A Discussion with Dr. Zilda Arns Neumann, Founder, Pastoral Criança, Brazil
January 24, 2009
Background: Dr. Zilda Arns Neumann, the founder and president of Pastoral da Criança, died in the Haiti earthquake on January 12, 2010. This January 2009 exchange with Katherine Marshall focused on her work and inspiration, and on her broad concept of peace and priorities. A pediatric and sanitary doctor, she was the founder and president of Pastoral da Criança (Children's Pastoral) and founder and national coordinator of the Senior Citizens' Pastoral. She was involved in social action organisms of the National Bishops' Conference of Brazil (CNBB) and many other official bodies in Brazil. She received different awards including: The Woodrow Wilson Award (The Woodrow Wilson Foundation, 2007); Public Health Heroine of the Americas Award (PAHO, 2002); Brazilian Person of the Year on Work for Children's Health (Unicef, 1988); and the Humanitarian Prize (Lions Club International, 1997).
You are a legendary figure in many circles. Can you tell us something of your journey and what has inspired you along the way?
At the end of this year, 2009, I will have been working as a doctor for 50 years! I have always worked for public health for the poor. I chose to be a doctor when I was just 15 years old because I truly wanted to be a missionary and to save the lives of poor children. I focused from the very beginning on children and on education as a way to bring about change.
We had a great deal of malaria in Brazil when I was growing up, and it killed many children. I wanted to address that problem, and worked in hospitals from a very early age. As a young volunteer, I saw the daily realities that the poor lived, and how rarely they had the chance to see a doctor. I also realized that most patients had diseases that could be prevented with vaccines and other basic care. So I began to question why I was spending my days at work healing diseases that could so easily be prevented. With this experience as my motivation, I began my studies, working along the way in clinics that provided support to parents. We started focusing especially on children who were under the age of six.
After I finished my studies, I became the director of a public network of health services in the city of Curitiba. There, I interacted with mothers to support their children's health. My husband and I had five children, and I worked there for 13 years. I then went on to be the director of the maternal and infant health department of Paraná State. In Paraná, we faced a polio epidemic and I was asked to coordinate the public health campaign. This brought much attention across Brazil to me and to our approach, which focused on innovative approaches to community involvement in vaccination (in this case, the Sabin vaccine). We worked with churches, schools, and health posts, using all the resources we could muster. Our successful vaccination campaign made a huge difference in Paraná. The Health Minister spent three days with us and was deeply impressed by our approach. I began to give speeches and participate in national policy conferences and discussions.
Then politics changed in Paraná, and I was out of the government. I started to move in different directions, focusing above all on prevention. I worked with UNICEF for a time. I came to see how much could be accomplished by working with mothers so that they knew how to better care for their children and thus prevent disease. My great mission became from that time to combine my medical practice and my faith—to work with faith and life.
I should also note that I am the twelfth of 13 siblings, out of which nine are professionals. Out of these nine, five are religious people: two Franciscan priests and the former cardinal Dom Paulo Evaristo Arns, well-known for his work defending human rights.
What was the origin of your work with the Pastoral da Crianca?
My brother, Dom Paulo Evaristo Arns, was the Catholic Cardinal of Sao Paulo in the early 1980s. At a meeting in 1982 on poverty and peace in Geneva, involving UNICEF and the United Nations, he met James Grant, the legendary head of UNICEF, who challenged him to act to halt child deaths. Grant suggested that the Catholic Church could and should do far more. My brother telephoned me to ask my views. Together, we came to see this as a challenge to the Catholic Church, and we saw the potential for what the Church could accomplish. Ever since then, that has been my mission, and my commitment, to working with and through the Church.
I was inspired by the Biblical parable that tells of how Jesus multiplied bread and fish, producing extraordinary results. That is the essence of our methodology, and we work through faith and life, to multiply Christian brotherhood in small, informal communities, and to assess how it brings about change and what concrete results our interventions achieve.
Armed with this vision, I presented a proposed approach and methodology to UNICEF. It consisted of educating families to better care for their children. We focused on the priorities identified by the World Health Organization (WHO): the prevention of child and maternal mortality, nutrition for pregnant women, access to public health education, care for mothering, for example breast feeding and understanding of child development, and finally, improving nutritional surveillance for underprivileged children. Our goal was, above all, to better conditions across the board from pregnancy through the first 6 years of life.
Please tell us a little about the history of the Pastoral, from its birth, and its engagement on public health?
About a year after my brother met James Grant, in 1983, the Catholic Bishops Conference of Brazil (CNBB) accepted the challenge and asked me to carry it out. In September 1983, The Pastoral da Criança began to work in the city of Florestópolis, in Paraná State.
Through all the years I had worked in public health, I saw more and more that health care for children under six years old was critical but received very little focus. The bishops appreciated this when we presented the challenge to them, partly in respect for my brother's wisdom and prestige, but also because of what they had witnessed of the conditions of poor people living in their parishes and dioceses. But the Church itself had neither the networks nor the methodologies to approach the problem. The bishops appreciated that we were talking about a new methodology, and that they needed new expertise and experience. The Archbishop of Salvador became my partner in this ministry, and UNICEF also joined us, with a special focus on maternal mortality.
In the region of Florianópolis, conditions were very harsh, especially for women in poor communities; 65 percent lived in the countryside, mostly working in sugar cane. The results of our initial work there opened new doors of hope for the church and UNICEF. In 1984, we presented the results of our work to the bishops. We were able to show quick and sharp declines in mortality among women after we had worked with them through their communities.
Quickly, many bishops wanted to start similar work in their dioceses. Several of the bishops were already friends, and when they saw the success of our work, they wanted to act. There was almost a daily multiplication of the effort. At the same time, there was considerable resistance from the Church for this new ministry. Many thought we were creating new bureaucracies, and did not understand that such work (including careful monitoring of progress and reporting) was necessary to achieve results.
Initially, we worked in six dioceses in Brazil with the support of a small group of bishops there. As you know, the work grew. Today, many years later, we are working in all the 261 dioceses in Brazil, as the Child Pastoral (Pastoral da Criança). We have about 260,000 trained volunteers (we call them leaders), and provide support for almost two million children. We work through home visits by the volunteers where we focus on an approach that combines a “democracy” of knowledge and a “democracy” of solidarity. Through the Pastoral da Criança, we celebrate life, and, as parents and the community are able to see their children survive and grow, they learn and come to appreciate and value more and more the knowledge that children can indeed grow and prosper, that malnutrition is not a problem just for their families, but for all Christians. The community can free the children from evil and suffering.
Community leaders are essential to make the visits possible, to encourage members of the community to meet together and to talk about the lessons learned. We focus sharply on their roles. In Curitiba, we have a national coordination office and we send all evaluation data there; it is analyzed and published every three months with updated results. We follow the activities of leaders and know how many leaders are intervening, and also what results they achieve, every three months.
The Pastoral da Criança began very small and has grown in part because of the core spirit but also because we have been focused and disciplined on organization. We had to reach the Brazilian government, to train and increase awareness among Brazil's leaders. And we were successful, and since 1985 Pastoral da Criança has received half of its financing from the Government of Brazil. I am committed to building this network, which depends on excellent organization. We began with little money. Working over this 25 year period, I feel that we have indeed come to where we wanted and needed to be.
We realized from the outset it is necessary to join efforts to be successful. When we started the ministry in Brazil there was much poverty and much illiteracy among mothers. We started with education and literacy training for mothers as a means of preventing the death of children. With our approach to education, we were able to promote vaccination and better child care, and we spread the idea of education within the family also, especially for mothers. It was quite a change in approach to do as we did, training community leaders in very poor communities, both through simple literacy but also understanding better the fraternity there could be among families.
This approach attracted UNICEF's attention as well as the Brazilian government. We have worked through pastoral care and the hard work of volunteers; we have found that people are never tired of going to the houses of mothers, to support poor children in this spirit of faith and life. Faith and life was what made the difference. Since we began our work, we have seen the rates of illiteracy among mothers decline. Many of our volunteers have passed public examinations and are now working as health agents, especially in the program called “Health in the Family.”
During the 1980s, the Pastoral da Criança and the organized civil society of Brazil fought hard to improve the legal framework and specific statutes that affect children and adolescents. Brazil introduced its public health system, a national free health system covering the whole country, in 1988. I have been a counselor in the National Health Counsel, which is responsible for the social control of this system, since the early 1990s. As a health counselor, it is possible to bring about important changes in the approach of the public health services. Above all, we have worked to increase access in rural areas. At the municipal level, people fought for better public policies for the population. Work with families is the most important element in public policy. These efforts have brought about important changes in Brazil. Child mortality of children followed up by Pastoral da Criança has fallen sharply, from 51 deaths per 1,000 births in 1991 to 11 deaths per 1,000 in 2008. We have achieved our targets; in the communities where the Pastoral da Criança works, rates have fallen more sharply than in the communities where it does not. The actual government official rate of infant mortality is 22.5 deaths per 1,000 in Brazil.
Can you say a little about the actual workings of the Pastoral? What does it actually do on the ground?
The basic idea behind our methodology is to shape Christian communities and others (as we are ecumenical) to train disciples and missionaries with a very practical mission. These disciples need to have the ability to spread and promote their faith. We work with 260,000 volunteers in Brazil in the Pastoral. They come from the communities and very often are mothers we have worked with. We have to make sure that they all have Jesus Christ inside their hearts, so that when they visit families every month, in order to multiply solidarity and knowledge, they can do this in the name of Christ, and can bring peace to the homes.
What we want is to get entire communities involved in treating malnourished children and looking out for their welfare. Once a month, we weigh these children in our communities as part of our nutritional programming. We have a pragmatic approach that relies on using the resources in the community. Early on, for example, as the Pastoral began to work in the Northeast, where we found very poor communities that had no equipment or places to weigh their children. So we started where we could. We hung our equipment from trees to weigh the children. When it was raining, we did it inside a little house made of adobe just big enough to hold us. God has showed us ways to cope no matter where we are.
We try to make the most out of what we have. There are favelas with no land around them, but they have pots, tin pots, where families plant vegetables under the sun. In this way we educate families to produce and eat these vegetables. Little children see this production and take great pride in showing visitors like me the vegetables growing in buckets.
Our faith is not hidden. Everybody knows the Pastoral's identity. We are the Church; we are not ‘from' the Church, we ‘are' the Church. It is by this means that we work to create these communities of faith and life. Our faith is an intrinsic part of our approach at all levels, the way we work with people with love, and our technical training. For example, we have a book that we call the “Leader's Guide” (guía do líder). In one part it talks about maternal breastfeeding, which is very important in reducing infant mortality and malnourishment rates. So we look for, in the Bible, references that might highlight maternal breastfeeding. And we reflect on this with the community. Another example would be oral rehydration therapy, which drastically reduces mortality caused by diarrhea. There, we highlight the topic of water, and where it can be found. So faith and life always go together.
Once a month, our community leaders meet to evaluate what has happened. In the “Leader's book”, we have 26 indicators, all of which are computerized in our headquarters in Curitiba. So from very early on, even at the pilot stage, we have been able to show our impact to the communities and beyond. In the early stages, I had to show our impact because I didn't have any money or resources to keep this going, and I needed to show prospective funders results. The database is used not only to create statistical information and to get financial support, but also to encourage our own leaders and volunteers. Our system today shows quantitative results from 43,000 communities in Brazil, which comprise more than 7,000 parishes, or more than 260 dioceses, in 27 states and the federal district.
Each community team of leaders receives a letter every three months. I digitally signed all the letters while I was the national coordinator. This letter says “Dear leader: Congratulations! Maternal breastfeeding is at 80 percent,” or whatever the database produced, or “Be careful! Maternal breastfeeding is weak, at 20 percent." The letter advises action, such as visiting pregnant mothers more often, specific timing of visits to mothers after delivery, or limiting use of bottles for feeding.
We issue a journal, of which we print 270,000 copies; it comes out monthly and is around 20 pages long. We use it to exchange our experiences and we hand it out together with the letter to leaders.
Let me give you some examples of how we use and reinforce our basic messages and combine it with our spiritual approach. On maternal breastfeeding we highlight the message, “So God created this child that needs to be breastfed. Up to the age of six months, only breastfeeding is good for the child.” We tell them, “If you want to give the baby cow milk or potatoes, you can do it, but it is better eat it yourself, and then the baby will eat it when it comes through your breasts. So the baby is getting the milk and other things.” In the culture of Brazil's Northeast, mothers prepare food for their children based on flour from the moment the baby is born, convinced that only this way can they ensure that the baby does not die. So we had little demonstrations where a mother prepared food for the baby, and the leader asked the mother to eat that food herself, emphasizing that it would get to the baby through her breasts.
Another booklet is for pregnant mothers. Called “Bonds of Love”, it might include comments like this: “Hi, Mom. I'm the size of a grain of rice. My heart is already beating. Go to the doctor and make sure you eat well.” It has Biblical passages about motherhood that encourage the women. This way, we avoid many abortions. We also use radio. There are 2,400 stations that transmit our messages for 15 minutes a week, giving the same message as the journal. And the same message is reinforced during house visits every month, because when individual education is combined with mass education, the result is stronger.
One volunteer told me how she does her rounds. She might go to a house, knock on the door, find the woman, and ask, “Is there a pregnant woman in this home?” The woman in the house might say, “How do you know I'm pregnant?” The leader says, “I have a letter from your baby. How many months have you been pregnant for?” “Two months.” “So here's a letter from your baby.” And she would then read the letter, which had a beautiful message. One mother started crying and said “Can you see that? I was going to have an abortion, and my child sent me the letter just before I was going to do it. Now I'm not going to do it.”
We work to promote spacing between pregnancies. We educate women so they breastfeed and plan their pregnancies with their husbands. The average number of children per women in areas where the Pastoral works is lower than the national average, even though the Pastoral works only with the poor. We also work to prevent domestic violence.
Early on we came to focus on the importance of literacy for women. I used to be part of the community leader training myself. A community might have 20 leaders, and only one could read and write. We prepared a manual on the importance of literacy for leaders and mothers in the communities. If they could read our documents, they could teach better. At one stage we were helping to produce 14,000 new literate people every year, though with budget cuts our literacy rates today are lower.
Can you say more about the Pastoral's monitoring system? How is it used? Does it relate to the public health system?
We focus, as I said, on showing results and monitoring our progress. The system is well developed. We have a computer center, where we have people working to process all the information. We work to make the most of our resources by centralizing our administration and decentralizing our activities. The cost of Pastoral da Criança is less than a dollar per child every month.
Our monitoring systems have information that is helpful to identifying problems and priorities for the public health system. For example, one indicator that we monitor is whether the pregnant woman who goes to a healthcare center gets help. If not, we ask why not. It might be that the doctor was not there, or it was too crowded. If a pregnant woman dies during delivery, we also track down the woman's history. It's all computerized. For example, the woman went to the health center for pre-natal care, she already had pains, but was sent back home. She went back, but was told that it wasn't time yet and she was sent home again. And then she died. We then go to the local Health Council to complain. If it was the doctor's mistake, we go to the Medical Council, trying to make sure this does not happen again.
We intervene to improve public health care and health policy also. In one community I visited, the doctor had a poor bedside manner, yet he was still regarded as being a good doctor. The kids got better, but he always treated everybody badly. The Pastoral leaders one day all wore their white Pastoral t-shirt, white being the color of peace, with the cross, symbol of fraternal work. They went to see him and asked to speak with him. He asked them to wait until the end. Then they gave him a birthday cake, and sang “Happy Birthday” to him. “It's your birthday today, and we're very happy that you see our children, that you have saved them, and we would like to support you.” Because of their kindness, a complete transformation took place in this doctor's approach, in the way he treated people. In another case, the public health family doctors pressed me to bring the Pastoral program to their area because we were able to achieve better results with our approach than they could.
The Pastoral leader sees on average 13 families, and works an average of 24 hours per month. This is not set out in stone, and each person works as much as he or she can. The public family doctors, in contrast, see 150 families. They also have a narrow focus. The Pastoral can do far more on topics like nutrition, for example organizing a workshop on the topic, highlighting the rich value of banana peels or egg shells (which contain calcium).
We always work closely with the government. One of my children is a doctor. For 19 years now, he's been working with the Pastoral, and he cross-references the Pastoral information with information from the government. He looks at where the poorest communities in a given parish are. We go to the poorest areas, which are the most costly for the public services. It's very costly to go to the Northeast, so we focus there.
We have developed ways to select the places where we will focus, and for that we need a really good organization. Communities send us their projects, which go through their respective dioceses first. The diocese evaluates these projects and sends them to us. And we have people trained by us for the whole country. We analyze their project and then send them the money for them to begin the project. They receive money every month which is used to retrain and update leaders. They hold meetings at the level of the parish and at the diocese level. Also, at the state level, dioceses have similar meetings.
Up until 15 years ago, it was only the bishop or the parish priest who selected the places where we would work and our leaders, but we wanted a more democratic system. The priest now chooses a leader out of a list of three, usually the one who is better trained and more capable than others. The same happens at the diocese and state levels. Every November we do a national level evaluation. I was the national coordinator for 25 years, as a founder, so we created a rule by which any given person can have a leadership role for up to eight years only, as many of them had been leaders for too long and had lost their spirit, they had family problems, and just didn't have time. A key to our success has been our linking of love and skill, faith and technical and scientific formation. They must go hand in hand, knowledge with the promotion of the soul, the promotion of the premise that the greatest commandment in God's Law is love.
And the results? What do you highlight?
We have many indicators, some of them classic public health indicators, others that we have developed ourselves. We follow the WHO guidelines. Just to give one example, the malnutrition rate in Pastoral communities is 3.1 percent, which the World Health Organization classifies as “controlled." Now are starting to keep an eye on obesity. We work closely with experts to improve our indicators and to make them relevant both to public officials and to the communities.
As we work with children, we also work with their families and their communities. Take street children as an example. To help them we need promotion among families, we need to strengthen their families and educate them so that children stay out of the streets. Prevention also takes place in the community, in various ways. Then we have the treatment of marginality and finally rehabilitation. This is a terrible problem in Brazil, as kids leave prisons worse than they enter. A parliamentary commission report on children recently, investigating sexual assault and family violence, concluded that of all the children on the parliamentary investigation commission (CPI) list, none of them belonged to the Pastoral.
How does the Pastoral da Criança work with and link to the Bolsa Familia?
When a similar initiative began, in the 1990s, it was called the Bolsa Escola (study package). As I had been the director of public health in Curitiba, I understood quite well how the Government interacted with poor communities and people, thus both the good and bad aspects of social assistance.
When Lula became president, he launched the Bolsa program, as part of a larger program called Fome Zero (Zero Hunger). It was an ambitious program that is steadily improving now, but as a response to the challenges, I would have to say that it does not yet truly respond to the needs. In some cases, the help still does not reach the poorest, and for the other half, the aid does not reflect the true needs of children and families in poverty, like having better education and development opportunities. The Pastoral da Criança is not engaged in distributing milk, food, and clothing. We realized that what mothers need is quality education, and by this means they will get food. That is the foundational approach and belief of our Pastoral to this day. There is also an activity called “Alimentação Enriquecida” (Enriched Food) which is used by the Pastoral da Criança to teach the families how to take better advantage of the richness of whole foods—to capture the nutrients in the skins, seeds, and leaves of food.
How have you navigated the complex political changes that Brazil has lived through?
We have done so in different ways. There was a time of dictatorship when the government was not friendly to the Church. My brother, who is a bishop, received a death threat. But during that very period we went to see the government and told them, “We've reduced mortality, malnourishment, we organize vaccination programs, and other things. But now we need money to publish our manuals.” Mr. Cordeiro, who was a university public health professor in Rio de Janeiro, was impressed and sent two doctors to check whether my assertions were for real. They went to Sao Pablo, Ipiranga, and also to another region, Campo Limpo. They stayed there for two weeks and witnessed our weighing day, which we call “Day of Life Celebration.” Mothers brought their children, their children were weighed, we taught them new lessons and they also taught us new things. The experts also attended a leader training meeting. As always, we spoke about faith and life, about the commitment to love your neighbor. Then they visited mothers, their children, and leaders at their homes, in two very poor favelas.
After all this, they suggested that we form a partnership. Some parts of the Church then asked, “How is it possible that the Pastoral da Criança is going to form a partnership with a corrupt government, with the dictatorship?” The Church's Permanent Council, which is composed of all regional presidents, called me and asked for an explanation. I replied, “The Pastoral da Criança reduces suffering and saves lives. The government works with money taken out of our pockets. The money belongs to the people. It's better for this government to spend money through the Pastoral da Criança than to waste it on other corrupt things.” So they voted; there were 13 bishops, and twelve voted in favor and one against the project. Our relationship with the government is based on the truth. If it does well to the people we approve it. Meanwhile, we are not afraid of pointing out the mistakes or the misuse of public funds.
How does the Pastoral work with other faith communities?
When we first began to work in Floranópolis, there were three evangelical churches. I believe that all children, not just Catholics, are part of our ministry. I saw at the start that there was much tension between the Catholic and Evangelical churches. I committed myself to ensuring that the program reached all. I visited three pastors from other religions. I told them that Jesus said: “I came that they may have life and have it abundantly.” Not only for Catholics or non-Catholics, but for everybody. Thus, our Pastoral da Criança had an ecumenical origin. I began to ask the evangelicals and Catholics if there is any part of our Christian religion that offends us and divides us, because what I want is that all may have life in abundance. We found good ways to work together from the start. Later in my career, I traveled to Guinea Bissau, a country where Muslims form a large part of the community. We work together, and I organized all the churches together for the presentation of the Pastoral da Criança. Among them were the pastors of the Assemblies of God and other evangelical pastors, as well as Catholics and Baptists. I was very pleased that we have been able to send our missionaries of the Catholic Church to work with local leaders and Muslims and the Catholic Church in Africa. All religions accept the ideas and work of the Pastoral da Criança, and that includes indigenous communities.
What does the Pastoral do beyond Brazil?
In 1989 we began to expand the Pastoral da Criança to other countries of Latin America. UNICEF paid for trips by bishops from elsewhere to Brazil, so they could see our work first hand. The experience was very similar to what had happened in Brazil: the bishops were excited and saw possibilities almost immediately and were keen to make a big push, immediately, to replicate the programs. We are now working in seven countries in Latin America. We have also begun to work in Africa and Asia. Just in Latin America, there are nearly 390 dioceses that have a Pastoral da Criança program, and in Brazil Pastoral da Criança reaches all the dioceses.
How does the Pastoral da Criança seek to achieve sustainability, and especially the funds needed to expand and continue to build opportunities for mothers and their children?
Love and tolerance must be enhanced and we should not focus on what is bad in a person or system. When I go to a favela (poor community), we work with people who are trained in the churches, and through these churches we are able to reach out and achieve our objectives. Participation is a very important thing for the success of our work. I work to ensure that all contribute financially, not just the rich, and I am amazed by the support that the poor themselves give in support of expanding the work of the Pastoral da Criança. I've noticed in life that the poor are more solid and reliable than the rich. In part, our support comes also from government ministries and from the states; 20 different states support the Pastoral da Criança. Beyond the support of the state and individuals, we also have private businesses that collaborate with us and support us.
I always say that when the government receives taxes from people, they take on the responsibility for caring for children, and preventing mortality. That is why the government supports us. When I visit a country, I visit government organizations and donors to secure support for the Pastoral da Criança in their country. We want to extend our work, as part of the global family of peace, and the government must be involved. Our government is truly changing in our country. I always share our results so that they can see the value of their investments.
The Church in Latin America has extraordinary power. In the Holy Father's Aparecida document , it included a diagnosis of the church in Latin America and the Caribbean. They (the bishops) proposed a framework that had much wisdom. It is very interesting, and you can verify it yourselves, that the Pastoral da Criança is completely reflected in the Bishops' declaration. At the same time, we are close to the poor, building their capacity. When I read this document from the Church, I thought to myself, “It feels like I'm reading about the Pastoral da Criança in this document.” And further, the Catholic Church brought together those organizations involved in social ministries across Latin America, in Colombia, and the Pastoral da Criança was praised in that occasion for its results and method and chosen as one of the priorities of Latin America and Caribbean Church.
The Church has great strength, and it has the potential to reach into communities in need of its support. For example, when the Pastoral da Criança serves as a Christian presence in the community, and trains its leaders, it also contributes to public education and to the development of sound and visionary public policies.