of the biggest problems was the executive’s unwillingness to create a permanent public health agency focused on HIV prevention and to delegate to it complete authority over all AIDS prevention and treatment programs. David Powell 18

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(2000) for example, argues that under President Yeltsin, only one agency was established at the federal level to help educate citizens on how the HIV disease was spreading. Yet Yeltsin made it explicitly clear that he was only going to keep this agency alive for 3 years (Powell, 2000). At the same time, Yeltsin made no effort to concentrate all prevention and treatment programs under one centralized agency, such as the Ministry of Health. For as Judith Twigg and Richard Skolnik (2005) argue, in 1991 the Ministry of Health “was divided into preventive (the State Committee for Sanitary and Epidemiological Surveillance) and curative (the Ministry of Health of the Russian Federation) branches; since then, separate structures for anti-AIDS work have co-existed in these two branches” (Twigg and Skolnik, 2005: p.14). Furthermore, in Moscow, the main federal institution established for the prevention of AIDS was the “Russian Federal Scientific and Methodological Center for AIDS Prevention,” which was attached to the Ministry of Health. It was responsible for conducting epidemiological surveillance work and generating reports. This occurred at the same time as the regional oblast AIDS centers were established to conduct research, disseminate data, and serve as a hub for health services. Concurrent was the establishment of yet another federal prevention center operating in St. Petersburg: the Federal Clinical Center on AIDS Prevention. At the same time, the Ministry of Education was delegated the responsibility of disseminating information on HIV/AIDS prevention, primarily on sex education. The Ministry of Justice (MOJ), on the other hand, had jurisdiction over the penitentiary system, the law enforcement community, and the legality of harm reduction practices and appropriate treatment for IDU (Twigg and Skolnik, 2005: p.15). It is important to note that the political leadership did nothing about the high degree of decentralized horizontal administration managing prevention and treatment programs. Indeed, as Twigg and Skolnik (2005) point out, the Soviet Union “bequeathed to Russia a tradition of horizontal separation of government agencies from one another, both geographically and institutionally.” What this meant is that the Russian health care system was, as in the past, completely decentralized, run by local health clinics and AIDS centers without any coordinating efforts on the part of the federal government. Each oblast differed, moreover, both in terms of the revenue that it could raise for its AIDS programs and its efficiency in rendering health care services. Throughout the 1990s, however, neither Yeltsin nor Vladimir Putin sought to rectify this situation by striving for greater coordination between the center and the states. Thus the end result was a vast array of differences in institutional resources and policy outcomes across the oblasts, with the larger cities like Moscow and St. Petersburg displaying impressive results as opposed to the rest. Undoubtfully Yeltsin implemented key legislation that improved the AIDS situation, i.e. there was a “policy response.” But the issue of “policy enforcement” is an entirely different matter. In addition to the implementation of the Law on Compulsory Medical Insurance, which established a national system of mandatory employer funding for health coverage, in March 1996 Yeltsin signed into existence the Federal Anti-AIDS Law placing most AIDS related activities under federal jurisdiction. The law guaranteed universal provision of professional and specialized medical services to citizens afflicted 19

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with HIV, as well as social support for the HIV-infected. Additionally, Yeltsin shocked many when he refused to sign a proposed bill to make compulsory testing for HIV a federal law. Instead, testing was voluntary. The biggest problem with these reforms, however, was that they were never clearly enforced. The dearth of fiscal resources of poor medical administrative services rendered little incentive and effort by the government to enforce legislation. Moreover, scholars found that while the “Ministry of Health published guidelines for the testing of specific groups on a voluntary basis … in practice, the majority of these group members are tested without prior counseling and consent from them. In many cases, the patient is not even notified of being subjected to testing, while the HIV-negative status is not told to them” (ILO, 2005). The dark Victorian spirit underlying all these reforms continued to indirectly punish society by motivating reformers not to enhance key preventive measures, such as safe sex education. Throughout the 1990s, despite the innovative policy reforms implemented, the government was still very much inactive when it came to safe sex education. Christopher William’s (1995b) excellent work on sex education throughout the Soviet era and the 1990s attributed this to government “inaction,” inspired by deeply puritanical principles, on one had, and social communist conservatism, on the other (Williams, 1995b: p.88). Have these weak institutional and dark Victorian trends persisted under the current Vladimir Putin administration? They have, and they have gotten worse. Since coming into office, Putin has not shown any commitment towards reforming federal and state-level public health institutions. Despite the fact that they are housed under the Ministry of Health, sub-national institutions still remain quite fragmented. As in the past, sub-national governments are on their own when it comes to financing and implementing policies. Putin’s seemingly apathetic response hit home to us all when we realized that it was not until 16 May 2003, in the State of the Union address that he finally mentioned Russia’s AIDS problem. Even then it was only mentioned in passing. On the other hand, Putin has been quite supportive of other governments’ efforts to combat AIDS. In July 2001, for example, he agreed to support the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFAM) by pledging US$20 million. Two years later, in September 2003, he agreed to continue giving money, despite acknowledging that there were several domestic challenges to overcoming the AIDS problem, such as drug addiction, which would take, as he put it, a “great deal of effort to restructure medicine and resolve the problem of addiction” (ITARTASS, 9/25/2003). Perhaps more than with any other previous administration, the Victorian impulse to discriminate against the largest populations afflicted with HIV, such as drug addicts, first and foremost, followed by homosexuals and prostitutes, has led to few if any efforts to sponsor HIV prevention and treatment programs. In this paper, I will mainly focus on the issue of government response to the pervading intravenous drug problem, which currently accounts for over 90% of the population infected with HIV. Notwithstanding escalating rates of infection via IDU, however, this area has received the least amount of direct federal assistance. Most assistance has come from sub-national AIDS centers and clinics, not the federal government, and I would argue that there are some moral and institutional reasons for why this is the case.

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First, Putin and his staff have in a sense revived the old Stalinist outlook towards drug addiction while supporting the church’s condemnatory views. Shortly after coming in office Putin stated that he believed drug addiction was a pervading sin. In 2002, for example, Putin compared drug addiction to illegal arms trafficking, illegal migration, and terrorism (ITAR-TASS, 9/25/02). In 2000, Putin’s Deputy Prime Minister, Valentina Matvienko, noted that drug addiction had become a “social evil,” and stressed the importance of adhering to the “spiritual traditions of the Russian Orthodox Church which made its real contribution of liberation of [the] people from drug slavery” (ITAR-TASS 11/29/00). The Church, moreover, has continued to pressure Putin into sponsoring federal legislation that would not allow for the distribution of clean needles for drug addicts. “The Church believes it unacceptable to pander sin,” was the position voiced by the spokesman for the Moscow Department of External Church Relations at a conference on civil society’s role in tackling the problem of HIV infection (ITAR-TASS, 4/16/2003). This Victorian spirit would have serious ramifications for federal direct assistance in combating drug addiction. For although Putin has openly acknowledged that drug addiction is a grave social issue, few if any efforts have been made to address it. Most of the IDU drug prevention and addiction programs have been implemented at the city and state levels. The most notable cases were the programs in the city of Kaliningrad in 1997, followed by St. Petersburg, Yaroslavl, and approximately 70 smaller harm reduction programs throughout the oblasts (Butler, 2003). Programs at these centers have focused on increasing harm reduction through the provision of clean needles for drug usage, anonymous consulting for drug addicts, and perhaps most importantly, educational lessons on drug usage and HIV (Kolkov, 2003). Because the central government has not provided direct assistance to these programs, they have relied to a great extent on voluntary and charity groups. In 2002, for example, a large charity campaign led by the Russian pop singer Oleg Gazmanov was established in Kaliningrad (home of the first major drug addiction/treatment program) (ITAR-TASS, 9/2/02). Multiple surveys have also shown that Russia’s addicts have little trust in the government’s anti-addiction campaign, while at the same time they fear that reporting their problem may lead not to medical assistance, but to incarceration. A survey conducted by Kolkov in 2003 indicated that most HIV-infected addicts were quite critical of the Ministry of Public Health and law enforcement agencies, especially when it came to activities aimed at controlling drug addiction (Kolkrov, 2003: p.37). Additionally, most drug users are afraid of being tested for HIV because they fear being thrown into jail as their behaviour warrants immediate incarceration through the 1998 Law on Narcotic an Addictive Substance. What is more, even private doctors are afraid to treat drug addicts because they would not want to be seen as accomplices to a crime. Private clinics are, by law, unauthorized to treat drug addicts who decide to receive treatment rather than face incarceration. While it is no longer compulsory for drug addicts to be tested for HIV, the possibility of being incarcerated provides enough incentive to refrain from seeking help.

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Figure 1 Federal budget allocations for anti-AIDS programs, 1996-2004 200 180 160 140 120 100 80 60 40 20 0 96

97

98

99

2000

2001

2002 2003

2004

Source: Twigg and Skolnik (2005)

Yet another problem is that the federal and state police are becoming increasingly hostile towards harm reduction programs with the motive that these programs are indirectly contributing to illegal behaviour by distributing clean needles. This, as Butler (2003) argues, is generating a great deal of hostility and tension between sub-national health administrators and the policing state. Moreover, Butler (2003) maintains that for this reason the federal government has not had any incentive to support such initiatives. Under these circumstances, AIDS centers providing harm reduction and drug addiction services have to keep a very low profile. They are on their own, seeking the assistance of various international agencies and private donors, such as the Open Society, which has invested a considerable amount of money in implementing harm reduction programs. One of the biggest contributing factors is of course the lack of financing that the federal government provides for drug addiction, prevention and treatment. For while drug addicts (and any other type of infected citizen) are guaranteed universal coverage for access to antiviral medication through the 1995 Federal Anti-AIDS Law, the government’s reluctance to provide money for these programs (notwithstanding relatively good economic times) has also led to a decrease in the actual number of patients that can be treated for IDU problems. Beginning in 2000, sub-national governments were receiving on average less than 30% of the total amount of funding needed to finance anti-drug addiction programs and policies (RIA 6/15/00). Unfortunately, the current Putin administration has not only been lackluster in its approach to the problem of IDU use and addiction, but it has also been uncommitted to increasing federal government expenditures for other types of prevention and treatment programs. This has occurred despite a somewhat modest economic recovery since the financial market crisis of 1998. As shown in Figure 1, overall trends in federal government expenditures in Russia for all anti-AIDS programs are puzzling: despite a sharp increase in 2002 to 182 millions rubles a year, expenditures have decreased by 60 million rubles since then, which reflects a waning level of financial commitment. Regarding anti-AIDS prevention programs, efforts to enhance safe sex education are just as abysmal as they were in the past. Currently there are no federally funded safe 22

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sex education programs. Consequently many oblasts have been working with international organizations and NGOs to give citizens proper sex education (Izvestiya 5/28/04). Additionally, and in sharp contrast to Brazil, there is no massive federally funded campaign to promote condom use. This is very troubling since the number of HIV cases among homosexuals is starting to increase once again, as is the number of syphilis cases. Regarding the production and financing of antiviral treatment, performance on the whole is also rather bleak. Currently there are only two major pharmaceutical companies producing two drugs available for usage; these are AZT and nicovir. However, standard global treatment requires the usage of a cocktail of three antivirals. Moreover, the HIV virus often mutates and builds immunity to these two drugs. The major problem is that the government is not trying to increase funding for the expansion of domestic pharmaceutical companies that can produce the additional drug. The high cost of each of these drugs, averaging an annual treatment cycle of $5,000-20,000, makes it impossible for Moscow’s various AIDS centers to finance them (Rossiyskaya Gazeta 11/5/03). Consequently, there are barely any drugs available, regardless of the universal health system in place. In conclusion, and as Figures 2 and 3 illustrate, these policies have contributed to continually escalating rates of HIV prevalence and death. While Putin may argue that he is committed to combating AIDS, it seems that the data and evidence do not support his claim. Future efforts to contain the spread of this epidemic in Russia would require a complete federal institutional overhaul and an unwavering commitment from the center to both finance and implement anti-AIDS policy measures while working with civil society.

Figure 2 # Infected with HIV & AIDS, Russia, 1994-2005 350000 300000 250000

HIV

200000 150000 100000 50000

AIDS

0 94

95

96

97

98

99

00

01

02

03

04

05*

Source: Federal Center for Scientific Research to Fight AIDS, Moscow, Russia, 2005 *Up to September

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Figure 3 Yearly deaths from HIV & AIDS, Russia, 1994-2005 8000 7000 HIV

6000 5000 4000 3000 2000

AIDS

1000 0 94

95

96

97

98

99

00

01

02

03

04

05*

Source: Federal Center for Scientific Research to Fight AIDS, Moscow, Russia, 2005 * Up to September

In contrast to Brazil, civil society in Russia never had the opportunity to effectively collectivize in response to the AIDS crisis. As mentioned earlier, the long phalanx of antihomosexual legislation generated few incentives for the gay community to act cohesively. There were two major responses to the discriminatory anti-gay laws mentioned earlier: reactionary or revolutionary. In other words, one had to decide whether to become part of a group that was trying to gradually work with the government or join one that was revolutionary in nature, aggressively (and at times violently) mobilizing against the state. As seen in the United States (the classic West coast, East coast clash), this choice generated rifts within the gay activist community, hampering its ability to effectively mobilize against the state (Shilts, 1987). While pro-gay civil rights organizations emerged at the end of the 1980s, internal divisions quickly ensued. In 1989, in a small apartment in Moscow, the Moscow Association of Sexual Minorities was formed. Led by the young charismatic leader Roman Kalinin the gay association was rather revolutionary in its response towards the state’s stance on homosexual behaviour. Not all of its members, however, shared the same ideas (Schulter, 2002). Many were upset by the Association’s revolutionary approach for achieving pro-gay civil rights and by the fact that its members supported homosexual acts with children. Several members broke from the Moscow Association to create the Association for the Equal Rights of Homosexuals (ARGO). In contrast to the Moscow Association, ARGO sought to register with the government as an official organization while gradually working with government officials towards some sort of policy change. Similar tensions emerged in other regions between the revolutionary members versus the more reactionary, politically strategic organizations. In Leningrad, for example, the revolutionary Chaykovsky Fund for Cultural Initiatives and Aid to Sexual Minorities was established, which quickly aligned itself with the Moscow Association and was equally reactionary towards the government. Nevertheless, this did not bode well with yet another conservative group in the area Banks of Nyevá (River), founded by a university professor that had been convicted for engaging in sodomy. Like the two groups mentioned 24

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above, these two associations could not agree on how to pressure the government for a more aggressive approach to the burgeoning AIDS epidemic. These two instances were also indicative of the growing tensions within the gay community over how they were going to respond to the federal government. Consequently, what resulted was paralysis, that is, a general inability to mobilize in opposition to the government. But even if the homosexual community could have organized effectively, it seems rather unlikely that they would have influenced policy. For although Yeltsin lessened the legal penalties associated with homosexual activity, the Putin administration would take an even harsher stance towards the gay community. Since he has been in power, Putin has shown absolutely no sympathy for the gay community, especially for those of its members afflicted with HIV/AIDS. Putin’s apathy and discrimination towards homosexuals was reflected when he did nothing in response to the Duma’s recent attempt to reinstate antihomosexual laws. In 2002, the People’s Deputy group in the Duma tried to pass legislation that would institute criminal punishment for homosexuality and send homosexuals to “labor camps” for about five years (INERFAX 4/24/02). People’s Deputy Leader Gennady Riakov’s justification for this amendment consisted of his “highly moral” considerations and conviction that homosexuality was alien to the Russian people’s traditions, history, and culture (INTERFAX 4/24/02). Although Duma’s members never viewed this piece of legislation as imperative, it is nevertheless disturbing that the legislation was considered. Putin’s reluctance to immediately reject this proposal was even more disturbing. His inaction in this case suggested that he might have sympathized with the People’s views, thus reinforcing his well known conservative values. In the case of intravenous drug users, there are few incentives for them to collectivize against the state. This is due mainly to fear of being seen as a drug user or supporter of such habits. The pressure that does exist for changing government policy mainly stems from international NGOs and other groups that are clearly not involved in intravenous drug abuse. The government’s response to domestic and international NGOs is equally problematic. Few if any domestic NGOs pressure the government for a change in AIDS policy. What is more, international NGOs are hesitant to appeal to the government for change because of the belief that Putin is openly critical and suspicious of their motives. International NGOs are viewed as a Western democratic ploy to challenge the government’s sovereignty and worse still, Putin’s capacity to manage the AIDS crisis on his own (Solnick, 2005). Putin, moreover, has viewed the international funding of Russian NGOs as a threat to the civil society’s ability to build organizations on its own: in his words, “Some Russian NGOs exist on foreign grants,” [but] “civil society must develop under its own resources” (INTERFAX 6/12/01).

VII. THE POLITICS OF GOVERNMENT RESPONSE IN BRAZIL As in Russia, Brazil’s initial response to the AIDS epidemic was marked by a high degree of fear and uncertainty, leading to a slight delay in federal government intervention. Yet, in contrast to Russia, the initial government response was not attributed to the dark side of

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Victorian moral politics, but rather to social fear and bewilderment.4 The delayed response was also attributed to the view that AIDS was a health problem mainly associated with the members of the affluent gay community, who could, as the government believed, finance medical treatment on their own. Nevertheless, the Health Ministry of São Paulo had already responded to the epidemic, signaling to the federal government that it needed to respond more aggressively. By 1985 President Sarney responded by creating a National AIDS Program (NAP). Like in the case of Russia, this program was housed under the Ministry of Health. But unlike Russia, the program controlled all of the activities associated with HIV/AIDS prevention and treatment. Thus policy and intervention authority was not as institutionally fragmented as in Russia. Moreover, Sarney delegated a high degree of autonomy to the program and appointed ministers that were viewed as non-political and technical. Despite initial complaints of his somewhat apathetic response to the AIDS situation, when he finally decided to act in 1985 his main priority was to construct a highly centralized agency governed by non-political appointees that were well versed in epidemiology (Serra, 2004). The president’s commitment to delegating complete authority to the NAP while staffing it with technical ministers continued. The first appointee was Lair Guerra de Macedo Rodrigues (1986-1990; 1992-1996), followed by Eduardo Cortes (1990-1992) and Pedor Chequer (1996-2000). Perhaps with the exception of Cortes, who was sorely criticized for his somewhat condemnatory PR campaigns, all of these ministers were allowed autonomy (Galvão, 2000). What is more, Galvão argues that the ministers often coordinated with other agencies at the federal level to insure that their initiatives were supported by the other branches, thus avoiding any overlap of responsibilities and conflict (Galvão, 2000). Since then, NAP directors have fought to maintain this autonomy while at the same time trying to obtain more resources from the Ministry of Health and international donors (Villela, 1999: p.190). In addition, each presidential administration has supported their autonomy, which in turn allowed a high degree of administrative, and thus program, stability. As in the past, scholars claim that the NAP continues to maintain a highly centralized form of governance, especially in its relationship with sub-national health agencies (De Costa Marques, 2002: p.137). Teixeira (1997) notes, for example, that according to the NAP all states and municipalities had to implement NAP’s policy suggestions from Brasilia; that the NAP was, “calling the shots from above” (Teixeira 1997: p.60). Teixeira also notes that throughout the 1990s the NAP often established municipal agencies working on monitoring HIV and implementing prevention/treatment programs despite the expressed discontent of state and municipal health agencies (Teixeira, 1997: p.63). This deprived the centralized elite of its arrogance that it could, as in the past, readily intervene in the state’s affairs. The centralized managerial authority of the NAP persists to this day. Each president since its inception has given NAP a high degree of autonomy. Relatively stable political conditions, especially under the presidency of Fernando H. Cardoso (1994-2000), combined with a very low turnover of political appointees, has created a highly centralized 4

My thanks to President Fernando H. Cardoso for pointing this out to me during our discussion in December 2004, São Paulo, Brazil.

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agency that continues to formulate and implement policy while imposing its will on subnational health agencies and NGOs (Galvào, 2000; Teixeira, 1997). This does not mean that the NAP or the Ministry of Health were completely isolated, despotic agencies. Although it maintains its centralized character, the NAP has always been simultaneously committed to consulting and representing the interests of civil society through NGOs while cooperating with other federal agencies. Since its inception in 1985, it has committed itself to institutionalizing the interests of civil society by establishing a federal AIDS Commission (Comissão Nacional de AIDS) which actively sought and represented the opinions of various NGOs, even the church (Villela, 1999). Such trends continued over time as NAP leadership worked to improve its programs (Parker, 1997: p.8-14; Villela, 1999: p.1997). At the same time, the NAP established several federal level commissions to obtain advice from other agencies, such as the Ministry of Education and Justice (Galvão, 2000). However, policy decisions were never influenced by NGOs or other agencies. To summarize, since the initial AIDS outbreak Brazil’s political elite, namely the President and directors of NAP, were quite responsive to the needs of the civil society. As in the past, the government retained its long held tradition of creating a centralized bureaucracy to curb the spread of HIV. What is more, it combined a high degree of bureaucratic autonomy with the establishment of a close working coalition with civil society and other bureaucratic agencies (Parker, 1994). This kind of elite response continues under the current Ignacio de Silva “Lula” administration. Lula and the NAP have retained a fervent commitment to autonomously implement policy while continuously working with civil society. Civil society also played an important role in the government’s initial response to AIDS. It should be noted, however, that the presence of historical institutions in Brazil, in this case, the presence of an authoritarian government, had a very different effect on the incentives and capacity of civil society to mobilize. Whereas the supercilious nature of the Russian state through its discriminatory legalities debilitated collective action, the absence of these factors in Brazil, coupled with the outgoing military’s interest in universal health care, fostered a more cohesive civil societal response. Years of military rule and the future (essentially guaranteed) possibility of a democracy generated very strong incentives for the homosexual community to work together in response to the epidemic. Bastos (1999) even went to the extent of arguing that “the fight for civil rights and AIDS grew up together. And that in some cases, the energy of AIDS activism helped strengthen the awareness of and fight for civil rights” (Bastos, 1999: p.9). Additionally, the wedding of human rights with access to medicine also emerged at this point. Fair and free access to medicine was an essential right that all Brazilians should be granted (Ortells, 2003). And this boded nicely with an emerging new federal commitment to universal health care. Equating civil and human rights with universal access to medicine led to the emergence of several old and new civic associations. The SomoS and Lampã gay right groups, which were created in the 1970s, reemerged to campaign against AIDS, while the Atobá in Rio and the Grupo Gay da Bahia (GGB) in the city of Salvador, Bahia, were established as well. Grupo de Apoio á Prevencã AIDS (Support Group of AIDS Prevention) was also formed in more than a dozen major urban centers by a diverse group of social workers, health professionals, gay activists and individuals concerned with 27

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providing social and psychological support for AIDS victims. The Group of Life (Grupo Pela VIDAA) was established in Rio at this time. This was the first publicized organization committed to fighting for the rights of gays and challenging the justice system for equal access to medicine. VIDAA was also the first organization to address the issue of “living with AIDS,” which was vital for uplifting those struggling with the virus on a daily basis. Other formal institutions emerged, such as ABIA, the Associacão Brasileira Interdisciplinar de AIDS (Brazilian Inter-Disciplinary AIDS Association), founded by influential intellectuals and scientists, and ARCA, the Apoio Religiose Contra AIDS (Religious Support Group against AIDS), an ecumenical group formed by liberal religious leaders (Parker, 1994). In sharp contrast with the polarized, ineffective Russian gay community, the Brazilian gay community’s strategy for collective action was quite innovative and effective. Gay activists believed that they could accomplish more not by immediately harboring their association with AIDS and their rights for medicine (as seen with the reactionary Moscow Association of Sexual Minorities), but instead by gradually, strategically lobbying the government and joining already well established human rights organizations concomitantly pressing for universal health care access. Bastos (1999) notes that the fight for citizenship in a country that was emerging from an authoritarian government provided a larger and better umbrella for anti-AIDS organizing than a strictly gay-based movement might have done. In a footnote, she claims that in various interviews, gays at the time shared their belief that they would be more effective at influencing policy by working with others than with their own (Bastos, 1999: p.176). The role of the church in Brazil was also quite different from that of Russia. For instead of trying to convince the government that it should punish the immoral “them” by neglecting to implement preventive legislation, it actually helped the governmental campaign to increase awareness and prevention of HIV/AIDS (Galvão, 1997). In a country where the majority of citizens are Roman Catholic, this activity bewilders many because the church has, in contrast to the Vatican’s wishes, openly promoted safe sex through the distribution of condoms and safe sex education. Furthermore, the church continues to be involved in periodic federal level commissions organized by the NAP and Ministry of Health to provide consultation. On the ground, however, its role has been vital in helping citizens in the most isolated areas of Brazil, mainly the Northeast and Eastern (Amazonian) region, where it is difficult for health administrators to treat citizens. The liberal nature of the Catholic Church in Brazil has contributed to the Church’s success. Both the church leadership and its members are depicted as participating in a light form of Catholicism, which, as noted earlier, takes morality out of the public sphere and secures it in the private. This, in turn, has facilitated the Church and gay community’s ability to collaborate with various NGOs and the international community when pressuring the government for a more effective response to AIDS (Associated Press 4/16/05). Recently, extensive survey research conducted by Silvia Fernandes, a sociologist with the Center for Religious Statistics and Social Studies in Rio, found some interesting results: “Our research shows most people aren’t worried about sticking to religious doctrine if it conflicts with the way they live, and this is especially true among the poor,” she noted (Associated Press 4/16/05). This type of attitude bodes well for a society that is genuinely concerned about working with its church and other organizations to learn more about HIV. 28

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It also bodes well for Catholic and other types of religious leaders seeking to educate church attendees about the importance of safe sex. Thus, in sum, the gay community has, with the help of NGOs and the church, worked together to collectively pressure the government for an aggressive response to HIV/AIDS. I have focused on the gay community because it was the one community with the highest rate of prevalence. Heterosexuals, prostitutes, and intravenous drug users have also worked together and through NGOs to voice their concern. Yet, it was really the gay community that was the most organized and committed to continually pressuring the government to address the AIDS problem in Brazil. What is crucially different from the Russian case in this regard is that it was the absence of a repressive state, through various discriminatory laws did exist in Brazil, that allowed the gay community and other civic associations concerned with human rights and access to medicine, to gradually develop under the military and to suddenly emerge and strategically work together to ensure the governmental response to AIDS. But what is more important to note is that the absence of suppressive laws, as seen in Russia, did not instigate polarizing responses within the gay community – i.e. a reactionary, versus a more gradual, calculated response - and thus conflicting views of opinion over how to go about pressuring the government. Rather, the absence of such laws in Brazil allowed the gay community to think strategically and to work with other NGOs over time for an effective address to the government. Their linkage with the NGO community, when combined with a supportive church, continues to provide perhaps the most propitious civic conditions for collective action and “bottom up” pressures for reform. Figure 4 Brazil: federal distribution of condoms, 1993-2002 350 300 250 200 150 100 50 0 93

94

95

97

99

00

01

02

Source: Ministry of Health, Brazil, 2005

The dual emergence of a progressive federal elite and active civil society has in turn led to the implementation of arguably the world’s best anti-AIDS prevention and treatment programs. Since the early 1990s the government has been committed to the implementation of various HIV prevention programs, ranging from free condom distribution to safe sex education and federally sponsored harm reduction programs. At the same time, the government is widely known for its continued commitment to providing antiviral drug medication and moreover, for finding ways to provide AV medication in the 29

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cheapest, most effective way possible. This section concludes, however, with the government’s remaining institutional challenges, namely, decentralization, and the need to combat other epidemics such as tuberculosis that are affecting the general population through HIV-infected individuals. With regard to prevention programs, Brazil, in contrast to Russia, has financed and implemented several condom distribution and harm reduction strategies, in addition to a very progressive safe sex education campaign through the media and public education. Efforts to distribute condoms started in 1993. Before then condoms were sold at regular prices with a distribution of approximately 10 million units per year. After 1993, however, the government invested heavily in providing free condoms and working with NGOs to provide condoms at a discount. As Figure 3 illustrates, the distribution of free condoms has increased from 18.8 million in 1994 to 300 million by 2002. The rest of the condoms are provided through regular commercial channels, while NGOs also distribute condoms at a discounted rate (Bacon et al., 2004). The government, nevertheless, remains committed to increasing the availability of free condoms. Recently, as part of its application for a third loan to the World Bank (AIDS III), the NAP has explicitly requested money for increasing condom sales to 550 million a year (Bacon et al., 2004). Other prevention programs in Brazil are equally impressive. Sex education, for example, has been vital. Over the years the government has sponsored various health education programs within schools while disseminating information through reports. As Table 2 illustrates, the government has sponsored several anti-AIDS educational programs focusing on the principal causes of HIV transmission, and a large percentage of schools have adopted these programs. Moreover, info commercials about safe sex, usage of condoms, etc. are used on a daily basis on the radio and TV. (Compare this to the United States where such federally Table 2 Percentage of population with correct knowledge of ways in which HIV is transmitted, Brazil Indicator N NE CW Total SE S % of Population with correct knowledge of how HIV is 57.6 57.5 71.8 73.5 70 67.1 transmitted % of population that believes HIV can be transmitted 4.3 7.3 3.4 4.1 3.3 4.6 through insect bight % of population that believes that HIV can be caused by 16.4 19.9 11.5 11.5 13.3 14.2 using public toilets % of population that believes that can be caused by 22.6 20.3 12.8 10.8 12.6 15.2 sharing cutlery, glasses and dishes % of population that believes that HIV can be 85.7 89.6 92.9 94.8 90.7 91.6 transmitted by sharing syringe needles % of population that believes that HIV can be 97.1 96.5 95.4 95.7 96 95.9 transmitted by having unprotected sex Source: PCAP-BIR, 2005; taken from the National AIDS Program website, Ministry of Health, Brazil, 2005

sponsored advertising is essentially non-existent.) The success of Brazil’s anti-AIDS campaign is illustrated by the high degree of civic awareness regarding how HIV is contracted. Table 2 shows that a survey analysis in 1999 revealed that in the most afflicted regions of the country, namely the southeastern and southern states, over 90% of the surveyed population was aware that HIV is contracted

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through intravenous drug use and unprotected sex. Other regions also scored very high on this question.

Figure 5 Number of persons receiving ARV treatment in all federal, south eastern and southern states, Brazil, 1997-2004

180,000 160,000

All

140,000 120,000 100,000 SE

80,000 60,000 40,000

S

20,000 0 97

98

99

00

01

02

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Source: Ministry of Health, Brazil, 2005

Lastly, in contrast to Russia, the Brazilian government has sponsored several harm reduction programs, helping to curb the contraction of HIV through intravenous drug use. The focus of these programs has for the most part been on distributing, through state and municipal health agencies and the NAP’s municipal AIDS agencies, clean syringes for drug use. Recently, the former Minister of Health under Fernando H. Cardoso, José Serra, stated that this activity did not, in the government’s opinion, indirectly contribute to solving the drug problem (Serra, 2004: p.5). (Recall that this is the reason why the Russian government has not sponsored these types of programs.) Rather the goal has been to improve the physical well-being of drug addicts. Serra argues that this would motivate addicts to become more involved in federal treatment programs, as they need to be healthy and have greater trust in the government before working on their psychological behavioral change (Serra, 2005: p.5). The government has realized that it takes time before an addict (or a prostitute) can abandon his/her habits. This is not to say that the government would not sponsor programs to address these addictions; it has and continues to do so. However, its first responsibility is to ensure that addicts remain safe from HIV before enrolling them into anti-addiction programs. As a result of these harm reduction programs, the number of IDUs decreased from 21% of those infected with HIV in 1994 to 11.4% in 2000. During eight years 160 projects aimed at harm reduction have worked with approximately 65,000 IDUs (Serra, 2005: p.5). The current government has remained committed to these programs and considers them vital for containing the rise of HIV. Since the beginning of the HIV/AIDS epidemic, the government has been committed to providing antiviral medication free of charge. After several years of complaints and law suits from constituents that they were not receiving all of the medication needed, in 1996 President Cardoso implemented into law the provision of free universal access for all antiviral medication. As of 2003, Brazil provides 17 individual types of antiviral medication (plus co-formulated AZT and 3TC), including nucleoside 31

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reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (Pis) (Bacon et al., 2004). Since then the government has kept its promise. Consequently the number of individuals receiving AV medication has increased substantially, from 35,892 in 1997 to 153,607 in 2003. Additionally, the federal government has been able to reduce and maintain low costs for AV production by establishing various production plants and bargaining with international and domestic pharmaceutical companies (Teixeira, Vitória, and Barcarolo, 2003).

Figure 6 Mean cost for total ARV therapy, double and triple NTRI therapy per patient/year, Brazil, 1996-2001 8,000 7,000 6,000

Total

5,000

Triple

4,000 3,000 2,000

Double

1,000 0 96

97

98

99

00

01

Source: Ministry of Health, Brazil, 2005

In order to insure that citizens are receiving the medication they need, the Ministry of Health announced two major initiatives. First, it established approximately 474 medical sites, mainly clinics in public hospitals, where citizens can obtain medication. This has proven crucial for ensuring that those residing in the most rural areas of Brazil receive proper treatment. Next, beginning in 1997 the government implemented a computerized program, the Computerized System for the Control of Drug Logistics (Sistema de Controle Logistico de Medicamentos, SICLOM), to monitor how many antiviral medications are being used and to provide immediate availability reports back to the Ministry of Health headquarters in Brasilia. These two initiatives continue to this day and illustrate the extent to which the federal government is committed to providing the local institutional and computational services needed to ensure that its citizens receive AV medication in a timely and efficient manner. Perhaps the most impressive part of the federal government’s campaign to provide free, low-cost AV services was its continued effort to pressure international and domestic pharmaceutical companies for reduction in drug prices. These negotiations took place shortly after 1995 (around the time when the WTO was created). Faced with a burgeoning AIDS crisis and a fiscal crisis, President Cardoso and his Minister of Health, José Serra, forced international pharmaceutical companies to lower their drug prices by issuing a decree, secured through the WTO TRIPS agreement obligations, that allowed governments to issue compulsory licenses for the production of AV medication in cases of national 32

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emergencies (Article 78) or abuses of economic power, such as high prices of drugs (Article 68). These threats worked and the companies began to lower their drug prices. Government financing of AV production sites began shortly thereafter, which contributed further to a reduction in prices of drugs. Figure 7 Government expenditures for ARV therapy and all federal AIDS programs, Brazil 1400 Total Government Expenditures

1200 1000 800 600

ARV Therapy

400 200 0 96

97

98

99

00

01

02

03

Source: Ministry of Health, Brazil, 2005

In a recent report, the former Minister of Health José Serra emphasized that these actions were taken in order to emphasize that democratic citizens’ health must supersede the monopolistic interests of large pharmaceutical companies, and that it was the duty of the federal government to undertake the most efficient means necessary to achieve this goal (Serra, 2004). The Cardoso administration was so committed to this principle that at the fourth WTO Ministerial Meeting in Doha in November 2001, Serra wrote that “Brazil took the initiative of defending the idea that it is up to national governments to decide the grounds upon which they will grant compulsory licenses for life-saving medicine … [and that] the initiative was fully successful: it was adopted in paragraph 5-B of the Declaration of the TRIPS Agreement and Public Health” (Serra, 2004: p.10). In sum, has the government retained its commitment to ensuring that citizens receive AV medication in a timely manner? The answer is yes: Lula remains fervently committed to this. He has also strived for a continued reduction in AV prices by increasing the production of drugs in Brazil, while at the same time working with other countries, mainly in Africa, to achieve the objective of lower drug prices. The empirical results of all these initiatives are impressive. As Figure 7 below illustrates, the number of cases of HIV has decreased, and so has the number of deaths directly attributed to AIDS. The government’s attempt to provide several prevention and treatment programs has for the most part paid off. Nevertheless, several challenges remain. Decentralization and the management of prevention and treatment programs is one of them, especially in Brazil’s highly fragmented context. However, and especially

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when compared to Russia, there is no question that the Brazilian government has saved its citizens from deplorable rates of HIV/AIDS infections and deaths.

Figure 8 Cases of AIDS and survey data of knowledge of transmission, Brazil, 1993-2004 25000 North

95% (US) 93% (S)

20000

NE

15000

SE

Death rate

10000

S 96% (US) 95% (S)

5000

CE Death

0

93

94

95

96 97

98 99

US - HIV transmissible via Unprotected Sex

00

01 02

03

04

S - HIV transmissible via syringe use

Source: Ministry of Health, Brazil; PCAP-BIR, 2005

VIII.

CONCLUSION

This paper presents an alternative approach to understanding the politics of government response to AIDS. In contrast to recent comparative political studies focusing on the contemporary politics of government response, this paper has combined historical institutional, cultural (moral), and state bureaucratic analysis to explain the origins of contemporary bureaucratic capacity and political commitment to AIDS policy reform. Based on this analysis, there are several potential lessons that Russia can learn from Brazil. These include the need for federal bureaucratic reforms centralizing control over all antiAIDS policies while coordinating with other agencies for enhanced policy implementation; new partnerships between federal AIDS bureaucracies and civic associations and NGOs; and an unwavering commitment for financing AIDS prevention and treatment programs. While the inter-disciplinary comparative approach in this paper has highlighted the historical, institutional, and cultural factors shaping governments’ capacity to respond to AIDS, it is important to note that this framework also has the potential of illuminating the unique politics of reform in different countries. I say “unique” because, as explained in the methodological section above, it has been my goal to conduct a comparative configurative historical analysis of the politics of AIDS, in order not to strive for theoretical generalizability through covering laws applicable to a host of different cases, but rather to accentuate the uniqueness of each case through detailed historical analysis and carefully 34

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chosen cases (Katznelson, 1997). For the purposes of exploratory analysis, however, let us examine how much leverage we can obtain from this approach to explain other cases. South Africa stands out as a case where the historical institutional, cultural, and state bureaucratic variables emphasized in this study may help to explain the government’s – until very recently – lackluster response to AIDS. Like Brazil and Russia, South Africa is a large federation, covering a vast amount of territory and with several provincial governments. Moreover, it is a decentralized federation, such that provincial governments wield a considerable amount of autonomy and responsibility in implementing policy. It should be noted however, that the degree of fiscal decentralization and revenue autonomy in South Africa, especially in the area of health policy, is much lower than in Russia and Brazil. Thinking in terms of historical institutionalism, and as seen in the case of Russia, in South Africa we observe the absence of an enduring federal government tradition of establishing a highly centralized, autonomous federal health agency committed to eradicating epidemics. Recent scholars note that this has been a major factor in explaining South Africa’s delayed response to AIDS (Gauri and Lieberman, 2004). To better understand why this is the case, the next step for researchers would be to trace out, over time, the endogenous reproductive mechanisms within federal health agencies which constrain the government’s ability to revamp bureaucracy for a more aggressive response to AIDS. Some scholars are now conducting this kind of research on the issue of failed states and AIDS, applying theoretical lessons from the new path dependency and institutional change literature to explain perpetual state incapacity to respond to AIDS and other types of epidemics, such as TB and Malaria (Gómez, forthcoming). Secondly, the historical institutional approach conducted herein also alludes to the importance of strong center-state coordination between the Ministry of Health and subnational health ministries. Similarly to Russia, South Africa’s Ministry of Health has repeatedly proven incapable of effectively coordinating with sub-national health agencies (Schneider and Stein, 2001). In part, this is related to the issue of constant government incapacity to establish an effective federal Ministry of Health. However, equally important is the fact that provincial health agencies were only recently appointed by the federal Ministry of Health to head local agencies and coordinate with the center. This in turn suggests poor federal planning and delay (Schneider and Stein, 2001). Additionally, the importance of having the central government create and delegate responsibilities to provincial health agencies, as seen with the case of Brazil, is critical. A major reason for the lack of center-state coordination in South Africa has been that provincial governments, rather than the center, are required to take the lead in crafting and implementing policy (Schneider and Stein, 2001: p.725). Lastly, yet another constraint is that the center retains the right to finance most AIDS and other social welfare programs, notwithstanding the provinces’ responsibility for implementing policy. This form of functional decentralization is not helping the center-state coordination process, which is vital for successfully financing and implementing AIDS policies. Finally, in South Africa, the influence of religious morality has not played as important a role in delaying the government’s response to AIDS as we saw in Russia. Instead, enduring racial tensions and conflict, especially at the provincial level (Gauri and Lieberman, 2004) have contributed to this delayed response. Morality constraints are most 35

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prominent in cases where there was an early institutionalization of a specific form of religious belief within the government, which was periodically reinforced though political and intellectual elite traditions. Although this was not the case in South Africa, this has been the case in China (Buddhism), the United States (Christianity), India (Hinduism), Nigeria (Christianity), and the Muslim faith in several Middle Eastern nations. Future research will need to explore how and why religious faiths were institutionalized early on and to what extent this has affected the timing and breadth of governmental commitment to helping those engaged in immoral activity, such as homosexuals, prostitutes, drug addicts, the poor, and of course, women in society, especially in Muslim societies. This kind of research is very much needed and comports with the new political science literature focusing on institutions, elites, and the political incentives for AIDS policy intervention. Other federations affected by the path dependent nature of federal health agencies deluged in deep moral conviction would have a difficult time responding to the AIDS epidemic. Reforming health agencies and policies within these contexts, and especially within highly fragmented, decentralized democratic federations, will be very challenging, since political and bureaucratic elites often prize safeguarding their moral traditions rather than modernizing policy and institutions for AIDS. While these reforms seem impossible, we may nevertheless still have hope, as one of the paradoxical benefits of a highly centralized government – as in the cases of Russia, South Africa, China, Cuba, and India is its ability to hastily reform institutions and policy when fully committed to doing so. Future work will therefore need to carefully trace the linkage between historical institutions and contemporary government in order to reveal the specific areas of administration with constraining path dependent tendencies. This agenda, in turn, may provide new opportunities for social scientists and policy practitioners to join forces and propose more informed policy prescriptions for Russia and other large, highly decentralized federations striving to overcome the cultural, institutional, and geographical barriers to curbing the spread of AIDS.

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Willian S (2000). Considering the impact of HIV/AIDS on democratic governance and vice versa. University of Natal, Durban, Health Economics and HIV/AIDS Research Division. Russian News Sources Consulted INTERFAX, Moscow, Russia, 4/12/2001. Putin calls for dialogue between authorities and NGOs. (Translated through the World News Connection). INTERFAX, Moscow, Russia, 4/24/02. Russia: reaction to anti-homosexuality legislation proposal reviewed. (Translated through the World News Connection). ITAR-TASS, Moscow, Russia, 9/25/03. Putin pledges Russia’s commitment to global struggle against AIDS. (Translated through the World News Connection). ITAR-TASS, Moscow, Russia, 9/25/02. Putin signs decree, provides measures to step up drug control. (Translated through the World News Connection). ITAR-TASS, Moscow, Russia, 11/29/00. Russian government makers make proposals for drug control program. (Translated through the World News Connection). ITAR-TASS, Moscow, Russia, 4/16/03. Orthodox Church opposes needle-exchange plans for Russian addicts. (Translated through the World News Connection). ITAR-TASS, Moscow, Russia, 9/2/02. Russia: campaign against drug addiction, Addiction launched in Kaliningrad. (Translated through the World News Connection). IZVESTIYA, Moscow Izvestiya, 5/28/04. Forecast of HIV/AIDS’s impact, efforts to promote sex in Russia reported. (Translated through the World News Connection). Moscow RIA, 6/15/00. Russian state cannot afford treatment for drug addicts. (Translated through the World News Connection). RIA 3/30/05. Russian cabinet calls AIDS prevention priority, demands joint effort with business. (Translated through the World News Connection). Rossiyskaya Gazeta, 11/5/03. Russia: virology center seen threatened by financial crisis, short-time working. (Translated through World News Connection). Other Newspapers Associated Press, 4/16/05. Brazilians like their Catholicism light.

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ACKNOWLEDGEMENTS The author would like to thank the following individuals for their comments and suggestions: Christopher Murray, Thomas Bossert, Yoi Herrera, Judith Twigg, and Sarah Potts.

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