Far-right Brazil President Jair Bolsonaro has warned that COVID-19 vaccines will turn people into crocodiles. He has spread conspiracies that the vaccine could give people AIDS. Bolsonaro has pointedly refused to get vaccinated himself ― at September’s G-20 summit in New York, he was the only world leader present who said he had yet to take the jab.
Bolsonaro has mimicked the worst tendencies of his American idol, former President Donald Trump. But his attempts to foment the sort of skepticism and hesitancy Trump helped generate in millions of Americans have fallen completely flat.
Last week, Brazil reported that 60% of its population is now fully vaccinated, pushing it past the United States, which had a four-month head start. More than 97% of Brazilian adults have received at least one shot, and virtually every adult in São Paulo, the country’s largest city, is inoculated. Polls in July showed that just 5% of Brazilians said they’d never get the vaccine; in the U.S., somewhere between 13% and 19% of Americans still say they won’t.
More than 610,000 Brazilians have died from COVID-19, a death toll that trails only the United States’. But as the U.S. stares down the beginnings of another winter surge, Brazil’s daily case numbers are at their lowest points since this time last year. Daily death tolls in the majority of its states are in the single digits, and special hospital units in former hot spots like Rio de Janeiro are completely empty for the first time since the pandemic began.
That’s a credit to the country’s public health system and cultural faith in vaccines. The question is whether Bolsonaro’s rhetoric will have a corrosive long-term effect.
Over the past 50 years, Brazil has built a robust national immunization infrastructure that has turned it into a global pioneer for the development and implementation of mass vaccination strategies. It’s also home to a massive public health system, of the sort the United States lacks, that helps distribute those vaccines to every corner of the continental-sized country, and immunizes Brazilians for free.
Deliberate public campaigns and innovative approaches to immunization, meanwhile, have created a celebratory culture around vaccines ― not just against COVID-19, but related to any number of the infectious diseases that thrive in Brazil’s tropical climate.
“Vaccines are in our DNA,” said Dr. Rosana Richtmann, an epidemiologist at Brazil’s Emilio Ribas Infectious Diseases Institute and the former head of the Infectious Diseases Society of São Paulo. “So even though we have [political] problems, people trust in vaccines. That is the huge difference between Brazil, Europe and the U.S.”
Brazil, experts say, is a model for how the U.S. and Europe can combat their much higher rates of vaccine skepticism.
Still, its success against COVID-19 carries with it a massive caveat: Overall immunization coverage in Brazil has been falling for a half-decade, as forced austerity has left the health system underfunded and reduced access to vaccines. And experts worry that a small but newly vocal anti-vaccine movement, fueled by misinformation and supercharged by Bolsonaro’s efforts to undermine the nation’s public health and immunization programs, could still reverse the decades of progress Brazil has made.
Bolsonaro has put yet another Brazilian institution at a crossroads. Now, Brazil must avoid repeating the mistakes that turned countries like the United States into “super-spreaders of anti-vaccine misinformation,” said Dr. Denise Garrett, an epidemiologist at the Sabin Vaccine Institute in Washington.
“The U.S. didn’t become that overnight,” said Garrett, who is Brazilian. “I think Brazil is making the same mistake, in the sense that we think we are immune to anti-vax misinformation. We think that because we have such a pro-vaccine culture, this is not going to affect us. There is a certain dismissiveness of the movement in Brazil that I’m afraid we may regret later, because we already see big signs of anti-vax movements really getting a foothold in Brazil.”
Like Trump in the U.S., Bolsonaro has waged complete war on Brazil’s public health institutions throughout the pandemic. He has fired one health minister, forced another to quit, and indulged in conspiracy theories about the virus and the vaccines meant to thwart it. Bolsonaro also cut funding from advertising campaigns that have historically played a central role in Brazilian vaccination campaigns. And the country’s National Immunization Program, one of the world’s most successful mass vaccination initiatives, has been without a director since July, when its leader resigned and alleged that Bolsonaro had “politicized” efforts to inoculate the population.
His efforts have succeeded in fomenting fake news about the vaccine, which increased by 383% on Facebook last summer, according to a study from the University of São Paulo, and has also spread on YouTube and other social media platforms. Brazil has no domestic version of Fox News, or the other right-wing infrastructure that has spread vaccine hysteria in the United States — factors that have contributed to lower vaccination rates among Republicans and conservatives in the U.S., studies suggest.
But misinformation has come from increasingly prominent sources. Mauricio Souza, a member of Brazil’s 2016 Olympic gold medal-winning men’s volleyball team, has repeatedly voiced skepticism about vaccines on radio programs, in YouTube videos and through social media posts to his millions of followers. Even members of the medical community have joined in, lending new imprimatur to vaccine skepticism.
“We have segments of society ― segments you wouldn’t expect ― that help propagate these things,” said Marcia Castro, a native Brazilian who chairs Harvard’s Department of Global Health and Population. “It’s not some random, low-level politician, or somebody that wants to show off. It’s people that seem very reliable.”
At first, it seemed like Bolsonaro’s attempts to generate widespread hesitancy might work. In December 2020, 22% of Brazilians said they would not get inoculated, a 13-point rise from that summer. But by the middle of this year, it was clear that Brazil’s 50-year campaign to build mass vaccine infrastructure and an overwhelmingly pro-immunization culture had blunted Bolsonaro’s attempts to destroy both.
Created in 1973, the National Immunization Program grew out of a successful effort to eradicate smallpox. Fifteen years later, the end of Brazil’s military dictatorship generated a new constitution that guaranteed access to health care, leading to the creation of what is now the world’s largest public health system. In tandem, the two programs guarantee free access to vaccinations and health care more broadly, and deliver vaccines to even the most remote corners of Brazil. This has paid dividends during the current pandemic: Unlike in the U.S., Brazilian officials haven’t had to constantly insist to a public skeptical of surprise bills that vaccines really are free.
The immunization program administers more than 300 million vaccine doses against 30 diseases each year, through 8,000 vaccination centers that stretch from major metropolises to the depths of the Amazon region. Brazil coupled the program with well-funded education campaigns ― in the 1980s, it deployed Zé Gotinha, a vaccine mascot with a name that translates roughly to “Joey Droplet,” to put a friendly face on immunization, and enlisted soccer stars and actors for television programs promoting inoculation.
“Brazil is not a very proud or patriotic country, compared to the U.S. anyway. But in terms of vaccination, there’s a patriotic feeling about Brazil about having one of the best national immunization programs in the world.”
– Dr. Denise Garrett, Brazilian epidemiologist at the Sabin Vaccine Institute
It staged vaccination drives at churches, schools, festivals and other events, and wrapped vaccination into its broader social welfare programs: Bolsa Familia, the globally renowned cash transfer program created under former President Luiz Inácio Lula da Silva, requires proof of immunization to access family benefits.
Brazil’s successes are legendary inside the world of epidemiology. In the late 1980s, it inoculated 10 million children against polio in a single day. By the turn of the century, it had eradicated rubella, polio, maternal and neonatal tetanus, measles and yellow fever. When outbreaks did occur, such as the reemergence of yellow fever in 2018, Brazil’s ability to craft novel approaches to immunization helped halt potential crises before they could fully explode.
That built a level of trust in immunization programs that few of Brazil’s other institutions currently enjoy, and turned vaccines into a symbol of celebration. Brazilian mothers in particular, Richtmann said, often decorate their family’s immunization cards, and beam when they present them to public officials as they apply for school and public benefits.
As a result, many Brazilians who already opposed Bolsonaro’s dithering approach to the early stages of the pandemic viewed his opposition to vaccines as something worse: an affront to a major symbol of national pride.
“Brazil is not a very proud or patriotic country, compared to the U.S. anyway,” Garrett said. “But in terms of vaccination, there’s a patriotic feeling about Brazil being such a renowned country about vaccination, and about having one of the best national immunization programs in the world.”
So Brazilians noticed the disappearance of their popular vaccine mascot, which Bolsonaro apparently sidelined after the launch of Brazil’s vaccine program last December. “Where is our beloved Zé Gotinha?” da Silva, the former president who is likely running to replace Bolsonaro in next year’s elections, asked during a fiery speech in March, delivering a line that quickly became a rallying cry for pro-vaccine movements.
When São Paulo’s Butantan Institute, which manufactures nearly two-thirds of the country’s annual vaccine supply, began producing Coronavac, a version of the Chinese vaccine, Brazilians celebrated with memes and adaptations of popular songs. Social media soon lit up with images of Brazilians wearing crocodile costumes to their vaccine appointments to mock the president. Globo, the country’s most-watched television station, ran mass pro-vaccination campaigns in place of the government’s typical advertisements. Even Brazilians who took a milder view of Bolsonaro’s fearmongering and misinformation, including many of his supporters, decided to simply ignore him.
The health system, meanwhile, continued its innovative approach to immunization: A Brazilian experiment in a small São Paulo town provided one of the planet’s first indications of the vaccination threshold needed to stop community spread. Brazil’s public health system, which is known as SUS, has also recently deployed mobile units to smaller towns and villages, allowing people to get vaccinated without leaving home.
Trust in SUS grew by 11 percentage points ― more than any other public institution in the country ― over the first year of the pandemic, according to one survey, and that was before its mass vaccination campaigns even began. Since then, “Long live SUS!” has become a common refrain from newly inoculated Brazilians. The country’s passage of the United States’ COVID-19 vaccination rate last week set off new rounds of cheers, with barbs at Bolsonaro mixed in: Had the far-right president not ignored Pfizer’s initial entreaties to provide vaccines to Brazil last year or hampered the country’s overall rollout, many Brazilians noted online, it would have passed the U.S. months ago.
But experts are unsure whether this trend will hold, particularly given Bolsonaro’s assaults and increased misinformation. Even before his election in 2018, worrisome signs about Brazil’s vaccination programs had begun to emerge: A deep, lasting economic recession that began in 2014 led to cuts to Brazil’s public health system and pushed millions of families back into poverty, circumstances that forced many mothers into the workforce and made it more difficult to carve out time for immunizations. In 2015, measles reemerged in Brazil’s northeast region for the first time this century. Vaccination rates, which for years had surpassed 90% for many viruses, have declined over the last half-decade, and reached a 20-year low this year.
Much of that decline is attributable not to anti-vaccine campaigns but to underfunding of the public health system and reduced access to vaccines, a problem the pandemic and its resulting economic collapse only exacerbated.
But Bolsonaro and the Brazilian right wing’s importation of anti-vaccine strategies that have prospered for decades in the United States and Europe ― part of his broader efforts to cozy up to far-right movements in both places ― have generated fears that Brazil could see real growth in anti-vaccine sentiment, especially against immunizations that don’t feel as urgently necessary as this one, if such sentiment is not combated in its nascent stages.
In a desperate bid to bolster his reelection hopes, Bolsonaro recently announced that he would replace Bolsa Familia, the popular welfare program, with a new scheme that will not require immunizations.
“Bolsonaro is doing everything he can to undermine vaccination in Brazil in every sense,” Garrett said. “I am not pessimistic. I am just trying to be cautious. … It took us 50 years to build this. I don’t think it’s going to be destroyed overnight, but I also don’t think it will take 50 years to destroy it.”
There is cautious optimism that the pandemic will reinvigorate Brazil’s pro-vaccine culture beyond the current COVID-19 inoculation, and spur conversations among political leaders about the sort of investments Brazil needs to make to broaden access and turn its current declines around ― even if real action may have to wait until after next year’s election, which polls suggest Bolsonaro will lose.
Already, though, Brazil’s pandemic experience has provided a valuable lesson to public health officials and political leaders around the world: Even in places with well-established immunization programs and minuscule levels of vaccine opposition, Richtmann said, “this campaign never stops.”