The SUS in the eye of the Trumpist hurricane

Brazil is under attack from the Trump administration. The first blow, the tariff hike, had contradictory effects on the national political environment, tilting our tense political balance in favor of President Lula. The second, directed at seven Supreme Court justices and, most seriously, Justice Alexandre de Moraes , proved ineffective in delaying former President Bolsonaro's imminent conviction for the right-wing coup of January 2023.

The government has found it difficult to cope with the daily humiliation of an embassy that, without even a serving ambassador, repeatedly attacks the country's authorities, its political system, and its judiciary. For most Brazilians, it is even more shocking that nearly 40% of our fellow citizens support these attacks, which are supported by at least two influential Brazilians in national politics—Congressman Eduardo Bolsonaro and blogger Paulo Figueredo.

It's difficult to understand how the country's vaunted patriotism is so empty, nor how part of the country's economic elite supports measures contrary to its economic interests. This ideological zeal, which lacks consistency and coherence, is surprising. The recent attack on Brazilian health authorities appears to be part of new approaches to exacerbate the country's political polarization, reviving a key theme of the Brazilian far-right, related to the presence of Cuban doctors in the Mais Médicos program (More Doctors) from 2013 to 2017.

On August 13, the Donald Trump administration announced the revocation of the U.S. visas of Mozart Júlio Tabosa Sales, current Secretary of Specialized Healthcare at the Ministry of Health, and Alberto Kleiman, a former employee of the same Ministry and PAHO. The justification for the decision, expressed on social media by U.S. Secretary of State Marco Rubio, is their active participation in the development and implementation of the Mais Médicos program in Brazil.

The program is cited as a "diplomatic fraud" by Cuba, allegedly involving the export of forced labor to other countries. On August 15, Mais Médicos was again invoked to justify the suspension of visas for the wife and daughter of Brazilian Health Minister Alexandre Padilha.

Although neither the health of the Cuban people nor the working conditions of its doctors abroad are the real concern of the US government in its latest aggression against Brazil, it is worth noting the weaknesses of the arguments that support such actions.

Since its inception 60 years ago, Cuban medical internationalism has operated in 165 countries, with missions that have mobilized 605,000 doctors. Defection rates are low, and many professionals are re-enlisting for new missions. Therefore, neither the argument that the international presence of Cuban doctors compromised the health of their compatriots nor the lack of interest of Cuban doctors in these missions holds water.

In 2014, when the Mais Médicos program was well established in Brazil, Cuba, despite being a poor country, had better health indicators than the United States. A quick look at the World Bank database will reveal that, in that year, Cuba had an infant mortality rate of 4.8 per thousand live births, while the US had 5.8; the number of hospital beds per thousand inhabitants was 4.0 in Cuba, compared to 2.8 in the US; and life expectancy at birth in the US was slightly higher (76.5) than in Cuba (75.7).

The text's biggest mistake is its failure to acknowledge Mais Médicos' contribution to reducing health inequalities in Brazil. An extensive list of evaluative studies indicates that the program reduced the shortage of doctors in remote areas and that users were satisfied with the care provided. They also observed fewer avoidable hospital admissions in the municipalities served, resulting in improvements in services provided. Several studies also reported improvements in doctor-patient relationships and increased continuity of treatment. The program was maintained under Bolsonaro's administration and is now strengthened under Lula, albeit without cooperation with Cuba.

President Lula , Minister Padilha, and Secretary Mozart Sales responded to these attacks. Overall, their reactions were in keeping with Brazil's political approach to the American ordeal: indignation—sometimes tempered with humor—assertion of the country's sovereignty, defense of Mais Médicos and the Unified Health System (SUS), denunciation of the blockade of Cuba, and the folly of involving family members in punitive actions against state agents.

Health has long been the subject of political manipulation. On issues such as immunization, abortion, and drugs, the appropriation of moral arguments is recurrent to cover up (and, paradoxically, legitimize) some of the most perverse political actions. Certainly, the deployment of doctors in remote areas has become a central focus of the extremist narrative since Dilma Rousseff's administration. A plot designed to attack progressive administrations in Latin America exploits both the accusation of corruption—by alleging that Brazil promoted a supposed "coercive export" of Cuban labor—and anti-communist rhetoric. Thus, an effort to delegitimize democratic and inclusive policies persists.

In any case, the episode of canceling American visas has little to do with the Program itself. It needs to be understood and incorporated as yet another piece in the political chess game fueling the diplomatic crisis artificially created by Trump. As Celso Amorim, the President's special advisor for international affairs, stated, it is yet another "aggression" against the Brazilian government and a gesture of "profound hostility" from Trumpism. In other words, irrational at first glance, the decision carries a clear political calculation, in which the stakes are constantly being doubled—the US wants to escalate the crisis.

It's unlikely that the SUS will remain in the eye of the political-trade dispute with the US. The issue is unlikely to serve as a rallying point for extremists, as the More Doctors for Brazil program has a low participation rate of Cuban doctors (10%). Bolsonaro failed to eradicate it when he was in office because he failed to produce a more robust alternative. Other agendas produced by the Supreme Federal Court (the final stage of the former president's trial) and by the legislative houses (the impeachment of Eduardo Bolsonaro) are likely to attract the attention of the Bolsonarists advising the US aggressors. However, other health agendas will always be available for extremists to exploit to retain their political influence over a significant portion of the country's electorate. Therefore, health will remain "in the middle of the whirlwind" in the conflicting fate of Guimarães Rosa's backlands.