Cash as medicine: How Brazil slashed TB by tackling poverty
Crislaine Souza lives with her husband and one-year-old son in a rural community in Ourolândia, a municipality in Brazil's north-east that suffered centuries of neglect.
She is unemployed and, though her husband works as an electrician and does what he can to support his wife and children, the family is among the poorest in the country.
The family is on the brink – her husband and her one-year-old son are both deficient in iron, vitamin B12 and vitamin D – but it has a lifeline.
Every month, she receives government cash to spend on essentials like nutritious food, health supplements and gas for cooking.
Across Brazil, there are around 21 million other families in a similar situation, and they all receive monthly payments as part of the Bolsa Família scheme – one of the largest and longest-running conditional cash transfer programmes to be found anywhere.
Ms Souza has been on the programme for four months and receives about $120 (£97) in monthly support.
In return, she must ensure her children are vaccinated, attend school and meet nutrition guidelines. If she doesn't comply with these conditions, her payments could be stopped.
Her family regularly travel on foot along unpaved roads to a primary health clinic in Ourolândia to attend health checks.
'My son started taking supplements for anaemia and deficiencies and is happy, smiling and lively, very intelligent and developing well. I am dividing the supplements between him and my oldest daughter, because she eats little variety, so she needs them too,' she said.
Ms Souza worries about money, but says Bolsa Família has helped a lot.
'I feel more relieved knowing that I don't have to depend on my husband to buy everything. Just knowing that I'll have the money next month makes me feel more at ease, and I can be sure that I can resolve anything my children need.'
The programme was launched in 2003 by Luiz Inacio Lula da Silva,
The politicians and experts behind the pioneering scheme never anticipated the remarkable effects it would have on the country's health.
In just over two decades, it has been credited with reducing new AIDS cases by over 40 per cent, cutting maternal mortality by 18 per cent, deaths from leprosy by 14 per cent, and preventing more than eight million hospitalisations.
But it has also been busy working its magic on the world's top infectious killer – tuberculosis.
Researchers from the Barcelona Institute for Global Health (ISGlobal), the Institute of Collective Health, and CIDACS-FIOCRUZ in Bahia, Brazil, analysed TB outcomes among 54 million low-income Brazilians.
What they found was a drop in TB cases and deaths by over 50 per cent among the extremely poor.
Cases and deaths among indigenous beneficiaries – whose income can double or even triple under Bolsa Família – fell by over 60 per cent.
Their findings, published recently in Nature Medicine, are a stark reminder that diseases of poverty cannot be addressed by scientific innovation alone.
Strongest impact among the poorest Brazilians
Dr Davide Rasella, coordinator of the study and a Social Epidemiologist who has published extensively on Bolsa Família, said: 'These numbers are close to biomedical treatments like a new drug or vaccine.'
'We knew that giving $100 a month to someone earning $1 or $2 a day transforms their life dramatically, but we didn't expect the effect to be this strong.'
Yet the data doesn't tell us anything new about who is most at risk of falling ill or dying from TB, an ancient bacterium that attacks the lungs and has plagued humans for thousands of years. And this lack of revelation is precisely why policymakers should pay close attention.
Last year the WHO cautioned that the world will not hit its targets to cut TB without urgent technological breakthroughs.
But what use does a new vaccine serve to the labourer who cannot afford a taxi to the clinic?
'It's extremely important that from one side we invest in biomedical innovation, but we must be sure that the extremely poor live in the right conditions to take advantage of it,' Dr Rasella said.
Bolsa Família's success provides a case study on why medical innovation alone cannot address the structural barriers keeping healthcare out of reach for so many.
Is it possible for the rest of the world to replicate Brazil's approach?
'Money is a necessary component for good health'
Today, almost every country in the world operates a cash transfer programme, and their use in humanitarian settings has doubled in recent years. In Britain, we call them benefits. Across the pond, it's welfare.
Experts agree these schemes save lives and maximise the impact of medicine.
'Money is a necessary component for good health. Without money, you can't prevent disease or benefit from the great outcomes we know are possible with modern medicine,' said Dr Miriam Laker-Oketta, Research Director at GiveDirectly, a nonprofit that sends cash to the mobile phones of poor families.
Dr Rasella agrees: 'We are showing that it is fundamental to eradicate poverty to reduce the burden of disease in the poorest populations.'
Yet how cash transfers reach the people who need them matters, and so do the terms.
Brazil's central bank last year revealed that millions of beneficiaries had sent three billion reais (around £400 million) to online gambling companies.
The government later banned betting with benefits, adding another rule, or condition, beneficiaries must abide by. But what are conditions and why do they matter?
How Brazil's cash-transfer system works
Mandatory vaccinations, health checks and minimum attendance at school are conditions that form the contract between beneficiary and state. They are what study authors Dr Rasella and Priscila Gestal believe the success of Bolsa Família hinges on.
Brazil's well-oiled administrative infrastructure makes conditions work. A central database, Cadastro Único, ensures cash goes to the neediest families, while local governments verify eligibility, monitor compliance, and deliver payments.
Even under welfare critic Jair Bolsonaro, the programme persisted under a new name.
But what would happen if Bolsa Familia cash came without strings? Ms Gestal said that without conditions, its impact would not be as strong.
'Conditions ensure people engage with public services for health and education. Child mortality reductions are linked to vaccinations, growth monitoring, and prenatal care. In the case of TB, mothers bringing children for check-ups may themselves get diagnosed and treated,' she said.
But Dr Laker-Oketta argues enforcement costs could go directly to families, and Jessica Hagen-Zanker, a Senior Research Fellow at ODI Global, said enforcing conditions isn't possible everywhere.
'Conditions can be expensive to administer, adding to the cost of the programme, and are ineffective in areas with insufficient or low-quality supply of services,' said Dr Hagen-Zanker.
For example, today more than 83 million people in Nigeria live in extreme poverty, and 45 per cent of all deaths in young children are linked to malnutrition.
Last year, Nigeria's Minister of Humanitarian Affairs and Disaster Management, Betta Edu, was removed from cabinet after she siphoned £500,000 of conditional cash transfer grants meant for the most vulnerable into a personal bank account.
What hope is there, then, for the millions of people living in countries where corruption or poor infrastructure make Bolsa Família's success impossible to replicate?
It's simple – just give cash without conditions directly to people who need it.
Nonprofit GiveDirectly
Rory Stewart, former Secretary of State for International Development and Advisor to GiveDirectly, said these programmes directly improve key indicators like health, education, and nutrition, while outperforming traditional aid interventions in cost effectiveness and long-term impact.
'In low-income countries, most health facilities are in urban centres, and underutilisation by the rural poor often boils down to costly travel time to health facilities,' he told The Telegraph.
But cash transfers can remove these barriers to access overnight.
'Cash makes it easier to get to health facilities and pay for medicines. After GiveDirectly sends cash, villages quickly fill up with bicycles and motor taxis. Families can now afford trips to the clinic and medicines they're prescribed.'
It isn't only the logistics of accessing healthcare that direct cash can improve. When people have money, they adopt healthy behaviours even if they aren't told to.
'In our Rwanda childhood nutrition programme, families who received unconditional cash without any other information were more likely to take up vaccinations,' Dr Laker-Oketta says. 'And in this same programme, cash led to a 70 per cent drop in child mortality.'
The key to this, Mr Stewart says, is quite simple – people know what is best for them.
'We spend tremendous time and money telling people what they should do to improve their health, ignoring that they are far too poor to act on this 'advice,' most of which they already know.'
So is private actor cash the answer, or just part of it? It depends on who you ask.
Economists argue that the only way to reduce global poverty and its associated diseases at scale, is by making poor countries more productive across the board.
William Easterly, Professor of Economics at NYU, said the evidence suggests cash grants help individuals but do not transform whole countries from poverty to prosperity.
'If a country is poor, it is often because of institutions like corruption and public mismanagement,' he said.
Lant Pritchett, a Development Economist and RISE Research Director at Oxford University's Blavatnik School of Government, agrees.
'My slogan is that the world is not full of poor people, it is full of people in poor places. National development is a machinery that nominates and solves people's problems, including health.'
But while GiveDirectly may not have the power to fix corrupt governments, its programmes are certainly generating interesting economic data.
'Cash transfer programmes consistently deliver a high return on investment, with some studies showing a multiplier effect – every dollar invested generates up to $2.50 in economic benefit,' said Mr Stewart.
How to tackle diseases of poverty
In Brazil, Bolsa Família has slashed TB rates and prevented millions of deaths from infectious diseases by tying financial support to vaccinations, health check-ups, and school attendance.
GiveDirectly's programmes show how direct, no-strings cash can improve health and economic outcomes in ways even the most ambitious aid programmes have failed to achieve, especially in places with poor administrative infrastructure.
Dr Rasella, the study coordinator, said: 'You can't think about developing incredibly effective vaccines if the extremely poor can't access them because it's too far away, or their immune systems are too weak to respond to an antiretroviral because they're undernourished.'
Cash transfers may not be a cure-all, but they are one of the most simple and effective prescriptions we have to address the structural barriers that keep healthcare out of reach for so many.
In Ourolândia, the Bolsa Família payments that Ms Souza receives have allowed her to feel hopeful about the future.
'I want to go back to work, wait for my son to grow up and have a job, and maybe one day open a restaurant, that's one of my dreams.'
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He wrote a prizewinning biography of playwright Jean Genet and books on Marcel Proust and Arthur Rimbaud. He was a professor of creative writing at Princeton University, where colleagues included Toni Morrison and his close friend, Joyce Carol Oates. He was an encyclopaedic reader who absorbed literature worldwide while returning yearly to such favourites as Tolstoy's Anna Karenina and Henry Green's Nothing. 'Among gay writers of his generation, Edmund White has emerged as the most versatile man of letters,' cultural critic Morris Dickstein wrote in The New York Times in 1995. 'A cosmopolitan writer with a deep sense of tradition, he has bridged the gap between gay subcultures and a broader literary audience.' In early 1982, just as the public was learning about Aids, White was among the founders of Gay Men's Health Crisis, which advocated Aids prevention and education. 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'We're in this post-gay period where you can announce to everybody that you yourself are gay, and you can write books in which there are gay characters, but you don't need to write exclusively about that,' he said in a Salon interview in 2009. 'Your characters don't need to inhabit a ghetto any more than you do. A straight writer can write a gay novel and not worry about it, and a gay novelist can write about straight people.' In 2019, White received a National Book Award medal for lifetime achievement, an honour previously given to Morrison and Philip Roth among others. 'To go from the most maligned to a highly lauded writer in a half-century is astonishing,' White said during his acceptance speech. White was born in Cincinnati in 1940, but age at seven moved with his mother to the Chicago area after his parents divorced. His father was a civil engineer, his mother a psychologist 'given to rages or fits of weeping'. Trapped in 'the closed, snivelling, resentful world of childhood,' at times suicidal, White was at the same time a 'fierce little autodidact' who sought escape through the stories of others, whether Thomas Mann's Death In Venice or a biography of the dancer Vaslav Nijinsky. 'As a young teenager I looked desperately for things to read that might excite me or assure me I wasn't the only one, that might confirm my identity I was unhappily piecing together,' he wrote in the essay Out Of The Closet, On To The Bookshelf, published in 1991. Even as he secretly wrote a 'coming out' novel while a teenager, he insisted on seeing a therapist and begged to be sent to boarding school. Edmund White was one of the leading gay American authors (Mary Altaffer/AP) After graduating from the University of Michigan, where he majored in Chinese, he moved to New York in the early 1960s and worked for years as a writer for Time-Life Books and an editor for The Saturday Review. He would interview Tennessee Williams and Truman Capote among others, and, for some assignments, was joined by photographer Robert Mapplethorpe. Socially, he met William S Burroughs, Jasper Johns, Christopher Isherwood and John Ashbery. He remembered drinking espresso with an ambitious singer named Naomi Cohen, whom the world would soon know as 'Mama Cass' of the Mamas and Papas. He feuded with Kramer, Gore Vidal and Susan Sontag, an early supporter who withdrew a blurb for 'A Boy's Own Story' after he caricatured her in the novel Caracole. 'In all my years of therapy I never got to the bottom of my impulse toward treachery, especially toward people who'd helped me and befriended me,' he later wrote. Through much of the 1960s, he was writing novels that were rejected or never finished. Late at night, he would 'dress as a hippie, and head out for the bars'. A favourite stop was the Stonewall and he was in the neighbourhood on the night of June 28 1969, when police raided the Stonewall and 'all hell broke loose.' 'Up until that moment we had all thought homosexuality was a medical term,' wrote White, who soon joined the protests. 'Suddenly we saw that we could be a minority group — with rights, a culture, an agenda.' His works included Skinned Alive: Stories and the novel A Previous Life, in which he turns himself into a fictional character and imagines himself long forgotten after his death. In 2009, he published City Boy, a memoir of New York in the 1960s and 1970s in which he told of his friendships and rivalries and gave the real names of fictional characters from his earlier novels. 'From an early age I had the idea that writing was truth-telling,' he told The Guardian. 'It's on the record. Everybody can see it. Maybe it goes back to the sacred origins of literature – the holy book. 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Edmund White, the groundbreaking man of letters who documented and imagined the gay revolution through journalism, essays, plays and such novels as A Boy's Own Story and The Beautiful Room Is Empty, has died. He was 85. White's death was confirmed on Wednesday by his agent, Bill Clegg, who did not immediately provide additional details. Advertisement Along with Larry Kramer, Armistead Maupin and others, White was among a generation of gay writers who in the 1970s became bards for a community no longer afraid to declare its existence. He was present at the Stonewall raids of 1969, when arrests at a club in Greenwich Village led to the birth of the modern gay movement, and for decades was a participant and observer through the tragedy of Aids, the advance of gay rights and culture and the backlash of recent years. A resident of New York and Paris for much of his adult life, he was a novelist, journalist, biographer, playwright, activist, teacher and memoirist. Author Edmund White at his home in New York in 2019 (Mary Altaffer/AP) A Boy's Own Story was a bestseller and classic coming-of-age novel that demonstrated gay literature's commercial appeal. Advertisement He wrote a prizewinning biography of playwright Jean Genet and books on Marcel Proust and Arthur Rimbaud. He was a professor of creative writing at Princeton University, where colleagues included Toni Morrison and his close friend, Joyce Carol Oates. He was an encyclopaedic reader who absorbed literature worldwide while returning yearly to such favourites as Tolstoy's Anna Karenina and Henry Green's Nothing. 'Among gay writers of his generation, Edmund White has emerged as the most versatile man of letters,' cultural critic Morris Dickstein wrote in The New York Times in 1995. Advertisement 'A cosmopolitan writer with a deep sense of tradition, he has bridged the gap between gay subcultures and a broader literary audience.' In early 1982, just as the public was learning about Aids, White was among the founders of Gay Men's Health Crisis, which advocated Aids prevention and education. The author himself would learn that he was HIV-positive in 1985, and would remember friends afraid to be kissed by him, even on the cheek, and parents who did not want him to touch their babies. White survived, but watched countless peers and loved ones die. Advertisement Out of the seven gay men, including White, who formed the influential writing group the Violet Quill, four died of complications from Aids. As White wrote in his elegiac novel The Farewell Symphony, the story followed a shocking arc: 'Oppressed in the fifties, freed in the sixties, exalted in the seventies and wiped out in the eighties.' But in the 1990s he lived to see gay people granted the right to marry and serve in the military, to see gay-themed books taught in schools and to see gay writers so widely published that they no longer needed to write about gay lives. 'We're in this post-gay period where you can announce to everybody that you yourself are gay, and you can write books in which there are gay characters, but you don't need to write exclusively about that,' he said in a Salon interview in 2009. 'Your characters don't need to inhabit a ghetto any more than you do. A straight writer can write a gay novel and not worry about it, and a gay novelist can write about straight people.' Advertisement In 2019, White received a National Book Award medal for lifetime achievement, an honour previously given to Morrison and Philip Roth among others. 'To go from the most maligned to a highly lauded writer in a half-century is astonishing,' White said during his acceptance speech. White was born in Cincinnati in 1940, but age at seven moved with his mother to the Chicago area after his parents divorced. His father was a civil engineer, his mother a psychologist 'given to rages or fits of weeping'. Trapped in 'the closed, snivelling, resentful world of childhood,' at times suicidal, White was at the same time a 'fierce little autodidact' who sought escape through the stories of others, whether Thomas Mann's Death In Venice or a biography of the dancer Vaslav Nijinsky. 'As a young teenager I looked desperately for things to read that might excite me or assure me I wasn't the only one, that might confirm my identity I was unhappily piecing together,' he wrote in the essay Out Of The Closet, On To The Bookshelf, published in 1991. Even as he secretly wrote a 'coming out' novel while a teenager, he insisted on seeing a therapist and begged to be sent to boarding school. Edmund White was one of the leading gay American authors (Mary Altaffer/AP) After graduating from the University of Michigan, where he majored in Chinese, he moved to New York in the early 1960s and worked for years as a writer for Time-Life Books and an editor for The Saturday Review. He would interview Tennessee Williams and Truman Capote among others, and, for some assignments, was joined by photographer Robert Mapplethorpe. Socially, he met William S Burroughs, Jasper Johns, Christopher Isherwood and John Ashbery. He remembered drinking espresso with an ambitious singer named Naomi Cohen, whom the world would soon know as 'Mama Cass' of the Mamas and Papas. He feuded with Kramer, Gore Vidal and Susan Sontag, an early supporter who withdrew a blurb for 'A Boy's Own Story' after he caricatured her in the novel Caracole. 'In all my years of therapy I never got to the bottom of my impulse toward treachery, especially toward people who'd helped me and befriended me,' he later wrote. Through much of the 1960s, he was writing novels that were rejected or never finished. Late at night, he would 'dress as a hippie, and head out for the bars'. A favourite stop was the Stonewall and he was in the neighbourhood on the night of June 28 1969, when police raided the Stonewall and 'all hell broke loose.' 'Up until that moment we had all thought homosexuality was a medical term,' wrote White, who soon joined the protests. 'Suddenly we saw that we could be a minority group — with rights, a culture, an agenda.' His works included Skinned Alive: Stories and the novel A Previous Life, in which he turns himself into a fictional character and imagines himself long forgotten after his death. In 2009, he published City Boy, a memoir of New York in the 1960s and 1970s in which he told of his friendships and rivalries and gave the real names of fictional characters from his earlier novels. 'From an early age I had the idea that writing was truth-telling,' he told The Guardian. 'It's on the record. Everybody can see it. Maybe it goes back to the sacred origins of literature – the holy book. 'There's nothing holy about it for me, but it should be serious and it should be totally transparent.'
