Abstract:

As the COVID-19 pandemic has spread worldwide in 2020, populations, authorities, and local and global health governance institutions have been affected differently. Global Health Diplomacy and “paradiplomacy” have become relevant instruments and arenas for the challenges raised by the pandemic, especially for non-State or subnational actors. This Essay analyzes the case of the Brazilian state of Maranhão during the pandemic, which used a “wartime operation” to purchase more than a hundred mechanical ventilators on the international market, over the Federal Government’s head, at a moment of fierce international competition for medical supplies and equipment. The Essay examines the principal aspects, contexts, reasons, factors, actors, and actions that contextualize the operation conducted by the state of Maranhão as an activity in paradiplomacy and Global Health Diplomacy by a subnational government in Brazil. We analyzed these concepts in light of the literature on the topic and studied the action by Maranhão based on cross-analysis of data from documents, statements, and news coverage. We conclude that the case of Maranhão illustrates the capacity of subnational bodies to respond to global emergencies, mainly in contexts of inefficacy or absence of the Federal executive, legitimizing independent action aimed at saving lives.

Keywords:
Pandemics; COVID-19; Global Health; Health Diplomacy; Leadership and Governance Capacity

Introduction

The battle for medical equipment is a phenomenon with major national and global repercussions in the context of the COVID-19 pandemic. The purchase of mechanical ventilators by the state of Maranhão through an “alternative” trade route is quite revealing of the “all-out war” between nations for medical and hospital equipment and clearly illustrates the increasingly fierce economic and diplomatic competition. It also exposes a disconcerting geopolitical element in the international diplomatic context, namely the absence of leadership by the Brazilian Federal Government, with the resulting emergence of new subnational actors in the international scenario ¹1. Lucena E, Lucena R. Prognóstico é ruim e vai piorar, diz Fiori. Tutaméia 2020; 10 abr. https://tutameia.jor.br/prognostico-e-ruim-e-vai-piorar-diz-fiori/.
https://tutameia.jor.br/prognostico-e-ru... ^,22. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... .

Due to the risk of the health system’s collapse in one of Brazil’s poorest states, the government of Maranhão decided to act. The “wartime operation” in Maranhão was assembled after three thwarted attempts by the state government to purchase ventilators for use in intensive hospital care. The logistics mounted for the direct purchase of ventilators from China, using funds donated by local businesses in an initiative organized by the Maranhão State Secretariat of Industry and Commerce (SEINC). Three trade operations were conducted with China that involved the purchase of more than 255 mechanical ventilators and 200,000 protective masks ³3. Secretaria de Saúde do Estado. Mais de cem respiradores chegam ao Maranhão para pacientes com coronavírus. https://www.saude.ma.gov.br/destaques/mais-de-cem-respiradores-chegam-ao-maranhao-para-pacientes-com-coronavirus/ (acessado em 20/Ago/2020).
https://www.saude.ma.gov.br/destaques/ma... . The strategy was laid out after the ventilators were reserved three times through the “normal” bureaucratic channels and blocked by the UNITED STATES, Germany, and the Brazilian Federal Government itself ⁴4. Rede Brasil Atual. Receita vai processar Flávio Dino por 'operação de guerra' que garantiu respiradores ao Maranhão. Rede Brasil Atual 2020; 20 abr. https://www.redebrasilatual.com.br/politica/2020/04/receita-vai-processar-flavio-dino-por-operacao-de-guerra-que-garantiu-respiradores-ao-maranhao/.
https://www.redebrasilatual.com.br/polit... . The government of Maranhão thus altered the purchasing route and brought the merchandise through Ethiopia. When the cargo was unloaded in São Paulo, it was shipped directly to Maranhão, where it underwent the routine procedures with the Brazilian Internal Revenue Service ⁴4. Rede Brasil Atual. Receita vai processar Flávio Dino por 'operação de guerra' que garantiu respiradores ao Maranhão. Rede Brasil Atual 2020; 20 abr. https://www.redebrasilatual.com.br/politica/2020/04/receita-vai-processar-flavio-dino-por-operacao-de-guerra-que-garantiu-respiradores-ao-maranhao/.
https://www.redebrasilatual.com.br/polit... ^,55. Após ser acusado de compra ilegal, Flávio Dino posta vídeo com respirador e "uma vida sendo salva". Jornal do Commercio 2020; 20 abr. https://jc.ne10.uol.com.br/politica/2020/04/5606680-apos-ser-acusado-de-compra-ilegal-flavio-dino-posta-video-com-respirador-e--uma-vida-sendo-salva.html.
https://jc.ne10.uol.com.br/politica/2020... ^,66. Mota E. Receita Federal diz que Maranhão trouxe respiradores ilegalmente da China; governo reage. Congresso em Foco 2020; 20 abr. https://congressoemfoco.uol.com.br/saude/receita-federal-diz-que-maranhao-trouxe-respiradores-ilegalmente-da-china-governo-reage/.
https://congressoemfoco.uol.com.br/saude... .

Nevertheless, despite the operation’s initial success, the Federal Government accused the government of Maranhão of overstepping its constitutional prerogatives and demanded possession of the equipment. The situation was resolved by the Supreme Court, which ruled that the ventilators should be returned to Maranhão, citing the emergency situation with COVID-19 ⁷7. Secretaria de Saúde do Estado. Mais 104 respiradores chegam ao Maranhão para reforçar combate ao COVID-19. https://www.saude.ma.gov.br/destaques/mais-104-respiradores-chegam-ao-maranhao-para-reforcar-combate-a-covid-19/ (acessado em 20/Ago/2020).
https://www.saude.ma.gov.br/destaques/ma... ^,88. Secretaria de Saúde do Estado. Em meio a disputa global. Maranhão recebe mais de 250 respiradores em menos de um mês. https://www.saude.ma.gov.br/destaques/em-meio-a-disputa-global-maranhao-recebe-mais-de-250-respiradores-em-menos-de-um-mes/ (acessado em 20/Ago/2020).
https://www.saude.ma.gov.br/destaques/em... .

International action by subnational governments, called “paradiplomacy”, represents a profound change in the field of studies on foreign policy analysis and International Relations ⁹9. Ribeiro MCM. Globalização e novos atores: a paradiplomacia das cidades brasileiras. Salvador: EdUFBA; 2009., mainly resulting from the globalization processes. The subnational paradiplomacy phenomenon is a geopolitical process involving proactive players acting autonomously in relation to the central government in International Relations ¹⁰10. Moreira FA, Senhoras EM, Vitte CCS. Geopolítica da paradiplomacia subnacional: um estudo sobre a extroversão internacional dos municípios da rede de Mercocidades. In: XII Encuentro de Geógrafos de América Latina ; 2009. https://works.bepress.com/eloi/122/ (acessado em 20/Ago/2020).
https://works.bepress.com/eloi/122/... , through international acts and agreements to obtain resources and solve specific problems quickly and smoothly without intervention by central governments.

Paradiplomacy thus points to changes in the traditional scale of international observation, since International Relations are no longer the exclusive focus of Nation-States, but are also developed by a plurality of other State or subnational actors, such as private, nongovernmental, municipal, and state-level paradiplomacies ¹¹11. Vigevani T, Wanderley LE, Cintra R. Ação Internacional das cidades no contexto da globalização. Cadernos Cedec 2006; (80). http://www.cedec.org.br/files_pdf/CAD80.pdf.
http://www.cedec.org.br/files_pdf/CAD80.... ^,1212. Milani CMS, Ribeiro MCM. Paradiplomacia y proyección internacional de las ciudades brasileñas: la elaboración del concepto de "gestión internacional local". Geopolítica(s): Revista de Estudios Sobre Espacio y Poder 2010; 1:23-40.. These actors in turn begin to act internationally in a more systematic and articulated way, often over the State’s own head, in the name of private, commercial, or economic interests, or in defense of various policy causes ¹³13. Milani C, Pinheiro L. Política externa brasileira: os desafios de sua caracterização como política pública. Contexto Internacional 2013; 35:11-41..

In parallel, Global Health Diplomacy as a research field has also stood out on the international and States’ foreign policy agendas, especially in a context marked by the evolution of the sustainable development concept and the recent scenario of the global pandemic. Global Health Diplomacy can generally be defined as a foreign and international theme or area dedicated to the main collective and public global health issues, also involving issues in trade, security, and sustainable development, manifested mainly by inter and intragovernmental cooperation among ministries, agencies, institutions, municipalities, and state governments ¹³13. Milani C, Pinheiro L. Política externa brasileira: os desafios de sua caracterização como política pública. Contexto Internacional 2013; 35:11-41.^,1414. Buss PM, Ferreira JR. Diplomacia da saúde e cooperação Sul-Sul: as experiências da Unasul saúde e do Plano Estratégico de Cooperação em Saúde da Comunidade de Países de Língua Portuguesa (CPLP). RECIIS 2010; 1:106-18..

In the context of the current pandemic and to the extent that the disease is spreading worldwide, the international action by the government of Maranhão thus triggered the current essay. Why has a subnational body engaged in efforts to pursue an international role?

This Essay proposes to analyze the case of paradiplomacy in the state of Maranhão in the purchase of ventilators from China in the context of the COVID-19 pandemic. Although the evidence concerning the Brazilian challenges for dealing with the novel coronavirus in the global health field is still incipient, based on the case of Maranhão, news coverage, official government statements, and reports by international organizations point to three essential elements for this analysis: the denialist discourse by the President of Brazil, boycotting the fight against the pandemic; diplomatic tensions and trade setbacks with China, Brazil’s largest trade partner and the largest global exporter of medicines and medical and hospital equipment and supplies; and diplomatic isolation, with criticism and attacks by Brazil against multilateralism and international agencies in global health governance. The Essay begins with the concept’s historical contextualization and the Brazilian experience in paradiplomacy.

Paradiplomacy: definitions and the Brazilian experience

The concept of “paradiplomacy” was developed to characterize any external action undertaken by a non-State or subnational actor that produces some international influence or result. This approach was initially developed by Snyder and Rosnau in the 1960s, reinforcing the premise that domestic actors and factors and international actors are relevant for foreign policymaking and its content ¹³13. Milani C, Pinheiro L. Política externa brasileira: os desafios de sua caracterização como política pública. Contexto Internacional 2013; 35:11-41..

The debate gained momentum in the 1980s in the North American literature with the work by Duchacek and Soldatos, who coined the term “paradiplomacy” to characterize international action by subnational bodies outside the traditional State structure, referring to the term “parallel diplomacy”. Paradiplomacy thus refers to the political, economic, and social relations and activities conducted by subnational actors (regions, provinces, federative states, cities, urban communities) with other national governments, subnational entities, international organizations, and other actors for political, commercial, industrial, financial, technical, cultural, or geopolitical purposes. The activities in turn can support, complement, correct, duplicate, or challenge the National State’s own diplomacy ¹⁵15. Gonçalvez FCNI, Oliveira PC. A política externa (sub) nacional: um estudo da paradiplomacia do Estado do Rio de Janeiro e de sua relação com o governo federal. Conjuntura Global 2017; 6:94115..

The 1990s ushered in the term “post-diplomacy” to characterize a process manifested beyond the National State and its traditional diplomacy, formulating the concept of “multilayered diplomacy” to refer to interactions between central and regional spheres and the themes that are relevant to both in the international scenario ¹⁵15. Gonçalvez FCNI, Oliveira PC. A política externa (sub) nacional: um estudo da paradiplomacia do Estado do Rio de Janeiro e de sua relação com o governo federal. Conjuntura Global 2017; 6:94115..

Paradiplomatic activities vary according to each country’s political and constitutional context and with different motives, interests, actions, strategies, and means. The inefficiency or weakness of central governments on political and economic issues impel subnational actors to relate to other federative entities, central governments, and international institutions ¹¹11. Vigevani T, Wanderley LE, Cintra R. Ação Internacional das cidades no contexto da globalização. Cadernos Cedec 2006; (80). http://www.cedec.org.br/files_pdf/CAD80.pdf.
http://www.cedec.org.br/files_pdf/CAD80.... ^,1515. Gonçalvez FCNI, Oliveira PC. A política externa (sub) nacional: um estudo da paradiplomacia do Estado do Rio de Janeiro e de sua relação com o governo federal. Conjuntura Global 2017; 6:94115..

Following this debate, paradiplomacy came to be defined as subnational governments’ involvement in International Relations through formal and informal contacts, whether permanent or temporary, with public or private foreign entities, aimed at producing socioeconomic and political results or others outside the scope of their constitutional prerogative ¹⁵15. Gonçalvez FCNI, Oliveira PC. A política externa (sub) nacional: um estudo da paradiplomacia do Estado do Rio de Janeiro e de sua relação com o governo federal. Conjuntura Global 2017; 6:94115..

In Brazil, the association of foreign policy with the National State and the Ministry of Foreign Affairs (or the Foreign Business Secretariat) dates back to the time of Portuguese colonization, extending through historical periods of Independence, the Empire, and the Republic. This process featured relative autonomy, professionalism, and Brazilian diplomacy’s historical tradition, notably in multilateral forums.

Starting in the 1980s, with the loss of the Ministry of Foreign Affairs’ monopoly over Brazilian foreign policymaking, other ministries took leading roles, such as the Ministry of Finance in international financial negotiations on the country’s foreign debt; inter-ministerial action coordinating multilateral forums; and conferences on sustainable development and global health. Nongovernmental organizations and subnational bodies also assumed growing roles ¹³13. Milani C, Pinheiro L. Política externa brasileira: os desafios de sua caracterização como política pública. Contexto Internacional 2013; 35:11-41..

Foreign and domestic structural changes (the end of the Cold War, globalization, the rise of new non-State actors, re-democratization, the 1988 Constitution) in the 1990s favored the protagonist role of actors previously neglected by the power structures ⁹9. Ribeiro MCM. Globalização e novos atores: a paradiplomacia das cidades brasileiras. Salvador: EdUFBA; 2009.^,1212. Milani CMS, Ribeiro MCM. Paradiplomacia y proyección internacional de las ciudades brasileñas: la elaboración del concepto de "gestión internacional local". Geopolítica(s): Revista de Estudios Sobre Espacio y Poder 2010; 1:23-40.. In parallel, the academic debate intensified in Brazil, classifying this phenomenon as federative diplomacy, with two interpretations: one “positive”, adding to classic diplomacy, and the other “negative”, considering federative diplomacy as a deviation from diplomacy per se ¹⁵15. Gonçalvez FCNI, Oliveira PC. A política externa (sub) nacional: um estudo da paradiplomacia do Estado do Rio de Janeiro e de sua relação com o governo federal. Conjuntura Global 2017; 6:94115..

In the legal and constitutional sphere, there is no legal statement on the legitimacy of international actions performed by subnational bodies. According to Brazil’s Federal Constitution, it is the Federal Government’s responsibility to conduct International Relations, with some exclusive prerogatives, while without prohibiting states and municipalities from conducting relations with other states or from participating in international organizations. Since 2005, the Brazilian Congress has been studying a proposed constitutional amendment that would establish greater autonomy and support for states and municipalities to conduct their own International Relations ¹⁰10. Moreira FA, Senhoras EM, Vitte CCS. Geopolítica da paradiplomacia subnacional: um estudo sobre a extroversão internacional dos municípios da rede de Mercocidades. In: XII Encuentro de Geógrafos de América Latina ; 2009. https://works.bepress.com/eloi/122/ (acessado em 20/Ago/2020).
https://works.bepress.com/eloi/122/... .

Brazil’s states and municipalities began to participate more actively in foreign relations, with processes of regional integration in South-South cooperation, in which the areas with the greatest articulation have been economic promotion and political and technical cooperation ¹⁵15. Gonçalvez FCNI, Oliveira PC. A política externa (sub) nacional: um estudo da paradiplomacia do Estado do Rio de Janeiro e de sua relação com o governo federal. Conjuntura Global 2017; 6:94115..

At the practical level, currently 22 Brazilian states (among the 26 states plus the Federal District) and 366 municipalities have some type of agency that deals with International Relations ¹¹11. Vigevani T, Wanderley LE, Cintra R. Ação Internacional das cidades no contexto da globalização. Cadernos Cedec 2006; (80). http://www.cedec.org.br/files_pdf/CAD80.pdf.
http://www.cedec.org.br/files_pdf/CAD80.... ^,1515. Gonçalvez FCNI, Oliveira PC. A política externa (sub) nacional: um estudo da paradiplomacia do Estado do Rio de Janeiro e de sua relação com o governo federal. Conjuntura Global 2017; 6:94115.. In the state of São Paulo, for example, local governments and politicians have encouraged municipalities to seek foreign partnerships and investments. Meanwhile, in the state of Amapá, some politicians have invested in closer relations with the French government due to the border relations with French Guiana, and this may also generate important actions and results in relation to policy for regional preservation of the Amazon ¹¹11. Vigevani T, Wanderley LE, Cintra R. Ação Internacional das cidades no contexto da globalização. Cadernos Cedec 2006; (80). http://www.cedec.org.br/files_pdf/CAD80.pdf.
http://www.cedec.org.br/files_pdf/CAD80.... .

Among the paradiplomatic initiatives by the State of Maranhão, at the start of his term, Governor Flávio Dino launched overtures to Chinese political representatives and business leaders on investments in the energy, steelmaking, and technology sectors, thereby strengthening International Relations with the Chinese market, besides prospecting for investments with the BRICS countries (Brazil, Russia, India, China, and South Africa) ¹⁶.

In 2017, Governor Flávio Dino received the Israeli Ambassador to discuss proposals for institutional and academical cooperation, agricultural development, and opportunities for local and international entrepreneurs ¹⁷17. Estado do Maranhão. Governo estreita relações de cooperação internacional com Israel. https://www3.ma.gov.br/maranhao-estreita-relacoes-de-cooperacao-internacional-com-israel/ (acessado em 20/Ago/2020).
https://www3.ma.gov.br/maranhao-estreita... . That year, the governor also signed a memorandum for technical cooperation with the Pan-American Health Organization (PAHO) and the World Health Organization (WHO) in maternal and child health ¹⁸18. Estado do Maranhão. Governo celebra cooperação com organizações internacionais e fortalece rede materno-infantil no estado. https://www3.ma.gov.br/governo-celebra-cooperacao-com-organizacoes-internacionais-e-fortalece-rede-materno-infantil-no-estado/ (acessado em 20/Ago/2020).
https://www3.ma.gov.br/governo-celebra-c... .

In 2019, Maranhão spearheaded the creation of the Northeast Consortium, a subnational block of states for political and socioeconomic cooperation that began to seek investments and public-private partnerships (PPP) for infrastructure and technology projects, including at the international level ¹⁹19. Froés R, Cardoso R, Barbosa A. Governadores do Nordeste assinam no Maranhão documento que cria consórcio entre estados. G1 2019; 14 mar. https://g1.globo.com/ma/maranhao/noticia/2019/03/14/governadores-do-nordeste-assinam-no-maranhao-documento-que-cria-consorcio-entre-estados.ghtml (acessado em 20/Ago/2020).
https://g1.globo.com/ma/maranhao/noticia... . The governors and representatives from the Northeast states participated in international trade missions to present the region’s economic potential and to negotiate investments with local entrepreneurs in various areas ²⁰20. Estado do Maranhão. Dezenas de empresários italianos conhecem oportunidades de negócio no Nordeste. https://www3.ma.gov.br/dezenas-de-empresarios-italianos-conhecem-oportunidades-de-negocio-no-nordeste/ (acessado em 20/Ago/2020).
https://www3.ma.gov.br/dezenas-de-empres... .

With the COVID-19 pandemic, the Maranhão State Government led a surprising paradiplomatic operation that called the attention of the news media and the medical and academic community, especially in the area of Global Health Diplomacy. The operation followed a trend already identified since the 1980s in Brazil and conducted by the state of Maranhão at other moments. Based on the concepts presented above, we will analyze the three essential elements, beginning with the Brazilian President’s denialist discourse.

The denialist discourse of the “Ostrich Alliance”

The first element involves the denialist discourse, actions defended by the Brazilian Federal Government and its implications, hindering the fight against the novel coronavirus by underestimating the impact of the virus, questioning social distancing rules, defending so-called “herd immunity”, and clashing with the positions of countries that have obtained effective results in controlling the pandemic ²¹21. Campos GWS. O pesadelo macabro da Covid-19 no Brasil: entre negacionismos e desvarios. Trab Educ Saúde 2020; 18:e00279111..

The case of Maranhão reveals the difficulties for dealing with COVID-19 and the constraints on ministers, governors, and other government administrators in the face of the President’s denialist position towards the abundant scientific evidence ²¹21. Campos GWS. O pesadelo macabro da Covid-19 no Brasil: entre negacionismos e desvarios. Trab Educ Saúde 2020; 18:e00279111., with restrictions on initiatives by the Ministry of Health, the Brazilian Unified National Health System (SUS), and state and municipal governments in the search for measures to save the Brazilian population ²²22. Conselho Nacional de Saúde. Carta aberta: CNS em defesa da vida, da democracia e do SUS. https://conselho.saude.gov.br/ultimas-noticias-cns/1140-cartaaberta-do-conselho-nacional-de-saude-em-defesa-da-vida-da-democracia-e-do-sus (acessado em 20/Jun/2020).
https://conselho.saude.gov.br/ultimas-no... .

The Brazilian President’s denialist discourse aligns him with a small group of world leaders (Belarus, Turkmenistan, and Nicaragua), who ignore the pandemic’s seriousness and severity and have thus been nicknamed the “Ostrich Alliance”, due to the comparison with the bird that hides its head in the sand when in danger ²³23. 'Aliança do Avestruz': FT destaca grupo de Bolsonaro e outros líderes que 'se recusam a levar coronavírus a sério' BBC Brasil 2020; 17 abr. https://www.bbc.com/portuguese/internacional-52328505.
https://www.bbc.com/portuguese/internaci... . The “Ostrich Alliance”, exposed in a recent edition of the Financial Times, questions President Jair Bolsonaro’s stance towards the pandemic in the global scenario, indicating a serious reversal in International Relations and Health Diplomacy ²⁴24. The 'Ostrich Alliance': the leaders denying the coronavirus threat. Financial Times 2020; 26 abr. https://www.ft.com/content/974dc9d2-77c1-4381-adcd-2f755333a36b.
https://www.ft.com/content/974dc9d2-77c1... .

In June 2020, of the 22.2 million confirmed cases and 780,000 deaths in the world (WHO Coronavirus Disease [COVID-19] Dashboard. https://covid19.who.int/, accessed on 20/Jun/2020), official reporting showed that Brazil was the country with the most confirmed cases in South America and the second most in the world, with more than 3.5 million Brazilians with COVID-19 and more than 112,000 deaths and a 3.2% case-fatality rate (Ministério da Saúde. Coronavírus Brasil. https://covid.saude.gov.br, accessed on 20/Jun/2020).

According to the WHO, the widespread underreporting of cases and deaths, due mainly to the low diagnostic testing of the population, together with an upward curve of new deaths, have already positioned Brazil as the most recent world epicenter in the pandemic ²⁵25. Barrucho L. BBC Brasil . Brasil: o novo epicentro da pandemia de coronavírus? BBC Brasil 2020; 20 mai. https://www.bbc.com/portuguese/brasil-52732620.
https://www.bbc.com/portuguese/brasil-52... .

Given the COVID-19 rates and the Brazilian population’s living conditions, the recent analysis by the Imperial College London (U.K.) recommends urgent actions. The institution, which is a reference on pandemics in the U.K., estimated that Brazil would double the number of deaths every 5 days, with a transmission rate (R0) of 2.81, the highest among the 48 countries studied ²⁶26. The Lancet. COVID-19 in Brazil: "So what?" Lancet 2020; 395:1461..

The needs created by the pandemic become even more urgent in a country with precarious work conditions as a structural reality, exacerbated with the expansion of the neoliberal agenda in the last 30 years ²⁷27. Pochmann M. O emprego no desenvolvimento da nação. São Paulo: Boitempo Editorial; 2008., especially for a working class increasingly stripped of rights and guarantees ²⁸28. Antunes R. O privilégio da servidão: o novo proletariado de serviços na era digital. São Paulo: Boitempo Editorial; 2018..

However, when questioned on the rapid rise in Brazilian cases, the President replied, “So what? I’m sorry, what do you want me to do?”, in a blatant and unprecedented display of irresponsibility and disrespect that exposed him as a serious threat to human health ²⁶26. The Lancet. COVID-19 in Brazil: "So what?" Lancet 2020; 395:1461..

Even after he was denounced in the International Court of Justice in the Hague for crime against humanity due to his negligence towards social distancing policies, Jair Bolsonaro continues on the fringes of the global debate, flaunting a drug with no proven efficacy (hydroxychloroquine) to treat COVID-19 and launching unjustifiable attacks on the recommendations by the WHO ²2. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... ^,2929. Eisenhammer S, Stargardter G. Bolsonaro colocou generais para combater coronavírus, e Brasil está perdendo a batalha. UOL Economia 2020; 26 mai. https://economia.uol.com.br/noticias/reuters/2020/05/26/especial-bolsonaro-colocou-generais-para-combater-coronavirus-e-brasil-esta-perdendo-a-batalha.amp.htm?__twitter_impression=true.
https://economia.uol.com.br/noticias/reu... .

The Brazilian President’s stance thus now poses one of the main difficulties in the fight against the novel coronavirus, given his denialist positions, twisting facts in the mainstream media, irresponsibly misleading the population, and raising obstacles to initiatives by governors and mayors ²2. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... ^,2626. The Lancet. COVID-19 in Brazil: "So what?" Lancet 2020; 395:1461..

With the advent of the pandemic, the government of Maranhão acknowledged the situation’s gravity and drafted a Contingency Plan with a series of decrees that established measures for prevention and social distancing and that reaffirmed the state of pandemic declared by the WHO ³⁰30. Estado do Maranhão. Decreto nº 35.660, de 16 de março de 2020. Dispõe sobre os procedimentos e regras para fins de prevenção da transmissão da COVID-19, institui o Comitê Estadual de Prevenção e Combate à COVID-19 e dá outras providências. Diário Oficial do Estado 2020; 16 mar.. However, regarding the purchase of medical supplies and equipment, the state government encountered difficulties due to the exacerbated global competition for medical equipment and the Federal Government’s inaction and disorganization in relation to the pandemic.

Importantly, the Northeast Consortium also created a scientific committee to assist administrators in the region to make decisions for confronting the pandemic. The initiative involves scientists from Brazil, Italy, Germany, China, and other countries to discuss solutions in the attempt to lower the spread of COVID-19 cases ³¹31. Santos A. Governadores do Nordeste criam comitê científico contra coronavírus. UOL 2020; 30 mar. https://noticias.uol.com.br/politica/ultimas-noticias/2020/03/30/governadores-do-nordeste-criam-comite-cientifico-contra-coronavirus.htm.
https://noticias.uol.com.br/politica/ult... .

Diplomatic tensions, trade setbacks, and “modern piracy”

The second element relates to the difficulties created by diplomatic tensions between Brazil and China and the passivity of the Federal government and the Ministry of Foreign Relations in the trade area in a context of global disputes for access to medical supplies and equipment. In this pandemic scenario, the economic lockdown and shortage of some products have launched some countries into a “global treasure hunt”, in which acts of “modern piracy” for the acquisition of medical supplies and equipment became part of global commercial transactions, revealing the lack of international solidarity and leadership and governance in the global health field ³²32. Lister T, Shukla S, Bobille F. Pandemia de coronavírus desencadeia disputa global por máscaras de proteção. CNN Brasil 2020; 5 abr. https://www.cnnbrasil.com.br/internacional/2020/04/05/pandemia-de-coronavirus-desencadeia-disputa-global-por-mascaras-de-protecao.
https://www.cnnbrasil.com.br/internacion... .

In this context, some national governments blocked, rerouted, and confiscated loads of equipment destined for other countries, as in the case of the UNITED STATES, Germany, and France, which rerouted cargo with medical equipment from China that were being shipped to Italy, Czech Republic, and Brazil. In the face of this phenomenon, the Brazilian Government remained passive towards the UNITED STATES (which diverted the Brazilian equipment) and engaged in diplomatic tensions with China (the largest exporter of equipment) for ideological reasons, fueled mainly by the President of Brazil and the Minister of Foreign Relations, costing Brazil some priority in relation to Chinese exports, besides cancellations and delays. This situation severely jeopardized the strategies of the SUS and state governments, which were forced to act through unofficial channels, as in the case of the government of Maranhão ⁶6. Mota E. Receita Federal diz que Maranhão trouxe respiradores ilegalmente da China; governo reage. Congresso em Foco 2020; 20 abr. https://congressoemfoco.uol.com.br/saude/receita-federal-diz-que-maranhao-trouxe-respiradores-ilegalmente-da-china-governo-reage/.
https://congressoemfoco.uol.com.br/saude... .

In addition, the structural dependence of Brazil’s economic and industrial complex in health means that the country is unable to meet the entire domestic demand for basic medical supplies and medical equipment, forcing it to turn to international trade. The “health economic and industrial complex” is defined here as all the actors and activities involved in production, research, innovation, and technology in health, conceived jointly and aimed at meeting the collective health demands, promoting national economic development and overcoming external structural difficulties ³³33. Gadelha CAG, Nascimento MAC, Braga PSC, Cesario BB. Transformações e assimetrias tecnológicas globais: estratégia de desenvolvimento e desafios estruturais para o Sistema Único de Saúde. Ciênc Saúde Colet 2018; 23:2119-32..

According to some authors, a situation of global asymmetry excludes countries, regions, and populations structurally from access to health, evidencing an international division of labor in which some countries become mere consumers of technology while others define the global technological standard, exercising geopolitical control that impacts universal social and health policies ³³33. Gadelha CAG, Nascimento MAC, Braga PSC, Cesario BB. Transformações e assimetrias tecnológicas globais: estratégia de desenvolvimento e desafios estruturais para o Sistema Único de Saúde. Ciênc Saúde Colet 2018; 23:2119-32..

Historically, Brazil’s deficit in this area has been filled by the technological and innovative capacity of the European Union and the United States, and more recently that of India and China, which have made strides with their respective industrial and technological complexes in recent decades (meanwhile, Brazil has cut investments in health, education, research, and development through Constitutional Amendment n. 95³⁴34. Brasil. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 15 dez., otherwise known as the Ceiling on Public Spending Amendment).

Equally important is that beyond the social and structural impacts of policies and practices in technological innovation in health, the development of drugs, vaccines, diagnostics, equipment, and innovations is also a field of political and economic disputes involving participation by manufacturing countries and technology-dependent countries, international agencies, private companies, public institutes, and national and international governmental organizations, among other relevant actors. In this sense, health is heavily influenced by institutions and policies (domestic, foreign, and international) and by issues such as trade, intellectual property, labor, or the environment, among others ³⁵35. Buss PM, Chamas C, Faid M, Morel C. Desenvolvimento, saúde e política internacional: a dimensão da pesquisa & inovação. Cad Saúde Pública 2016; 32 Suppl 2:e00046815..

Given Brazil’s structural dependence, the country is forced to seek supplies and equipment through international trade, often subject to economic and geopolitical issues and interests, which requires a more realistic and pragmatic view of the international reality to achieve its objectives. Still, at the international level, in addition to the disconcerting lack of leadership by the Brazilian government in the principal international forums and initiatives in the fight against the pandemic and for universal access to the vaccine and the necessary equipment, Brazil has acted unpragmatically in relation to its foreign trade policy, creating tensions with China, investing little or erroneously (e.g. chloroquine) in its health economic and industrial complex, and taking a passive stance towards the recent phenomena of modern piracy.

These situations expose Brazil’s external dependence in relation to medicines, equipment, and medical and hospital supplies and reveal the deficiency and difficulties of a health industrial and technological complex that is unable to meet the domestic demand, creating dependence on China and opening room for action by states, as in the case of the government of Maranhão. As for Brazil’s international trade, according to the Ministry of the Economy, the trade flow (exports and imports) between Brazil and China totals some USD 100 billion, with a trade surplus for Brazil of USD 30 billion, and the Chinese accounting for 27.8% of the exports and 20% of the imports ³⁶36. Aranha C. Clima esquenta na OMS com acusação de negligência feita por Taiwan. Exame 2020; 14 abr. https://exame.abril.com.br/mundo/clima-esquenta-na-oms-com-acusacao-de-negligencia-feita-por-taiwan/.
https://exame.abril.com.br/mundo/clima-e... .

Various recent insinuations by Brazilian politicians created embarrassments and tensions in relations with the Chinese government ³⁷37. 'China é aquele cara que você sabe que tem que aguentar', diz ministro Paulo Guedes. G1 2020; 22 mai. https://g1.globo.com/politica/noticia/2020/05/22/china-e-aquele-cara-que-voce-sabe-que-tem-que-aguentar-diz-ministro-paulo-guedes.ghtml.
https://g1.globo.com/politica/noticia/20... ^,3838. Freitas C. Maia: Não entendo como o governo desqualifica a China neste momento. Valor Econômico 2020; 19 abr. https://valor.globo.com/politica/noticia/2020/04/07/maia-nao-entendo-como-o-governo-desqualifica-a-china-neste-momento.ghtml.
https://valor.globo.com/politica/noticia... (considered Brazil’s main foreign trade partner and the world’s largest producer of personal protective equipment and mechanical ventilators), intensifying the difficulty in obtaining equipment both for the protection of health workers and for life support for severe COVID-19 patients ³⁸38. Freitas C. Maia: Não entendo como o governo desqualifica a China neste momento. Valor Econômico 2020; 19 abr. https://valor.globo.com/politica/noticia/2020/04/07/maia-nao-entendo-como-o-governo-desqualifica-a-china-neste-momento.ghtml.
https://valor.globo.com/politica/noticia... .

With these diplomatic incidents, President Bolsonaro’s positions towards the pandemic have left governors without support and constrained in their strategies to care for their constituents, requiring subnational governments to redefine their international roles. Under this new logic, the governors have disregarded the President’s positions and assumed the responsibility for themselves to lead measures in the fight against COVID-19, including the definition of the country’s foreign policy direction, since the implementation of decisions tends to be increasingly decentralized, as do its effects on the promotion of social welfare.

PPE and mechanical ventilators are globally scarce products, not available readily or in sufficient quantities. The availability of mechanical ventilators for severe COVID-19 patients can make the difference between survival and death. In the struggle for economic hegemony and the global technological standard, both of which are highly relevant for national health policies, the fact that a country is independent of the global market or has commercial access can guarantee citizens’ safety ³²32. Lister T, Shukla S, Bobille F. Pandemia de coronavírus desencadeia disputa global por máscaras de proteção. CNN Brasil 2020; 5 abr. https://www.cnnbrasil.com.br/internacional/2020/04/05/pandemia-de-coronavirus-desencadeia-disputa-global-por-mascaras-de-protecao.
https://www.cnnbrasil.com.br/internacion... .

The spread of the coronavirus has taught the world that the production of medicines, equipment, and medical and hospital supplies is concentrated in just a few countries, and to the extent that supplies dwindle, either the governments are reluctant to allow the equipment to leave their countries or the equipment is offered at exorbitant prices. Despite the WHO alert on the hoarding and scarcity of PPE and the enormous financial speculation and the global dispute over these products leave frontline workers vulnerable in the fight against COVID-19 ³²32. Lister T, Shukla S, Bobille F. Pandemia de coronavírus desencadeia disputa global por máscaras de proteção. CNN Brasil 2020; 5 abr. https://www.cnnbrasil.com.br/internacional/2020/04/05/pandemia-de-coronavirus-desencadeia-disputa-global-por-mascaras-de-protecao.
https://www.cnnbrasil.com.br/internacion... .

In the context of the pandemic, “guaranteeing access by developing countries’ populations to health products at non-abusive prices should be a top priority for global health” ³⁵35. Buss PM, Chamas C, Faid M, Morel C. Desenvolvimento, saúde e política internacional: a dimensão da pesquisa & inovação. Cad Saúde Pública 2016; 32 Suppl 2:e00046815. (p. 8) and the World Trade Organization (WTO). In the midst of a global race for thousands of supplies and equipment manufactured by China, the situation in Maranhão also exposes this global dispute and the criminal behavior of modern piracy, which intercepts and seizes merchandise and products that belong rightfully to others ²2. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... .

Various European countries, including France and Germany, have warned of the difficulty in obtaining PPE for health workers, accusing the UNITED STATES of trying to sequester their orders for masks and gloves. The rerouting of crucial supplies has generally been done by intercepting the delivery of orders and the attempt to pay Chinese suppliers three or four times the original price ¹⁹19. Froés R, Cardoso R, Barbosa A. Governadores do Nordeste assinam no Maranhão documento que cria consórcio entre estados. G1 2019; 14 mar. https://g1.globo.com/ma/maranhao/noticia/2019/03/14/governadores-do-nordeste-assinam-no-maranhao-documento-que-cria-consorcio-entre-estados.ghtml (acessado em 20/Ago/2020).
https://g1.globo.com/ma/maranhao/noticia... .

There was also an interruption in all exportation of masks produced in the United States when that country invoked the Defense Production Act of 1950, which grants the government broad powers to redirect its industrial production during emergences ³²32. Lister T, Shukla S, Bobille F. Pandemia de coronavírus desencadeia disputa global por máscaras de proteção. CNN Brasil 2020; 5 abr. https://www.cnnbrasil.com.br/internacional/2020/04/05/pandemia-de-coronavirus-desencadeia-disputa-global-por-mascaras-de-protecao.
https://www.cnnbrasil.com.br/internacion... .

After the international trade and logistic operation by Maranhão, Governor Flávio Dino highlighted the constitutional principles ruling International Relations in Brazil and the break produced by the Federal government in Brazilian foreign policy. According to the Governor, Brazil’s traditional foreign policy independence was overridden in an unprecedented way, following unilateral guidelines from a single country, the UNITED STATES, in virtually automatic alignment. Even worse, the evidence has repeatedly shown that this has been a lopsided Platonic relationship, with scanty results and serious contradictions ³⁹39. Estado do Maranhão. Artigo do Governador: o Brasil e o mundo. https://www3.ma.gov.br/artigo-do-governador-o-brasil-e-o-mundo/ (acessado em 20/Ago/2020).
https://www3.ma.gov.br/artigo-do-governa... .

Diplomatic isolation, criticism for multilateralism, and weaknesses in global health governance

The third element underscores the obstacles in relations between Brazil and international agencies in global health governance like the WHO. The controversial interception by the United States and Germany of ventilators purchased by Brazil points to a process of exacerbated global competition and aggravation of the global governance crisis at the WHO, underscoring the existence of global technological asymmetries that structurally exclude countries, regions, and populations from access to health and exacerbating the inequalities in national development standards and social iniquities ²2. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... ^,3333. Gadelha CAG, Nascimento MAC, Braga PSC, Cesario BB. Transformações e assimetrias tecnológicas globais: estratégia de desenvolvimento e desafios estruturais para o Sistema Único de Saúde. Ciênc Saúde Colet 2018; 23:2119-32..

On January 30, 2020, the World Health Organization declared that the outbreak of the disease caused by the novel coronavirus constitutes a Public Health Emergency of International Concern (PHEIC), considered the highest-level WHO alert according to the International Health Regulations. This is the sixth time in history that a PHEIC has been declared, and this type of declaration potentially requires a coordinated and immediate international response, intensifying global cooperation and solidarity to interrupt spread of the virus ⁴⁰40. Organização Pan-Americana da Saúde. Folha informativa - COVID-19 (doença causada pelo novo coronavírus). https://www.paho.org/bra/index.php?option=com_content&view=article&id=6101:covid19&Itemid=875 (acessado em 17/Jul/2020).
https://www.paho.org/bra/index.php?optio... .

On March 11, 2020, the WHO declared COVID-19 a pandemic, referring to the geographic distribution of the disease rather than its severity. This classification acknowledges that there are currently outbreaks of the novel coronavirus in various countries and regions of the world. Both these landmarks with the novel coronavirus further emphasized global health issues both in the geopolitical debates and the population’s daily debates ⁴⁰40. Organização Pan-Americana da Saúde. Folha informativa - COVID-19 (doença causada pelo novo coronavírus). https://www.paho.org/bra/index.php?option=com_content&view=article&id=6101:covid19&Itemid=875 (acessado em 17/Jul/2020).
https://www.paho.org/bra/index.php?optio... .

The expression “global health” should prioritize “the health needs of the entire planet’s population over the interests of nations in particular” ⁴¹41. Brown TM, Cueto M, Fee E. A transição de saúde pública 'internacional' para 'global' e a Organização Mundial da Saúde. Hist Ciênc Saúde-Manguinhos 2006; 13:623-647. (p. 625), valuing the growing importance of actors beyond government and intergovernmental agencies and organizations. The expression “global health” emerged as part of a historical and political process in the context of a neoliberal world order. In this context, the WHO is seen as an intergovernmental agency that performs international roles with the objective of improving global health ⁴¹41. Brown TM, Cueto M, Fee E. A transição de saúde pública 'internacional' para 'global' e a Organização Mundial da Saúde. Hist Ciênc Saúde-Manguinhos 2006; 13:623-647..

However, this new era of global health has witnessed the reformulation of “old ideological, geopolitical, and methodological disputes that operate in the international sphere, shaping a field that can both offer real opportunities for the pursuit of equity while disguising a wide range of private interests and agendas” ²2. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... .

The WHO was originally conceived as the leading technical authority and voice for health in the world, directing and coordinating international action in the health field. One of the main roles of the WHO was to provide States with a kind of political and technical framework in public health. However, the WHO “saw its role, previously dominant, being challenged, and it began to reposition itself in the sphere of a set of power alliances in transformation” ⁴¹41. Brown TM, Cueto M, Fee E. A transição de saúde pública 'internacional' para 'global' e a Organização Mundial da Saúde. Hist Ciênc Saúde-Manguinhos 2006; 13:623-647. (p. 641).

This role of the WHO in global health governance has been received with much criticism, triggering a series of reforms in the organization with limited reach due to the current complexity of national and global social and health policies ³⁵35. Buss PM, Chamas C, Faid M, Morel C. Desenvolvimento, saúde e política internacional: a dimensão da pesquisa & inovação. Cad Saúde Pública 2016; 32 Suppl 2:e00046815.. The WHO has experienced difficulties since 1990, especially the reduction of its protagonist role in the face of competition with other international agencies and private entities, including philanthropic organizations; the scarcity and nature of its financing; the experts’ conflicts of interests; communications difficulties; and internal governance problems ⁴²42. Ventura D, Perez FA. Crise e reforma da organização mundial da saúde. Lua Nova 2014; (92):45-77.. In this context, nongovernmental organizations, private foundations, other U.N. agencies, and large transnational corporations have increasingly occupied spaces in global policymaking ³⁵35. Buss PM, Chamas C, Faid M, Morel C. Desenvolvimento, saúde e política internacional: a dimensão da pesquisa & inovação. Cad Saúde Pública 2016; 32 Suppl 2:e00046815..

The COVID-19 pandemic has lent a new dimension to the WHO crisis, increasingly hindering its capacity to orchestrate responses to global health challenges, including the fact that the world’s top health authority has a modest budget and does not enjoy the necessary political prestige, leaving it dependent on financers whose priorities are not always aligned with the populations’ needs ⁴³43. Santos JV. "Sem democracia, sem ciência, sem educação, sem renda, sem políticas sociais e sem direitos, seguiremos muito doentes". Entrevista especial com Deisy Ventura. http://www.ihu.unisinos.br/159-noticias/entrevistas/597307-sem-democracia-sem-ciencia-sem-educacao-sem-renda-sem-politicas-sociais-e-sem-direitos-seguiremos-muito-doentes-entrevista-especial-com-deisy-ventura (acessado em 25/Mai/2020).
http://www.ihu.unisinos.br/159-noticias/... .

The international complexity of recent decades, alongside the global economic crisis and the current pandemic, further increase tensions between countries and international organizations, especially the UNITED STATES and China, as well as in the WHO. This context highlights the suspension of financing from the UNITED STATES, resulting in a loss of 15% in total funding for the WHO. One of the justifications by the American president for this measure at the peak of the coronavirus epidemic in the United States was that the WHO was benefitting China in the response to the pandemic and was not holding the Asian country accountable for the origin and spread of SARS-CoV-2, which Donald Trump claimed was a “China virus” that had originated in a laboratory in the city of Wuhan, China ⁴⁴44. Fiorillo M. Corte de financiamento da OMS pelos Estados Unidos pode ter consequências globais. Jornal da USP 2020; 17 abr. https://jornal.usp.br/radio-usp/corte-de-financiamento-da-oms-pelos-estados-unidos-pode-ter-consequencias-globais/.
https://jornal.usp.br/radio-usp/corte-de... ^,4545. Roubicek M. Como China e EUA acirram tensões na pandemia. NEXO 2020; 18 mai. https://www.nexojornal.com.br/expresso/2020/05/18/Como-China-e-EUA-acirram-tens%C3%B5es-na-pandemia.
https://www.nexojornal.com.br/expresso/2... .

The German authorities expressed doubts over the explanation given by the American authorities, and the Chinese government classified the accusations against their country as “insane”, calling the Trump government xenophobic and claiming that the American president was trying to shirk responsibility for the pandemic’s impact in his country. The WHO denounced the declarations as “speculative” and unfounded, since the Americans failed to present any proof to back their theory. China reiterated its support for the WHO and opposed the attempt by the UNITED STATES to politicize the pandemic ⁴⁴44. Fiorillo M. Corte de financiamento da OMS pelos Estados Unidos pode ter consequências globais. Jornal da USP 2020; 17 abr. https://jornal.usp.br/radio-usp/corte-de-financiamento-da-oms-pelos-estados-unidos-pode-ter-consequencias-globais/.
https://jornal.usp.br/radio-usp/corte-de... ^,4545. Roubicek M. Como China e EUA acirram tensões na pandemia. NEXO 2020; 18 mai. https://www.nexojornal.com.br/expresso/2020/05/18/Como-China-e-EUA-acirram-tens%C3%B5es-na-pandemia.
https://www.nexojornal.com.br/expresso/2... ^,4646. Alemanha questiona explicações dos EUA sobre origem do coronavírus. Correio do Povo 2020; 5 mai. https://www.correiodopovo.com.br/not%C3%Adcias/mundo/alemanha-questiona-explica%C3%A7%C3%B5es-dos-eua-sobre-origem-do-coronav%C3%Adrus-1.419666.
https://www.correiodopovo.com.br/not%C3%... . Donald Trump’s lack of interest in leading the response to the health crisis and China’s leading role pointed to a reversal in the power relations between the two countries ²2. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... .

In this context, the American president threatened to withdraw the UNITED STATES from the WHO and suspend the country’s financial contributions indefinitely, criticizing what he considered the Organization’s dependence on China and suggesting that the WHO should disengage from Beijing ⁴⁷47. Trump ameaça retirar Estados Unidos da OMS. PODER 360 2020; 19 mai. https://www.poder360.com.br/coronavirus/trump-ameaca-retirar-eua-da-oms-dw/.
https://www.poder360.com.br/coronavirus/... . Trump later announced that he was cutting off relations with the WHO and that he intended to reallocate the funding to other initiatives ⁴⁸48. Trump rompe com OMS e acusa China de ser responsável por 'sofrimento no mundo'. G1 2020; 29 mai. https://g1.globo.com/mundo/noticia/2020/05/29/trump-diz-que-esta-encerrando-relacoes-com-a-oms-e-faz-criticas-a-china.ghtml.
https://g1.globo.com/mundo/noticia/2020/... .

Importantly, the United States is the largest funder of the WHO, with annual contributions of 400 to 500 million dollars. The UNITED STATES is also the country most affected by the COVID-19 pandemic, with more than 5.4 million cases (https://covid19.who.int/, acessado em 20/Jun/2020) ⁴⁷47. Trump ameaça retirar Estados Unidos da OMS. PODER 360 2020; 19 mai. https://www.poder360.com.br/coronavirus/trump-ameaca-retirar-eua-da-oms-dw/.
https://www.poder360.com.br/coronavirus/... .

Taiwan has also accused the WHO of failing to challenge the initial Chinese version on COVID-19, when Beijing contended that the virus was not transmitted from one human being to another ³⁶36. Aranha C. Clima esquenta na OMS com acusação de negligência feita por Taiwan. Exame 2020; 14 abr. https://exame.abril.com.br/mundo/clima-esquenta-na-oms-com-acusacao-de-negligencia-feita-por-taiwan/.
https://exame.abril.com.br/mundo/clima-e... .

In this serious conjuncture, the case of Maranhão also points to a significant change in the Brazilian State’s international leadership role, particularly in international health forums, since Brazil began to adopt positions of isolation or conflict and has often been considered an “international pariah” due to the disconnect between the Brazilian government and the principal countries that are discussing the issue and taking action against the pandemic ²2. Ventura D. Geopolítica da pandemia: "A verdade é que hoje o Brasil é um pária internacional". Pública 2020; 27 abr. https://apublica.org/2020/04/geopolitica-da-pandemia-a-verdade-e-que-hoje-o-brasil-e-um-paria-internacional-diz-especialista-em-saude-global/?fbclid=IwAR27NHU34_QppKNgkUIf1Jbg2QuEqMpE6roPlX_eqN3e87GOWUVfB7mRfoI.
https://apublica.org/2020/04/geopolitica... .

Brazil played relevant roles in various moments of contemporary history, both leading and criticizing in various public and global health issues, like the case of the creation and development of the WHO and the fight against tropical diseases. Brazil also expanded the concept of Public Health by creating the field of Collective Health, built in the struggle for re-democratization in the 1970s. The country is a signatory to the WHO Alma Ata Declaration in 1979 and the Astana Declaration on primary health care (PHC) in 2019. Brazil has stood out internationally for its SUS, comprehensive, public, free, and universal, and for its PHC model, its Family Health Strategy (FHS), and for the financing model placing PHC in the position of ordering the entire Health Care Network (RAS) ⁴⁹49. Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde Debate 2018; 42 spe 1:18-37.^,5050. Russo LX, Scott A, Sivey P, Dias J. Primary care physicians and infant mortality: evidence from Brazil. PLoS One 2019; 14:e0217614..

In the international scenario, Brazil played a relevant role in the evolution of the emerging field of Global Health, exercising both a critical and conciliatory stance in international health forums and promoting debates, consensuses, and multilateral solutions based on South-South Cooperation, when it became acknowledged as an important articulator of interests between developed and developing countries. The country was fundamental in the discussions under the WTO on health and intellectual property, which resulted in the Doha Declaration on the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and Public Health. Brazil has always been active in the Pan-American sphere, mediating decisions backed by the technical groups and chambers, promoting support for other Latin American countries and exerting pressure on pharmaceutical companies and the health industrial complex to improve access and qualification of care for populations. In the South American sphere, Brazil led the creation of the Health Council of the Union of South American Nations (UNASUR) and the South American Institute of Government in Health (ISAGS), with headquarters in Rio de Janeiro, with the responsibility of coordinating national health policies and promoting cooperation between countries. In the Southern Common Market (MERCOSUR), Brazil led the creation of a price bank for medicines and coordinated the joint purchase of medicines by the countries as a block ⁵¹51. Buss PM, Tobar S. Diplomacia em Saúde e Saúde Global: perspectivas latino-americanas. Rio de Janeiro: Editora Fiocruz; 2017..

In antitobacco policy, Brazil chaired the commission of the WHO Framework Convention on Tobacco Control (WHO-FCTC), in addition to having one of the world’s most advanced legislations in this area ⁵²52. Silva ST, Martins MC, Faria FR, Cotta RMM. Combate ao Tabagismo no Brasil: a importância estratégica das ações governamentais. Ciênc Saúde Coletiva 2014; 19:539-52.. In HIV/AIDS programs, Brazil became a solid international reference in public policies to fight the epidemic, with outstanding action in patent breaking and distribution of medicines in the 1990s and 2000s ⁵³53. Cueto M, Lopes G. AIDS, antiretrovirals, Brazil and the international politics of global health, 1996-2008. Soc Hist Med 2019; hkz044.^,5454. Kitchenman S. Inúmeros desafios do passado proporcionam aos portadores de HIV o largo acesso aos antirretrovirais no presente. Physis (Rio J.) 2012; 22:1243-8.^,5555. Barreto ML, Teixeira MG, Bastos FI, Ximenes RAA, Barata RB, Rodrigues L. Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs. Lancet 2011; 377:1877-89..

However, Brazil has abandoned its tradition as articulator and critical leadership of health diplomacy, culminating in the demise of the country’s participation in South-South Cooperation since 2019 ⁵⁶56. Buss PM. A pandemia e a cooperação internacional em saúde. Abrasco 2020; 30 mar. https://www.abrasco.org.br/site/noticias/opiniao/artigo-a-pandemia-e-a-cooperacao-internacional-em-saude/46217/.
https://www.abrasco.org.br/site/noticias... . Various backstepping positions followed in international policy, as well as in domestic policy activities, exacerbating the dismantlement of the SUS and prioritizing the private sector, aggravating inequalities and social vulnerability for the majority of the Brazilian population.

During the pandemic, the Governor of Maranhão also emphasized that Brazil lost part of its “soft power” in the world and its capacity to influence other nations and establish relations of trust. Governor Flávio Dino also expressed regret that Brazilian diplomacy had lost its professionalism, relegating development agendas in the areas of education, health, human rights, and the environment and scorning multilateralism, aligning itself with bellicosity against supranational bodies, supposedly prioritizing bilateral agreements. He also underlined the difficulties in Brazil’s relationship in the Mercosur, the impasses with the European Union, and the weakening of the BRICS alliance by the Brazilian Federal government. He also recalled that Brazil’s economic reality requires foreign trade partners, and that it is necessary to rethink the country’s diplomatic policy to protect companies and jobs. Finally, he criticized the Federal Government’s shouting matches and ideological deliria, reinforcing the need for greater independence, responsibility, and understanding in the national interest ³⁹39. Estado do Maranhão. Artigo do Governador: o Brasil e o mundo. https://www3.ma.gov.br/artigo-do-governador-o-brasil-e-o-mundo/ (acessado em 20/Ago/2020).
https://www3.ma.gov.br/artigo-do-governa... .

Final remarks

The government of the state of Maranhão conducted a surprising international trade and logistic operation for the purchase of mechanical ventilators, organizing a “wartime operation” in the midst of a global commercial and geopolitical dispute between the main international powers. This operation can be characterized as a concrete example of “paradiplomacy” and Global Health Diplomacy. However, there were factors, actors, actions, and strategies that made this undertaking possible and that are part of a recurrent and growing phenomenon in Brazil since the late 20th century.

The operation by Maranhão was an external action promoted by a subnational entity that practiced paradiplomacy, but that faced difficulties that blocked adequate prevention and the fight against COVID-19. To overcome these adversities, the state pursued local and international partnerships, in addition to demonstrating its alignment with WHO and PAHO guidelines and policies, besides its action in the area of Global Health Diplomacy. This study’s findings underscore the importance, relevance, and need for a protagonist role by local public bodies, which can and should position themselves in the international scenario when necessary in emergency situations (but not only in them), exploring international partnerships that aim to protect the local population, as long as backed by solid scientific knowledge.

The conjunctural difficulties and weaknesses include not only the pandemic itself and its economic consequences, but also the crisis of multilateralism and Global Health Governance, “modern piracy”, the Federal Government’s denialist discourse towards science, the ideological alignment of Brazilian foreign policy, diplomatic tensions with China and the WHO, and the Federal Government’s own disorganization and incapacity to deal with the situation pragmatically, based on scientific evidence. The Governor of Maranhão thus intensified the practice of paradiplomacy given the void left by the weaknesses and lack of leadership by the Federal government at the domestic, international, and global levels.

As a counterpoint to the difficulties, the paradiplomacy conducted by the government of Maranhão helped expand the political dialogue, trade, and technical cooperation and other social relations, deepened mainly during Governor Flávio Dino’s first term, in 2014, especially with China, Israel, Italy, WHO, and PAHO. He also directly led the creation of the Northeast Consortium, a concrete counterpoint to the Federal Government’s economic policies and foreign policy.

The strategies featured trade missions, diplomatic dialogues, initiatives of subnational coordination, and especially the “wartime operation” mounted to import mechanical ventilators and other medical and hospital supplies and equipment and to escape the “modern piracy” caused mainly by the UNITED STATES and Germany, and the possibility of seizure by the Internal Revenue Service. Finally, the governor expressed his opinion openly on Brazil’s current foreign policy and his criticism of the Federal government.

The subnational overtures to the international system are also explained as part of a deliberate policy in pursuit of political and socioeconomic opportunities, advantages, and benefits that may or may not be aligned with the central government’s positions, thereby developing a relationship of cooperation or conflict, since the growing involvement of subnational governments in foreign policy can also be seen as evidence of significant decline in the trust placed in central governments. This does not mean that central governments should rely only on the leadership of local authorities; both public health and other social issues should be the result of a balance between financial responsibilities and management between local and national governments within a national governance arrangement, in the Brazilian case, based on the federative pact between the Federal, state and municipal governments.

In Brazil’s national context, the pandemic revealed the character of a Federal government committed to neoliberal interests of rentier capitalism, abstaining from its inherent social responsibility in a scenario of chronic inequality. The case of Maranhão revealed the difficulties, solutions, and emergence of new conflicts with the Federal Government. As a result of these activities, the governor is being accused of breaching the federative pact and is facing criminal charges brought by the Internal Revenue Service. Meanwhile, the crimes against humanity, crimes of piracy, and neglect for the country’s public health are still going unpunished.

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