On December 16, 2021, the Brazilian Health Surveillance Agency (ANVISA) authorized Pfizer-BioNTech COVID-19 vaccine for use in children 5 to 11 years old. On the same day, President Jair Bolsonaro said that he had requested the names of all involved in its issuance and intended to publish the list so that the public “could come to its own judgment” about the vaccines. Bolsonaro’s pronouncement was received by ANVISA officials as an attempt to intimidate and to foment more threats against them, as officials were already targeted by anti-vax groups in Brazil in the previous months.
Even though Bolsonaro never published the list, the perceived goal of his speech was achieved. In the two months following the authorization, ANVISA officials received more than 458 threats. As a result, ANVISA asked for better security of its premises and its personnel — a request that has so far been ignored. Despite these circumstances, ANVISA didn’t budge on the pediatric authorization and, on January 20, 2022, authorized the use of a second pediatric vaccine: Coronavac, the Sinovac-Biontech vaccine.
This controversy wasn’t the first time that Bolsonaro has attacked or tried to delegitimize ANVISA, since he has previously criticized, ignored, and distorted their decisions and guidelines. But, every time, ANVISA has continued doing its work of issuing COVID-19 prevention guidelines and evaluating new medical products — something that certainly prevented Brazil from having an even worse pandemic response. Brazil’s experience may have something to teach other countries about how to protect technical bodies from interference from high-ranking antivax and science denying public officials.
The peculiarity of ANVISA might be better understood by comparing it to the Brazilian Ministry of Health, another body that should be able to make technical decisions based on science. Not only did Bolsonaro fire two health ministers in the middle of the pandemic for disagreeing with him, but their successors filled the ministry with senior officials that, as recently as January 2022, have adopted positions favorable to hydroxychloroquine and against vaccines. This hasn’t happened only in the Ministry of Health — on other matters, such as environmental and public safety issues, those who disagree with Bolsonaro are either fired or end up quitting. But ANVISA seems to be the one exception. ANVISA’s president not only disagreed with Bolsonaro, but did so quite vehemently, and yet he still was able to stay in his job.
ANVISA was able to remain independent and issue its technical decisions despite political pressure, first, due to its officials’ job security. In Brazil, regulatory agencies’ directors have five-year mandates, with no possibility of reelection, and can’t be fired. All of the current ANVISA directors were appointed in 2020, so its composition won’t change until 2025, which prevents Bolsonaro from interfering in ANVISA’s vaccination decisions.
Two nomination-related requirements also contribute to ANVISA’s independence. First, since 2019, nominees for the director board of any Brazilian regulatory agency need at least 10 years of experience in their sector and academic titles compatible with the role. This prevents nominations of officials with few credentials other than that of being ideologically close to Bolsonaro, as it became common practice in other public bodies such as those related to education. The current legislation was passed to restrict partisan control of regulatory agencies, and it seems that, so far, it has succeeded. According to the National Regulatory Agencies Officials National Union, this change diminished the number of political nominations in favor of a higher number of nominations of technical personnel that built a career at the agency to which they have been nominated.
The second requirement is that any nomination needs the Federal Senate’s approval. This additional scrutiny also differentiates ANVISA’s director nominees from the minister of health and Brazilian ministers in general, who don’t need congressional confirmation. Due to Brazil’s fragmented party system, it’s basically impossible for any president to hold a strong majority of the National Congress — Bolsonaro’s party currently represents only eight percent of the House of Deputies and six percent of the Federal Senate. This makes it harder for a president to have any success nominating radical ideological partners to bodies such as ANVISA, since he would need to win the vote of political actors who don’t adopt the same COVID-19 denying positions that he does. In Bolsonaro’s case, controlling the Senate is even harder, since the states in the northeast of Brazil are proportionally overrepresented and this region of Brazil is home to Bolsonaro’s worst electoral performance. As a result, it is also home to senators that form the majority that is opposed to Bolsonaro’s government. Combined, both of these requirements on who may be nominated and how the nomination will be analyzed have pushed ANVISA’s nominations away from the most radical science denial groups that Bolsonaro supports.
This system certainly isn’t perfect. ANVISA’s current president, for example, who is a former military doctor, joined Bolsonaro in a public event without a mask before his nomination to the post, contradicting ANVISA’s own guidelines. He was criticized for doing so, and this situation raised concerns his nomination, as he was then seen as a Bolsonaro ally. At that time, no one knew how he would act regarding vaccination protocols. Since then, he has distanced himself from Bolsonaro in favor of science — he has stated that he regrets participating in that event and has been avidly defending ANVISA against Bolsonaro’s attacks. The other ANVISA directors — all also nominated by Bolsonaro — joined him in defending the institution against Bolsonaro’s accusations.
The process is robust but not foolproof. Although Bolsonaro failed to fill ANVISA with officials who support him, if the nominations had come at a different time Bolsonaro may have attempted to nominate more partisan officials or curtailed ANVISA in other ways. Had ANVISA’s nominations mostly been due in the end of 2021, instead of in 2020, he may have been more careful about the level of support he demanded from his nominees, and may have more closely evaluated the position each one of them would take regarding children’s vaccination.
When it comes to health regulatory agency models, none are perfect. Each country might benefit from adopting a different model, but every country should evaluate them in light of the rise of antiscience politicians and the certainty that new pandemics will come. Discussing each model’s strengths and weaknesses cannot wait until the next pandemic comes — that will be way too late for a number of people who may die from a government that ignores science and doesn’t adopt the necessary measures to prevent new infections. Health regulatory agencies play a vital role, and their resilience to political pressure should be analyzed. Brazil’s ANVISA is a positive case study in how institutional design can shield these important institutions from undue political influence.