Date Published: April 20, 2010
Publisher: Public Library of Science
Author(s): Kelley Lee, Luiz Carlos Chagas, Thomas E. Novotny
Abstract: As part of the PLoS Medicine series on Global Health Diplomacy, Kelley Lee and colleagues provide a case study of Brazil’s growing influence in international relations and global health, using as an example that country’s role and use of “soft power” in the negotiation of the Framework Convention on Tobacco Control.
Partial Text: One of the key developments in international relations during the early twenty-first century is the ascendance of the BRIC countries (Brazil, Russia, India, and China) (see Box 1 for terms and definitions). While their rising status stems largely from their demographic and economic growth (together accounting for about 40% of the world’s population and 40% of global GDP ), also important has been what international relations scholars refer to as the growing use of “soft power.” The term “soft power” was coined by Joseph Nye during the 1990s to describe “how power is changing in world politics” since the end of the Cold War. He argued that, while military force and conquest remain important, power derived from technology, education, and economic growth have increased in significance. The result has been “a general diffusion of power” to a broader range of state and non-state actors. Given that “the solutions to many current issues of transnational interdependence will require collective action and international cooperation,” Nye argued that governments must use an appropriate balance of “soft power” (co-option and attraction) and “hard power” (coercion and payment) when pursuing their interests .
As part of a broader project on “The tobacco industry, public policy and global health” and our case study of the FCTC and global health diplomacy, the authors sought to obtain views of Brazil’s role in the FCTC negotiations. The authors carried out key informant interviews with Brazilian policy makers, diplomats, and public health advocates on the country’s role in FCTC negotiations from December 2008 through January 2009. Interviews were conducted by LCC in Portuguese, transcribed, and translated. Triangulation of reported perceptions was achieved through a literature review of primary and secondary sources including government reports and Web sites, industry documents, reports by nongovernmental organizations, and unpublished research dissertations.
Brazil has become increasingly prominent in international relations in recent years through its leadership in climate change , trade, energy policy, and nuclear nonproliferation negotiations . By combining economic growth with progressive domestic social policies, the country has defied orthodox thinking on development. It has been in the realm of global health, however, that Brazilian diplomacy has been particularly noteworthy, beginning with negotiations on access to medicines for treatment of HIV/AIDS. Because of its constitutional requirement for equity in access to antiretroviral (ARV) therapy , and the political will to address the issue, Brazil successfully confronted and negotiated a satisfactory resolution to barriers imposed on drug availability by the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). With the US government aligning with powerful corporate interests, Brazil’s championing of free and universal access to ARVs earned worldwide respect among public health advocates . While other countries, such as Thailand and South Africa, also sought to challenge the pharmaceutical industry on restrictive pricing policies, as Nunn and colleagues argue, Brazil became the first developing country to offer free ARV treatment to HIV/AIDS patients despite claims by the World Bank that such a policy was not cost-effective . Importantly, the country has seen a dramatic decline in AIDS-related morbidity and mortality as a result of its treatment program, a success story that has served as a role model for the expansion of global support for HIV/AIDS treatment in other countries. In this way, Brazil helped bridge a chasm between public health and trade policy through its national HIV/AIDS policy .
Brazilian leadership was critical to the successful conclusion of the FCTC negotiations in 2003. Following the establishment of a model national tobacco control program, Brazilian medical doctor and former coordinator of the National Tobacco Control Programme, Vera Luiza da Costa e Silva, was recruited to lead WHO’s Tobacco Free Initiative (TFI), and Brazilian diplomats were appointed to chair the Intergovernmental Negotiating Body (INB) for the FCTC. A fuller understanding of Brazil’s contribution to the FCTC process may provide lessons about the conduct of global health diplomacy in other contexts.
Brazil’s ability to grapple with the diversity of interests at the national level, including a powerful tobacco industry, began with the establishment of the Inter-Ministerial National Commission on the Control of Tobacco Use in 1999. Backed by the highest levels of government, the Commission was a consultative body to determine the official government position on the FCTC negotiations. Importantly, nine ministries were represented on the Commission, including Inland Revenue, Trade and Development, and Agriculture –. This commission, including all pertinent stakeholders, ensured that tobacco control was embodied in consistent policies throughout government and not only as a health ministry issue. The close involvement of the Ministry of Foreign Affairs, in particular, backed by the highest levels of government, ensured a clear and unified endorsement of health goals within Brazilian foreign policy:
A strategically important decision by the WHO TFI was the appointment of Celso Nunes Amorim, then Brazil’s Permanent Representative to the United Nations and other international organizations in Geneva, as INB Chair. Amorim was recognised as a skilled and experienced diplomat, particularly during his tenure as negotiator in UN talks on disarmament, trade, and security. The US delegation described him as “a steady hand and [providing] good leadership” . When Amorim became Ambassador to the United Kingdom in 2002, he was succeeded as INB Chair by another experienced diplomat, Luiz Felipe de Seixas Correa. Along with skilful diplomats, Brazil was enabled by the strong support of the Minister of Health, José Serra, who recognized that the international negotiating process had direct effects on Brazilian national tobacco control efforts and public health, according to Vera Luiza da Costa e Silva.
Brazil’s leadership in global health diplomacy must be understood as part of the country’s political and economic ascendance in international relations. As the world’s tenth largest economy, and an integrated member of the world trading system, the country’s influence over a wide range of global health issues is likely to grow in coming decades. Brazil has recognised that traditional practices of hard power can be inappropriate in a globalized world. Its understanding of soft power, in the form of normative leadership and the use of “opinion-shaping instruments” , suggests that a new kind of diplomacy is emerging to achieve collective action on shared challenges such as global health. Through its principled stance on ARVs, and its domestic commitment to strong and effective tobacco control, Brazil has earned widespread credibility as a diplomatic leader. This, in turn, has helped to reinforce domestic policy on tobacco control. Brazil’s remarkable example also suggests that engagement in health diplomacy is increasingly seen as a core component of what it means to be a global citizen .