Three Decades Devoted to Brazil

Yale School of Public Health Professor Rafael Pérez-Escamilla, Ph.D., has worked around the world during a long and productive career to create better health and nutrition outcomes, with a focus on promoting breastfeeding, household food security, and combatting malnutrition, including obesity. He has spent a significant amount of time over the past 30 years in South America’s largest country, Brazil, where he has worked with colleagues to improve health outcomes and also help to train a cadre of health professionals. His work has taken him throughout Brazil and lead to many collaborations and partnerships that thrive to this day. His work in Brazil has touched many, and prompted the legendary Pelé to give him a signed soccer ball.

What first drew you to work in Brazil?

RP-E: In the early 1990s, I was asked by the U.S. Agency for International Development (USAID) to work on a three-country study examining the impact of the UNICEF/WHO Baby-friendly Hospital Initiative. One of the countries was Brazil, and that’s how I started my three-decade-long collaboration with Professor Ana Maria Segall-Corrêa, emeritus professor at the University of Campinas in Saõ Paulo. The study in Brazil ended up being the first demonstration of how impactful the BFHI was at improving exclusive breastfeeding duration. That initial work in Brazil was very rewarding and had a major influence in my career, as it taught me that it was possible to translate evidence-based interventions into practice on a large scale. One of my collaborators in Brazil, Dr. Keiko Teruya, happened to be the pediatrician of Pelé’s daughter, and I ended up receiving a soccer ball from Pelé in recognition for my work toward improving the health and wellbeing of children and mothers in Brazil.

What were some of the public health challenges encountered in your first years there?

RP-E: Brazil is a large country formed by a diverse set of immigrants who were drawn to the land’s rich natural resources. But European colonies left behind a painful legacy of abuse, including slavery, against aboriginal communities. Since my arrival in Brazil, I observed huge health disparities across the country and its regions, resulting from its colonial past and neocolonial present. So, the first challenge was really to try to understand how maternal-child public health interventions could be adapted to the very diverse social, cultural and economic contexts across regions while remaining effective. This challenge made me think about the great poverty, racism and discrimination faced by aboriginal people and people of color, and I now ensure that any intervention I get involved with is inclusive and socially just.

Describe the types of public health work that you have done in Brazil.

RP-E: My work in Brazil has strongly contributed to research and policy advances on a large scale across the country.

First, since 1990, my work has led to improvements in breastfeeding outcomes through the UNICEF/WHO Baby Friendly Hospital Initiative. I used the success of Brazil’s breastfeeding initiative to inform other countries on how to successfully scale up their own programs. This work led to the development of the Breastfeeding Gear Model and its operationalization through the global Becoming Breastfeeding Friendly initiative, led by the Yale School of Public Health.

Second, the development of the Brazilian Food Security Scale (EBIA), starting in 2003, led to an explosion of research in food insecurity that continues today. This research has helped us better understand the determinants and consequences of household food insecurity, including poor child development, infectious diseases, stunting, and obesity. My work in this area was also very timely policy-wise, as it strongly justified the Zero Hunger Program (Fome Zero) and informed the design of the Bolsa Familia program, the largest conditional cash-transfer program in the world, as well as the structure of local food security committees. Indeed, it was through EBIA that the government of Brazil was able to demonstrate how its increased investments in equitable social policies led to a reduction of food insecurity by about 30% between 2004 and 2014.

Third, through my work with the 2016 Lancet Early Childhood Development Series and the World Health Organization, I contributed to the development of the global nurturing care framework that was fundamental for the design and launch of the Criança Feliz parental-skills home-visiting program, which serves millions of low-income families across the country.

Is there a public health intervention that you were part of that has been particularly successful?

RP-E: I would say that my collaborative work in Brazil has played an important role in the success that the country has had with improving and sustaining more optimal breastfeeding outcomes. Likewise, the household food security national measurement project was fundamental in supporting the more equitable social and food security policies from previous administrations, as well as protecting against the dismantling of programs that otherwise would have already been dismantled by now by the current political leadership. For example, data from this initiative helped counterbalance the message from the country’s president that there is no hunger in Brazil by clearly showing not only that is there hunger in Brazil, but also that the problem has gotten worse, especially for the very poor, under his administration.

What is your favorite memory of your time in Brazil?

RP-E: By far, my favorite memory of Brazil is the time I spent with my family during a sabbatical leave at the University of Campinas in 2003. During that time, I was able to share with my family the natural wonders of Brazil and the incredibly rich cultures that together represent what Brazil actually is – a vast and highly diverse country with incredible people, art, music and literature. Ana Maria Segall-Corrêa and her family were incredible hosts, and though them, we got to establish many friendships and collaborations in Brazil that we treasure. During this sabbatical, Ana Maria and I launched what became the national project to map household food insecurity across Brazil. This work, which benefitted from a strong collaboration with Professor Rodrigo Vianna at the Federal University of Paraiba, helped build capacity and vastly improved food security education, training and research in academic and research institutions all over Brazil. It not only ended up strongly influencing food security research and policies in Brazil, but also led to major improvements in household food insecurity measurement and research throughout Latin America and globally in strong partnership with the United Nations Food and Agriculture Organization (FAO).

What are some challenges that you have faced with your work in Brazil?

RP-E: The biggest challenge by far has been the major negative public health consequences of the abrupt changes in social, economic and public health priorities brought by the political administrations since 2016. The environment created by this regressive political thinking has led to the dismantling of evidence-based public health nutrition programs and a dramatic reduction in research funds for public health and social determinants of health across universities in Brazil. The efforts by the current administration to disempower universities has been so strong that some public universities don’t even have a budget to pay for electricity and other basic operational needs. In spite of this, our collective collaborative work continues to be done, and we hope that in the near future it will help reverse the current dire situation the country is facing.

What is the state of public health in Brazil today?

RP-E: Unfortunately, hopes for major advances like universal health care have now been seriously harmed by the current administration. The level of severe cuts and intentional efforts to undercut the public health system in Brazil, including universal health care, has not been seen in in a country that, until recently, took pride in acting upon its constitutional mandate to recognize health and food security for all as a human right. For example, the dismantling of the local heath and food security committees by the current administration is truly disheartening. At the end of the day, the implication of how harmful these measures have been to Brazil’s population is reflected on the incredibly irresponsible and ineffective response by its government to the COVID-19 pandemic. As of now, Brazil has the second-largest number of COVID-19 cases and deaths in the world, only after the U.S.A. The country is also lagging behind in its vaccine rollout, an unthinkable situation in a country with previous vast expertise in massive vaccination campaigns.

What are some of your goals as you continue to work in Brazil?

RP-E: First and foremost, I will continue training and mentoring more students and scholars in the years to come. While doing this, I will continue and launch new collaborative public health nutrition projects along the way. I have made a two-year commitment to collaborate with Professor Cristiano Boccolini from the Fio Cruz Foundation of Rio de Janeiro on big-data approaches to examine the relationship between the Baby Friendly Hospital Initiative and neonatal mortality; with Professor Rosana Salles-Costa from the Federal University of Rio de Janeiro on Household Food Insecurity trends and food assistance programs; and with Professor Emeritus Cesar Victora of the Federal University of Pelotas in Rio Grande do Sul on global epidemiology of infant-feeding practices. So, my extraordinary adventure in Brazil will continue for years to come! To learn more about Yale's partnerships in brazil visit brazil.yale.edu.