Articles

Estudios Fronterizos, vol. 23, 2022, e088

Public health governance on the Brazil-Bolivia border: what the pandemic teaches us?

Gobernanza en salud pública en la frontera Brasil-Bolivia: ¿qué nos enseña la pandemia?

Douglas J. Voks^a https://orcid.org/0000-0002-7725-4389
Anderson L. Santo^a ^* https://orcid.org/0000-0001-6507-974X

^a Federal University of Mato Grosso do Sul, Center for Social Innovation Studies in Border, Corumbá, Brazil, e-mail: douglas_voks@hotmail.com, anderson84luis@gmail.com

^* Corresponding author: Anderson L. Santo. E-mail: anderson84luis@gmail.com

Received on November 16, 2020.
Accepted on March 1, 2022.
Published on March 9, 2021.

CITATION: Voks, D. J. & Santo, A. L. (2022). Public health governance on the Brazil-Bolivia border: what the pandemic teaches us? [Gobernanza en salud pública en la frontera Brasil-Bolivia: ¿qué nos enseña la pandemia?]. Estudios Fronterizos, 23, e088. https://doi.org/10.21670/ref.2204088

Abstract:
The purpose of this article is to present and reaffirm the importance of shared public health management on the Brazil-Bolivia border. To this end, bibliographic and documentary surveys were carried out, as well as interviews with 14 experts who form the Community of Inquiry, an investigation method developed by John Dewey that provides a useful lens for studies on shared management, as it emphasizes the plurality of actors beyond the actions of the State, demonstrating how public health problems are dealt with in the region. Specifically, we detail part of COVID-19's first operations (February to June 2020) in the municipalities of Corumbá and Ladário (Brazil) and Puerto Quijarro and Puerto Suarez (Bolivia). Recognizing the political dimension of the problematic situation, we rekindle the importance of governance for combating the COVID-19 pandemic and for the shared management of other urgent local epidemics, such as dengue and H1N1 on the border.
Keywords: governance, shared management, COVID-19, community of inquiry, border.

Resumen:
Este artículo busca presentar y reafirmar la importancia de la gestión compartida de la salud pública en la frontera entre Brasil-Bolivia. Se realizaron encuestas bibliográficas, documentales y entrevistas con 14 expertos que conforman aquí la Community of Inquiry, método de investigación desarrollado por John Dewey que brinda una lente útil para los estudios sobre gestión compartida, ya que enfatiza la pluralidad de actores más allá de la acción del Estado, demostrando cómo se abordan los problemas de salud pública en la región. Así, detallamos parte de las primeras operaciones acerca de COVID-19 (febrero a junio de 2020) en los municipios de Corumbá y Ladário (Brasil) y Puerto Quijarro y Puerto Suárez (Bolivia). Reconociendo la dimensión política de la problemática situación, reavivamos la importancia de la gobernanza para combatir la pandemia de COVID-19 y para el manejo compartido de otros endémicos locales urgentes, como el dengue y el H1N1 en la frontera.
Palabras clave: gestión compartida, COVID-19, comunidad de investigación, frontera.

Introduction

This article aims to present and reaffirm the importance of shared management of public health at the border. Through an inquiry process (Dewey, 1938), we present readers with part of COVID-19's operations on the Brazilian border (cities of Corumbá and Ladário) and Bolivia (Puerto Quijarro and Puerto Suarez), which led us to the following reflection: how rethinking about epidemiological surveillance services in border cities?

The emergence and diffusion of the COVID-19 pandemic generated a worldwide crisis among human collectives, which faced great uncertainty and are now in a problematic situation, of unusual proportions. Since December 2019, the uncontrolled proliferation of the disease caused by the SARS-CoV-2 coronavirus is leading the world society to face enormous challenges in the areas of health, economy, education, national security and many others.

In this pandemic, Brazil has been suffering the perverse effects of its continental size. In border zones, for example, the virus represents a catalyst for existing problems and revives an old national problem: the integration and development of the Border Strip (BS)¹.

Social isolation and the closure of the borders were some of the actions implemented by the Brazilian government to face the pandemic, following, the most necessary actions of the World Health Organization (WHO). However, when we talk about ‘closure of the border’, it is worth recognizing the size of the challenge. Brazil has 15 719 km of land border, which borders of countries in South America. In this strip there are 588 municipalities and about 10 million inhabitants. The country, however, despite this extension, has only 200 agents to police the entire border, that is, 1 agent for every 85 km² (Santo, 2018).

Given these continental proportions, COVID-19 exemplifies the emergency that challenges public administration, regarding its responsibility and the plans of emergency for this moment. If public problems are becoming increasingly complex, new negotiated orders need to be discussed in order to recognize an alternative to govern. That's because, COVID-19 resurfaces numerous epidemiological problems in this region (Dengue, H1N1, Zika virus and Chikungunya fever), in addition to respiratory problems caused by smoke from wild fire, which have reached the Pantanal since December 2019, whose burned area is equivalent to 15 times to the city of Rio de Janeiro (Cabral, 2020). Facts that demonstrate the social urgency to address public health issues in this region and that revive the importance of governance.

In this study, governance is understood from Lascoumes & Le Galès (2012), that is, as shared management. An instrument for the coordination of various actors (public, private, civil society organizations, others) that, by means of rules and at different decision levels, seek to collectively build objectives, goals and results aimed at the well-being of society.

This work is divided into eight parts, starting with this introduction and the methodology. We then demonstrate that governance continues to be essential for public management, especially in border areas, however the counterpart is the low effectiveness in the participation and operationalization of democracy. Public policies are created, but not enforced. Xenophobia and other forms of prejudice, exist, directly affecting the individual's perception of seeing himself as a 'border citizen' and perceiving the other, in this case, the Bolivians who seek for medical care in Brazil.

Following, we present, in the form of theses, the visions about COVID-19 and public health at the border, the reasons that prevent shared management of health, and some of the conditions necessary for governance to represent an alternative public health management for the populations of this border who, despite their proximity, have difficulties to integrate.

Methodology

The epistemic-methodological construction of this study (qualitative and interpretive-theoretical) was inspired by the pragmatic works of John Dewey, referring to participation, the notion of public, public problem and experimentation, which makes it possible to reconnect the Social Sciences to the practices of the actors, since emphasizes the deliberations and negotiations necessary for society (Shields, 2003). Through this focus, we seek to identify and analyze the collective dynamics and controversies that define the problem and the action to try to solve² it, through a Community of Inquiry, in which it is possible “to effectively examine how they approach problems, consider data, and communicate with different actors who work with the phenomenon in question” (2003, p. 510).

Methodologically, a bibliographic (in books and scientific articles) and documentary (journalistic data, technical health research, laws and public policies) survey was carried out based on the keywords presented in the abstract of this work, prioritizing a qualitative analysis of the data. Next, we identified and interviewed 14 specialists who form the Community of Inquiry here, presented in Table 1.

Table 1. Description of the Community of Inquiry
Consulted 1	University researcher on Public and Border Management
Consulted 2 and 3	Public Health and Epidemiology at the Border Researchers
Consulted 4 and 5	Public Health Doctors from Mato Grosso do Sul who were working on the front line of the fight against covid in the region were consulted
Consulted 6	Public Health Nurse from Mato Grosso do Sul who were working on the front line of confronting covid in the region
Consulted 7	Representative of the Public Defender of Mato Grosso do Sul
Consulted 8	Representative of the Municipality of Corumbá and member of covid's coping coordination in the municipality
Consulted 9, 10 and 11	Teachers of the Municipal Network of Corumbá consulted
Consulted 12	Social Organization that works with voluntary actions
Consulted 13	Individuals infected with the virus
Consulted 14	Individual who has lost family members to the virus
Source: The authors.

These specialists were identified from the bibliographical and documental review, and not chosen by chance. They are people who, in fact, were working on or researching the topic during the preparation of this research. There was a concern to maintain the confidentiality of these people, so that they will be represented, in this article, as C-1 (for Consultant 1; C-2; for Consultant 2 and successively for the other participants). Due to social isolation, queries were made via WhatsApp (video call) between August 26 and September 11, 2020.

Governance: an indispensable reference in contemporary discourse

Public management is going through a period of profound changes. Public problems, those disorders that affect a given collectivity and require its manifestation, such as COVID-19, do not cease to transform, thus implying the challenge of defining the general interest.

For Enjolras (2008), the general interest is not an absolute notion, but a social construction, which varies in time and space and affects everyone, not just consumers of a given service or commonweal. An example of this is health services, considered to be of general interest, in the means that, their availability or unavailability, affects the fundamental principles of a particular group.

In the case of Brazil, this is represented by the Federal Constitution of 1988, article 196: “health is the right of all and the duty of the State, guaranteed through social and economic policies aimed at reducing the risk of disease and other grievance and universal access and egalitarian actions and services for their promotion, protection and recovery”. Thus, different organizations act to define the general interest. It is important to point that the “universal access” mean, in simple words, that health care is free in Brazil to everyone that is on its territory, including anyone that is visiting the country independently the reason, duration or legality.

In recent decades, socioeconomic changes have culminated in the reform of the State and its administration in several countries. In this, the political arena has diversified due to the pressure on politics carried out by different interest groups. These groups argue that current democratic practices are no longer capable of dealing with society's public problems. Thus, public management went from a centralized system, dominated by the actions of the State, to a decentralized management system, which includes an institutional polyarchy (Thoenig, 2008), breaking the boundaries between the public and the private; the local, the national and the supranational, and redefining the territory.

Thoenig (2008) teaches us that the perception of territory is central to the understanding of political institutions. Far beyond geographical limits, the territory is places and arenas, made and remade by individuals (territoriality). In this understanding, political institutions constitute territories for public policy and representation. In other words, the notion of governance, will try to explain how public and private actors will form networks of cooperation and shock, public action, to treat public intervention more openly.

The term governance is very diffuse and full of meanings, but today, “it seems like a hope shared by everyone” (Gaudin, 2002, p. 14). It is a reference for action, in which the State is open to different actors who, with diffuse ideas, arguments and needs, seek to outline, implement and achieve collective goals. It is an operationalization of public action that promotes democratic progress on the one hand (due to participation in public decision); and the efficiency of the management of another (implementation of public policy). For this reason, as argued by Gaudin (2002) and Hermet (2005), public action occurs through the fundamental triad: regulatory agencies, contract policies and public policy forum, involving public and private actors.

However, its use has become commonplace (Hermet, 2005). The celebration of governance, through cooperation and labor agreements, for example, has turned into a real war against the operationalization of national public policies and difficulties in economic redistribution. Another fact argued by Hermet refers to the false sense of participation, because, often, the need for quick changes led to the elaboration of centralized policies and decisions, with only the participation of the State, except when there are some experts, not promoting the progressive learning and the democratization of participation.

To understand participation, it is necessary for local interactions to establish continuous connections with the global debate. In this relationship, the practices emerge and demonstrate the experiences of facing and “governance of the current public problems, which generate conditions, resources and opportunities for change, but also for inertia and stagnation, in terms of promoting new styles of development” (Andion et al., 2020, p. 184). The practices demonstrate the participation of the actors in different groups, and how they co-produce products, or services and commonweal.

However, according to Dewey (1927), not every agenda manages to form a public, after all, there is a nebula cloud over democracy. For the author the low, or no participation of individuals in public life, compromises the strengthening of the democratic state. In ‘The Public and its Problems’, Dewey sought to “understand how a great society of individuals can become a great community - active in democratic life” (1927, p. 134).

This work, from 1927, remains current for us Brazilians, because the public is in eclipse, motivated by technological, social, cultural advances and by the conformity with political life. This eclipse is caused by the confluence of these elements and the great challenge is to remove the public from this state, which will only happen, according to the author, when the public discovers its own identity.

For Dewey (1938, 2011), reconstructions are necessary, a change in the communication between the State and society; in addition to the role of education, as defended by Paulo Freire (1987), which must have a popular culture method, which raises awareness and politicizes our people, based on his own experience. In this process of falling asleep, or eclipse, science gains prominence. Reconstruction requires the transfer, to moral and human themes, of a type of method by which the understanding of human nature becomes essential. Science has a fundamental role in producing knowledge through theory and practice, in addition to discussing the place of participatory democracy in public management. We are facing what the author called the Community of Inquiry, the formation of knowledge through scientific inquiry.

At first, like all research communities, the focus is on identifying the problematic situation (qualifying a disturbance or disorder as problematic) and publicizing it (numerous activities that lead to the constitution of the public around the problem). For Shields (2003), the problematic situation is a catalyst that allows the constitution of the community, generating a reason to carry out an investigation. Community members bring a scientific view of the problematic situation, through data collection, hypotheses and data interpretation. The results generated can even be used by the State. But it is worth remembering that governmental matter, such as education and health, are also technically complicated issues to be handled by specialists.

For this reason, Dewey (1927, 1938) warns that an exclusive community of experts, in which the masses do not have a chance to participate and inform their dilemmas, will become an oligarchy managed in the interests of the few. For the author, free and voluntary collaboration is necessary for the success of the community, which will depend on the cooperation of various actors, not just experts.

In this understanding, experts need to comprehend how a collective dynamic creates fields of experience, in which scenes are presented, argued and justified by the actors, who try to inscribe their causes (Cefaï & Terzi, 2012). Sooner or later, this problem will involve State public bodies, such as city halls or the public prosecutor's office. For this reason, the analysis of the trajectory of the public problem demands reknowing the public policies and laws in force, since this problem is transformed over time and institutionalized through judicialization, when the State will have/must have to 'solve' the problem.

In these new relations between the State and civil society, spaces for social participation were established, such as the National Conferences (Avritzer & Souza, 2013), which expanded and redefined participation. New actors were emerging and being recognized; new rules and understandings began to guide the State's action.

After a period of 20 years (mainly between 1995, the beginning of the Fernando Henrique administration, passing through the Lula government, until Dilma in 2016), specialists, such as Avritzer & Souza (2013), argue that, in a political context favorable to social movements, political participation has grown since redemocratization. There was a greater deliberative dynamic with the State and necessary conditions for discussion, articulation and the elaboration of public policies. Since the 2016 Coup, nevertheless, we have seen an inversion of these conditions, and the assumption of a malaise in democracy (Avritzer, 2018). In the midst of great instability and national political polarization, several conferences, forms of organization, representation and participation were dismantled. This causes a great setback and problems of effectiveness in the participation and operationalization of democracy.

In the next section, we describe COVID-19's operations on the Brazil-Bolivia border and the effects on the border closure process, which is so porous that it puts at risk not only the local population, but a good part of the population of both countries, since the border is the gateway to a flow that spreads throughout the national territory. The challenge is to describe these dynamics and institutional means as they occur (Cefaï, 2009).

Border, shared management and epidemiological problems

When studying Brazil's borders, it is worth recognizing that, for the most part, they had exclusively security and defense functions in the national territory. Historically they have not been priorities for public policies (Santo, 2018). This focus only changed in the late century XX, under the influence of global regionalization, which culminated in the formation of numerous agreements and development blocks.

The understanding of boundaries is constantly subjected to a profound discussion and reframing. In this work, the border is understood as a space of life, marked, at the same time, by inequalities and cultural diversity. The border zone is composed of a cluster of cities located in the FS, from two or more countries, which concentrate inhabitants, housing, leisure, education, diverse sociability, economic activities, etc.

Public management in border zone suffers direct action from the historical and cultural ties of neighboring municipalities, in addition to the current social and commercial dynamics and other interactions of border populations (Santo & Voks, 2020). The border demands the presence of the State for development and integration to occur, otherwise, the lack of collaboration between countries and the lack of dialogue, celebration and operationalization of diplomatic (led by the federal government) and paradiplomatic (led by subnational or regional governments), can directly impact the lives of the people who live there.

For Santo et al. (2017), shared management in border zones can happen through ‘cross-border cooperation agreements’, signed at the federal level, between two or more countries; or through Comitês de Fronteira (Border Committees), a space for binational dialogue, celebrated at the federal level and headed by the respective consul of each country. However, according to the authors, the cooperation agreements are mainly intended for large projects, such as commercial and infrastructure agreements (construction of ports and highways). The committees, on the other hand, deal with guidelines related to drug trafficking and vehicle theft. In addition, the committees have a discontinuity of functioning, weakening local politicization. In other words, there is no discussion of more substantive agendas that prioritize the life of the border, such as education, health, tourism, environment and others.

With about 160 thousand inhabitants, 45 thousand on the Bolivian side, the Brazil-Bolivia border (Figure 1) has an intense cross-border flow (Costa et al., 2018), which favors socio-cultural and economic exchange, but also supports networks of illegalities. In this way, proximity creates particular norms that often reflect new territorialities.

Figure 1. Brazil-Bolivia border

Sorce: Santo, et al., 2017, p. 33.

With regard to public health, there are serious epidemiological problems on this border, especially regarding Dengue and H1N1, which, until February/2020, totaled, on the Brazilian side, in 1 500 cases and 2 deaths; on the Bolivian side, 399 cases and 2 deaths. There are also numerous reports of Zika virus and Chikungunya fever. These numbers may be much higher, due to the possibility of unconfirmed cases, of those who die unknowingly, of those who did not seek medical help, or of asymptomatic cases (Cavalcante, 2020).

With so many epidemiological problems, the scenario, due to the wild fire in the Pantanal (green area in Figure 1), which tripled, worsened between the months of January to August 2020. More than 1.250.000 hectares (about 4.826.28 square miles) of vegetation have been destroyed. In February 2020 alone, Corumbá recorded more than 3.000 fire outbreaks, placing the city at the top of the national ranking of wild fire. Experts point out that this is already the worst wild fire in the last 20 years. In order to have a dimension of this historical problem, in 2019 334% more fires were registered than in 2018. Consequently, the temperature increased to 6ºC and the rains decreased 25% (Dantas, 2019).

The problem becomes a neighbors’ game, in which Brazilian and Bolivian mayors place, at certain moments/narratives, ‘blame’ on each other about respect to the burnings, as if the fire respected the international limit. The population suffers from the consequences of smoking, with a 40% increase in the number of emergency room visits in the city, due to respiratory problems.

Dengue, H1N1, Zika, Chikungunya, respiratory problems and now COVID-19, have similar symptoms: high fever, runny nose, cough, body aches and difficulty breathing (Coronavírus Brasil, 2020).

It is in this scenario that COVID-19 represents a catalyst for problems at the border. It increases the demand in the health area, requiring more beds and treatments, in addition to rekindling xenophobia³, in which case the unfamiliarity about transmission, control and intolerance are verbalized by the population. The government, on the Brazilian and Bolivian sides, prefers to understand these questions as a problem that refers to the other side of the border. Operations are slow to start, as in the case of fire fighting. And, in a year of municipal elections in Brazil, COVID-19's operations in Corumbá and Ladário follow the pace of other Brazilian municipalities, marked by dysfunctions and limitations, since social isolation, for example, is not being carried out to the letter.

To date (11/13/20), 6 064 cases of COVID-19 have been recorded on the Brazilian side; and 110 cases on the Bolivian side (up to 5/8/20, most recent data). But the consequences of this pandemic are already numerous.

The critical moment and COVID-19 operations on the Brazil-Bolivia border

On March 19, 2020, around 7:00 pm, there was a generalized panic that was intensified by WhatsApp groups in Corumbá. The information circulating was about a Bolivian woman infected with COVID-19, who was coming by bus from São Paulo, about to land in Corumbá. The news materialized a few hours later the bus being escorted by the Federal Police. The passenger in question was a young Bolivian woman, with symptoms that led her to believe that she could be infected with the virus, but the confirmation was missing. This critical moment⁴ was sufficient to create a scandal (Boltanski & Thévenot, 2006), and this easily became a violence, the xenophobia. Residents immediately sentenced, via WhatsApp and local media, that the virus had arrived at the city and it was the Bolivians’ fault (Alves, 2020).

Until that moment, there was no confirmed case of COVID-19 in Corumbá; just a few suspicions. Schools, universities and commerce were partially closed and a decrease in the number of people on the streets marked the city's scene. Yet, this decrease in the circulation of people was not only due to fear of the disease, but also due to the decision of the Bolivian government to close the border with Brazil, interrupting a large flow of people.

Even with the border closed, the Bolivian authorities organized to receive the young woman. Exams were carried out in Brazil and also in Bolivia. Two days later, the results confirmed that she was not infected. At that time, a large part of the Brazilian population saw, as the best form of prevention against COVID-19, the closure of the border by Brazil.

Until March 19, Bolivia had 12 confirmed cases, all far from the BS. In Brazil, the number was 647 cases. The data showed that the transmission of the virus in Brazil was on a large scale, including community transmission, which triggered a warning about the imminent spread of the virus. However, in the popular imagination, the problem and the risk were in Bolivia; hence the urgency and the need to close the border. In the media, this fear was reinforced by numerous reports, such as that of a local newspaper:

Not even with the tightening of the border closure in Bolivia with Corumbá has prevented Bolivian patients from being taken to the city hospital, which can be overwhelmed in times of pandemic. The constant sending of patients coming from Bolivia has occupied about 30% of the visits made by the city's hospital, and this has generated a lot of concern for residents, who fear being left without medical care in times of coronavirus. One resident questioned the attitude through social media: “How long will Bolivia see Corumbá as a deposit for patients? The authorities need to take a stand and impose a limit; we Brazilians, who paid this bill and would, in theory, have the right to a dignified service, did not receive it as it should be. Are we also going to have to bear the cost of assisting foreigners?”, He asked. (Alves, 2020)

The idea that the problems came from across the border was reinforced with the announcement of the repatriation of 750 Brazilians who lived in Bolivia, mostly medical students. These Brazilians are not necessarily from Corumbá; on the contrary, the vast majority are from São Paulo, Minas Gerais and other regions. In the early hours of April 3, federal and state agents, staff from the Brazilian Army and the Corumbá city government began the process of screening for returnees who crossed the border (Sousa, 2020a). Initially, 500 people went through the IRS, but the sanitary measures adopted were doubtful. The procedures focused on checking documents, collecting information (such as origin, final destination in Brazil and contact phone) and checking the temperature. Then, these Brazilians were sent to the state capital, and from there they went to their destinations in the rest of Brazil.

We see, in this problematic situation, an inefficiency of the Brazilian government. People traveled for hours until they reached the border. Local epidemiological experts and WHO indicate that they should have been sanitized, fed and tested in relation to COVID-19, in order to identify the person who should remain isolated (Coronavírus Brasil, 2020). But all were directly directed to the capital, in a six-hour trip. At that moment, a trace of possible transmission of the virus can be observed, after all, along the route, there were stops for people to eat and, already in the capital, they were directed to the bus station, a place with a large flow of people. From there they spread throughout Brazil. Knowing the high transmission capacity of the virus, the approach adopted by the federal government is inconsequential, due to the danger of contagion/transmission.

In Corumbá, once again, the population's feeling was of fear and indignation, because, even in the case of Brazilians, with a legal right to enter the country, the opinion was that the border should be totally closed, under the justification that the virus could come from the neighboring country. In Bolivia, the feeling was the same. Military occupied the streets of the cities and guided the population on the prevention measures imposed by the country. One of them was the closing of the border (3/19/20) (Sousa, 2020b). That same day, in interviews broadcast by social networks, Bolivian military’s, under the justification of protecting people and saving lives, stated:

There will be medical, migratory, police and military control. Suspected cases of coronavirus in this city [Corumbá] are a danger to Bolivia. And that [the crossing] will not allow. We don't care about commerce or anything. What matters is saving the lives of Bolivians. In case of symptoms, people will not pass, as we are harmed. Brazil is not doing anything; that's your policy and that's why we have to take care of ourselves. If there is a case in Corumbá, we will close the border completely (Bolivian military in interview, excerpts).

It is worth mentioning that, in the state, the isolation rate until August/2020 was 35.5%, the third worst in the country (Frias, 2020). The first case of COVID-19, across the border, was only confirmed on April 6, in Corumbá, by a man who had no contact with returnees or Bolivians, but was in contact with a tourist from the northeast of Brazil, possibly being this is the cause of the contamination. This exemplifies that the danger does not come only from the neighboring country, but from people's own misinformation and resistance to adhere to social isolation, thus revealing the existing xenophobia in the city, with the idea that the problem is always the other. While the border was open, fear was widespread; the moment it was closed, the fear subsided, and people broke through social isolation.

Closing the border can give the national population the idea of security, of forced isolation. But it is illusory to believe that this closure could reduce the flow of people between the two countries, because, through the ‘pores’ (Santo, 2018), the daily and mobile flows that characterize the border continue. Police approaches generate mechanisms that lead people to circumvent the very few areas monitored by agents, as has been happening with Bolivians who risk taking clandestine routes to obtain medical care in Brazil (G1, 2020). Many are deported. Others manage to enter.

On both sides of the border, there is a feeling that problems always arise because of the other (Melo, 2020). Blaming this other is a more practical way of relieving our responsibilities as citizens, who, at that moment, should follow WHO recommendations, with social isolation, when possible, with the use of masks and extra hygiene, thus reducing contagion and spread of COVID-19.

So many problems in public health generated commotion, conflict and even silence in the local sphere, which ended up affecting the operationalization given to the prevention of COVID-19. In the first days of social isolation in Brazil, the numbers of contagion and death caused by Dengue and H1N1 were used emphatically as examples to prioritize local endemic diseases, and not the possible effects of the pandemic. In addition to justification for not isolating (resisting) and closing trade, minimizing COVID-19.

Visions about COVID-19 and public health at the border

According to Cefaï (2007), a public problem does not occur in a vacuum, it is pre-formatted by precedents. In this logic, it is possible to relate that the current problems caused by COVID-19 on this border are ancient, and revive so many others. Methodologically, we can look at problems around public health from two angles. First, by identifying public policies and international agreements that aim to transform the public problem into a political problem, when it is included in the agenda (Lascoumes & Le Galès, 2012). Second, identifying the community of inquiry (Dewey, 1938; Shields, 2003), described above in Table 1. Everyone was asked to answer the following question: Are the cities on this border doing their best to prevent the proliferation of COVID-19? (What could have been done? What are the consequences?).

The main arguments, in this sense, will be exposed by five theses.

a) Identification of public policies: Public policies are even created, such as the Sistema Integrado de Saúde das Fronteiras (SIS-Fronteira)⁵, which emerged in 2005, with the objective of promoting the integration of health actions and services, the organization and the strengthening of local health systems in border municipalities. It is a legitimation of the Migration Law nº 13.445/2017, which refers to the State's responsibility to guarantee basic social rights to citizens, regardless of their nationality.

The SIS-Fronteira provides, for its operationalization, the creation of working groups on both sides of the border. However, the lack of disclosure is pointed out as the main limitation of the project, as described by Ferreira et al.

Regarding the understanding of SIS-Fronteira and the role of Corumbá in the project, the most recurrent response among respondents was that service providers are unaware of what SIS-Fronteira is. Among the justifications presented are: lack of disclosure of the project and the origin of the majority of health professionals in practice being from other municipalities and, therefore, they do not have an understanding of what it is to work in a border municipality (2015, p. 78).

Experts consulted in the health field (C-1; C-2; C-3) have pointed out that the project has not been put on paper; the groups have not yet been created yet and many health professionals are even unaware of the proposal. Therefore, they highlighted the need to resume and operationalize the SIS-Fronteira.

Alongside this project is the Acordo Interinstitucional de Cooperação em Saúde na Fronteira Brasil-Bolívia⁶ (AICSF), formalized by the Ministries of Health of Brazil and Bolivia, in October 2017, with the objective of stimulating the development of mutually beneficial actions in the area of health.

ACISF proposes to create and implement working groups that can act on several fronts, such as the exchange of experiences; exchanges of information about programs and projects; promoting community participation and the organization of health services; and, the one that most called attention in COVID-19 times, the “strengthening, in the border zone, of epidemiological, sanitary, environmental surveillance, traditional medicine and other topics considered relevant by both countries” (Ministério das Relações Exteriores, 2017, art. 1, point e).

However, two recent studies, by Ferreira et al. (2015) and Krüger et al. (2017), point out that both programs were doubtfully implemented generating an unprovable result, as also reported by experts C-2 and C-3, consulted in this research.

It is true that idealizing international projects and agreements are challenging, since different legal systems coexist, aside from the financial issue, the availability of beds, the human resources to provide care, in addition to the lack of public policy and the difficulty in perceiving the ‘other’.

These difficulties, notwithstanding, should not be perceived as obstacles, or impossibilities of shared management. On the contrary, they should be the starting point for holding forums and setting up the planned working groups themselves, with a view to expanding knowledge and participation. Therefore, it is necessary to resume such policies; verify the need for updates; organize working groups and research in public health at the border.

In this sense, C-7, representative of the Public Defender's Office, reported that because it is a border zone, the contingency plan for the spread of the virus should be done in partnership. The impacts on the economy would be inevitable, as in the rest of the world, however, the law is clear when it prioritizes the protection of life and health, a universal human right. And continued:

In the case of Corumbá, as it is a border and receives foreigners daily, temporary closure is vital, not only on the other border side, which, by the way, was made, but also on the Brazilian side. There must be a prevalence of human rights in international relations, as established by the Federal Constitution; in addition to monitoring and tracking suspected cases, including biosafety measures in places with the greatest demand and sanitary barriers. But there was no strong enough restraint on the border line, as the City Hall says it does not have competence in the agreements signed between the federal government and Bolivia (Consulted 7).

According to C-8, representative of the Corumbá City Hall and member of Covid's coping coordination in the city, all possible restrictive measures were adopted, such as the sanitary barrier and the 7-day isolation of people who arrived in the municipality. In contrast, the reports of C-2; C-3; C-11 detail that the city was unable to operationalize this strategy, after all, most people were not contacted, due to the lack of professionals and technological resources to meet the demand; and, sometimes, the barriers were without agents for assistance. “Despite the guidelines of WHO regarding the pandemic, only time will tell if the measures taken were sufficient to delay the speed of the virus's spread among residents” (C-7).

Therefore, how defend Lascoumes & Le Galès (2012), a greater number of actors from different areas must participate in the elaboration of public policy. Indeed, the organizational intensity of civil society is very low at the border (Krüger et al., 2017). Thus, the formation of critical and self-critical conscience in the community is necessary for the group to understand, for example, that poverty is injustice and perceive the world before them (Demo, 1988). Then, the role of education emerges for the formation of participatory citizenship.

b) Educational actions, culture and xenophobia: There will be no integration and development if both countries do not face the existing cultural gap. Or, as argued by Dewey (1938), the only way for the public to discover its own identity is through educational reconstruction.

A citizen education would enable the subjects to recognize themselves as agents that transform their reality, perceiving the problems and mobilizing themselves to try to solve them. In this sense, a professor reported:

If certain problems affect both countries, such as COVID-19 or H1N1, the solutions need to be considered collectively. Now, what is least needed is frivolous, doubtful or disrespectful human life. An intercultural project to value and respect different cultures would help to overcome xenophobia and, perhaps, to strengthen ties to address border problems (Consulted 10).

Programs such as the Projeto Escola Intercultural Bilíngue de Fronteira⁷ (PEIBF), created in 2005, aim to promote exchanges between teachers from Mercosur countries (Ministério da Educação, n. d.). However, Krüger et al. (2017), acknowledged that there was an advance in education on this border, but an advance due to national programs, and not specific to PEIBF.

“Culture is an instrument of participation” (Demo, 1988, p. 55). Thus, teachers from the municipal school system (C-9; C-11), signaled “the need to reformulate school curricula, with a view to also addressing border issues in an intercultural perspective, seeking to value and respect the different cultures”. This action can contribute to an expansion of the notion of citizenship and the formation of critical, autonomous and active subjects, ready to face the problems and challenges of the border cities.

It is also fruitful to reinforce the PEIBF; extension projects that prioritize cultural recognition and respect (aimed at reducing violence resulting from xenophobia); the expansion of the notion of citizenship; and the role of individuals in the political life of the border, so necessary for the integration and development of the region.

c) The opinion of technical experts: The real chaos of public health in these cities and the slowness in the work of the State, show that COVID-19 launches clues about challenges, consequences and necessary future work.

In general, researchers in public management and public health at the border, health professionals (doctors and nurses) and social organizations that are dedicated to helping the poor (offering food and hygiene products) argue that, at first, there was a commitment and efforts to create measures to break the advance of COVID-19. However, as the contagion in the interior of Brazil did not occur in the same period of the big centers (for example in São Paulo), a discouragement and weakening in the adopted measures began.

Doctors and nurses who have been working on the front line of covid's confrontation in the region reported the fact that Corumbá does not have a large municipal clinical analysis center. In the city, the municipal laboratory performs blood, urine and feces tests. “Most complex exams, for the most part, are collected and transported to the capital, delaying a faster reading and prompt assistance” (C-4). They also signaled the lack of training, warning that, because it is a land border, “with or without a pandemic, there should be continuous biosafety training. This theme is addressed in the curriculum of any health professional, but many have never put it into practice” (C-5). This pandemic shows the need for training and a biosafety plan for both epidemics (Zika and Chicungunha) and pandemics (COVID-19).

This region presents an interesting panorama, because, on the one hand, it requires quick and ingenious interventions, where State participation is essential. On the other hand, it offers the dynamism of the border, several plural organizations (individuals, groups, associations, politicians, companies and others) that share a collective identity and, in networks, seek to reverse a certain public problem on this border, how to eradicate poverty; immigration and refugees and others⁸. “The mobilization of resources (human, financial or donations of food and hygiene products) occurs in an intense and fast way, allowing to assist several people and groups of families” (Consulted 12).

d) The lived border and the frontiers: The lived border, as discussed by Santo (2018), is the type of border that has more meaning for the society that is on the border, as it reflects and refers to their daily lives. In that sense, we talked to two victims of the virus.

The first report is that of a municipal public servant who, despite being away from her face-to-face activities, contracted COVID-19, supposedly, from her husband, who was not removed from his activities. “For me, social isolation is still the best prevention of a disease as mysterious as the coronavirus” (C-13). She also mentioned the quality of the health team, but that, with so much flexibility in the city (commerce and crowded streets), they end up in great demand due to the lack of a more rigid strategy by the city and awareness of the local population.

The lack of a strategy and rigidity in isolation was also pointed out by the second interviewee, from Corumbá, who lived with three family members and lost them all through COVID-19.

Everything was so fast and in such a short time. One after another they were diagnosed positive and then passed away. The pain is incalculable, but, about the COVID-19 operation itself, it is being totally weak, almost nonexistent. There is a resistance to creating stricter measures and, for my part, I have doubts if all patients are being examined for the virus (Consulted 14)

In both arguments, it was clear that the lack of a broad, transparent and participatory strategy is one of the main dilemmas with regard to the prevention of coronavirus. These are basic measures, which have been debated in all media for months and which still cost to be fulfilled here, and in Brazil as a whole.

e) For public health governance: Governance in the field of public health in this border zones were the focus of research by Costa et al. (2018), in which they analyzed the challenges of Dengue prevention and control. Interviewing 5 managers and 63 professionals from the Santa Casa de Misericordia de Corumbá (main public hospital unit on the border), the authors concluded that the difficulties of carrying out governance are linked to insufficient financial resources, difficulty in cross-border mobility, reduced border cooperation and the 'culture' of Bolivians.

This ‘culture’ was pointed out by the interviewees as being largely responsible for the difficulties in facing Dengue. However, Costa et al. (2018, p. 17), they very well pointed out that, “health professionals incorporate the discourse that Bolivians are associated with backwardness and poverty, therefore, with the binomial dirt/disease”. What generates this perception of the Bolivian, creating the blame of the ‘other’, exempting the responsibilities of Brazilians. Thus, part of the Brazilian population on the Brazil-Bolivia border perceives the ‘other’ as a host, in the sense of Sayad (2004), ready to invade their system.

Even in the face of so much adversity, the researchers concluded that “the study reinforces the need for bilateral or multilateral cooperation for better health care in border territories” (Costa et al., 2018, p. 17). Furthermore, as a public health researcher reported:

It is necessary to investigate health on this frontier, in addition to public hospitals, after all, the number of Bolivians looking for the private health system in Corumbá, medical clinics and obstetrics; pharmacies; dentists; ophthalmologists; clinical analysis laboratories; others, are numerous, which inevitably ends up heating the local economy. Outside Brazilians looking for pharmacies and prosthetics in Bolivia (due to the price and the ease of purchasing some products) and even the public hospital in Puerto Suarez, after all, it is worth remembering that before the arrival of Cuban doctors in Brazil (Programa Mais Médicos⁹), they were already present in Bolivian cities, which led several Brazilians to seek treatment, consultation and even surgery in that country (Consulted 3).

In addition to these formal dynamics in the area of health, the ‘informal dynamics’, those that are illegal for the State, but which in practice end up happening. This is the case, as reported by C-1, “of Brazilian women who seek pharmacies in Puerto Quijarro and Puerto Suárez to perform abortions; and men and women who go to these same pharmacies to apply anabolic steroids and purchase illegal supplements in Brazil, in search of the perfect body”. In other words, there are several dilemmas around health at the border that deserve to be treated and discussed more widely.

This plot signals the potential to idealize governance at the border. From public debate forums (Hermet, 2005), for example, the participation of individuals in the political arena could be guaranteed. In these spaces, they would have a chance to discuss the policy, in addition to designing, evaluating and implementing public policies. Examples, in this sense, exist, such as the response that civil society has been giving to confronting COVID-19 in other regions of Brazil (Andion, 2020).

Conclusion¹⁰

In this study, we seek not only to present the importance of shared public health management for border zones, but also to reaffirm the urgency of this type of governance. Through John Dewey's notion of Community of Inquiry, we articulate different methodological sources to understand how to (re)think epidemiological surveillance services in border cities.

From the organization of the collected information, it is possible to infer that, in order to rethink the epidemiological surveillance services in health at the border, an initial path is to understand this network of cities (their territorialities). However, there will be no integration if both countries do not accept and face the existing cultural distance, including xenophobia, shown in journalistic articles, in the views of some residents and in other scientific works, and open themselves to new possibilities of shared management; in addition to a citizen education. In other words, it is necessary to intensify international cooperation, sharing the management, financing and implementation of these policies in border cities ─and not just their creation.

We saw that public policies on these themes (integration and development; education and culture; public health) are even created, but not fulfilled and, in the case of the two public health policies analyzed (SIS-Fronteira and AICSF), doubtfully implemented. Therefore, the main adversity, in our understanding, refers to the identification and articulation of the work of different actors on this border (universities, public bodies, social health organizations and other civil society initiatives), which gain importance and responsibility in times of crisis. They have numerous challenges, and range from assessing possible means of governance; demand the operationalization of existing public policies; vindicate their participation in the political arena, to the distribution of goods and services in support networks.

Methodologically, as highlighted by Shields (2003), one can ask: so what? What is the pragmatist contribution of John Dewey's notion of community of inquiry? This study demonstrates that shared management is not just the celebration of cooperation and work agreements between heads of states. This type of management demands the participation of different actors in the territory, since once such public policies are created, they cease to be State properties and gain public interest from a network of actors-researchers; civil society organizations; local politicians; media; doctors; nurses and the population itself, who need this care. So, it is up to the State to promote progressive learning and the democratization of civil society participation, after all, shared management must be participatory, involving different members in its constitution and discussion, the Community of Inquiry.

We recognize that the information discussed in this study refers specifically to this spatial cut-out (Brazil-Bolivia border). However, the lessons learned around this case have a lot to teach us. In different border zones the virus changes, but the problem continues and the threat intensifies. The challenges of the COVID-19 pandemic are enormous, but they also offer a set of circumstances for looking at old problems in new ways, reaffirming the importance of science, governance and public health policy planning for border development and integration.

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Notes

¹ The BS is 150 km wide parallel to the land dividing line of the national territory. It came up with Law nº. 6.634/1979, regulated by Decree nº. 85.064/1980, the content of which was ratified by the Federal Constitution of 1988, in the §2nd of article 2, Registration of Brazilian municipalities with an area totally or partially located in the BS.

² More step-by-step details of this Dewey-inspired operationalization are described in the next section.

³ According to Sayad (2004, p. 16), it is in moments of crisis that the true image of immigration is revealed. “The immigrant only exists in the society that he calls it, from the moment he crosses his border and steps on his territory”. In turn, xenophobia, racist violence distilled to immigrants, arises, according to the author, when it is perceived as a 'parasite', which invades the new system (in this case, Brazil), becoming a problem for the country (public health).

⁴ Critical moments, according to Boltanski & Thévenot (2006), are critical activities and moments of crisis that arise, from time to time, through discomfort, when people realize that something is wrong, or that they can no longer live with a given problem. In this, the actors end up trying to debug actions and practices that can impact their social bond. Scandals are evidence that happens in the lives of actors.

⁵ Translation: Integrated Border Health System.

⁶ Translation: Interinstitutional Agreement on Health Cooperation on the Brazil-Bolivia Border.

⁷ Translation: Bilingual Intercultural School of Frontier Project.

⁸ An analysis and deepening of public problems in border zones and the emergence of organizations to tackle these problems can be found in Santo & Voks, 2021.

⁹ Translation: More Doctors Program. For more information, visit: https://bit.ly/3noPeTc

¹⁰ Conclusive title inspired by the studies of Shields (2003), and the despicable argument of President Bolsonaro-“So what? Am sorry. What do you want me to do?” commenting on the number of deaths by Covid. See https://bit.ly/3gXthYF

Douglas J. Voks
Brazilian. PhD and Masters in History from the State University of Santa Catarina, Brazil. Professor of the History Course of the Federal University of Mato Grosso do Sul, Brazil. Researcher at the Center for Social Innovation Studies in Border (UFMS, Brazil). Research lines: history of the present time, with an emphasis on power relations, political cultures, history of America and frontier studies. Recent publication: Santo, A. & Voks, D. (2021). Rethinking border studies: participation and social innovation in border zone development. Organizações & Sociedade, 28(99), 860-887. https://doi.org/10.1590/1984-92302021v28n9906EN

Anderson L. Santo
Brazilian. PhD in Administration from the State University of Santa Catarina, Brazil. Masters in Frontier Studies from the Federal University of Mato Grosso do Sul, Brazil (UFMS). Adjunct Professor of Administration course of the UFMS. Researcher at the Center for Social Innovation Studies in Border (UFMS, Brazil). Research lines: social innovation, democracy and public action in cities and rural territories, sustainable territorial development, pragmatism, frontier studies. Recent publication: Santo, A. & Andion, C. (2020). Imigração e cidades: uma cartografia da arena pública de apoio aos imigrantes e refugiados em Florianópolis. Interações, 21(4), 781-799. https://doi.org/10.20435/inter.v21i4.2717

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