Commentary / Work by Donna Bowater

Pragmatic Public Activism

The timing of Christopher L. Gibson’s new book, Movement-Driven Development: The Politics of Health and Democracy in Brazil, is both unfortunate and fortuitous.

It is unfortunate because Gibson’s rigorous analysis of the extraordinary achievements of Brazil’s public health system from the late 1980s comes just as analysts warn of fresh backsliding under a newly inaugurated right-wing president. At the very least, Jair Bolsonaro takes office following the first rise in infant mortality in decades, while the World Bank also notes an increase in poverty from 2016 to 2017, reaching almost 55 million Brazilians, after years of reductions under the left-wing Workers’ Party (PT).

But the publication of Movement-Driven Development is also fortuitous: it offers a timely reminder of the enormous potential for development through citizen and civil-society actors, even in a complex or unsupportive political climate.

An assistant professor at Simon Fraser University’s School for International Studies, Gibson assesses the role of Brazil’s civil-society actors in driving the move toward universal health care during the country’s transition from dictatorship to democracy in the 1980s. He especially celebrates the contributions of Brazil’s loosely defined Sanitarist Movement (Movimento Sanitário), which united activists and public health professionals, in both creating and occupying institutions and systems to deliver primary health care. 

Clearly, Gibson’s focus and research here predate Brazil’s contemporary political instability, ignited by the 2014 Lava Jato (Car Wash) corruption scandal, which implicated officials in money laundering and bribery at the state-controlled oil company Petrobras and led to the impeachment of leftist President Dilma Rousseff in 2016. He notes briefly in the concluding chapter that the Sanitarist Movement of activists with ties to public health demobilized before this. Consequently, the narrative arc of Gibson’s research falls short on contemporary context and relevance. This is a book that is already crying out for a second edition.

Nonetheless, such a respectful and optimistic review of improvements in Brazilian public health care offers hope, as the country enters a new phase in its democratic history, for achieving extraordinary social development and progress, ruling political party notwithstanding. In fact, Gibson’s work questions the popular assumption that a leftist government, by virtue of its ideology, necessarily results in more pro-social policies. He points out that this view cannot explain fully how President Fernando Henrique Cardoso, during his two terms, from 1998 to 2002, was able to introduce pioneering health programs in Brazil’s relatively young democracy well before the rise of the PT.

Circumnavigating the Rules

According to Gibson’s study, what has been missing until now is a full exploration of the role of “pragmatist publics” in addressing public health challenges, such as infant mortality rates. He specifically points to sanitaristas and their mobilization within centrist local governments, when necessary, to achieve improvements in public health.

Gibson takes us back to the late 1980s and the end of the dictatorship, when infant mortality in Brazil was worse than it is in sub-Saharan Africa, at 61 deaths per 1,000 live births, despite consistent GDP growth under military rule. Even after health care became a constitutional right in 1981, infant mortality rates remained at more than 50 deaths per 1,000 live births in many larger cities. In the worst cases, such as in the Amazonian capital of Manaus, 80 of every 1,000 newborn babies died. Gibson suggests that strong economic growth under the dictatorship explains this pattern as a result not of poverty but rather of political and social factors.

He contends that the decentralization of government during the transition to democracy was sufficiently disruptive to create the opportunity for political and social reform by stealth. And because the new constitution enshrined a right to health care, a movement emerged both to champion and to honor it.

Though Gibson criticizes existing literature for reducing the political influence of sanitaristas to their expertise in public health, he does not offer a more robust definition of the movement or its principles. Early on, he describes sanitaristas as “movement activists and veterans with ties to a changing public health profession,” without pinpointing additional factors or motivations.

His broader consideration of the medical profession as an inherently political practice is incisive; he notes that the ideology underlying the Sanitarist Movement derived from the “struggle to enact a right to health” and “correct society-wide health inequalities.”

Gibson draws out this concept in two chapters on the state capitals of Belo Horizonte and Porto Alegre, where he identifies strong links between public health workers, student and union activism, and the Diretas Já campaign for direct presidential elections. In Belo Horizonte, the Sanitarist Movement succeeded through public-office holding, while in Porto Alegre, municipal health councils were treated as “civic arenas” in which citizens directly monitored performance. More generally, he aligns these councils with “pragmatist publics” to explain their political agency, which perhaps indicates their loose and somewhat fragmented identity—an idea that later becomes relevant.

According to Gibson, this loose band of sanitaristas has been insufficiently credited with the ongoing delivery and improvement of the country’s public health system (the SUS), and his book seeks to correct this oversight. Gibson defines three distinct approaches as minimalist, programmatic, and participatory-programmatic, the last of which he treats as the gold standard. Under the participatory-programmatic trajectory, office-holding sanitaristas capitalized on political inconsistency to maximize state building for basic health-care provisions. In cities where health democratization took a “programmatic” trajectory, sanitaristas were able to mobilize the delivery of primary health care. Cities with a “minimalist” trajectory largely blocked sanitaristas from public office, limiting their ability to build state capacity for primary health care.

Gibson’s study touches on six Brazilian capital cities, offering two examples of each approach before delving into four chapters on the “healthy” cities that adopted programmatic and participatory-programmatic approaches. Among these were Belo Horizonte, a city with a participatory-programmatic approach, where infant mortality fell from 57.57 in 1988 to just 12.17 per 1,000 live births in 2002.

His research includes empirical analysis, as well as interviews with key figures in state public health, including former President Fernando Henrique Cardoso. Such select personal testimony not only offers firsthand accounts of the development of public health in Brazil but also affords Gibson the opportunity to demonstrate his admiration for such key players, along with his—and their—passion for public service and civil society. Such subjective sources and experiences highlight the variation and inconsistency in development across Brazil.

From one of his fascinating interviews, Gibson quotes Dr. Lídia Tonón, a sanitarista who later became second in command within the municipal health secretary in Belo Horizonte. Her comments reveal the level of improvisation involved in establishing key primary health services: “We invented jobs among us that didn’t exist. … We made up a prenatal and neonatal program because it was possible and because it had to be done.”

Gibson describes this approach as reminiscent of Deweyan pragmatism for its efficiency and expediency derived from practical insights into the political climate, and it is perhaps here that the book comes closest to characterizing the Sanitarist Movement most explicitly. It is a cultural insight worthy of further exploration, not least because it is also reminiscent of the positive aspect of what Brazilians crudely call jeitinho, or the custom of finding a way to navigate rules to achieve a desired outcome.

Most often, jeitinho is used as negative  shorthand for circumventing or corrupting the rules, but such “common sense” or “inside-out” pragmatism, together with “guiding normative principles,” can also represent a force for good, if only in a limited way. As Gibson notes, “The absence of anything like sanitaristas within the state-society politics of Brazil’s public education sector may contrastingly help explain why and how comparatively less institutional change and social progress has occurred in that sector.”

Local Pragmatism

While Brazil’s sanitaristas may have helped to propel public health care forward, it is a clear limitation of civil society and subnational movements that, by their very nature, they are most effective in localized settings. Indeed, in his chapters on the development of health care in Curitiba and Fortaleza, Gibson traces the roots of reductions in infant mortality rates beyond the presence of left-party politicians and sanitaristas.

Gibson also highlights two cities with “minimalist” trajectories of health democratization—Rio de Janeiro and Salvador—where legacy politicians even blocked sanitaristas from public offices, but he fails to further analyze where and why the movement did not take hold. In fact, Gibson observes only nonrobust development in Rio, despite its “status as a nationwide center for the Sanitarist Movement,” and thus concedes that “history has not been fate, and commonly deployed variables struggle to account for subnational variation.”

It also leaves open his initial question about “what maximizes improvements in public health and social development.” Gibson draws no easy conclusions but characterizes movement-driven development as an amplifier of latent political and social transformation.

Gibson draws no easy conclusions but characterizes movement-driven development as an amplifier of latent political and social transformation.

Elsewhere, Gibson makes the compelling case for the role of sanitaristas in persuading politicians to support hugely significant programs such as the Bolsa Família welfare allowance, which lifted millions out of poverty on the condition that families access health care and education.

But what a reader is to take from the book, beyond a greater understanding of development during Brazil’s transition to democracy, remains unclear. For all the country’s success in establishing the SUS and populating it unevenly at the highest levels with sanitaristas, the delivery of health care in Brazil is among the persisting indicators of social inequality. While improvements in the recent past are clear, fundamental institutional weaknesses remain—particularly in public funding. Despite the fact that expenditures on public health surpassed 8 percent of GDP by 2014, for example, per capita expenditures since 2015 have declined. 

Gibson’s reflections on sanitaristas’ success with the legacy of dictatorship can offer inspiration for the current political climate, as he refers to the language of efficiency used to convince officials of the benefits of public health reform. Ultimately, his book rounds out existing narratives about the expansion of public health care in some of Brazil’s cities, rather than extends them by offering insights relevant to contemporary challenges. 

In Gibson’s words, his book is the first study to “systematically demonstrate that pragmatist publics have mattered for society-wide health outcomes even when considering the separate influences of other factors.” This is an important contribution to academic understanding of civil society’s role in and contribution to development amid a range of other factors and variables. However, it stops short of offering solutions or inspiring any kind of revival of such activism at a time when Brazil, once again, needs it most.

Originally published by the Stanford Social Innovation Review in Spring 2019.

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