Public health institutions are under threat by populist governments across the globe.

From Budapest to Jakarta, Indonesia, public health agencies are being stripped of funding and independence. Meanwhile, disinformation has sown distrust in scientific experts. The results are already visible through the return of diseases once thought eliminated or controlled, like measles and whooping cough.

The United States is no exception to this trend. Since Robert F. Kennedy, Jr. was confirmed as secretary of Health and Human Services in February 2025, he has fired over 10,000 staff, cut budgets and attempted to gut childhood vaccine recommendations. Though medical and public health groups have pushed back with some success, key government health institutions face a leadership vacuum, and national public health policy has fractured into “health alliances” formed by groups of states.

Doctors and scientists across the country worry about long-term damage to the country’s health system.

As a researcher studying the politics of health care, I believe it’s helpful to look to countries that have successfully managed similar threats. As my co-authors and I have argued, Brazil’s experience offers insights into how public health institutions can preserve power and authority in the face of assault.

Much like the U.S., Brazil has a fragmented and polarized Congress, it has powerful self-interested lobbies, and it has a federal system of government. And much like in the U.S., health outcomes suffer from stark race and income gaps.

But when a populist president attacked the Brazilian health care system during COVID-19, the public successfully rallied to its defense

A health system under attack

Brazil’s health system, established in its current form in 1990, provides free universal health care to all its citizens. Despite some significant flaws, including unequal access to care in poor and rural areas, its focus on preventive care is widely considered a model worldwide.

Prior to the administration of right-wing populist Jair Bolsonaro, from 2019 to 2022, Brazilians had trust in vaccines. They had what public health experts call a vaccine culture, thanks to the hard work of health workers who had spent years promoting them and making them easily accessible. Vaccines even had a beloved national mascot in Zé Gotinha (Joe Droplet), a cartoon vaccine droplet with a Pillsbury Doughboy-like visage.

When COVID-19 hit Brazil in March 2020, Bolsonaro – dubbed by many as the “Trump of the Tropics” – launched unprecedented attacks on Brazil’s vaccine program. Among other measures, he fired the senior leadership of the health ministry and appointed as minister an active-duty military officer with no health credentials.

Bolsonaro’s attacks on the vaccine program – a backbone of Brazil’s preventive health efforts – were especially strong. He pressured Brazil’s drug regulatory agency to ban pediatric vaccines. He blocked resources for vaccine procurement, and he spread misinformation, notoriously suggesting the vaccine could give people AIDS.

After Bolsonaro’s initial attacks on Brazil’s COVID-19 response efforts, the entire health system appeared on the verge of collapse. However, Brazil’s public health workers then marshaled broad support to defend their vaccine program.

Opposition governors offered important but limited help by producing their own vaccine guidance and procuring their own vaccines. But political support, on its own, couldn’t overcome Bolsonaro’s attacks.

That’s because Brazil’s vaccine program depended not just on independence, but also on resources to operate. And governments with an anti-science bent have many ways to deprive even well-established agencies of resources without broad congressional approval.

Brazil’s vaccine program ultimately survived because allies outside government stepped in to defend it not only with political advocacy, but by donating money and resources and with social activism.

Business leaders to the rescue

Businesses filled gaps in government resources with donations of private-sector funding. Two business coalitions gave a total of over 270 million real (US$54 million) to help two public laboratories, the Institute of Technology in Immunobiology, known as BioManguinhos, and the Butantan Institute.

One of the largest foundations in Brazil, the Lemann Foundation, paid for AstraZeneca’s clinical trials in Brazil. Ambev, one of the largest firms in South America, lent its logistics team to help BioManguinhos acquire supplies and equipment.

Women of Brazil, a nonpartisan network of female business leaders, even built a campaign called United for the Vaccine to help towns and cities acquire the vaccine distribution equipment they needed. They provided local health officials with cheap supplies, like coolers and refrigerators, as well as costlier investments, such as boats and even planes for carrying vaccines to the isolated communities of the Amazon.

As pulmonologist Margareth Dalcolmo, who consulted for United for the Vaccine, emphasized to me in an interview: “All their requests were met, without one cent of government money being used.”

From the ground up

Another hugely important component of defending Brazil’s vaccine program was support from trusted local grassroots groups.

When vaccines became available, community-based groups across the country jumped in to combat disinformation with their own locally produced information campaigns – especially in underserved communities.

One group I spoke to distributed 5,000 informational posters across their neighborhood. Another, Tamo Junto Rocinha, or We’re in it Together Rocinha, published a book with lessons for kids to do with their parents while school was canceled – all with vaccination information embedded. Voz das Comunidades, or Voice of the Communities, a neighborhood news service, even created a smartphone application to combat misinformation while also notifying community members of daily death tallies.

So many grassroots groups organized to counter Bolsonaro’s attacks on COVID-19 vaccines that researchers began to map the campaigns bubbling up across the country. By early 2021, one map had identified over 1,300 grassroots efforts and over 800 organized by universities.

By August 2022, despite Bolsonaro’s disinformation campaigns, 81% of Brazil’s adult population was fully vaccinated against COVID-19. These vaccination rates equaled those of New Zealand and the Netherlands and were well above that of the United States, where only 67% were fully vaccinated at the time.

This is not to say that Brazil was immune to disinformation campaigns. Vaccination rates for some diseases, such as measles, declined, as they have across the world.

But in many ways, the attacks on Brazil’s vaccine program paradoxically strengthened it. By the end of 2022, thanks to donor support, BioManguinhos had already built a new testing laboratory, and Butantan was constructing a new vaccine production facility. Brazil even had a new national health surveillance institute. By 2024, once Bolsonaro was voted out, overall spending on the health system had increased from the prior year by 27%.

Playing the long game with public health

In my view, these emergency countermeasures in Brazil worked effectively because the country had already spent years building a foundation of trust in – and ownership of – the shared goals of its public health system.

Decades ago, in the 1980s, Brazilians successfully demanded that their politicians make health care accessible to all – driving the genesis of the country’s universal public health system, known by the acronym SUS.

Brazil’s health ministry continues to invest heavily in making sure citizens take ownership of it. Cities and towns are postered with signs declaring “SUS is ours!” or “Health care is your right!”

As I found in my recent research in Brazil, this kind of advertising makes people feel their institutions are an earned right and reduces the power of partisan messaging.

Brazil also invests in integrating health workers into the communities they serve and cultivating public trust in their expertise. Government health care workers routinely set up shop in public plazas to advertise cancer screenings or give vaccinations. They regularly visit schools, where doctors or nurses talk to young people in accessible language about what the nation’s public health system offers its citizens. As one health care worker told me: “It’s like they are constantly saying, ‘Look, the doors are open. You can come. You’ll be seen and supported.’”

These long-term relationships between communities and the public health system helped lay the groundwork in Brazil for mounting a unified defense when political turbulence threatened public health agencies. Worldwide, a long-term view toward building or strengthening these relationships may help the public embrace the idea that public health institutions are worth defending.

Jessica A.J. Rich does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Bipartisan calls for President Donald Trump’s removal from office increased on April 7, 2026, after he issued threats to destroy “a whole civilization” if Iran refuses to reopen the Strait of Hormuz.

These calls have come from across the political spectrum, from Democratic Reps. Alexandria Ocasio-Cortez of New York and Melanie Stansbury of New Mexico to former Rep. Marjorie Taylor Greene and right-wing pundit Alex Jones. Unlikely allies seem to agree that the president has gone too far and needs to be reined in.

Their concerns have emerged as Iran has walked away from talks to end the war and Trump’s language suggests that he plans to escalate it by destroying the country’s power plants and bridges.

Concerns over Trump’s fitness for office have grown in recent weeks as his commentary has become more erratic.

If lawmakers do attempt to remove Trump from office, here’s what would happen:

25th Amendment

The Constitution’s 25th Amendment provides a way for high-level officials to remove a president from office. It was ratified in 1967 in the wake of the 1963 assassination of John F. Kennedy – who was succeeded by Lyndon Johnson, who had already had one heart attack – as well as delayed disclosure of health problems experienced by Kennedy’s predecessor, Dwight Eisenhower.

The 25th Amendment provides detailed procedures on what happens if a president resigns, dies in office, has a temporary disability or is no longer fit for office.

It has never been invoked against a president’s will, and has been used only to temporarily transfer power, such as when a president is undergoing a medical procedure requiring anesthesia.

Section 4 of the 25th Amendment authorizes high-level officials – either the vice president and a majority of the Cabinet or another body designated by Congress – to remove a president from office without his consent when he is “unable to discharge the powers and duties of his office.” Congress has yet to designate an alternative body, and scholars disagree over the role, if any, of acting Cabinet officials.

The high-level officials simply send a written declaration to the president pro tempore of the Senate – the longest-serving senator from the majority party – and the speaker of the House of Representatives, stating that the president is unable to discharge the powers and duties of his office. The vice president immediately assumes the powers and duties of the president.

The president, however, can fight back. He or she can seek to resume their powers by informing congressional leadership in writing that they are fit for office and no disability exists. But the president doesn’t get the presidency back just by saying this.

The high-level officials originally questioning the president’s fitness then have four days to decide whether they disagree with the president. If they notify congressional leadership that they disagree, the vice president retains control and Congress has 48 hours to convene to discuss the issue. Congress has 21 days to debate and vote on whether the president is unfit or unable to resume his powers.

The vice president remains the acting president until Congress votes or the 21-day period lapses. A two-thirds majority vote by members of both houses of Congress is required to remove the president from office. If that vote fails or does not happen within the 21-day period, the president resumes his powers immediately.

The case for impeachment

Article II of the Constitution authorizes Congress to impeach and remove the president – and other federal officials – from office for “Treason, Bribery, or other high Crimes and Misdemeanors.” The founders included this provision as a tool to punish a president for misconduct and abuses of power. It’s one of the many ways that Congress could keep the president in check, if it chose to.

Impeachment proceedings begin in the House of Representatives. A member of the House files a resolution for impeachment. The resolution goes to the House Judiciary Committee, which usually holds a hearing to evaluate the resolution. If the House Judiciary Committee thinks impeachment is proper, its members draft and vote on articles of impeachment. Once the House Judiciary Committee approves articles of impeachment, they go to the full House for a vote.

If the House of Representatives impeaches a president or another official, the action then moves to the Senate. Under the Constitution’s Article I, the Senate has the responsibility for determining whether to remove the person from office. Normally, the Senate holds a trial, but it controls its procedures and can limit the process if it wants.

Ultimately, the Senate votes on whether to remove the president – which requires a two-thirds majority, or 67 senators. To date, the Senate has never voted to remove a president from office, although it almost did in 1868, when President Andrew Johnson escaped removal from office by one vote.

The Senate also has the power to disqualify a public official from holding public office in the future. If the person is convicted and removed from office, only then can senators vote on whether to permanently disqualify that person from ever again holding federal office. Members of Congress proposing the impeachment of Trump have promised to include a provision to do so. A simple majority vote is all that’s required then.

This is an updated version of an article originally published on Jan. 9, 2021.

Kirsten Matoy Carlson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

The 250th anniversary of the Declaration of Independence isn’t the only important anniversary in 2026. This year also marks the 75th anniversary of an extraordinary case of student activism that helped lead to the Supreme Court’s decision outlawing segregated schools.

In April 1951, 16-year-old Barbara Rose Johns organized a student strike to protest the shabby conditions and inadequate education at her segregated Black high school in Prince Edward County, Virginia.

Prince Edward County is located about 65 miles southwest of Richmond and around 30 miles east of Appomattox, or 48 kilometers, in a part of Virginia known as Southside. African Americans constituted almost half the population, but they were largely prevented from voting before passage of the Voting Rights Act in 1965 and could not eat in local restaurants before passage of the Civil Rights Act of 1964. The public schools were segregated, and for decades there was no Black high school at all.

In 1939, following years of pressure by Black residents, the white authorities opened a high school for African Americans. That segregated institution was named for Robert Roosa Moton, who had been raised in Prince Edward County and served as an administrator at Hampton Institute in Virginia before being appointed as the second head of Tuskegee Institute following the death of Booker T. Washington.

The new building became severely overcrowded almost immediately. Although it was designed for a maximum enrollment of 180, attendance reached 219 the year after it opened and 377 in 1947.

The following year, the school board put up three temporary outbuildings to accommodate the overflow. Many Black residents scorned these buildings as “tar paper shacks” because of their covering and dilapidated condition. They had inefficient wood stoves that provided limited heating, and their thin walls often leaked when rain fell.

The shabbiness of these interim structures became a source of continuing tension, as negotiations between the Black community and white authorities for a more permanent facility dragged on inconclusively into early 1951.

Johns makes her move

As an 11th grader at Moton High School, Johns began talking with some of her fellow students about taking action to protest the shacks and improve their education.

On April 23, 1951, someone lured Moton’s principal, Boyd Jones, out of the building on the pretext that two students were in trouble elsewhere in town. After Jones left, Johns summoned the student body to the auditorium, where she exhorted her peers to walk out to protest the deplorable condition of their school.

Johns also sent a letter to Oliver W. Hill and Spottswood W. Robinson III, two Richmond civil rights lawyers who worked closely with the NAACP, asking for their legal assistance.

The strike went on for two weeks. During that time, Hill and Robinson met twice with hundreds of students and parents. The meetings grew out of the lawyers’ initial skepticism about litigating over school conditions in rural Prince Edward County, where they feared that plaintiffs would be subject to severe physical and economic retaliation.

Those meetings persuaded Hill and Robinson that the Black community broadly supported an effort to obtain desegregation rather than mere improvements in the separate Black schools. The lawyers therefore filed their lawsuit in the United States District Court for the Eastern District of Virginia on behalf of scores of Black students and parents, alleging that segregated schools violated the 14th Amendment.

Victory – and messy history

Johns’ initiative had both short- and long-term consequences.

In the immediate aftermath of the strike, the all-white school board fired Jones, whom they regarded as having put the students up to their activism despite his – and the students’ – insistence that the whole affair was a student initiative.

The lawsuit – and other similar suits filed in South Carolina, Delaware and Kansas – failed in the lower court. The plaintiffs appealed to the Supreme Court, which reversed those judgments and ruled in the consolidated case called Brown v. Board of Education that segregated public schools were unconstitutional.

Meanwhile, in the wake of the student strike at Moton, Johns’ family feared that she would be in physical danger if she remained in Prince Edward County for her senior year. They sent her to live with her uncle Vernon Johns, a minister and outspoken civil rights advocate, in Montgomery, Alabama.

Johns graduated from Drexel University and worked for many years as a public school librarian in Philadelphia before her death in 1991.

The post-Brown history of Prince Edward County is very complicated. White authorities closed the public schools for five years to avoid desegregation. For a long time afterward, virtually all the white children went to a private academy that opened when the public schools closed.

But that messy history cannot detract from the courage and impact of Barbara Johns.

In December 2025, her statue replaced that of Robert E. Lee as one of the two Virginians displayed in the U.S. Capitol. Johns is there – along with George Washington.

Jonathan Entin does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.