Unusually for a social policy adopted by a developing country, Brazil’s AIDS program has drawn considerable scholarly attention. The country achieved great success by boldly deviating from conventional wisdom and supplying antiretroviral drugs to patients; in so doing, Brazil also defied the US and multinational pharmaceutical companies to make its novel approach fiscally feasible.

Although numerous scholars have already examined Brazil’s AIDS policies, Jessica Rich manages to develop an interesting, novel argument in this fairly crowded field. Whereas extant studies highlight the bottom-up pressures of patients and activists in the initiation of the AIDS program, Rich stresses the crucial role of state–society cooperation for guaranteeing the AIDS program’s continuation and lasting success.

Rich agrees with the prevailing view that demand-making by infected people and their supporters was crucial for launching Brazil’s AIDS program (pp. 55–85). State officials initially pursued different priorities, working to extend health care to the large numbers of poor people in this highly unequal country. Providing comparatively expensive medicines to a small group diverged from these plans. Therefore, social movement pressures were decisive for advancing the interests and needs of AIDS patients: they induced state officials to embrace this goal and promoted the recruitment of AIDS activists into the public administration.

Yet as Rich emphasizes, this was only the beginning of a long struggle. What has undergirded Brazil’s sustained effort to combat AIDS is the intricate collaboration and interpenetration of state officials and societal activists that emerged during the 1990s. The new crop of public bureaucrats helped maintain social movement pressure and actively promoted the formation and demand-making of numerous new associations, which then backed governmental policy initiatives and program implementation.

Such “state-sponsored activism” was decisive for guaranteeing the reliable implementation of innovative AIDS policies in this far-flung country and for extending the struggle to related issues. For instance, popular mobilization stimulated from above allowed Health Minister José Serra (1998–2002) to win concessions from the powerful pharmaceutical industry, which made the AIDS program financially sustainable.

Developing countries are littered with innovative, promising programs that start with great fanfare, yet soon wither away as newly incoming governments seek to claim credit, start their own high-profile initiatives, and neglect or butcher their predecessors’ pet projects. As Rich emphasizes, Brazil’s AIDS program is remarkable for maintaining its functioning, performance, and accomplishments for decades, across several changes in government and partisan control (pp. 12, 95). Her argument about state officials building, assisting, and guiding their own activist support base in society is decisive for explaining this interesting puzzle.

Scholars privilege the analysis of change, such as the creation of new policy programs. Investigating such temporal variation is comparatively straightforward: Who or what made the difference? It is more difficult to notice unexpected continuities and to account for them; the counterfactual is less obvious, and it is harder to uncover the crucial forces guaranteeing persistence.

Jessica Rich’s book makes a valuable contribution by taking on this important task and carefully tracing the complex mechanisms through which state officials have fostered and cooperated with social movements to produce unexpected, lasting success (pp. 40–52, 111–86). The book is impressive in its comprehensive development and thorough documentation of significant, albeit not earth-shattering, insights. The grounding in the relevant literature, especially the ample writings on state–society relations, is masterful.

The social movements literature likes to highlight participatory energies and bottom-up pressures emanating from society. Rich is to be commended for demonstrating the important role of state officials in strengthening and thereby perpetuating movement activism and in extending it across an incredibly heterogeneous country. After all, social movements have difficulty maintaining mobilization over time, as Sidney Tarrow showed in his work about “cycles of contention.” Moreover, in an unequal nation like Brazil, social movements are often concentrated in developed urban areas (pp. 4–5, 22) but are weak or nonexistent in the vast, poorer interior. When these movements are left to their own devices, their activism inadvertently reflects and even reinforces the existing stark disparities. After all, their pressures may lead to more resources being allocated to better-off areas while exacerbating the neglect of disadvantaged regions and segments.

Jessica Rich’s exceedingly well-researched analysis shows how active state involvement has counterbalanced these tendencies in Brazil’s AIDS program and has thus been essential for ensuring fairer, countrywide coverage. Top-down support has also forestalled the usual downswing of social movement operations by subsidizing and helping coordinate bottom-up mobilization. By thoroughly investigating the close cooperation between activists and state officials, many of whom hail from social movements, Rich uncovers the secret of the lasting success of Brazil’s AIDS program. Moreover, she makes a significant and broader contribution by moving beyond the distrust of the state—as an agent of co-optation or neglect—that pervades a good part of the social movements literature. Instead, State-Sponsored Activism demonstrates the valuable payoffs of a productive collaboration between these two poles (chaps. 5–7).

The book is admirable in its penetrating, comprehensive analysis, which is based on a great deal of useful field research. One wonders, however, whether the focus on state–society relations underemphasizes the role of partisan politics. Rich conceives of public officials as pursuing substantive causes and policy goals (pp. 4, 37, 46, 135, 154–56). Yet did partisanship come into play as well? After all, the big boost to state support for social movements started in 1998 (pp. 22, 101, 105–7, 121)—remarkably, “just as the AIDS crisis was ending in Brazil” (p. 23). What, then, explains these additional efforts? In 1998, ambitious politician José Serra became health minister. To prepare for his presidential candidacy in 2002, Serra energetically promoted several innovative health programs and raised their public profile. Did Rich underestimate this office-seeker’s role and thus overlook the importance of partisan politics?

Note also that from the 1980s onward, Brazil’s health care administration attracted many left-wingers—initially, Communists and then Workers’ Party militants—who sought to use concrete social improvements to win political support for their transformative goals. Did these partisan interests help propel Rich’s notion of state-sponsored activism? For instance, was bureaucratic support for social movement formation in Brazil’s poorer, “backward” regions designed not only to bring AIDS relief but also to undermine and dislodge the clientelistic conservative politicians who had traditionally dominated these areas, limiting the advance of left-wing parties? Thus, political-electoral interests may deserve more attention.

As Rich joins the prevailing consensus on the striking success of Brazil’s AIDS program, one also wonders whether this praise does not neglect the opportunity costs of the government’s targeted allocation of voluminous resources. Given clear fiscal constraints, what health programs and population segments received less attention than they otherwise would have? As the AIDS program turned into the “rich cousin of healthcare” (pp. 2, 95–99, 157–58), what happened to the poor cousins and stepchildren? This counterfactual is certainly difficult to determine. But a common limitation of studies focused on a single policy program is that the very important question of opportunity costs remains unaddressed.

In conclusion, Jessica Rich’s book advances an interesting and distinctive argument, explains and documents it impressively well, and thus makes a significant contribution to the social movements literature and to policy studies.