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HIV Prevention Among Female Sex Workers (Honors Thesis in Brasil)

15 Sep

In response to the number of requests I’ve gotten from current Duke students/study abroad students who are interested in reading about my work in Brazil with female sex workers, I’ve dedicated this post to focusing on the details of my research project.  If you are interested in my motivations for working with HIV prevention and sex workers, you can read more about my experiences in the field in one of my previous postings. And for those who are interested in the socio-cultural backdrop of the project, you can read here about why I selected Salvador (Bahia), Brazil as my site for undergraduate research and why the HIV/AIDS prevention model is so unique in Brazil.

Talking to one of the coordinators about disease prevention among Female Sex Workers

Talking to one of the coordinators about disease prevention among Female Sex Workers

I want to address the issue of culturally-competent community engagement briefly. For anyone who is working with marginalized groups, it is ALWAYS important to bear in mind that you should approach your research in the most non-intrusive way possible. You never want to come off as exploiting the persons with whom you are working for the benefit of your research and publications. Because Female Sex Workers (FSWs) are a marginalized and stigmatized group, many of the women with whom I worked were initially unwilling to participate in my project.  I was American, “over-privileged”, and it didn’t help that I had a rudimentary and “textbook” knowledge of Portuguese at the time of my first visit to the organization where I worked, O Projeto Força Feminina–The Female Force (Empowerment) Project (September 2011).

To overcome any cultural/linguistic barriers and earn the trust of the women at O Projeto Força Feminina, I dedicated the first few weeks of my project to establishing a relationship with the women. I taught basic English classes and engaged the women in belly dance and makeup classes (eyebrow threading), which they loved! It was truly a beautiful exchange of cross-cultural interests: I shared aspects of my Middle-Eastern culture. In exchange, the FSWs taught me some forms of Brazilian dance and helped me with my Portuguese. Ultimately, we established a firm sense of camaraderie that allowed them to trust me and have me interview them about their work and sexual behaviors. I also demonstrated my commitment to working with the group by returning to my project site again last summer (May-August 2012). While I will not be able to return to Salvador until next summer, I still maintain contact with many of the women at the organization.

Below is my finalized research abstract with some pictures from my time at O Projeto Força Feminina. Please email me at with any questions.

“Who Cares about Us–We are Just Women of the Street”–Combating HIV Transmission and Gender Disempowerment among Female Sex Workers in Salvador, Brazil 
Authors: Rachel Safeek, Sherman James, Ph.D
Duke University 

BACKGROUND: While Brazil is lauded for its exemplary HIV prevention model, the majority of HIV prevention programs promote safe sex through education, ignoring the realities of gender disempowerement and inequality, which increase the susceptibility of female sex workers (FSWs) to instances of violence and disease. This paper analyzes factors associated with gender disempowerment and lack of condom use among FSWs in Salvador (Bahia), Brazil who engage in heterosexual interactions with male clients. An understanding of the sources of gender disempowerment is key to developing culturally-appropriate and effective policy interventions.

METHODS: Over a seven-month period, formal interviews were conducted with sixteen female sex workers and focus group discussions were conducted with 35 female sex workers at Projeto Força Feminina. The latter is an organization located in Pelourinho, the Historic District of Salvador, that works with FSWs to promote safe sexual practices and combat gender-based violence. Three life histories were also conducted with three of the sex workers. Additionally, Dr. Edivania Landim, the former head of the HIV/AIDS program of Bahia, was also interviewed.

RESULTS: Interviews and focus groups revealed that economic vulnerability (financial instability), drug use, and instances of gender-based violence (structural violence) and rape/sexual assault from police and clients disempower FSWs, increasing their susceptibility to the transmission of disease. In each case of disempowerment, the factors contributing to women’s decision to engage in intercourse without condoms or other types of risky or unsafe sex were influenced by their inability to defend themselves as women and as FSWs, a social group of women isolated on the bottom rung of Brazil’s social and economic ladder. The respondents were clear that their gender was a definite factor in the many difficulties they faced.

DISCUSSION: Increased emphasis should be placed upon female-specific forms of protection, e.g. female condoms, microbicides. Unionization among sex workers is necessary to gain political acknowledgement of sex worker rights through legalization of the profession.

KEY TERMS: HIV/AIDS, Female Sex Workers (Profissionais Do Sexo), Race, Economic Vulnerability, Disempowerment, Gender-Based Violence, Structural Violence, Health Disparities, Human Rights, Salvador, Brazil

–Rachel Safeek

"Empower women in the situation of prostition"

“Work in solidarity with women in the situation of prostition”

Colorful sitting room

Working on art projects

Working on art projects

Mission Statment

Mission Statment

In focus group discussion

In focus group discussion








On Brazilian Time

25 Nov


The title of this post refers to the manner in which I’ve decided to write this months after I’ve already returned to the United States. In Brazil, the concept of time is not the same as we view it in the United States. Deadlines are flexible. Meeting times are subject to change ten minutes prior to the start of the meeting (even past the ten minute beforehand mark it’s sometimes okay to make the “can we meet fifteen minutes later call”…chances are both parties are running late…it’s Brazil). The mentality of Bahia is sometimes characterized by the  “why worry about something you didn’t do today when you have all day to do it tomorrow” mentality. Talk about low pressure and stress-free expectations. No one does the casual ” fashionably late” like Brazilians (o jeitinho brasileiro).

So, months later, after plenty of time to reflect on my research and travel experiences and add perspective to how these experiences will affect my academic and professional career goals, I can say with absolute certainty that (1) I love Brasil, (2) my experiences there have been the most meaningful and most fun times of my life, (3) not a day passes when I don’t reflect on something I learned in Brasil.

In Brazil–and in the US to some extent–I work with HIV/AIDS prevention among female sex workers. A wide array of reasons led me to pursue this cause. You can read about them in detail in my other posts, specifically this one or my “about me” section. But, in summary, I am a public health/health policy major, studying health disparities from a sociological, human rights, and policy perspective, and these interests have led me to studying health disparities and HIV prevention.

Brasil is a country renowned for its model HIV/AIDS system, in addition to a universalized health care (long post about this). While organized prostitution (brothels, the management of prostitutes through a pimp) is illegal in Brazil, it is not illegal for one to work as a prostitute. The high rates of HIV among female sex workers, despite the highly successful model of the nation’s HIV/AIDS program and the legitimization of the profession, drew me toward investigating this study. One would reasonably assume that a profession which is legitimized and acknowledged by the federal government is accompanied by some form of regulation. This does not appear to be the case in Brazil . Despite the Brazilian government’s attempts to exercise tolerance toward a marginalized group, female sex workers still disproportionately account for high rates of disease transmission, representing a principal disparity in women’s health in Brazil. For a country with an exemplary HIV/AIDS program, this seems paradoxical, and it is this line of thinking that served as my impetus to pursue a research project in Salvador, Brazil where this disparity is highest.

I spent my summer working with O Projeto Forca Feminina, a non-profit, Catholic-based organization located in Pelourinho, Salvador, Bahia, Brazil. The organization’s goal is to work in solidarity with women who are involved with prostitution, providing women with a safe haven they can go to during the day. The sex workers participate in self-esteem building exercises which empower them to see alternatives to sex work or, should they choose to remain in their profession, to do so in a manner in which they are educated about their rights as women and as workers. The primary focus of the organization is to combat violence against women in all forms: physical, mental, verbal, or sexual. Whether the manifestation of violence is physical bruising, mental anguish, or the spread of sexual disease, the goal of the organization is to empower women to realize that any form of violence against women is unacceptable, and whether or not women choose to leave prostitution, they can take preemptive and proactive measures to defend their health and well-being.

I helped to coordinate English classes, belly dance classes, and art activities for the female sex workers at the organization. On the side, I conducted formal life history interviews with the workers. In my interviews, I was interested in learning how women entered their profession, what experiences they have had with gender-based violence, if any, and what factors contribute to whether or not they engage in protected sex in their encounters with clients. The last question is key for prevention of disease transmission and was the main focus of my study. For reasons why condoms were not used, women cited incentives of cash bonuses for engaging in sex without a condom, drug use or intoxication/impaired judgement, pressure from clients, and instances of rape and violence from clients and the police as the primary factors that contributed to the lack of condom usage among workers.

The results suggest that public health policies should promote prevention methods that engage female-controlled forms of disease prevention(e.g. female condoms and microbicides designed to kill sperm, bacteria, and viruses). These methods should be emphasized in both classrooms and public health campaigns and be made more available to the public sphere, perhaps distributed in the same locations where condoms are made readily available. Furthermore, sexual education courses should also incorporate female-specific forms of protection.

While the primary focus of my trip was to conduct my research, I found that most of my time was spent listening to the stories of the women at the organization, their struggles and near-death experiences. The saddest story came from a woman who I became very fond of through my English class. She told me how her ex-husband abused her( “he tortured me for months”), burning her, hitting her, and eventually leaving her with nothing. With three children to feed and no education, she felt compelled to enter prostitution. She saw my English course as a way to make her more marketable for other work. She is only one of many women with whom I have worked with who have similar stories, a multitude of intense trials and tribulations which they had to overcome. Hearing these stories have inspired me to continue my work with human rights and pursue a line of work addressing gender disparities and women’s health.

Beyond my research, I have so many wonderful memories from this past summer. I have a large group of Brazilian friends, with whom I am very close to. There are like family to me. After weeks of experiencing life without speaking any English, or being near any other American, I began to feel really integrated in the culture, and when I was there, and I felt that it…nothing could feel more perfect. I don’t care how many grants or scholarships I have to apply for, how many cover letters I have to send out, even if I have to wait until after I graduate from medical school…Aut viam inveniam aut faciam (either I will find a way or I will make one)…I am going back.

Here is a drawing that a sex worker made for me after I finished interviewing her. She told the most incredible story. It’s says “Rachel, you are this rose. Kisses. -Haide”.


The night time view from my apartment…..If I have ever at any moment in my life felt at loss words, thoughtless and full of emotion all at once, it was here. Countless hours spent gazing over the balcony at the Atlantic ocean. Que saudade….


On my own overseas

17 Jun

The title of this post is a bit misleading because while, indeed, I did come here on my own, am living on my own, and am (supposedly) caring for myself, much of my time in Brasil thus far has been spent with friends, family, and co-workers who I am already familiar with.

I am currently here in Brasil under research funding from DukeEngage. Unlike many students who applied for funding for independent projects, I did not apply to go to an unfamiliar place. I instead opted to return to a place that I have lived in previously, Salvador, Brasil. Because I already have an orientation for the city, having spent 4 months here in the fall of 2011, my experience here thus far has been a fairly easy transition, both enjoyable and productive.

I have plenty of friends and family to rely on and I’ve been able to begin my volunteer work and research right away. While I am sure it would have been exciting to travel alone to some place new, I think it would be insane for Duke to let anyone come here on there own without them already having have lived here before.

Salvador is the third largest city in Brasil, and as always the case with big cities, it is very dangerous, ESPECIALLY for foreigners. Not many people here speak English so getting around could be incredibly difficult. Even something as simple as arranging for housing or purchasing a meal could be a hassle of you don’t understand or speak Portuguese. Not speaking Portuguese also makes you a target for getting ripped off, or worse assaulted or robbed.

Having already established myself here, however, Duke gave me the benefit of the doubt and trusted me enough to live in Brasil completely on my own with an organization that has never had an American volunteer before me.

That being said, this summer is turning out to be exactly what I imagined it to be. I am working and volunteering regularly by day and enjoying the culture of Brasil with my friends and family at night. Having people here that I care about has made the experience so much more meaningful for me, and it’s the only reason why my research project is possible. After all, I am working with HIV/AIDS, sex workers, pimps, drug dealers, etc. How many people can say they do this type of research on their own in a country other than their home country at my age?

So thank you, Duke, for affording me the opportunity to come here and carry out my passion for working with marginalized populations and allowing me simultaneously to live my life in the place I call my second home.

Will post more about my research and volunteer experiences soon. Until then, boa noite… From my apartment.


Picking Up Right Where I Left Off

17 Jun

I have my own apartment with a seaside view in Santo Antônio, located next to the historic district of Salvador, Pelourinho.





Night time view from my apartment in Salvador, Brasil

Night time view from my apartment in Salvador, Brasil


About My Project-Airport Ramblings (Lexington, Kentucky)

5 Jun

Thank you for visiting my blog page! I am gearing up for my second trip to Brazil in a year, my last visit being last September-December 2011. I am traveling to Salvador Brazil to volunteer and conduct a research project funded through DukeEngage. Salvador is the capital of Bahia and the third largest city in Brazil. It is home to the largest Afro-Brazilian population. Having lived in Salvador before, I can attest to the manner and degree to which Bahia remains in touch with its African past. From the traditional foods, to the dance, to the everyday lifestyles, the influence of the region’s African roots is hard to ignore, which makes living in Salvador (in my opinion) a cultural and historical experience. Besides the rich culture of the area, Salvador is a very vibrant city, known for hosting the biggest party in the world, Carnaval. Due to its laid-back lifestyle and sometimes lack of the concept of deadlines (time), Salvador is sometimes referred to as the happiness capital of Brazil.

So, obviously, that’s why I chose to spend my summer there….

Well, that, and also because of my interest in health care systems and population health. With the highest Afro-Brazilian population in all of Brazil, Bahia as a whole is disproportionately affected by poor health outcomes. As a fourth-year pre-med/health policy major at Duke University, I am currently studying disparities in health, and the manner in which structural inequalities and barriers within societies create injustices in health care outcomes across racial and gender lines. I am particularly interested in the intersection of race, gender, and culture, and the role each plays in creating disproportionate figures among health and socio-economic outcomes.

I fundamentally believe that health is a human right, and that various structural inequalities embedded within societies disbar certain groups of individuals from attaining their optimal health status. The relegation of racial, ethnic, and gender groups within a society to a lower social status leads to a neglect of this group’s basic social and economic rights. This neglect manifests itself through poor health outcomes in comparison to other members of the population. These disparities represent key societal injustices and present substantial barriers for those who are attempting to advance themselves socially or professionally, as they remained trapped within a cycle of poverty and disease.

Given my background interests in studying health from a sociological and human rights perspective, I have chosen to focus on marginalized populations for my research. My research is centered around studying HIV/AIDS transmission among female sex workers working in Pelourinho, Salvador, Bahia-Brazil. For my project, I am conducting focus groups, life history reports, as well as formal one-on -one interviews with female sex workers working in Pelourinho to determine what structural and societal factors contribute to a lack of condom usage in their profession. The factors that I am particularly interested in targeting involve corruption among police/governmental workers, drug use among workers or their clients, and instances of rape, sexual assault, or gender-based violence.

While it seems like a very loaded topic, I think the nature of my project capitalizes upon the manner in which health is a multi-dimensional topic, stemming from a wide array of structural barriers and inequities, extending beyond mere access to health care and appropriate health care infrastructure.

That’s all for now. I would love if they would stop telling me that they are doing maintenance on plane because I can clearly see the plane, and its pretty much been sitting there for the past hour.

The Positive Right to Health

21 Dec

As a public health, human rights, and health disparities major, I believe that it is important to address the issue of health and health care as I have studied it within the Brazilian context. The situation of health in Brazil is so unique because in Brazil health is regarded as a universal service that is not prioritized for any one individual or group. Rather, everyone is afforded the same right, and the right must be acknowledged equally. The Brasilian government and minister of health have mandated through the Sistema Único de Saúde (SUS) that health care be provided for everyone, not just Brasilians….ANYONE in the country. Furthermore, if treatment is not available in the area of injury/ailment, then, by law, the person seeking treatment must be transported to a locale in which treatment is available.

While there is some discrepancy as to whether or not this system effectively promotes optimal health for all Brazilians and adequately acknowledges inequities in health care access and community conditions that promote good health—inevitably, no one system is perfect—I believe that the acknowledgement of health as a right in Brazil reinforces the system as a progressive one, worthy of praise.

As an American student, I cannot help but reflect upon the differences between the capitalistic health care system in the United States and the universal system of health that is provided and acknowledged within Brazil. With the recent controversy surrounding the Health Care Reform Act in the United States, much time and many strenuous efforts have been exerted by United States citizens and legislators toward debunking the social, economic, and ethical ramifications of implementing a new system that promotes a “positive right” to health.

Supreme efforts have been made by proponents of the health care bill to argue for the acceptance of the law because of the benefits that it awards those who were once barred from access to adequate health care due to lack of coverage by a health care provider. Alternatively, arguments from the opposing viewpoint acknowledge the partiality of the “pay your way” system, in which those who are deemed capable of affording their own health care are also responsible for funding the new health care system for others as well.

Difference #1:Community Empowerment and Community Mobilization

While I understand the “anti-socialism mentality” of those Americans in opposition to universalized health care, my experiences within Brazil have reinforced my belief that health is a human right, which should be acknowledged equally for all. While, indeed, there remains much room for improvement within the Brazilian health system, I believe the addition of health as a human right to Brazilian law has empowered a community effort and fostered a social cohesion among Brazilians to know, understand, and utilize as well as improve their right to health.

In the United States, this right is non-existent; thus, it cannot be so forcefully demanded. There exists solely a conception of health as a privilege. In this manner, the absence of a formal written law regarding health as a benefit and basic necessity for all serves as barrier among Americans struggling to improve their health. Lack of acknowledgement of health as a human right by United States policy disempowers Americans who lack the health benefits they could otherwise demand from the government under a system similar to the Brazilian health. Their inability to demand their rights keep them disbarred from socio-economic progress and attaining optimal health status.

In general, I have gathered the impression that social cohesion among Brazilians is very powerful. Community mobilization is often utilized and recognized as a key method to inspire and demand change in policy. From just my short time within the country, I have witnessed several “em greve” (on strike) posters on the outside of banks and posts offices. My own host mother participated in a strike with several others from her work place for higher pay from her employer at UFBA (Universidade Federal da Bahia). There is a sense of empowerment among the Brazilian people that is also visible among issues related to health care. I once spoke with a group of public health students from UFBA about their perception of the health care system. They all agreed that the idea was laudable, but they believed more could be done to promote health, particularly throughout the state of Bahia. Coincidentally, they were on their way to a protest demanding improved access to public health materials in health posts in rural areas.

Difference #2: The Definition of Health-Treatment vs. Prevention

Although I believe the United States is progressively realizing health as a human right for all, the shift toward providing universalized insurance coverage is only the first step to acknowledging health as a right. In this manner, I perceive Brazilian health care laws as having proactively surpassed American health care laws in terms of progressively attempting to improve health for all. I believe that unlike the empowered language of Brazilian health laws, the laws which reinforce health within the United States lack both the vernacular and the intent to accept health as right.

In the United States, there is an emphasis on the provision of health care, rather than an overall desire to improve health status for Americans, i.e. an overall focus on the treatment of disease. In Brazil, however, there is an acknowledgement of the all-encompassing factors that affect health and access to health care and a provision made through law to address both pre-existing health conditions as well as to prevent conditions that may arise as a result of socio-economic class and living conditions, deficiencies in education, unequal access to health care resources/underdeveloped health care infrastructure, etc.

I consider the most unique and important aspect of Brazil’s right to health to be the definition of “health” that has been adopted into the Brazilian constitution:

A saúde tem como fatores determinantes e condicionantes, entre outros, a alimentação, a moradia, o saneamento básico, o meio ambiente, o trabalho, a renda, a educação, o transporte, o lazer e o acesso aos bens e serviços essenciais; os níveis de saúde da população expressam a organização social e econômica do País.

“Health has determining factors and conditions, among, food, housing, sanitation, environment, labor, income, education, transport, leisure, and access to essential goods and services; levels of the population express the social and economic organization of the country” (LEI Nº 8.080, Article 3º, Lei Organica de Saude).

In today’s society there is a demonstrated need for acknowledgement of one’s rights within the realm of overall health beyond simple access to care. I believe that ensuring equal opportunity for individuals to gain access to a decent minimum of health care does not ultimately affect the social gradient in mortality, implying that guaranteeing access to universal health services alone does not improve health overall. Health care is only one socially controllable factor that significantly contributes to overall health; there are other factors affecting health care, i.e. biology and social determinants of health (e.g. environment, availability of resources, socioeconomic status etc.) which play a defining role in the determining the overall health of an individual.

Because access to health care comprises only a single social determinant of health, the overall quality of health of an individual cannot reach its potential unless all social determinants of health are addressed. Defining a right to health through a universal health care law, as it is defined within the United States, is, therefore, an incomplete approach to promoting a decent standard of health because it neglects many of the biological and societal factors involved in determining the health of an individual.

In addition to universalized health care, SUS also mandates that everyone should have their right to health acknowledged equally. This element of equality cannot be effectively acknowledged simply by guaranteeing free health services as the health care legislature in the United States promotes. One must also consider the structural inequities and social factors which deter or prevent individuals from seeking and receiving access to health care resources and facilities, exacerbating pre-existing disparities in health.

Despite guaranteed free access to care, many still encounter financial and socio-cultural barriers that may lead to discrimination in who actually receives care. For example, even with an extension of health care insurance coverage, there are still issues related to an individual’s ability to exercise to his right to see a health care provider. Lack of transportation to a health care provider, pharmacy, clinic, etc. is a considerable obstacle for many without personal vehicles. Even public transportation can be a burden for many who are pressed for time between working long, tiresome jobs, or are disabled.

Lack of transportation is one particular determinant of health that I noticed was accounted for by the  Brazilian health care system, even within rural communities. Through the Programa Saúde da Família (PSF), a national public health program afforded as a right through SUS, individuals can receive preventative care and treatment or recommendation to see a specialist at their local health care post. During a visit that I made to Cachoeira, a city in the interior of Bahia, I observed a PSF nurse make several visits to the homes of patients who were physically disabled or bed-ridden for a check-up and to ensure that they were being cared for regularly, taking their necessary medications, and adhering to their daily regimens. I was also able to make a grocery delivery to the home of a bed-ridden tuberculosis patient in Santo Antônio de Jesus, another city within the interior of Bahi. Within the United States, no such national program exists; the concept of a “home visit” is outdated and generally frowned upon. I was surprised to see such efforts being made by nurses and physicians to attend to the needs of their patients, as I had never witnessed any similar program within the United States.

Overall, I believe that “health” as defined by Brazilian law adequately capitalizes upon the manner in which health status is dependent upon a wide array of social and behavioral factors. This acknowledgment of health as a multi-dimensional issue is something which I perceive is lacking in American policies and in the discussion of health-related policies. Because the United States has not adopted a right to health like Brazil, there remains a lack of discourse over the social determinants of health and the fundamental causes of disease. I believe that before within American health care policy, a paradigm shift from an access to treatment model to the Brazilian model, affording health as general well-being and way of life will be necessary to effectively address health care disparities.

Difference #3: Cultural Willingness to Advance Health—A Community Support System

One aspect of SUS that I believe is very important to address is the manner in which I believe the idea that the system promotes, universal and equally accessible health for all, adequately reflects the cultural mentalities of the Brazilian people. I noted that in the United States, no such right to health exists. However, I believe this is because the cultural perception of Americans will not allow this to be so. I have noticed in Brazil a valiant effort made by other, e.g. people, doctors, nurses, teachers, passerbys, etc., to help other people. Even the Brazilian government acknowledges the rights of Brazilians and strives to protect these rights. One distinct and powerful example of this that made a significant impression on me is the refusal of the Brazilian government to accept $40 million from U.S. AID grants in May 2005 because they did not agree to the terms of acceptance, which demanded the exclusion of sex workers, transvestites, and homosexuals from benefiting from the money.

Currently, there still remains a stigmatization and unwillingness to declare health and human right within the United States. Much of this unwillingness stems from a cultural uneasiness to fund free services for others; however, there is a slow movement toward the internalization of health as a right for all and this realization will require some sacrifice.  I believe that this strong sense of community care and support is unique to Brazilian culture and that the United States is progressively realizing these same values.

Perceived Issues with the Universalized Health Care System-SUS

While the concept of SUS represents an idealist response to eliminating injustices in health, the system maintains its flaws. From my conversations with my host family and neighbors, public health students, and medical students, I have gathered that, in general, Brazilians agree that SUS is “um process em construção” ( a process in construction). My host mom, along with many others, mentioned to me that they would never seek treatment for an emergency at a SUS hospital, only a private hospital. This is because, through the SUS system, the time that one must wait to be attended to is often very slow. Hospitals remain over-crowded and there is not a sufficient number of doctors to attend to all the patients around the clock.

This was observed during an organized visit to Hopsital Central Roberto Santos (the largest public hospital in Bahia). The emergency room was so crowded that patients were being attended to by family members in the hallway, only being check on occasionally by the nurses and physicians. Despite the efforts of Programa Internação Domiciliar, which prepares patients to live at home under the care of another family member who is competent in assisting them with taking their medications, many patients remain in the hospital. Having taken advantage of the universalized health care system in Brazil (SUS), I found that it was fairly easy to receive treatment. Granted, I arrived at the the hospital at 3 A.M. when there was rarely anyone there.

Another issue associated SUS is the failure of the system to fully account for disparities associated with marginalized groups in society. Not all individuals are equally exposed to the same level of health care, education, and home lifestyles, etc. that would guarantee him the ability to make “healthy” life decisions and maintain his health. For example, if someone is raised in a neighborhood plagued by poverty and rampant drug use, his predisposition to unhealthy behaviors may affect his ability to personally care for himself.

In his Pathologies of Power, Dr. Paul Farmer, a physician and medical anthropologist (as well as a Duke grad!), discusses the manner in which historically rooted social processes within societies (e.g. racism, gender discrimination, poverty, etc.) pose significant barriers toward attaining a decent standard level of health. These structural disparities which Farmer terms examples of “structural violence” plague societies beyond access to health care.  In Brazil, particularly within in Bahia where the population is primarily comprised of Afro-Brazilians, structural violence plays a key role in the health of the population.

The relegation of Afro-Brazilians to an inferior status is a historically rooted process that began when slaves from Africa were brought to Brazil. As slaves, they represented the lowest rung of the socio-economic ladder and regarded as the bottom class. In this manner, their rights were neglected and they were afforded a substandard agree of care and resources. This social construction within Brazilian history placed Afro-Brazilians at a social disadvantage since their arrival in the country.In this manner and from my experiences visiting health posts and observing health issues that plague populations, there is a connection between one’s place in society and one’s health status.

While I agree that the system in Brazil is far superior in construction and implementation to the system currently utilized within the United States, I believe more social policies should be adopted which consider the situations of marginalized populations, such as Afro-Brazilians. These social policies should incorporate a positive shift toward catering to the social determinants of health which put marginalized populations at a disadvantage for attaining optimal health status.

Cross-Cultural Reflection: Firm Sense of Cultural Identity

19 Dec

Dear Family and Friends,

Weeks have passed since I’ve written about my experiences and travels within Brasil. Needless to say, my fascination with the country, the people, and my new community have distracted me long enough to delay bi-weekly postings. Luckily, I have plenty photos, twitter updates, and memories to rely upon for this new blog entry (especially since I am now back in the States…well, for about a week).

Coming to Brasil has ALWAYS been a dream of mine. I’ve wanted to learn Portuguese, to learn more about the culture, and to immerse myself into a new society so different from that of my own. As I reflect upon some my experiences from my hometown of Lexington, KY and my college town, Durham….(DUKE), North Carolina, Salvador feels almost like a false reality.

The differences are so profound that writing about them in my private blog seems almost a futile task; it’s impossible to adequately describe the manner in which I’ve perceived these differences between my life in Salvador and my life at home.

For starters, there are the everyday friendly gestures that Brazilians exchange among family, friends, and even complete strangers: a  “Bom dia! Tudo bem?” and a kiss on each cheek. There is the Bahian woman who will reach out and grab my arm to pull me away from a passing bus. The street vendor who gives me a reassuring embrace after I’ve just frantically asked her for directions in a place I am unfamiliar with. Even the manner in which whole neighborhoods come out to celebrate the birthday of one of it’s oldest members: people of all ages dancing together to the same songs, the older members challenging the youth to “dance-offs”.

This way of interacting with other people is one that is so foreign to me, living in the States.  The social cohesion of families: sons and daughters living in their parents’ house even after college, or nearby if married. Youth and elders, alike, bonding and enjoying themselves over a few drinks and popular music. Random strangers extending themselves so far to help others.

This is  not to say that I have not experienced this close communal sensation before. In fact, the constant presence of family, everyone going to “festas” or family gatherings, random aunts or uncles passing by the house everyday reminds me off my time in the Philippines staying at my grandparents’ house in Baguio City. It’s remarkable to note the sense of social cohesion that is found among families in other nations. Here in the States, it’s been many years since I’ve lived even relatively close to a grandparent. Years have passed since I’ve last been able to see certain cousins.  Granted, my family comes from all over the world (literally–spanning three continents, possibly more?), and this distance has always served as a barrier for me and my siblings to grow closer to our heritage and form relationships with other family members.

I am an American of mixed Filipino-South American-Middle-Eastern descent, and I’m very proud of this. My background has fostered a sense of tolerance for others and has made me a more “worldly citizen”, having had the opportunity to travel plenty with my family. But beneath this charm of an “exotic” background, I feel as if I’ve never truly been able to establish a sense of identity with any of my ethnic backgrounds.

Indeed, I have traveled, met relatives, eaten foods, familiarized myself with religious practices, and gotten to know different parts of the world, but to this day, I don’t know any Tagalog (the language of the Philippines). When my grandfather passed away in the fall of my freshman year of high school, I found it very difficult to feel for someone I hardly knew. And to this day, this has been my biggest regret, feeling so disconnected to someone who was so close to me, so important to my mom and to me and my whole family. If there’s one thing I’ve learned in my short time in Brasil, it’s the importance of establishing a firm cultural identity that you gain from experiences with family.

Is it possible to fully identify with your cultural background when your parents speak different languages, practice different religions, and come from different cultural backgrounds? This is a question that has been posed to me many times before, and I’ve often found myself  pondering it at times. After many years of thinking over this, meeting and being exposed to new groups of people, and participating in new cultural experiences, I have concluded that having multiple or many cultural influences is a separate identity in and of itself, and the mix (sometimes clash) of cultures, language, and religion can be a beautiful one.

For evidence of this, I look at the culture of the Brasilian people. The unique thing about the people of Brasil is that you can find people of every skin tone, hair texture, eye color, etc. who identify themselves as Brasilian. This is because the development of the Brazilian culture was the result of the mixing of the indigenous people of Brazil, Africans who arrived as slaves, and the Portuguese. For this reason, the sense of culture and race in Brazil is very blurred. Everyone is mixed and Brazilian culture is a reflection of this.

Going to Brazil has helped me to reconcile my differences in my cultural background. Whereas previously, I made an effort to separate my cultural identities, perhaps even associating more with one over another, today, I’ve learned to embrace them together. Brazil has made we want to return to the Philippines and learn Tagalog and to become closer to that side of my family, because that side has always been the hardest to get to know because of the distance. Brazil has made me want to make every effort to become closer to my family and where I’ve come from.

I’ve always been a very outgoing and friendly person, but since I’ve come back from Brazil, I’ve found myself more connected to the people here, even though I have been apart from them for so long. I have a genuine interest in getting to know more about others and becoming closer to and forming relationships with family and friends. When I greet others, it is always with a hug (sometime as kiss on the cheek out of habit from Brasil), and I make sure to listen to what I am being told, every piece of advice, every warning.

I have two souls now, my American one and my Brazilian one. I cannot explain or fully describe to anyone the experiences that I’ve had in Brasil because they are meaningful to me within the context and scope of Brazilian culture. Unless you’ve lived within the cultural context, you cannot fully grasp the excitement and beauty of the experience. In the same manner, I found it difficult to describe to my Brazilian family and friends about my life here. They are two different worlds, and I feel 100% part of both. And while these two worlds may never ever meet, I will always remember my time in Brazil as the most testing, riveting, inspiring, and growing experience of my life. I learned Portuguese, I learned to dance (better), I learned to live independently in a foreign land where my native tongue is rarely spoken and the dynamics of the city are far different from that what I am accustomed to in my own home town. But beyond all of this, I became a part of the culture and a system that represents something opposite of what I am used to, and I did so successfully, and the lessons that I have taken from this experience will remain with me forever.

Estou com saudades do meu segundo país, Brasil. Um parte do meu coração vai ficar lá para sempre. Mal posso esperar para voltar…Até mais.

This post is dedicated to my mom, Gina, whose birthday passed almost a month ago when I was originally writing this. I’m so proud to have a Filipina mother who is so strong and has always encouraged me  through all of my endeavors. My biggest hope is to one day return to the Philippines and get to know the place of your birth and what you knew as a child because it’s an important part of who you are and an important part of who I am.