Breast cancer impacts millions of people worldwide, and in Peru, breast cancer is the most common cause of cancer related death among women. Breast cancer treatment is physically and emotionally burdensome and challenging for patients.In-depth interviews were conducted with 14 female breast cancer patients and survivors in Lima, Peru. The interviews explored four main themes: the women’s emotional experiences, coping mechanisms, resources available or needed, and advice for newly diagnosed breast cancer patients.Respondents described a tremendous lack of informational support during and after diagnosis and treatment and requested more of this support from health professionals. Social support groups were helpful to participants; however, these forms of support were not available to all participants. Emotional and esteem support seemed amply received from family and friends, faith organizations, and fellow cancer patients. Participants experienced a range of emotions upon diagnosis and during treatment including fear, anxiety, difficulty accepting bodily changes, loneliness, and denial.Breast cancer and its treatment can be a long, emotional journey; more extensive forms of informational support could help patients cope with this process. Breast cancer has the highest incidence rate of any cancer in the world and led to the death an estimated 685,000 women in 2020 . Breast In mostly qualitative studies on the emotional journey and need for support resources for patients with breast cancer, patients most commonly report feelings of anxiety, depression, fear, and negative body image , 5. WomeOnline communities, face-to-face support groups, familial support, and informational resources are associated positively with coping among breast cancer patients –14. HealSimilar to many other countries in Latin America, Peru is facing a rise in both the incidence and mortality rates of breast cancer with an estimated 70% increase in deaths due to breast cancer between 2012 and 2030 . EffortsIn one study considering the perspectives of women in the Amazonian region of Peru, Collins et al.  found thThe aim of this study was to examine the challenges – emotional, coping strategies, and resources available or needed – that were faced by breast cancer survivors throughout diagnosis and treatment in Lima, Peru. During our in-depth interviews with 14 women, an overarching theme that emerged was the need for different types of support and health education about breast cancer before, during, and after treatment. This qualitative study provides guidance regarding the types of health education and health promotion activities that could be strengthened for this group of women.This study took place in a range of middle- and low-income districts in Lima, Peru. In Peru, health care is offered in several types of facilities; 77.2% of the population receives government sponsored health care through the “Seguro Integral de Salud” (SIS) which is supposed to cover most health service costs for patients, 22.3% of the population is covered through employer based mandatory insurance also paid through a parallel government system of “EsSalud”, and the remainder have private health insurance . The MinSnowball sampling was used to recruit participants older than 18 years of age who self-reported a past diagnosis of breast cancer; only women were identified. All participants were Spanish-speaking. Five interviewees were women of middle socioeconomic status, determined based on the location and condition of their residence. The remaining nine interviews were conducted in lower income neighborhoods – regions on the outskirts of Lima considered low income compared to the rest of the city, and that initiated as squatter settlements in the 70s and 80s. The age of interviewees ranged from 43 to 74 years at the time of the interview. Only one woman was still undergoing treatment at the time of the interview, whereas four interviewees had been cancer free for ≥ 5 years (“survivors”), and nine were in remission (completed treatment but not yet cleared of cancer for ≥ 5 years). Overall, stage of treatment varied from having completed chemotherapy in the month prior to the interview to having completed all treatment  19 years prior to the interview. The majority (nine) detected their own lump via self-exam, whereas the remaining five were detected by a health professional.Fourteen in-depth interviews were conducted using a semi-structured interview (SSI) guide in Spanish by a graduate student with previous work experience in Peru. All interviews were conducted in women’s homes. The SSI guide covered four main topics: emotional experiences upon diagnosis and through treatment, coping mechanisms, resources available or that they would have liked to have, and advice to other women with a recent diagnosis of breast cancer. Interviews were recorded using a digital recorder, and detailed notes were simultaneously taken by a research assistant hired to assist in the process. Two interviewees declined to be recorded, citing “personal reasons”. Interviews were conducted with only the interviewee, the interviewer, and the research assistant present. In one case, the interviewee’s husband was present to help her hear and understand the interview question, as she self-reported being hard-of-hearing.Coding was both deductive and inductive. A coding guide was created based on the four main themes (deductive), and subthemes were added as they emerged inductively from the collected data; data from subsequent interviews were analyzed and new categories were added to the initial coding guide if any had been missed. Early transcripts were revisited to ensure that these were coded based on the final version of the coding guide.Social support provides a useful structure to conceptualizing how our findings regarding patients’ needs fit together; hence, we organize the results based on four of the five types of social support: informational, social network support, emotional, and esteem (encouragement and confidence-building) support. Due to insufficient information on tangible support, this was not included in the results.This study was approved by the Institutional Review Boards of both Tulane University (protocol 315711-11) and the Asociación Benéfica PRISMA (CE 0957.12), the collaborating organization in Lima, Peru. All the steps and methods were performed in accordance with the relevant guidelines and regulations. Informed written consent to participate in the study was obtained from all participants.“One of the things that has made me most tense was my daughter. I thought I was going to die, and my daughter is going to grow up alone and she is a baby, no?” (#13). Women also discussed difficulty accepting changes to their bodies resulting from removal of one or both of their breasts. Feelings of depression and loneliness generally accompanied these issues with body image, with some women reporting feeling like there was no one to understand their experience and/or that cancer was taking away too much from them. One woman stated, “I felt mutilated” (#8) and said that, “To look at myself in the mirror was not easy” (#8). Another reported feeling like “an incomplete woman” (#1) and even gave her spouse permission to leave her.The majority of women primarily reported experiencing fear at diagnosis, both for their personal fate and for that of their families, particularly their children. As one woman raising a toddler at time of diagnosis shared, “I was silent. I did not have a reaction… I did not accept, I really did not accept the treatments, I did not accept I was sick, I did not accept anything” (#12). Upon later being diagnosed with a recurrence, the same woman stated that she left the doctor’s office and did not return for over a year. Others mentioned that they could not believe it was happening to them; it was a surreal experience where they could not process any other information being given.In addition to these common emotional experiences, women throughout the study expressed denial in accepting their diagnosis, or as one describes, All respondents reported a need for information. They reported a lack of information at each stage of their treatment: a lack of resources to confront and overcome breast cancer, a lack of guidance regarding what to expect, a lack of information as treatment ended, and even a lack of health education around prevention. Many described it as a blind process, where they arrived at each stage in treatment unsure of what to expect next, learning to cope and manage their situation along the way.grasa (a fat deposit) or as a benign lesion or fibroadenoma. In the search for information, another respondent called in during a health broadcast on the television and requested advice from the network’s featured physician. The physician, in turn, informed her over the phone to seek medical help based on the characteristics she described, “Well, it is not hard, it moves… it could be a fatty cyst” (#12). Consequently, she turned to a family physician to remove the lump, only discovering after the lump was sent for analysis by her physician that it was, in fact, cancerous.Four respondents  reported receiving an initial misdiagnosis of their cancer as Numerous respondents had never received or heard of mammograms. While every respondent had heard of cancer, the extent of their actual knowledge prior to their diagnosis varied tremendously:“I was one of those people who had a completely distorted perception of cancer. Initially I thought that it was only hereditary. In my family… no one had had cancer. So, I thought, ‘I’ll die of anything except cancer.’ I didn’t worry, nor did I inquire or ask anyone, nothing, and 20 years ago, there was little information, no? All I knew about cancer was that it was something serious that could kill you” (#13).“I felt that I spent lots of time informing myself… I wanted information in writing” (#14). Some participants reached out to friends and/or acquaintances who had either a history of or more information about breast cancer. Another woman reported that she “asked up front for more information from the doctor” (#4). Others, however, felt they had little opportunity to ask questions of the physician, and one woman, when asked if there was any information that she would have liked to have, responded, “I still don’t even know what I would ask” (#8).A frequently reported occurrence was receiving the diagnosis of cancer without any explanation from a physician or nurse regarding the implications. For those referred to an oncologist, few were aware of why they were being sent to that type of physician; one asked a friend what “oncologist” meant. Those who did not receive an explanation at the time of diagnosis reported either seeking information about their diagnosis on their own or simply accepting the diagnosis without question. Some respondents reported utilizing the Internet to find additional information about the illness. One woman stated, “They should be more human, tell us what we have, and not as abruptly, so that we understand, instead of leaving us with such anxiety” (#8). Another respondent shared that having either a nurse educator or a patient advocate who provided information would be helpful. One woman (#14) was told she would need a catheter port for her chemotherapy and went out to the waiting room to ask if they could put it in – not knowing it was a surgical procedure. For most, it was not discussed upfront that each oncologist chose a different combination of chemotherapeutic drugs or requested procedures ahead of time  or after the fact. The lack of information continued throughout treatment for many participants, and most still had limited information related to their illness even after completion of treatment. When asked what information she would like since completing treatment, one respondent stated, “that they had given me more information about what I have… about my diagnosis of cancer” (#4).Another commonly reported theme was a shortage of information regarding what to expect during treatment. Frequently, the lack of information contributed to their fear and uncertainty about the illness and its treatment. One respondent stated, as advice to her physicians, The 12 women who underwent chemotherapy generally reported not knowing what to expect. One talked about being caught off guard with the side effects—mouth ulcers, diarrhea , overwhelming nausea that made eating and drinking difficult. For example, she (#14) described getting mouth sores that made it painful to eat and, in mentioning this to the nurse during her next chemotherapy appointment, described being told then to “swish bicarbonate” in her mouth; the participant expressed annoyance that no one had said this to her prior to getting mouth sores. She wished she had more advice from her oncologist and nurses about what to expect and how to best manage it, before being affected by symptoms so abruptly and having to learn from other oncological patients about how they manage these problems.“And I also began, for example, to realize that I needed certain clothes, right? I had recently had my operation… I didn’t have the same mobility, I needed open clothing” (#13). Another stated, “I asked my doctor if I needed to bring any special clothes for after the operation. He looked at me surprised, and said ‘no’. And yet, I left with two drains hanging from me!” (#14). Their varied knowledge about resources came from sharing experiences with other patients; none of them reported receiving this practical information regarding need for camisoles or wide clothing from their providers prior to their operations or during treatment.For women who underwent surgery, many of them reported a lack of information about how to deal with the drains left in the surgical site immediately after: one used a small purse from a friend to store the drains at her side, another was given a special camisole with extra pockets for the storage of the drains, and another respondent shared having to utilize wider, airier clothing stating, “I still look even now, on the Internet… I read a lot of books, and I asked people that knew about breast cancer” (#5). Two other respondents reported searching the Internet; one who spoke English found information on the American Cancer Society website, whereas the other searched with her family for herbal/plant therapies to help alleviate her treatment-related symptoms: “Every single morning I looked [for information] …on fruits and vegetables… things that would help increase the hemoglobin levels” (#2). Another respondent utilized home remedies of which she already had knowledge, stating, “I didn’t look up additional information because I drank medicine made from tree sap, drank honey, and rubbed Copaiba tree oil on my breast” (#1).For those who did seek out additional information on their treatment and its management, the resources varied from scholarly articles on breast cancer and self-help books to home remedies and information from other cancer survivors. One respondent reported finding self-help books about confronting her cancer-related emotions more helpful than information specifically about her illness. A second respondent sought information via a variety of methods: “the mockery of the people here” (#4). Another described, “When my hair started falling out, at first I said it did not matter. When I looked at myself in the mirror, I cried and cried and went to the Central Market to buy myself a wig” (#7). Another respondent shared, “A scarf was more comfortable, lighter, and people would know that something was wrong, but you wouldn’t get the stares or attention that you might get from going around totally bald. It would help me get seats on combis [minibuses], which was very helpful since I felt so weak” (#14). Many women also reported using makeup products to address the issues of eyebrow and eyelash loss, as well as the appearance of ashen skin.In many instances, participants found that useful information came from other breast cancer patients. During chemotherapy carried out in rooms with other patients, some women spoke about how this shared space resulted in information exchanges about various symptoms and how to address them: nutrition, or where to buy wigs or prosthetics, as well as obtaining emotional support from women who understood the experience. Respondents most commonly spoke about learning coping information from other patients including the benefit of using wigs, hats, and/or scarves to cover their heads, either for aesthetic reasons, practical reasons (i.e. cold weather), disguising factors , or all of these. One respondent felt she was “It was horrible, but you have to experience it to know” (#12). Participants also expressed frustration upon receiving advice from people who had not experienced cancer themselves: about caring for oneself, about nutrition, about alternative therapies and treatment. One respondent indicated that such advice was not appreciated and even annoying because those giving the advice had never shared her experience, nor did they have proof of such advice being of actual benefit, increasing her sense of isolation and not wanting to share more.Many respondents did not have access to formal social support systems and did not know of support groups in their health facility. These groups would have likely benefited survivors, particularly as some respondents felt as though they could not relate to those around them anymore, and others withdrew themselves to hide their illness. When asked to generally describe their experiences confronting cancer, many echoed the response that, “If they could do it, then I also have to do it” (#12). For those who perhaps did not have access to a support group and/or did not utilize one, most indicated that they would have liked to have attended such a group during treatment or even now, years after treatment. Another respondent reported having informal support group sessions with the regular faces at the chemotherapy sessions (held in a room with numerous comfortable chairs facing each other). Others found benefit in attending charlas (monthly group sessions) offered by volunteers at a local hospital, where topics related to cancer and its treatment were discussed. A few respondents stated that volunteering at support groups for breast cancer survivors has helped them to confront many of their difficulties post-treatment.Participants who did have access to social support groups, spoke highly about their experiences. Three respondents described the benefits of attending regular cancer support groups; the shared experience was very therapeutic and beneficial for their own ability to overcome cancer. One respondent reported drawing strength from witnessing other patients confront their illness: “When you are down and wondering how to keep going, you sometimes have to focus on taking one step at a time” (#14). Another stated, “Symptoms are inevitable. Do your part” (#8). Another respondent advised, “Fight…. Don’t lose happiness; a smile is a great therapy” (#7). Remaining positive while being treated with chemotherapy, radiation therapy, and surgeries can be difficult, but, as one respondent shared, “Chemotherapy isn’t there to knock us down, but rather to cure us. Be content and confident and keep fighting to keep going” (#7). Many participants advised trying to remain positive and confident, and despite not always feeling they were receiving the amount of information they wanted or needed, still trusting their health providers or having faith: “Have confidence in God and in the doctor. Do everything they say” (#6).When asked to provide advice to future breast cancer patients, respondents demonstrated the potential benefit and emphasized the crucial role of social support in maintaining a positive outlook and staying motivated to fight. One participant stated that she was fighting for her young children; she wanted them to have a mother. On particularly bad days, she described, “My daughters were incredible… In that moment, they were both my mothers” (#12). For another, the support came from her spouse: “My husband gave me moral support. My family gave me money, visited me, called me…” (#10). Support also came from friends in many forms. For example, one participant spoke positively about the benefit of laughter from funny videos a friend sent. When participants currently in the middle of treatment spoke about advice they would give future patients, they most commonly stated to remain positive and seek support – whether through family, friends or one’s spiritual beliefs.Most respondents reported that their greatest source of emotional support was family -- spouses, children, or other family members -- particularly with overcoming the emotional toll of dealing with breast cancer. One described the support of her daughters: “Faith moves mountains” (#4). One respondent reported feeling braver and that she was ready to deal with anything else because she felt that God had given her all the support she needed to survive.Two respondents reported attending mass regularly to help them face their illness. Others reported asking family and friends to pray for them, whereas others reported praying to God, a trusted saint, or a combination of these. One respondent who reported attending mass daily, reasoned her actions by stating, The most striking – and actionable – finding from the interviews was the tremendous lack of informational support from health professionals. Participants reported a lack of information on a range of topics: general information on breast cancer, types of treatment they might expect and should discuss with their doctors, side effects associated with treatments and how to avoid these, preparations for surgery including what to expect right after , emotions they might experience when treatment was over, etc. Women in this study stated that some of the more helpful information they received came from other breast cancer patients. Furthermore, a considerable proportion of women in this study were misdiagnosed. Misdiagnosis of breast cancer is also seen in number of other studies  includinBreast cancer patients and survivors who participate in support groups report improved quality of life and less pain, which results in better compliance with medical treatment and even extended lifespan , 29. SimThe programmatic implications of this finding are various. First, both public and private sector facilities can join efforts to make health education information available for women at different stages of their breast cancer journey: from diagnosis, to treatment, to what to expect as treatment comes to an end. Written health education materials that women – often in shock or denial – can refer to as the initial shock wears away or as the next step in treatment approaches could be one step to provision of information that could be useful. As mentioned, those in support groups spoke positively about these, but Lima is a large city with much traffic, and a lot of women have time or movement limitations. Offering breast cancer patients ways to connect via regular Zoom meetings or even forming chats or a Facebook page that those interested could join could also be helpful and evaluated. This would allow for the benefits of peer support, but in a way that may be more feasible for those involved. Pairing women starting the journey with women further along in the journey could also be useful for some – even if the women connect virtually versus in person.There are several limitations associated with this study: a small sample size, our lack of use of a standardized measure of psychological distress, and our one-interview format, which did not allow us to explore certain topics more extensively, such as issues related to stress of medical bills, managing family or work lives while in treatment, managing fear of recurrence, or dealing with physical symptoms post-surgery . Another potential limitation includes respondent recall bias over the emotions they experienced, or how information availability might have changed over time, given that one participant had received treatment up to 19 years prior to the interview, which could affect recall, especially for less severe emotions that may have been experienced. An additional limitation includes the sampling strategy; in lieu of a large census to identify breast cancer patients or survivors, or identifying breast cancer patients in an oncological center, the authors used convenience and snowball sampling. Therefore, the women from each of these groups may have referred us to others with similar doctors or in the same treatment centers. This study took place in the capital city of Lima, and, with the centralization of resources and health personnel, it is most likely that the informational support needs of breast cancer patients are even higher in other urban and rural sites in Peru, outside of Lima . FinallyBreast cancer and its treatment present a long and emotional journey. Expansion of informational support can facilitate a better treatment environment and promote the health and emotional well-being of breast cancer patients in Peru and similar countries in the region.


In this work, the problem of master–slave outer synchronization in different inner–outer network topologies is presented. Specifically, the studied inner–outer network topologies are coupled in master–slave configuration, where some particular scenarios concerning inner–outer topologies are addressed in order to disclose a suitable coupling strength to achieve outer synchronization. The novel MACM chaotic system is used as a node in the coupled networks, which presents robustness in its bifurcation parameters. Extensive numerical simulations are presented where the stability of the inner–outer network topologies is analyzed through a master stability function approach. The emergence of rhythmic behaviors, such as synchronization, is a phenomenon that can occur in many areas of daily life. Specifically, the phenomenon of synchronization, i.e., the temporal adjustment of events between two or more objects or subjects, see , is exteIn many recent works, the synchronization problem is addressed for different, or even combinations, of the aforementioned cases, where the case of outer synchronization is taken as a more general case. We can cite some examples: in , the autAs we can see, many recent works have focused on analyzing outer synchronization, disclosing that it is a topic of current interest. On the other hand, in most of the aforementioned works, the effect of combining the different cases of communication and coupling among nodes in a network is not analyzed, which gives rise to the conception of this work, which focuses on addressing the analysis of different ways to couple and communicate nodes in networks. Particularly, in this work, we focus on analyzing synchronization for different inner–outer network topologies in master–slave configuration.This work is organized as follows. In M networks composed of N nodes. The inner–outer coupling network topologies are represented by n-dimensional chaotic dynamical system, described as followsi and i. Moreover, a diffusive coupling that is well-known and extensively studied is used as follows,In this section, we give some preliminaries of complex networks, inner–outer coupling network topologies, and synchronization. In this work, we consider follows,A=c1Ain+cNow, suppose we have connected complex networks, it can be shown that zero is an eigenvalue of ive, see ,27. FiguAccording to , the comIt is desired that coupling conditions  and 3)  3) guaraWe use the master stability function to study and compare the stability of inner and outer network synchronization . Accordiξ·k=Df in o in oAi clogy see a) is as ee Ai is0Ai=Air=0ee Ai isAi=Air=00ogy  were us


Can illusions provide insights into the operations of a perceptual system? If so, do they also cast light on the operations of the brain, and do they predict behavior—do false impressions cause erroneous actions? After all, illusions might be artistic but represent only unimportant failures of a system that otherwise extracts needed information from the visual environment. These questions raise large issues, several of them addressed by the papers in this Research Topic.departures from reality.” Reality is hard to define and most “illusions” are either mistakenly labeled, or are simple consequences of “how our perceptual systems work,” or reflect impoverished stimuli. Labeling the Ames room and Adelson's checker shadow as “illusions” is mistaken; both are facsimiles of real stimuli that produce similar patterns of light on the eye. An example of “how the system works” is metamerism; color mixture is a true “departure from reality” but is not classified as “illusory,” its cause (trichromacy) being known. “Illusions” due to impoverished stimuli have been discussed since J. J. Gibson, and need no outing here.Rogers  asks “WhTyler accepts (and expands on) Gregory's classification of illusions, but also objects to Gregory's claim that illusions depart from reality as assessed by “simple measurements with rulers, photometers, clocks, and so on.” Instead, illusions occur when the perceiver can directly compare the illusory percept with the “ground truth” as revealed by direct observation. This neatly eliminates Rogers' paradox that metamerism would count as “illusory” for Gregory. The Ames room remains illusory, as people's heights are directly verifiable outside it. Tyler's phenomenalistic definition of illusion may prove more useful than Gregory's.Blakeslee and McCourt study illusory brightness induction from adjacent and remote backgrounds, arguing they produce brightness contrast effects of the same or opposite polarity, depending on the luminance polarity of these regions relative to target patch luminance. Target brightness is determined by the relative strength and direction of brightness contrast from the adjacent and remote backgrounds, but, importantly, there is no evidence for brightness assimilation.Kimura  demonstrLaeng et al. present a white field with a large, blurry, central black oval surrounded by a large number of small sharp black ovals. For 80% of observers, the central black oval appears to expand toward them, and as it does, the apparent brightness of the display decreases. In Kitaoka's “Ashai” illusion, a central white blurry region, surrounded by darker ovals, appears brighter than the white field. The authors report that pupil diameters are 4.8 mm for black holes and 3.4 mm for white holes, an astounding difference of 1.4 mm due entirely to illusory brightness differences.Mruczek et al.  find thaBachmann  reports Kaneno and Ashida discuss the sense of body ownership during the rubber hand illusion. They hypothesized that a smiling facial expression would elicit a stronger rubber hand illusion, compared to a neutral or disgusted face. Subjects elicited these expressions by varying the position of a wooden chopstick held in the mouth. The proprioceptive drift of the real hand toward the fake one, a motoric index of the illusion, is enhanced when the subjects displayed a disgusted compared to a happy face, but the subjective reports of the illusion were not affected, a novel disassociation.Wilson et al. presented Neker cubes for 1 s, followed by blank ISIs of 400 ms, so they could synchronize stimulus onset to the band-pass filtered multi-electrode EEG, and find that perceptual reversals of the cube are predicted almost one second before they appear by a change in ERGs generated mostly in the right para-hippocampal place area. The reversals seem spontaneous, but are predictable ahead of time.Sugihara and Pinna presented 2D wireframe pictures that have different 3-D interpretations based on either rectangularity or symmetry, but, unlike standard images such as the Necker cube, not both. They find that rectangularity generally trumps symmetry, and this rather remarkably helps explain some illusory visual deformations of specific solid objects when the viewpoint is moved continuously.Zavagno et al. report that Mona Lisa's image appears to look directly at an observer when the picture is viewed from 4 m or more away, but becomes more ambiguous as the image is brought closer in, with increasing numbers of people judging her gaze to be diverted. Critically, at 0.5 m, the eyes alone, when cropped out of the entire image, were still judged to be smiling - almost as much as was the entire face - even though they appeared to be diverted. My ‘take' (not that of the authors) is that Leonardo captured an intrinsic expression, one of self-satisfaction, rather than a communicative facial gesture.Blakeslee and McCourt; Laeng et al.) and colorimetric (Kimura, In conclusion, it seems clear that the term “illusion” covers too much ground for any over-arching theory of them to be plausible. Rather, illusions may either reflect systematic error in the visual system, not pruned out by evolution, or result from the proper working of a visual mechanism selected by evolution but tested with reduced stimuli. Both cases are of interest to those who wish to probe the working of the visual brain. A final point is that some illusions do “depart from reality” as determined by photometric ( Kimura,  measuremBP and AR wrote the editorial. All authors contributed to the article and approved the submitted version.


Satisfaction surveys were distributed to all MDT professionals employed by the clinic in April 2021 . Participants represented medicine, rehabilitation, and mental health professionals. Results: Analysis of interviews generated five themes: (1) adaptation to virtual care, (2) benefits of virtual care, (3) limitations of virtual care, (4) shifting stance on virtual care over time, and (5) considerations for implementing virtual care. The satisfaction survey data revealed that respondents were able to effectively provide appropriate diagnoses, recommendations, and/or care plans for pediatric chronic pain via virtual care . Detailed survey responses are presented by discipline. Conclusions: This study provides a rich exploration of HCPs’ experiences in providing MDT for pediatric chronic pain within a virtual care model. The current results may contribute to the future development of guidelines for virtual care delivery with pediatric chronic pain populations.Background: The onset of the coronavirus disease in 2019 necessitated a rapid transition to virtual care for chronic pain treatment. Methods: A mixed methods design was implemented using qualitative interviews and quantitative satisfaction surveys. Interviews were conducted in February 2021 with a sample of healthcare professionals (HCPs;  Chronic pain affects 20–35% of school-age children ,2. ThoseGiven that a latency of 6 months from the time of referral to treatment for chronic pain is associated with deterioration in health-related quality of life and psychological wellbeing, the importance of efficient and timely care for chronic pain cannot be overstated . TherefoFurther, given that the optimal paradigm for chronic pain management involves psychological, physical, and pharmacological approaches, the transition from in-person care to a full-scale virtual model was no easy feat ,16. MultNow, nearly 3 years since the initial shift in modality of care, it is apparent that virtual healthcare has endured beyond needing to meet social-distancing requirements ,21,22. VCollecting stakeholder feedback is essential to program evaluation and is best obtained by using combined quantitative and qualitative data to capture the richness and complexities of program implementation ; therefoThe current study was conducted at a pediatric chronic pain clinic providing outpatient MDT pain assessment and management within a large urban tertiary care hospital. Ethics approval for this research study was obtained from the institution’s research ethics board (REB #1000071310).In this paper, “virtual MDT care” refers to psychology and physiotherapy assessment and treatment delivered using PHIPA -compliant Zoom for healthcare.The chronic pain clinic at which this study took place successfully transitioned all clinic appointments  over a 2-week period to virtual care . PatientEach treatment block consisted of four sessions of weekly psychology and physiotherapy care (one hour each) and a 1-hour pain education session delivered to patients and families, with adjunctive pharmacology and occupational therapy support as needed see . AdditioThe majority of psychology and physiotherapy assessments and treatment sessions had been virtually delivered over Zoom since the onset of the COVID-19 pandemic (88.8% of physiotherapy appointments and 96.4% of psychology appointments over the study period). For selected cases, our team provided in-person assessments where virtual care would not have been feasible—e.g., very young children (<5 years old), those with developmental considerations, children who required an in-person physical exam , or individuals who faced barriers to accessing virtual care .Utilizing purposive sampling to ensure that each discipline that provides MDT in the institutions’ pediatric chronic pain team was represented, a portion of the clinic’s HCPs were invited to participate in semistructured interviews (SSIs) regarding their experience in delivering virtual care. It was determined a priori that a sample of six participants was adequate for producing cross-case generalities while still considering each participant as an individual identity . The sixTo assess the extent to which the experiences described by the subset of HCPs generalized to the entire MDT team, a questionnaire examining HCP satisfaction with provision-of-pain assessments and treatments via the virtual modality was disseminated to all MDT professionals employed by the clinic. Information on the purpose of the surveys, as well as the access links, were emailed by K.S. in April 2021. Surveys were hosted in Redcap (Research Electronic Data Capture), a secure, web-based application designed to support data capture for research studies . An implSSIs were virtually conducted by using PHIPA-compliant Zoom throughout February 2021. The interviewer was a predoctoral psychology resident (M.T.) with training in qualitative interviewing. SSI guides see  were creSSIs were transcribed verbatim and reviewed for accuracy. Following transcription, the data were coded by K.S. and J.B. in Dedoose , a SaaS Descriptive data were analyzed from the satisfaction surveys. For ease of interpretation, responses to items one to three and five to seven were merged into agree and disagree categories, respectively. Lastly, “neither agree nor disagree” responses remained as one response category.In total, six HCPs from a group of six eligible participated in the SSI (100% response rate). Five overarching themes, namely (1) adaptation to virtual care, (2) benefits of virtual care, (3) limitations of virtual care, (4) shifting stance on virtual care over time, and (5) considerations for implementing virtual care, as well as corresponding subthemes, were generated. They are described below. Disciplines have been attached to the quotes below in the following manner: medical professional includes physicians and nurses, rehabilitation professional includes physiotherapists and occupational therapists, and mental health professional includes psychologists and nurse practitioners (psychiatry). Please see The first major theme examines participants’ observations of the shift from the in-person delivery to the virtual delivery of pain assessment and treatment. Three factors were echoed by multiple HCPs across disciplines, comprising three subthemes: (a) teamwork/togetherness, (b) virtual modality necessitating innovations in care delivery, and (c) ease of transfer to virtual care given the service model.(1)Teamwork/togetherness—many HCPs described that the MDT team had to work closely with each other to navigate new technology and ensure treatment goals were being adequately addressed:“I think it was really great, everybody came together and we were developing these different protocols, you know, quite quickly… it was a steep learning curve but really great for everybody because we all put our heads together and were trying to deliver the best care to our patients and families.” Group cohesion as well as an openness to sharing knowledge with each other was essential in the shift to virtual delivery:“I think it came with a bit of a learning curve because there was no formal teaching on how to [transition to virtual care]. And so, we just kind of had to fly by the seat of our pants, but managed through sharing information and doing a bit of research.” (2)Virtual modality necessitating innovations in care delivery—participants often needed to flexibly adapt and/or modify their assessments to adequately deliver service and address treatment goals in the virtual space, as shown in the following quote:“To do a handwriting assessment I’ll sometimes ask them to send me an actual video of them handwriting. It’s just easier than seeing it on the screen sometimes, they can get better angles with their phone.” Further, clinicians in the mental health discipline also highlighted the use of the virtual modality as a form of treatment:“When they have social anxiety, they don’t want to be on the screen and seeing themselves. You can actually use that as a little bit of an intervention and exposure.” (3)Ease of transfer to virtual care given the service model—when considering the overall shift to virtual service delivery, participants echoed sentiments that the multifaceted delivery of pain care made this adaptation relatively seamless. One participant summarized this as follows:“I would say it’s the nature of chronic pain assessment and treatment that it lends itself to being more successful virtually, as opposed to primary care… a lot of it is not hands-on type of treatment. So, whereas assessment it’s helpful to get a bit of the hands-on, if possible, the treatment is mostly active therapy.” This sentiment was expanded on by other HCPs, who emphasized that many aspects of pain treatment boded well in the virtual modality:“My treatment, delivery of pain education… [consists of] the debrief and giving of diagnoses and recommendations, providing prescriptions and so, I didn’t feel that there were barriers to [virtual care], no.” This theme was generated to reflect the common benefits of virtual care delivery described by HCPs. Many participants described virtual appointments as being more geographically and financially accessible . The related two subthemes are (a) convenience and comfort and (b) continuity of care.(1)Convenience and comfort—the convenience of providing care through virtual appointments allowed for changes in some participants’ daily routines that decrease in logistical stress:“I don’t have to get up so early in the morning, I’m not racing to work, I’m not, [going to] the clinic, all the logistic things. So, I feel, personally, a little more refreshed.” HCPs also described that seeing the patients in the comfort of the family’s home environment boded well for rapport and for treatment planning:“But the other benefit, too, is you actually get to see and get more information about what the patient and family’s home is like, and what the conditions are like, that you wouldn’t necessarily see in an outpatient visit.” (2)Continuity of care—the ability to provide pain care despite the restrictions related to the pandemic was another benefit of the virtual model of delivery described by many participants:“I think being able to continue to provide the care using the virtual technology allowed us to continue to support these kids who are really struggling with their pain, so in that way, it’s been positive, that we’ve been able to do that. And not shut down our clinic like some of the other programs had to do.” HCPs were able to successfully navigate new technology to continue to meet treatment goals:“I’m really proud that our clinic really did a quick, kind of, pivot to virtual care, and we didn’t have huge gaps in providing care to our patients and families, and I think that’s a real strength.” Participants identified several limitations when providing virtual multidisciplinary treatment for pediatric chronic pain. The noted challenges included (a) limitations in observing nonverbal cues, (b) barriers to physical examination, (c) privacy concerns, (d) technology glitches, (e) virtual fatigue and engagement challenges, and (f) inequities in access.(1)Limitations in observing nonverbal cues—participants discussed the limited nonverbal communication and feedback in virtual care, which had a reciprocal effect on both HCPs and patients:“When we’re in a room with the patient, I have the privilege of them looking at me, looking at others, picking up on nonverbal communication that is just not present in a video format. So, it’s not about comfort, it’s just about the fact that I don’t feel like I’m really getting the best experience with observing the patient, or them receiving any kind of feedback from me, even if it’s not verbal, just an acknowledgement when they’re sharing whatever it is. They don’t get the nods, and the encouraging words, because it’s much more scripted and formal.” Further, restricted nonverbal cues in the virtual modality impacted clinical observation, as one participant described:“With [virtual] delivery, you can’t see if their leg is shaking under the table, or maybe they’re wringing their hands, or things like that. Or for depressive symptoms necessarily, their hygiene.” (2)Barriers to physical examinations—especially pertinent to multidisciplinary treatment for chronic pain, participants recognized the challenges of performing a physical examination as part of virtual care. One participant reported the following:“In terms of, let’s say, the initial assessment, which we have to do for the observation, like, very thorough examination of a joint to really determine whether there is anything else medical going on. So, not just gross motor movements. I remember a time where it was just really hard to see, like, is there swelling on the foot, is there a change in color? We have to go by the patient’s report, which isn’t ideal.” Additionally, patients were at times brought to the clinic for in-person care in response to such barriers:“There was one time that I joined like a multi-d assessment with a physiotherapist, a psychologist, the whole team. And the child actually had a lump on his back that we couldn’t see through the video, just because of the quality. So, I mean that one, like, we ended up bringing him in eventually, but, yeah we couldn’t assess that properly through the multidisciplinary virtual assessment.” (3)Privacy concerns—participants across disciplines expressed concerns regarding privacy limitation associated with providing virtual care. It was noted that such challenges have the capacity to limit patient disclosure:“We have no idea who is sitting behind that kid, or outside of the camera. And I feel like sometimes the kids will just not open up and share things with us that they otherwise would’ve shared with us one on one. I can’t tell you how many times in in-person visits in the past, when we’ve had those teens on their own, some of the things they share with us, they would say “don’t tell my mum this, don’t tell my dad this” and they would disclose really important issues that have allowed us to, really, work that in with their care. And now, I just don’t feel like we can get that genuine feedback from the kids.” At other times, privacy concerns completely prohibited aspects of virtual care:“There were a couple of situations where either the patient had come and was, kind of, logging in from, a non-private place and you could tell that they weren’t 100 percent comfortable. So, in that situation they actually declined the assessment, the physical part of the assessment.” (4)Technology glitches—participants identified technology-specific challenges such as audio-video interruptions and bandwidth limitations, which occasionally impeded treatment:“If there were technical challenges and it kept on zoning out, or kind of, glitching, then I wasn’t able to complete the session.” Participants also outlined that technological disruptions occurred on both HCP and patient ends:“Some of the families live so remote that they had very intermittent internet. Or even some of the staff were challenged where other family members in the home were also using the computer so it was affecting the bandwidth, so some people would cut out in the middle of an appointment, or their video would go off.” (5)Virtual fatigue and engagement challenges—limited engagement during virtual appointments was noted as a challenge for participants. This was amplified when both patients and HCPs alike experienced screen fatigue from engaging in so many virtual interactions:“I think for a few cases it would definitely be beneficial for them to come in, engagement can be hard sometimes virtually, again because they’re always online. And I know that the kids get overwhelmed with all the virtual appointments, that’s not only with our clinic, a lot of our kids are complex, so they have so many virtual appointments. I get tired of looking at screens and I know the kids do.” Participants also described limited engagement and rapport with caregivers during virtual appointments:“I found that I wasn’t able to necessarily engage as much with the parents. When they would come in to the hospital, the parent would always be with them, so we would do a recap at the end. At this point, especially the teenagers, who are really doing this whole online thing on their own, the parent wouldn’t be present or they’d be in a meeting, and I did lose some of that rapport with the parents.” (6)Inequities in access—insufficient access to the resources required for effective virtual care, such as a home computer, stable internet, and a confidential environment, was reported as a limitation by participants:“I also think about families who don’t always have access to a stable internet connection, access to computers, access to a safe space.” Another participant described erroneously assuming that all patients have access to the required resources:“Sometimes for families, they don’t have a confidential space, or they actually don’t have data on their phone, or regular internet access, so maybe they have to go and use a neighbor’s. We assume that everybody has internet access, they have good data plans, and we are assuming that, and they don’t necessarily have that.” A theme was constructed to describe how the evaluations and perceptions of virtual care from the perspective of HCPs, patients, and caregivers change over time. Participants’ statements were organized into two subthemes: (a) the change in HCPs opinions on virtual care and (b) the change in patient and caregiver perception of virtual care.(1)The change in HCPs’ opinions on virtual care—participants reported an overall positive shift in opinion on providing virtual care, from the beginning of the COVID-19 pandemic onward:“For me personally, initially it was very stressful, and then it got much easier. To the point where I think it’s going very, very well overall, in terms of providing the care.” It was also noted that although physical-distancing restrictions facilitated the mandatory shift to virtual care, this transition encouraged HCPs to view the potential of providing virtual care beyond the COVID-19 pandemic:“I think it’s been a good experience. It’s really broadened my view of providing telepsychology and virtual care, so I think it’s been a good experience.” (2)Change in patient and caregiver perception of virtual care—in contrast to the positive shift of opinion toward virtual care described by HCPs, participants reported a negative trend in patient and caregiver perceptions of virtual care, citing scheduling challenges as a main concern:“What has shifted, is that we’re getting more pushback from families about when they will schedule appointments with us because their kids are now in online school, and the kids are telling us they have pressure, they don’t want to miss class because of this need to keep up with the other students. Now, which I find interesting, because kids were missing almost a full day of school to come for their treatment prior to COVID, so I’m not quite sure what’s behind that. Again, I don’t know if it’s just that expectation, but I think, some of that positivity initially, I think is probably shifting.” Another echoed this sentiment:“As things have progressed now, because it’s more informal, and maybe there’s an appearance that it’s easier to schedule, that often patients and families are wanting the virtual appointments to move around their schedule with school. So, they’ll be asking for evening appointments, or weekend appointments. Whereas, I mean, and we’re a pain clinic in a hospital, so I don’t know another ambulatory clinic like cardiology where you would have evening appointments or weekend appointments.” The final theme addressed considerations and recommendations for implementing virtual multidisciplinary treatment for pediatric chronic pain. This theme included (a) the preference for a hybrid model and (b) recommendations for implementing virtual care.(1)The preference for a hybrid model—HCPs across disciplines outlined a preference for hybrid care, which would incorporate both in-person care and virtual care as needed according to evidence-based practice and family needs:“I think we need to ensure that we are providing treatment that is in accordance with best evidence and that is in accord with the child and family’s preferences and values. And then I think that, what would be ideal, is to have a hybrid model. So that if the patients want to come in, that they see the people who you feel really need to see them.” Participants also specified a preference that initial appointments for new patients be in person at the clinic, in order to build rapport and effectively obtain confidential information from patients in a secure space:“What I think would be amazing is if the new patients were coming in person so we could all get to know them, get to hear their story, pull those kids separately, get the information, you know, in confidence, which we would normally do. But then maybe, return appointments could be done in this type of format for convenience. But that way they’ve already met the team and they kind of know what it’s all about. So maybe a blended model of the two.” (2)Recommendations for implementing virtual care—finally, participants outlined their recommendations and suggestions for adopting and optimizing virtual multidisciplinary care for pediatric chronic pain. It was noted that technological considerations must be factored in to achieve clear and uninterrupted virtual appointments and to enhance the virtual care experience:“I think people could do a better job of optimizing [the technology]. So, I think to have a crisp picture and really good sound is really important to reduce the impact of not being there in person.” One participant suggested providing scheduling instructions for families to mitigate the abovementioned scheduling challenges when booking virtual appointments:“Giving [patients] the guidelines of when, you know, setting the appointments, not necessarily having so much flexibility, even though it appears that it’s not a big deal. If we made that a little bit more clear, maybe there would be less of those requests.” Participants also commented on the pilot triage system that was developed by the clinic’s HCPs to schedule patients for virtual or in-person appointments:“We came up with criteria for triage to say, here are some specific populations that we would prefer come in person for their appointment, rather than doing this virtually. And that was through trial and error with specific diagnosis, and age group, and whatnot.” n = 12) of respondents described virtual care as an effective treatment for pediatric chronic pain and agreed that virtually gathered information pertaining to a patient’s symptoms was sufficient to inform appropriate diagnoses, recommendations, and/or care plans. Rapport did not appear to be impacted by virtual care, all participants indicating an ability to develop a therapeutic relationship with the patient and caregiver.In total, 13 HCPs from a group of 20 eligible HCPs completed the satisfaction survey (65% response rate). Overall, 92.3% (n = 4) of HCPs from the medicine and rehabilitation disciplines rated that the discussion of sensitive topics  was more, or equally, challenging between modalities. HCPs in the mental health discipline did not endorse a difference. Similarly, when probed about the absence of physical contact in a virtual assessment, all HCPs in mental health  agreed it was not a problem. However, 50% (n = 5) of professionals in the medicine and rehabilitation disciplines reported that the lack of in-person physical examination made virtual assessment more challenging. Notably, they shared sentiments that assessments of skin color, temperature, texture, range of motion, and muscle tension had to be modified .Of the 13 participants, 5 HCPs were in medicine, 5 were in rehabilitation, and 3 were in mental health. When asked to consider ways that virtual care differed from in-person care, 40%  described an overall positive experience, whereby they encountered few to no technical difficulties. When asked about their preferences for virtual use in the future, all HCPs participants agreed they will continue to use virtual care in some capacity. Participants expressed a preference for a hybrid model of delivery , whereby some sessions are delivered in person and some virtually. Mental health professionals  were more apt to remain virtual, even if in-person appointments were offered. Please see n = 13) were in agreement, and Regarding technological logistics, HCPs across disciplines . The current study’s qualitative and quantitative analysis supports the growing body of literature describing the overall benefits and challenges of providing virtual care ,32,33,34Specifically, the results from the descriptive quantitative analysis support virtual care as an effective modality to inform chronic pain diagnoses and recommendations in care for children living with chronic pain. This is in line with many studies across both adult and pediatric populations, suggesting that virtual care enabled HCPs to provide essential treatment and intervention throughout the pandemic ,18. NotwOur qualitative analysis complements these findings and highlight five main themes related to HCPs’ experiences: (1) adaptation to virtual care (2) benefits of virtual care, (3) limitations of virtual care, (4) shifting stance on virtual care over time, (5) considerations for implementing virtual care.A key finding in the first theme was the perception that a high level of cohesion and togetherness between the HCPs across disciplines aided in the shift to virtual care. This finding offers an opportunity to better understand characteristics described as common features found in high-functioning healthcare teams ,37. MoviThe second and third themes were developed to describe the benefits that HCPs believed virtual care offered  and its limitations to the provision of pediatric chronic pain . As described, these outcomes are consistent with many other studies exploring the delivery of pain care in the virtual space ,17,33,34Indeed, HCPs described observing two shifts in the perceptions of virtual care. First, they observed patients’ and caregivers’ initial enthusiasm for virtual care dissipate over time, citing virtual fatigue and scheduling challenges as the main factors driving this change. As previously noted, HCPs observed an increase in weekend or afterhours appointment requests and experienced perceived frustration from patients and families when these requests could not be met. Research has suggested that matching patients’ booking requests with providers’ availability is a major barrier when creating outpatient appointments and may contribute to a reduction in patients’ perceived value of care ,40. RecoThe last theme highlights that across disciplines, HCPs noted a preference for a future hybrid model of care delivery that incorporates both in-person care and virtual care. More specifically, and like other studies, providers described that assessing a patient in person for their initial appointment and then transitioning to virtual care would be the ideal model of care ,22,43. TThe current study provides important information on HCPs’ experiences in delivering virtual pediatric MDT chronic pain care. However, there are several limitations to this study that need to be considered. The first limitation relates to the generalizability of our findings. When considering the dynamic nature of the COVID-19 pandemic, it is important to highlight that data were collected during a specific point of time during the pandemic . HCPs’ perspectives on virtual care may differ in later waves of the pandemic and recovery. Future studies may consider using longitudinal methods to investigate the changing perspectives of HCPs as the pandemic has evolved. Relatedly, all participants in this study worked within an urban Canadian tertiary care setting. Our results, therefore, may not be generalizable to providers working in either rural and remote locations or alternative ambulatory settings. Furthermore, because of the nature of the methodology (questionnaire) and the small sample size, our capacity to conduct formal statistical analyses was limited, albeit still informative. Future work may consider expanding recruitment to examine experiences associated with MDT teams on a larger scale, and they could also investigate HCPs’ experiences by using other virtual care applications, such as mobile phone applications in the treatment of pediatric chronic pain ,45.Virtual care for pediatric chronic pain has become an essential tool during the COVID-19 pandemic, and its benefits will continue to be relevant even after the pandemic has passed. In a post-COVID-19 scenario, virtual care provides accessibility, flexibility, and convenience to patients, families, and providers. Future virtual care models may look to incorporate tools such as video consultations, mobile phone applications, online educational resources, and remote monitoring devices ,45,46. TAnother consideration is the integration of virtual care into existing pediatric pain management programs, including multidisciplinary pain clinics. A recent study by the authors examined experiences of patients and caregivers who received virtual MDT for pediatric chronic pain between March 2020 and August 2021 at the pediatric chronic pain clinic where the present study was conducted. Patients and caregivers were overall satisfied with virtual care, and the most reported preference was for a hybrid model of care incorporating at least some in-person contact with providers. In light of these findings, the chronic pain clinic at which the current study was undertaken has implemented a pilot triage system by which patients are scheduled for virtual or in-person appointments on the basis of personal and provider preferences, access to technology, and specific presentations that require in-person physical exam ; see  for furtFinally, recommendations and guidelines must be established for the safe and effective use of virtual care for the treatment of pediatric chronic pain. Consensus guidelines are needed to identify whether certain patient presentations are best seen in person and whether specific methodologies for assessment and treatment should be considered for provision of multidisciplinary pediatric pain care. Additionally, recommendations are required for optimizing the use of virtual care for both patients and providers , as well as ensuring virtual care resource accessibility for patients and providers . Finally, specialized training should be considered for safety situations that may arise when providing virtual care .Overall, this study adds depth to the emerging literature capturing HCPs experiences of delivering virtual care for pediatric chronic pain throughout the pandemic. Our mixed methods study allowed for a unique understanding of these experiences within a multidisciplinary team and underscores the value of virtual care to assess and treat pediatric chronic pain. Moving forward, it will be important to incorporate these findings with other studies that conduct similar investigations throughout the pandemic to inform the creation of evidence-based educational resources and training tools for facilitation of optimal virtual care in a post-COVID world.


Tsuptó and Ricardo haveknown each other for over three decades, since 1990. James was in Pimentel Barbosa forthe first time in the early 2000s. During this period, Ricardo, James and other OswaldoCruz Foundation (Fiocruz) researchers, in collaboration with colleagues from otherinstitutions, participated in numerous research projects at Pimentel Barbosa, focusingon topics such as social determinants of indigenous peoples’ health, socialorganization, historical ecology, among others. In the early 1990s, there were onlythree villages in the Pimentel Barbosa Indigenous Land; currently, there are more than20. The communities multiplied as the bonds of trust and partnership betweenwarazu (“non-indigenous”) researchers and the A’uwẽ of PimentelBarbosa.Ricardo’s cell phone emitted a sound indicating a new message. He took a look and, nextto Tsuptó’s name, he saw his image, in which his hair caught the eye, painted with thebeautiful bright red urucum that the A’uwẽ (Xavante) are so fond of. Tsuptó is theHi, this is Tsuptó. I need to talk toyou”. They started a dialogue that unfolded over the following days,dealing with issues such as creating a new logo for the Xavante Association of PimentelBarbosa, preparing a text to raise funds for a meeting of dozens of leaders of bothPimentel Barbosa and the nearby Areões Indigenous Land, and reviewing minutes from ameeting that had recently taken place in the Tsuptó’s village related to health.It had been a few months since Tsuptó and Ricardo had last communicated. The intermittentinternet connection in the aldeia did not always help. Perhaps this is why, in the fewseconds involved in pressing the keys until reaching the audio message, so many memoriesflashed through Ricardo’s mind. “At first glance, these may seem to be local, day-to-day issues, but they can be seen asrepresentative, on a broader scale, of the paths (and sometimes detours) of publicpolicies aimed at indigenous peoples in Brazil. They also reflect expectationssurrounding recent political processes, such as the creation − in the scope of thefederal administration that recently took office in January 2023 - of the BrazilianMinistry of Indigenous Peoples; the fact that the Brazilian National Indigenous PeoplesFoundation (FUNAI), the new designation for the former Brazilian National IndianFoundation, will for the first time have an indigenous leader as president; and thestrategic position of head of the Special Department for Indigenous Health (SESAI), inthe Brazilian Ministry of Health, will also be occupied by an indigenous person.The Pimentel Barbosa Indigenous Land is located in the so-called Legal Amazon (aBrazilian sociogeographic division); however, it is not covered by tropical rainforest,as is common in the social imagination about the Amazon region, but rather by Cerradovegetation, one of the biomes of Brazil that has suffered the most devastation.Nowadays, like many other indigenous territories in the country, Pimentel BarbosaIndigenous Land is a preservation enclave, which says a lot about the role of indigenouspeoples when it comes to the pressing environmental and climate issues that are ofglobal concern today. It is one of the largest areas of preserved Cerrado in all of theCentral Brazil. It is circumscribed by lands dominated by soy cultivation and othermonocultures. Extensive areas of the Amazon, a region pictured on the covers of the 2023issues of CSP, are covered by Cerrado, and this biome requires greater attention.In the days that followed the initial contact between Tsuptó and Ricardo, they alsotalked about how the last years in the aldeia had been. The COVID-19 pandemic, of greatimpact on indigenous peoples, reduced the frequency of researchers’ trips to PimentelBarbosa. Tsuptó spoke of the difficulties in health care, the many sick children andolder adults, and the complexities of taking the most serious cases to health care unitsin nearby cities due to lack of transportation. He also mentioned his growing concernabout hunting, fishing, and gathering resources in the indigenous land, perceived asaffected by deforestation in the surroundings. But he also spoke with pride of therituals, which remain central to the A’uwẽ social life.Tsuptó, why a new logo, if you alreadyhave one?”. He replied that A’uwẽ leaders are planning to travel soon toBrasília to present their many demands, as well as to meet the new authorities at thehead of the government agencies that deal with indigenist policies. For such, they areholding meetings to define an agenda of points for discussion. He spoke of his hope thatthe situation will improve, including the progress in the process of recognition, by theFederal Government, of the Wedezé Indigenous Land, a contiguous territory to thePimentel Barbosa Indigenous Land, which was taken from them in the 1960s-1970s. Ricardoand James know this situation well, as they participated in 2009-2010 as specialists,along with Carlos Coimbra Jr. and Nancy Flowers, in the preparation of a report for theofficial recognition of the Wedezé Indigenous Land, a case that is still pending in theFederal Court Ricardo asked in one of the messages: “cacique, Tsuptó had to type the text of the minute on hiscell phone and asked the warazu researchers for help in reviewing it.The legal apparatus of the Brazilian National Policy for Health Care of IndigenousPeoples is filled with references to concepts such as interculturality and respect forcultural differences ,The subjects in exchange of messages encapsulate much of the despair with what hashappened in recent years, marked by the dismantling of public policies. But they alsoexpress the expectation for a more efficient performance by the Brazilian Stateregarding indigenous peoples. In these conversations, the issue of producing writtenminutes for a meeting about replacing indigenous health and sanitation agents, demandedof the Xavante by the Special Indigenous Health District (DSEI) attends to their primaryhealthcare, can be seen as a critical and, at the same time, illuminating, example. Itis a pointed example of how self-centered the State apparatus can become in tis dailyroutine, even when public policies are explicitly focused on contexts involvingotherness. As Assurance and reparation of social and environmental injustices, expectations for morestructured and efficient health services, concern for the protection of territories,perception of food insecurity... The list of concerns is long and, by the way, notrecent. But Tsuptó also turned his attention to thinking about a new logo to have in aperiod when a process of reinvigoration of public policies aimed at indigenous peoplesis expected. He wants to use it in documents to be sent to Brasília in preparation fortrips he expects to take in the coming months to discuss the demands of PimentelBarbosa’s A’uwẽ.The situation of the A’uwẽ, since permanent contact in the 1940s, has always beendifficult, marked by the usurping of areas, unfairness, even involving abrupt populationreductions and loss of territories. In practice, the A’uwẽ, like other indigenouspeoples from the Central Brazil, had already been experiencing the harmful effects of“contact before contact” for many decades, as epidemics of infectious diseases, amongother consequences, arrived even before the first more direct interactions danho’rebzu’a , the main image isof a Xavante leader named Sere’wã’rã, who was the brother of one of Tsuptó’sgrandfathers. He was recorded in a photograph taken in the years following contact.Sere’wã’rã has one of his arms stretched out in front of him, while his lips seem toarticulate a word. Tsuptó says that he was speaking, in the A’uwẽ language, somethingequivalent to “stop”. In the new logo, such a powerful image, while representative ofcolonial violence, communicates the vicissitudes of present times. As Tsuptó commented,it can be understood as the statement “respect us”.The new logo of the Xavante Association of Pimentel Barbosa is a bridge of meaningsbetween past and present. Having as a frame the representation of aWithout a doubt, it is a past-present in which the Brazilian nation remains very indebtedto indigenous peoples. Tsuptó mentioned in one of the messages his sadness of learningabout yet another tragedy, resulting from illegal mining and other forms of violence,befalling the Yanomami. Moreover, he stressed that it is important to pay attention tothe difficult situation faced by many other indigenous peoples in the country. Illegalmining and logging are not problems in the region of the Pimentel Barbosa IndigenousLand, but the widespread use of pesticides in the extensive monocultures in thesurroundings Federal Constitution states these rights, but theyremain far from being translated effectively into everyday life.The sentence that gives title to this editorial is from Sereburã, a very respected elderof the Pimentel Barbosa community, who died a few years ago. It is in a book, authoredby the A’uwẽ themselves, in which they tell their story and their myths