Amy Nunn's book provides the reader with a wealth of information about the Brazilian response to the AIDS epidemic. While it complements other books and articles written on the subject, The Politics and History of AIDS Treatment in Brazil elevates our understanding of the topic to a new level. Nunn constructs the narrative as a puzzle where every piece counts and little by little the bigger picture is revealed. It is possible to say that the sophistication of her analysis consists of showing that sometimes we must first understand the trees in order to truly see the forest. With an impressive attention to almost all aspects of what she calls ‘the development of Brazil's AIDS treatment institutions’, her method has paid off with a book that it is a must-read for all of us interested in understanding how Brazil, against all odds, became a model country that is successfully managing the AIDS epidemic and inspiring changes in health policies at the global level. The book is compact, with seven chapters flowing together without losing momentum, beginning with a discussion of how public health was rediscovered and interpreted by Brazilians in the 1980s after almost two decades of military dictatorship. Nunn's methodology is eclectic and combines interviews of key actors with intensive historic research, including examinations of archives and publications of governmental and non-governmental organisations (NGOs), as well as literature review.
In the book's Introduction, Nunn tells the story of Ezio Távora, a well-known Brazilian activist living with HIV. Ezio's trajectory, as presented by Nunn, illustrates the path of a nation via the life of an HIV-positive person – from denial to embracing and respecting the rights of its citizens living with HIV and AIDS. Ezio survived the bad times of the Brazilian response to the epidemic because he was able to pay for his treatment, but since 1996, as described in detail by Nunn, Brazil has been providing AIDS medicines free of charge through the public health system, allowing Ezio and thousands of other Brazilians living with HIV to enjoy their right to health as established by the 1988 Brazilian Constitution. Unfortunately, however, Ezio and Brazil don't represent the typical individual and national trajectories in the fight against the AIDS epidemic.
Millions of individuals are still dying without access to AIDS treatment, and some countries are still not responding to the AIDS epidemic in the way they should. As described by Nunn, the worst predictions of HIV infection in Brazil didn't materialise. Nonetheless, we can see the difference in terms of outcome when a country implements a comprehensive response with a multi-sector approach and without a dichotomy between prevention and treatment. As a contrasting example to the Brazilian experience, we can look at South Africa: in the 1990s, Brazil and South Africa reported having the same levels of HIV infection among their respective populations, but currently Brazil is estimated to have approximately 600,000 to 890,000 people living with HIV, while the estimates for South Africa are approximately 5.7 to 6.6 million HIV-positive people. Besides these sombre numbers, another tragic result of this lack of commitment is the more than 300,000 deaths that a recent report attributed to the South African government's use of denial as a response to the AIDS epidemic.
Some of the topics discussed by Nunn – especially those related to the initial response to the epidemic in Brazil in the 1980s – are not new, and reflect what people familiar with writings about the AIDS epidemic in Brazil already know: the identification of the first AIDS cases in the early 1980s when the country was emerging from a military dictatorship; the connection of public health and human rights as a core element to explain the achievements of the Brazilian response; the politicisation of the field of health in Brazil in the 1980s with important actions such as the Movimento da Reforma Sanitária (Sanitary Health Reform Movement), which fought for changes in the public health system; the involvement of people from this movement as well as anti-authoritarian activists and former political exiles in the creation of the first AIDS-related NGOs; and the importance of the participation of civil society organisations, including organisations of people living with HIV/AIDS, in the development of the Brazilian response to the epidemic. What is new, however, is the way that Nunn examines these well-known facts, highlighting new aspects and in doing so revealing the complexities and the nuances of the Brazilian response.
The last Epidemiological Bulletin published by the Brazilian Ministry of Health (MOH) reported that the cumulative number of AIDS cases in the country (1980 to June 2008) is 506,499, and the cumulative number of AIDS deaths is 205,409. The national authorities estimate that Brazil today has approximately 600,000 HIV-positive people, while early World Bank estimates indicated that Brazil would have 1.2 million people living with HIV by the year 2000. What isn't in doubt is that the costs associated with treatment are still rising – with new and more expensive drugs being introduced – and the number of people in need continues to grow. In 1996, 35,900 patients were receiving antiretroviral treatment (ART); at the end of 2008, the figure was more than 185,000. The Brazilian National AIDS Programme predicts that by 2011, approximately 260,000 people will need ART. As pointed out by Nunn and other scholars, this is a challenge for the Brazilian MOH in terms of the sustainability of its treatment program. As Nunn describes, however, the Brazilian government is continuing to show that AIDS treatment is a priority and is finding ways to maintain it, via negotiations with the international pharmaceutical companies, local production of medications by public and private laboratories, and for the first time in 2007, the use of compulsory licensing (referred to as ‘breaking the patent’ and permissible in Brazilian law if a patent holder abuses their rights, for example by not manufacturing the patented product) for an antiretroviral drug.
With the Foreword written by former Brazilian President Fernando Henrique Cardoso (who signed the 1996 law mandating that all HIV-positive Brazilians should be treated free of charge in the public health system) and Francisco Bastos (a prominent Brazilian AIDS researcher), Nunn's book captures the reader's attention with an unbiased analysis of the development of the Brazilian treatment response to the AIDS epidemic. As poetically mentioned by Bastos, Nunn's collaboration with Brazilian research institutions was a successful one, and follows the centuries-long Brazilian tradition of attracting ‘traveller-scientists’.
Nunn's study explains the process by which Brazil's AIDS treatment institutions developed, but the result of her work is more than this. For the reader acquainted with the literature on the AIDS epidemic in Brazil, this book will be like seeing a familiar painting being restored – all the details were there before, but after the restoration new colours and textures come to life. Those not familiar with the present literature will learn by the Brazilian example how national HIV/AIDS policies (when properly implemented) can change the life of a country's citizens and have the potential to influence the field of global health by showing that positive outcomes are possible when access to health is understood as a human right.
