Originally from China, I am honored to receive the WAPPP’s Cultural Bridge Fund for her summer internship with the Iracema-COVID cohort study at the Federal University of Ceará, Brazil. My commitment to this cause deepened during an HSPH-led field trip to Brazil, where I for the first time stepped into the land of Brazil and was then deeply moved and inspired by the warm welcome and the complexities of the Brazilian health system. Determined to give back to the wonderful people I met, I am now deeply engaged in the Iracema-COVID cohort study, addressing the urgent mental health needs of women who were pregnant and gave birth after the lockdown in Fortaleza during the pandemic. 

For this internship, I aim to bridge the evidence gap regarding perinatal depression and its consequent impact on child health outcomes, which is crucial for informing families, healthcare practitioners, and policymakers. My main activities and responsibilities include participating in training with local researchers to understand the data collection process for the 6th wave of the Iracema-COVID cohort study, visiting implementation sites to assess the pressing demands and challenges in local maternal and child health programs, and performing data analysis to produce policy brief and deliverables for local policymakers and practitioners.

This blog, Iracema, serves as an important archive for me to write down any thoughts and insights from this previous summer internship opportunity. The name of the blog originated from the novel by José de Alencar, revolving around the relationship between a Tabajara indigenous woman called Iracema and a Portuguese colonist Martim. By remaking the history of the birth of the state Ceará, Iracema represents the specialty of the Brazilian population as a mixture of native race and European race. With this name, I would like to account my story in Fortaleza, Ceará, as an outsider, a witness, and more importantly a listener to the lives of local people. 

I would like to express great thanks to the generous support of the Cultural Bridge program at the Women and Public Policy Program at Harvard Kennedy School. 

Iracema to be continued in July, 2024...

Extract from the "Perspectivas Cruzadas" exhibition

"In a broader sense, art refers not only to aesthetics, beauty, and subjectivity but also to the human ability to see the world in various ways, especially beyond obvious forms of perception. In this way, it also affects our understanding and practices of health and disease, both for patients and professionals. In medical institutions, art has been used to promote health in several ways.

Thus, this exhibition proposes a dialogue between different humanistic approaches and contemporary visual arts. This exhibition does not pretend to show the linear history of scientific and artistic ideas. Rather, it presents cross-references between them, showing how each can deepen our understanding of the other. These crossed perspectives offer alternative views on health, illness, the body, and life.

Art is also a form of resistance to the norm. In this exhibition, it shows how artistic forms of seeing the world can resist and reimagine the norms of biomedical science. We hope that by examining these alternative perspectives, we can foster a more inclusive and comprehensive view of health, one that integrates scientific and artistic ways of knowing."

This first week has been an enlightening experience, providing me with valuable insights into the challenges and complexities of our research. I am excited to contribute to the upcoming wave of data collection and to work on the impact of maternal mental health on early childhood development alongside such a passionate team.

In conclusion, my first week at the summer internship has been a blend of academic and cultural enrichment. The support and guidance from my supervisor and colleagues have set a positive tone for the weeks ahead. Fortaleza's warm embrace and the opportunity to work on such a crucial project make this summer an unforgettable chapter in my academic journey.

Driving through the community, I can feel the impact of violence, drug addiction, and alcoholism in the graffiti on walls and in Prof. Machado's introduction. However, upon entering the gate of 4 Varas, a lush, green landscape unfolds before you. The name "4 Varas" originates from an ancient tale. It is said that an old man instructed his four sons to find the hardest stick in the world. When they returned with their sticks, he asked them to see whose was the hardest to break. While the sons were confused about how to compete, the old man easily broke each stick individually. He then took four sticks and bound them together, saying, "When you unite, nothing can break you." Inspired by this simple yet profound tale, Project 4 Varas was created to unite community members, heal people, and fight against human suffering and violence.

I had the honor of visiting Project 4 Varas with medical students from the Federal University of Ceará. The healing tutors, who are psychologists or trained mental health professionals, guided us through a series of therapeutic activities. We sang and danced to local music, held hands, and shared our deepest fears and anxieties. We expressed gratitude by kissing each other on the cheek, meditated, and enjoyed foot and head massages. These activities are free and open to all community members in Pirambu and Fortaleza.

Inside 4 Varas, there is also a laboratory where pharmacists from around the world develop mental health medicines. People can receive acupuncture and cupping therapy by appointment. Project 4 Varas now attracts global psychologists and physiotherapists who come here during the summer for residency projects or independent research.

Visiting 4 Varas was a healing, inspiring, and mind-blowing experience for me. Beyond the experience itself, I felt the power and love from these healing tutors. Facing the violence that has become a common occurrence for local people, finding ways to combat it with local knowledge and community strength is crucial. They have worked for decades to bring together talents from around the world, with the hope to cure, heal, and revive the beauty of the community.

The basic health unit is divided into three blocks: one for inpatient care, one for dentists, Bolsa Familia (a social assistance program) registration, and public health data surveillance, and one serving as a medical training and practice center for UFC medical students.

We visited the basic health unit on a Thursday morning, just as the unit was welcoming a new doctor. While the inpatient building was well-organized, excitement filled the air as patients, nurses, and doctors eagerly discussed the new addition to the team.

I had the chance to visit the dental clinic and speak with a dentist on duty. That morning, she was scheduled to see six pregnant women, but only two showed up. The reasons for this are varied: some mothers fear that dental visits could be risky for their pregnancy, while others face transportation constraints preventing them from reaching the clinic.

Under the guidance of Prof. Farias, I spoke with several patients, community health agents, and nurses about their experiences in seeking and providing healthcare services. One particularly inspiring aspect was the introduction of the child health guidance book. Every parent has a notebook for their child, whether a boy or girl. This book includes milestones for newborns, immunization schedules, breastfeeding tips, and nutrition information. It serves as a guide for new parents and demonstrates the health system's commitment to child health, showing that health workers are always available to help and support.

During my January trip to Manaus with the Harvard School of Public Health field course, I learned about Brazil's comprehensive and rigorous health data surveillance system. Community health workers collect data in the field, while data analysts process and report health conditions on a dashboard. This facilitates budget planning for municipalities and helps community health workers stay updated on local health statuses. The organized surveillance system clearly identifies vulnerable groups, enabling targeted health policy initiatives to address specific diseases and health needs.

Although my visit to the basic health unit was brief, I gained valuable insights into how the Brazilian health system mobilizes resources to maximize health outcomes and meet health needs. The universal health system, free to all in Brazil, strives to embody the mantra of "health for all."

IPREDE is the only center in the North and Northeast regions of Brazil focusing on mother-child dyad development and empowerment. Its mission is to promote the health of children, adolescents, and their families, with an emphasis on nutrition and human development, creating replicable social technologies. IPREDE’s multidisciplinary team provides individual care, group activities, and early therapy for language skills and psychosocial interventions. These activities are held in various structured environments and are developed into courses and workshops.

Attention to detail is evident throughout IPREDE. Different areas are painted in vibrant colors that are easily identifiable for children. Furniture is often round to prevent accidents, and the building's decorations are child-friendly, creating an inviting atmosphere for family and child development.

IPREDE is a place filled with love. The professionals working here are more than just doctors, tutors, or teachers—they are friends and family members. People continuously greet and hug each other in the corridors, fostering a warm and welcoming environment.

While children are the focus, mothers play an irreplaceable role. Children with developmental delays, such as autism and malnutrition, visit IPREDE every two weeks. During these visits, children receive classes tailored to their medical conditions, including speech therapy, music therapy, body coordination exercises, and more than ten other activities. Meanwhile, caregivers, often the mothers, receive comprehensive interventions. These include consultations with psychologists and anthropologists, and empowerment courses such as sewing and weaving.

Project Vai Maria (translated to "Go Maria," with Maria being one of the most common female names in Brazil) encourages women to design and sew clothing in these empowerment courses. Participants receive skill certificates, and the clothes they create are sold to the community.

I had the chance to observe a screening process with medical students and professionals from UFC. IPREDE serves as a secondary health center within the Fortaleza health system, providing a training ground for medical students. During the screening, one medical resident assessed the child’s development status with the caregiver, while another resident observed and recorded the child's behavior in the play area, testing six domains of early childhood development: language, cognition, motor skills, socio-emotional health, physical health, and mental health. The screening process considers not just indicators but also the background knowledge and social context of the child and family. In the case I observed, the child showed no significant signs of developmental delay, but his family context indicated a higher risk of vulnerability in later stages of development. As one doctor mentioned to me, "Sometimes, it's more than just a decision; a single screening can critically influence an entire family."

Fortaleza is a city of both prosperity and danger. Child health is a multifaceted issue that cannot be separated from its social context. Behind each child's face can be stories of drug addiction, gun violence, or homicide. IPREDE stands as a beacon of hope for mother-child development, striving to make a positive change from the very unit of the family.

Lacemaking is a traditional activity in the Northeast region of Brazil, originating from Portuguese colonization. Early colonists made lace to pass the time and supplement their families’ income, making doilies, collars, and tablecloths out of white and colored linen threads. Lacemakers, mostly women, rapidly maneuver two dozen wooden bobbins and make a pleasant clicking sound as they work. 

Nowadays, lacemaking has become an important source of income for women who live in remote areas. As fewer women know the techniques of lacemaking, women with traditional skills would make different products out of lace and linen and then sell them in local markets or tourist attractions. I witnessed a woman preparing the lace clothing with intricate skill. She was so skilled that she was able to compose different patterns while explaining to us. When she talked about the techniques in these patterns, I saw the passion and love from her eyes. 

The lacemaking is not limited to decorations, but also the making of pillows, baskets, hats, hammocks, and dresses. This time, the UFC art museum organized an exhibition to pay tribute to rendeiras (lacemaking) and all the women who inherited this traditional art. During the opening ceremony, women had the chance to speak up about their experience and their thoughts on this form of production and art. I saw many children and youths curious and excited to see these amazing skills as women made an example with the workspace for lacemaking. I believe this exhibition would incentivize more children to inherit this heritage and pass it on to future generations. 

The school's director guided us through the culinary school, showcasing its learning center, agroecological garden, warehouse, and lounge area. Predominantly female, the students I met receive free culinary training to hone their skills in baking, cooking, and dish development. According to the director, approximately 80% of the students secure local employment or work as cooks or servers in various establishments such as restaurants and school cafeterias after completing their training.

The school places a high emphasis on preserving the local food culture, advocating for the maintenance of traditional culinary habits from the Northeast region of Brazil and promoting the use of local ingredients. Besides hosting local officials and international guests, the school also motivates its participants to innovate and market processed products like wine and coffee. Given the high illiteracy rate among local women, they uniquely mark their products with drawings to ensure effective production and trademark recognition.

Additionally, I participated in a reunion with professors from public health and social entrepreneurship sectors. During this event, attendees discussed the impact of the COVID-19 lockdown on health and economic conditions in underdeveloped areas, noting that public policies often overlook the significance of gastronomy and food supply. This culinary school not only draws political attention but also highlights the essential role of food in everyday life. With malnutrition and obesity coexisting in Fortaleza, the challenges to public health are multifaceted. Thus, the growth of this culinary school could help mitigate reliance on ultra-processed foods and foster a reconnection with traditional culinary practices.

The institute's director took us to the conference room for a brief introduction to this cross-cultural experience hub. The Confucius Institute in UFC is one of the many around the globe. Each year, students and teachers would have the chance to visit China and be exposed to authentic Chinese daily lives. Furthermore, the institute's library was a treasure trove of resources, stocked with books, films, and music from China. This extensive collection enables students to immerse themselves in Chinese literary and cinematic culture, enhancing their language skills and cultural understanding. The language classes themselves were an impressive display of pedagogical excellence. The institute offers three levels of Mandarin classes for undergraduate students and some high school students. The teacher used a variety of engaging methods, including songs and interactive digital tools, to make the learning process both fun and effective. Students were not only learning a language but also gaining insights into Chinese etiquette, societal norms, and business practices.

Before I came to Brazil, I had been learning Portuguese on my own. Though my language ability is limited, I can experience more native culture during my stay in Brazil with the help of the language. I have always believed that language is a media of culture. Witnessing firsthand the enthusiastic engagement of Brazilian students with Chinese culture reaffirmed my belief in the power of language learning and cultural education to bring diverse communities together. 

This week, I had the chance to visit the health surveillance centre in Fortaleza, which gave me the chance to reflect on the cultural exchange experience throughout this whole internship. During this visit, I engaged in a deep conversation with Higor, a dedicated data scientist who collaborates with both the WHO and the local health surveillance center. Our discussion illuminated the striking contrasts and surprising similarities between Brazilian and Chinese approaches to health management and data science. 

One of the most apparent differences lies in the organizational structure and decision-making processes. In China, the systems tend to be more hierarchical, where decisions are often centralized and the execution is top-down. This structure is mirrored in various sectors, including health, where policies and directives generally flow from higher authorities to the grassroots level. In contrast, Brazil exhibits a more decentralized approach, especially in public health management. Local bodies have significant autonomy to adapt strategies that best suit their community's specific needs, fostering innovation and flexibility but also sometimes leading to variability in effectiveness across regions.

Though both countries value data and evidence-driven policies, the accessibility to open data is different. In Brazil, the focus is often on real-time data collection and rapid response, necessitating agile systems that can adjust to the dynamism of public health challenges. In China, data can hardly be accessible for unprofessional usage. Sophisticated emphasis is put on accurate calculations and long-term planning from data insights. 

We also shared some understandings of what is usually called as "Brazilian way of doing things" (jeitinho brasileiro), which is to describe a method of finding a way to accomplish something by circumventing or bending the rules or transgressing social conventions. The result of such social norms could be highly correlated with the colonization and revolution history of Brazil and the characteristics of Brazilians being very welcoming and feeling bad to refuse others. 

This cultural exchange experience, especially within the context of such an impactful field as public health, has been incredibly enlightening. It has not only broadened my understanding of how different cultures tackle similar problems but has also deepened my appreciation for the nuanced ways in which cultural contexts shape systemic approaches. As I continue my research after this internship, I carry with me these insights, reminded of the power of cross-cultural learning in enriching our professional practices and personal perspectives.

Linda - Beauty of Hope

Ten years ago, Brazil was nothing more than a colorful image in my geography textbook, a distant land of samba, football, and the Amazon rainforest from my hometown in China. Back then, I couldn't have imagined how deeply I would one day connect with this place. My two months here have revealed a country that is far more intricate and nuanced than any book could capture. Brazil is a land where vibrant festivals like Fortal and Carnival coexist with the stark realities of social inequality; where the rhythm of samba, the melody of forró, and the pulse of fervo are in constant dialogue with the challenges of violence and drug abuse. 

Standing on Praia de Beira Mar, with soaring skyscrapers on one side and the sprawling favelas on the other, I felt like I was witnessing the dual faces of Brazil—a place of both aspiration and adversity. The more I immersed myself in the daily life here, the more I appreciated the profound beauty and complexity that define this country.

Every conversation I had with those working in the health system in Fortaleza was a lesson in resilience. The vitality in their voices was undeniable, a testament to their unwavering commitment to healing and to challenging the entrenched inequalities that plague their communities. At one of the basic health units, I noticed something striking—fathers were conspicuously absent. Only mothers were there, tirelessly tending to their children's needs, guiding them through vaccinations and consultations. This absence puzzled me until a week later, when I visited IPREDE. A pediatrician specializing in child developmental disabilities explained that many fathers in Fortaleza were either incarcerated or had fallen victim to the cycle of drug addiction, leaving women to shoulder the burden of raising their children alone. As a result, not only were the children traumatized and suffering from health conditions, but the mothers were also overwhelmed, struggling to raise their children while desperately needing assistance and support. This revelation brought into sharp focus the inextricable link between poverty, violence, and the challenges of family development and maternal and child health in this region. 

However, hope is never absent. There are so many health workers that I have met who worked in this field years after years, only in the hope of making people live more healthily, happily, and comfortably. Now, psychologist and psychiatry experts from foreign countries are willing to take residency in 4 Varas to help design more comprehensive and community-based therapies to cure the depression and other mental disorders; IPREDE received the latest funding to build up a new block in the organization space for mother's healing and group therapy to listen carefully to their traumas and to accompany them during their personal growth as a mother, but more as a woman, and as a person; more and more women empowerment programs are established, not only to offer financial help, but to witness their growth in literacy, employment skills, and self-confidence. I saw so many smiley faces, all come from the hope deep down in their hearts.

Saudade - Yearning for Connections

My cultural exchange experience also provided me with a chance to reflect on cultural and value differences. In China, the concept of collective interest is crucial under a centralized political system, especially when it comes to shaping public policy objectives. In Brazil, however, the emphasis on family and community takes precedence in the decentralized policy-making process. Community-based approaches that target specific needs and improve the status quo serve people to the fullest extent.

Programs like the cooking school, lacemaking dissemination, and Project Vai Maria never demand more from women than they are willing or able to give. Instead, these initiatives, born from public funding and social organizations, provide women with a platform to showcase their talents, explore possibilities beyond their previous limitations, and encourage them to create their own treasures. These programs were established in response to community needs and were designed for the collective good through collective action.

Many Brazilian friends have told me they are not in favor of the "jeitinho brasileiro," a uniquely Brazilian way of doing things by personalizing relationships and bending rules to suit individual needs, even at the expense of social or legal conventions. However, I found it fascinating that this same cultural trait makes Brazilians incredibly welcoming and open to making new friends. I felt so welcomed when I first visited Brazil, which encouraged my return. This time in Fortaleza, with more time to stay, I had more opportunities to immerse myself in the local atmosphere. Every coin has two sides, but the warmth and hospitality I experienced made Brazil uniquely captivating, inviting foreigners like me to learn, exchange cultures, and fully embrace the experience.

Valeu - Witness of Personal Growth

I chose to major in global health because I deeply believe that health is one of the most fundamental human rights. Responsibility for health should never rest solely on individuals; society must act as a safeguard, providing a protected, efficient, and equitable environment where everyone has the opportunity to pursue better health.

The two months I spent in Fortaleza allowed me to immerse myself in a culture entirely different from my own. More importantly, I had the chance to apply my professional skills, analyze data, draw meaningful insights, and contribute to the development of a health system that empowers mothers and children in need of support.

As I conclude my blog, I would like to express my heartfelt thanks to Professors Castro and Machado for supporting my dream of coming to Fortaleza. My gratitude extends to all the friends I made in Fortaleza—David, Raimundo, Mari, Yuri, Clara—and the students from UFC Medical School who helped me settle in and introduced me to diverse activities and explorations of authentic local life. I had a full experience of being a Fortalezense during this amazing July and August. Summer might not be a special season for Fortaleza, where there are 300 sunny days a year, but for me, this summer was extraordinary because I met all of you.

There is a Chinese word I love a lot called “因缘际会” (yīn yuán jì huì), which means that all the encounters could only happen under a complex interplay of fateful coincidence and personal efforts, and sometimes may be beyond one’s control. This serendipity that brings me to Brazil and brings you to me has been one of my biggest treasure in life. Thank you for accompanying me in this journey!

Finally, I extend my deepest gratitude to the Cultural Bridge program at the Women and Public Policy Program at Harvard Kennedy School for financially supporting this unforgettable stay in Fortaleza.