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Brazil’s audacious plan to fight poverty using neuroscience and parents’ love

Osmar Terra is a tall man with a deep voice and an easy laugh—one that disguises the scale of his ambition to transform Brazilian society. A federal representative for nearly two decades, he is the driving force behind the world’s biggest experiment to prove that teaching poor parents how to love and nurture their infants will dramatically influence what kind of adults they become, and give Brazil its best shot at changing its current trajectory of violence, inequality, and poverty.

Terra, aged 68, first became obsessed with the question of how humans develop nearly 30 years ago. As a cardiologist in the 1990s, he would read endless research papers about the neuroscience of early childhood. When he entered politics, becoming mayor of Santa Rosa in Rio Grande do Sul in 1992, he continued to grapple with the question, even studying for a master’s degree in neuroscience. The science, he believed, shuold lead to smart policy. As a doctor and a manager, a mayor and a state health secretary, he was always trying to figure out how to to tackle poverty head-on. “In every single activity I always ask myself, ‘What is the public policy that can be more transformative?'” he says. “How can we most dramatically improve the quality of life for our citizens, their health, their education?”

The answer to that question, he came to realize, lay in starting at the beginning, at pregnancy, and in the first few years of a child’s life.

Decades of groundbreaking research shows that the love and sense of safety experienced by a baby directly impacts how the child’s brain is wired. Adversity—especially persistent, stress-triggering adversity like neglect and abuse—hampers that development, and can result in poorer health, educational attainment, and early death. While science underpins his mission, Terra’s palpable passion for the topic and his skill at politicking eventually led him to create Criança Feliz, a highly ambitious parent coaching program he helped launch in 2017 to try and reach four million pregnant women and children by 2020.

Under Criança Feliz, an army of trained social workers—a sort of national baby corps—are dispatched to the poorest corners of Brazil. Traveling by boat—sometimes battling crocodiles and floods—by foot, by car, by truck and by bus, these social workers go to people’s homes to show them how to play, sing, and show affection to their infants and young children. They explain to parents why this matters: Emotional safety underpins cognitive growth. Intelligence is not fixed, but formed through experience.

Home visitor,Sissi Elisabeth Gimenes visits a family in Arujá (Hannah Yi)

Parent coaching, and specifically, home visiting, is not new. The most famous program, which took place in Jamaica in the 1970s, showed that well-trained home visitors supporting poor mothers with weekly visits for two years led to big improvements in children’s cognition, behavior, and future earnings. One group of infants in that program who received coaching in their earliest years earned 25% more than a control group more than 20 years later.

But Brazil’s ambition is audacious. No city or country has ever attempted to reach so many people in such a short amount of time. (The largest program doing this now is probably in Peru, reaching about 100,000 families; Criança Feliz is already reaching 300,000.) “They are raising the bar for what is possible nationally,” says Jan Sanderson, the former deputy minister of children from Manitoba, Canada, who is an expert in home visiting and recently traveled to observe the program.

 Talking to lawmakers in Brazil can feel like wandering around a neuroscience convention. Just how Brazil—a massive country with endemic poverty and grating inequality—came to embrace parent coaching as the next frontier in combating poverty is a story of Terra’s political will, the strategic savvy of a few foundations, the pivotal role of a Harvard program, and the compassion of a growing group of unlikely allies, from communists to far-right wing politicians. Talking to lawmakers in Brazil can feel like wandering around a neuroscience convention: One senator from the south can’t stop talking about working memory, while a mayor from the northern town of Boa Vista in Roirama state is fixated on synapse connection. At least 68 senators and congresspeople, judges, and mayors have converted to the cause, becoming evangelical in their focus on early childhood development.

“I believe that this is the solution, not only for Brazil, but for any country in the world in terms of security, public security, education, and health care,” says José Medeiros, a senator from the state of Mato Grosso who heads the parliamentary committee on early childhood development. “It’s a cheap solution.”

Terra’s claims are more dramatic. “We will change the world, starting from the very beginning.”

Those words are hardly surprising coming from the man whom Ely Harasawa, Criança Feliz’s director, calls the program’s “godfather.” But the devil, of course, is in the details—and in Terra and his allies’ ability to steer a course through some rather treacherous political terrain.

Hannah Yi

Criança Feliz in action

On a hot day in May, Adriana Miranda, a 22-year-old accounting student, visits Gabriela Carolina Herrera Campero, also 22, who is 36 weeks pregnant with her third child. Campero arrived in Brazil less than a year ago from Venezuela, fleeing with her husband and two children from that country’s financial collapse and ensuing chaos. She lives in Boa Vista, a city in the north of Brazil where 10% of the population are estimated to be refugees.

Adriana Miranda visits Gabriela Carolina Herrera Campero, who fled Venezuela’s financial collapse with her family one year ago. (Hannah Yi)

The two women greet each other warmly and start chatting, in spite of the fact that Miranda is speaking in Portuguese and Campero in Spanish. They sit together on plastic chairs on a concrete patio as Miranda goes through a checklist of questions about the pregnancy. Has Campero been to her prenatal visits? (Yes.) How is she feeling? (Hot.) Is she drinking enough water? (Yes.) And walking? (When it’s not too hot.) Is she depressed or anxious? (No, but worried, yes.) Does she feel supported by her husband? (Yes.) How is she sleeping and what kinds of foods is she eating? (She’s not sleeping well because she always has to pee, and she is eating a lot of fruit.)

Miranda moves on to talking with Campero about attachment—how to create a strong bond with a baby in utero, and also once the baby is born. Does she know that at five months, the baby can hear her and that her voice will provide comfort to the baby when it is born?

“It’s important the baby feel the love we are transmitting. When he is in distress, he will know your voice and it will calm him,” says Miranda.

The curriculum. (Jenny Anderson)

It’s a topic they have discussed before. Campero is eager to show what she has learned about the baby. (A part of the program requires that visitors check for knowledge.) “It has five senses, and if I talk, he will know my voice,” she says. “The baby will develop more.” They discuss the importance of cuddling a baby and being patient.

Having a baby in the best of circumstances can be challenging. As an impoverished refugee, in a new country, it can be utterly overwhelming.

I ask Campero, in Spanish, whether the program has been helpful. After all, she already has two kids. Doesn’t she know what to expect? She starts to cry. “They have helped me emotionally,” she says. “She has taught me so many things I didn’t know.” For example, she didn’t know to read to a baby, or that her baby could hear her in utero. Her son used to hit her belly; he now sings songs to the baby because she explained to him what she learned from Miranda. “I feel supported,” she tells me.

 ”I raised my kids as if I were taking care of a plant,” Medeiros recalls.   Many people, rich and poor alike, have no idea what infants are capable of. Psychologists and neuroscientists believe they are creative geniuses, able to process information in far more sophisticated ways than we ever knew. But for that genius to show itself, the baby needs to feel safe and loved and to have attention.

Medeiros explains how he viewed parenting before he went to the Harvard program.

”I raised my kids as if I were taking care of a plant,” he recalls. “You give them food, you take care of them.” He says he did the best he could, but “I did not have all this information. If I had encouraged them, stimulated them more, I would have been able to contribute much more to their development.”

He is hardly the exception. A 2012 nationally representative survey in Brazil asked mothers, 52% of whom were college educated, what things were most important for the development of their children up to three years of age. Only 19% mentioned playing and walking, 18% said receiving attention from adults, and 12% picked receiving affection. “So playing, talking to the child, attachment, it’s not important for more than 80% of the people who are interviewed,” says Harasawa, the director of Criança Feliz.

Criança Feliz is part of Brazil’s welfare program for its poorest citizens, called Bolsa Familia. Started 15 years ago, the welfare program is rooted in a cash transfer system that makes payments contingent on kids getting vaccines and staying in school, and pregnant mothers getting prenatal care. Vaccination rates in Brazil exceed 95% and primary school enrollment is near universal. Originally derided, and still criticized by some in Brazil as a handout program for the poor, Bolsa Familia is nevertheless being replicated worldwide. But a powerful coterie of Brazil’s political leaders believe it’s not enough. Cash transfers alleviate the conditions of poverty, but do not change its trajectory.

 “You’re in their home, you can’t interfere. But you are there to change their mindset.” That’s where Criança Feliz comes in. The program is adapted from UNICEF and the World Health Organization’s Care for Child Development parent coaching program. Trained social workers visit pregnant women every month and new parents once a week for the first three years of a child’s life. Sessions last about an hour. The goal is to not to play with the baby or train the parent, but to help parents have a more loving relationship with their children. The program costs $20 per child per month. The ministry of social development allocated $100 million in 2017 and $200 million in 2018.

Cesar Victoria, an epidemiology professor at the Federal University of Pelotas in Brazil, will conduct a three-year randomized control trial comparing kids in the program to kids who are not, on measures of cognition, attachment, and motor development. Caregivers will be evaluated to see what they have learned about stimulation and play.

Criança Feliz neither pities poverty nor romanticizes it. It recognizes that low-income people often lack information about how to raise their children and offers that information up, allowing parents to do what they will with it. “It’s one thing to say ‘read to your baby twice a day,'” says Sanderson. “It’s another thing to say, ‘when your baby hears your voice, there are little sparks firing in his brain that are helping him get ready to learn.'”

Of course, it’s a delicate balance between respecting the right of a family to raise their children the way they see fit and offering information and evidence that could help the child and the family. “You’re in their home, you can’t interfere,” says Teresa Surrita, mayor of Boa Vista. “But you are there to change their mindset.”

Liticia Lopes da Silva 23, a home visitor from Arujá, outside Sao Paulo, says that the initial visits with families can be hard. “They don’t understand the importance of stimulation and they are resistant to the idea of playing with children,” she says. “They are raised a different way, their parents did not have this interaction with them.” The issue is not just that some mothers don’t play with their babies; some barely look at them. Others treat the visitors as nannies, leaving them to play with the child, thus thwarting the very purpose of the visit—the interaction between parent and child.

 “It’s amazing to see the families evolve.” But after a few weeks of watching a social worker sit on the floor, playing with the child, and talking with her about the baby’s development, the mothers sometimes join in. “It’s amazing to see the families evolve,” says one home visitor in Arujá. “Three to four months after, you see the difference [in how] the mother plays with the child. In a different way, the whole family gets involved. Fathers often get involved and many families start to ask the visitors to come more often, although the visitors cannot oblige.

When a home visitor named Sissi Elisabeth Gimenes visits a family in Arujá, she brings a color wheel painted onto a piece of recycled cardboard, along with painted clothespins. She asks Agatha, age three, to put a brown clip on the brown color. Agatha doesn’t know her colors and gets very shy. Sissi encourages Agatha while chatting with her mother, Alda Ferreira, about how play benefits brain development. She quietly models how to use encouragement and praise, praising Agatha for finding white—”the color of clouds”—as the girl slowly gets more confident and gets off her mother’s lap to play.

The activity is intentional. The clips hone Agatha’s fine motor skills as well as her cognitive ones; the interaction with her mother helps create the synaptic connections that allow her brain to grow and pave the way to more effective learning later on. Alda tells us her daughter knows many things that her older daughter did not at the same age.

Agatha, age 3. (Hannah Yi)

The process changes the social workers as well. One social worker, who has a three-year-old herself, says that as parents, we think we know everything. “But I knew nothing.” In Arujá, where the home visitors are all psychology students at the local university, working with the program as part-time interns, many admitted to being shocked at seeing the reality of what they’d been taught in the classroom. Poverty looks different off the page. “We are changing because we are out of the bubble,” said one. “Theory is very shallow.”

As we leave Campero’s house, I ask Miranda what she thought of the visit. She too starts to cry. “Gabriella recognizes the program is making a difference in her life,” she says, embarrassed and surprised at her own emotions. Campero had told Miranda a few weeks earlier that she was worried because the baby was not moving. Miranda suggested that Campero try singing to the child in her womb; the baby started to move.

The man who made it happen

In 2003, as secretary of health in Rio Grande do Sul, Terra created Programa Primeira Infância Melhor (the Better Early Childhood Development Program, or PIM), a home visiting program based on Educa tu Hijo, a very successful case study from Cuba (pdf). Results have been mixed, but Terra saw the impact it had on families and communities. He set his sights on expanding the program nationally.

One of the most persuasive arguments for the program, he knew, was the science. But he had to build votes for that science. In 2011, he started lobbying everyone he could to try and get financial backing from congress to fund a week-long course that he helped create at Harvard University’s Center for the Developing Child. He thought if lawmakers—who would be attracted to the prestige of a course at Harvard—could learn from the neuroscientists and physicians there, they might also become advocates for the policy.

“Anybody in the corridor he sees, it’s a hug, it’s a tap on the chest, and then it’s early childhood development,” says Mary Young, director of the Center for Child Development at the China Development Research Foundation and an advisor to Criança Feliz. “He’s got the will and the skill.”

 “Anybody in the corridor he sees, it’s a hug, it’s a tap on the chest, and then it’s early childhood development. He’s got the will and the skill.” One convert, Michel Temer, who was vice president from 2011 and became president in 2016 when his boss was impeached, tapped Terra to be minister of social development. Soon after, Criança Feliz was born. But trying to get Terra to talk about legislation can be a challenge. What he wants to talk about are neurons, synapses, and working memory. Did I know that one million new neural connections are formed every second in the first few years of life? And that those neural connections are key to forming memories?

“The number of connections depends on the stimuli of the environment,” he says. And the environment of poverty is relentlessly unkind to the stimuli available to children.

Osmar Terra’s enthusiasm is infectious. (Hannah Yi)

Attachment, he explains, is key—not just psychologically, but neurobiologically. “If a child feels emotionally safe and secure and attached they explore the world in a better way. The safer they feel, the safer their base, the faster they learn,” he says.

The first 1,000 days

Over the past 20 years, scientists have focused on the importance of the first 1,000 days of life. Brains build themselves, starting with basic connections and moving to more complex ones. Like a house, the better the foundation of basic connections, the more complex are the ones that can be built on top. In an infant’s earliest days, it’s not flashcards that create their brains, but relationships (pdf), via an interactive process that scientists call “serve and return.” When an infant or young child babbles, looks at an adult, or cries, and the adult responds with an affectionate gaze, words, or hugs, neural connections are created in the child’s brain that allow them to later develop critical tools like self-control and communication.

 “Children who experience profound neglect early in life, if you don’t reverse that by the age of two, the chance they will end up with poor development outcomes is high.” If kids do not experience stimulation and nurturing care, or if they face repeated neglect or abuse, the neural networks do not organize well. And that, says Charles Nelson, a pediatrics professor at Harvard Medical School, can affect the immune system, the cardiovascular system, the metabolic system, and even alter the physical structure of the brain. “Children who experience profound neglect early in life, if you don’t reverse that by the age of two, the chance they will end up with poor development outcomes is high,” he says. The strongest buffer to protect against that? A parent, or caring adult.

The case for early childhood as policy was elevated by Nobel Prize-winning economist James Heckman. As founder of the Center for the Economics of Human Development at the University of Chicago, he demonstrated the economic case for why the best investment a policymaker can make is in the earliest years of childhood, because that’s when intervention has the highest payoffs.

“The highest rate of return in early childhood development comes from investing as early as possible, from birth through age five, in disadvantaged families,” Heckman said in 2012. His work showed that every dollar invested in a child over those years delivers a 13% return on investment every year. “Starting at age three or four is too little too late, as it fails to recognize that skills beget skills in a complementary and dynamic way,” he said.

More than 506 Brazilian legislators, judges, mayors, state politicians and and prosecutors have attended the Harvard course that Terra helped set up. There, Jack Shonkoff, a pediatrician and professor, explains what infants need to thrive, what toxic stress does to a child and how to build resilience. The attendees are put in groups—maybe a state senator from one state with council members from municipalities in the same state—to spend the week on a project; in the next two-and-a-half months, they finish it with the help of a technical facilitator.

”It’s a little facilitation and a little manipulation,” says Eduardo Queiroz, outgoing head of the Fundação Maria Cecília Souto Vidigal, a foundation which has played an integral role in supporting and shepherding Crianza Feliz. “We create a community.”

It costs $8,800 to attend the program. Some pay their own way. Congress pays for lawmakers to go, and the Fundação Maria Cecília Souto Vidigal funds between 10 and 12 scholarships a year. The fellowship does not require the participants to do anything with their knowledge. But many have. Surrita, who is in her fifth term as mayor of Boa Vista, focused her early governing efforts on working with teens, tackling drugs and gangs as a way to help them. After her week at Harvard, she changed her approach, deciding to make Boa Vista the “early childhood development capital of Brazil.” Investing in young children, she argues, will mean not so many problems with teens:

<blockquote>”After taking this course Harvard on the ECD I realized how important it would be for us to work with the kids from pregnancy up to 6 years old that to develop them mentally and cognitively and that way I realized that it would be possible for us to improve the performance of the teenagers lives by working on them when their kids.”</blockquote>

Obstacles and opportunities

Criança Feliz faces two significant threats: the prospect of being shut down, and the challenges created by its own ambition.

Although a legal framework for early childhood—la Ley de Primer Infancia, passed in 2016—underpins Criança Feliz, it currently exists as a decree of the president. Of the last three presidents, one is in jail, one was impeached and the current one, Temer, faces criminal charges. With approval ratings of around 3%, Temer has decided not to run again, and the program’s supporters are worried that whoever wins the election will dismantle what the previous government has done (a common practice in Brazil). “We are concerned every day because the program is ongoing and we don’t know if the president will support it,” says Ilnara Trajano, the state coordinator from Roirama state.

 “We are not trying to replace the family. We are trying to support it.” Mederios and Terra say the solution to avoiding political death is to create a law that will automatically fund Criança Feliz at the state level, rather than relying on presidential support. Terra, who exudes confidence and optimism, is sure such a law can be passed before the October date set for presidential elections. Others, including Harasawa, are not so sanguine. “We are in a race against time,” she says. She is working around the clock to build support one municipality at a time. She worries that not everyone thinks the government should play a role in parenting. “We are not trying to replace the family,” she says. “We are trying to support it.”

Beyond its political future, the program itself faces a host of issues. In many places, there aren’t enough skilled workers to act as home visitors. There’s also the fraught logistics of getting around. In Careiro da Varzea, in Amazonas state, home visitors often travel five hours, by foot, to reach pregnant women and young children; they are tired when they arrive. In Arujá, seven home visitors share one car to visit 200 families, or 30 visits each, per week. Internet services can be terrible, and wild dogs often chase the social workers.

The visitors are trained in a curriculum that tells them which materials to use, what to teach and when, and the research that underpins the guidance they give to mothers. But they need more training, and the curriculum does not always prepare them for the poverty and distress they see. Some mothers want to give up their babies; they did not want them in the first place. Many suffer from depression. The social workers are trained to support nurturing care, but they are not mental-health experts. Inevitably, turnover is high.

 In Careiro da Varzea, in Amazonas state, home visitors often travel five hours, by foot, to reach pregnant women and young children.  The evidence for the value of home visiting at scale is at once highly compelling and frustratingly imprecise. Consider the case of Colombia: From 2009 to 2011, researchers there studied 1,419 children between the ages of 12 to 24 months to see whether coaching their mothers on interactions with their babies could help the children’s development. After 18 months, the researchers found a host of benefits. The children whose mothers had received coaching got smarter. Their language skills improved, and their home environments were judged to be more stimulating. But when researchers went back two years later, they found the children—now about five years old—had not maintained those benefits. “Two years after the intervention ended, we found no effects on children’s cognition, language, school readiness, executive functioning, or behavioral development,” the study reported. (Criança Feliz run for a longer period of time, however.)

Governments face notoriously hard choices about where to invest their money. “Early childhood development is a really valuable investment,” says Dave Evans, an economist at the World Bank. “But so is primary education and the quality of primary education, and if you spend a dollar in one place, it’s a dollar you aren’t spending in another place.”

Samuel, Keith, and Giliane

One of the virtues of a home visiting program, compared to say, building child-care centers, is that social workers can see what is happening inside a home: signs of domestic violence, other children in need, a mother’s depression, a father’s unemployment. They can help with kids like Samuel, who was born with cerebral palsy.

At two-and-a-half years old, Samuel loves his ball, and shrieks with delight when he is presented with a truck. He can’t stop smiling as his mother, Giliane de Almedida Trindade Dorea. She and social worker Keith Mayara Ribeiro da Silva, gather around him to talk and play.

“Where is the dog? Yes! That’s the dog. Very good Samuel!” says da Silva.

The two encourage Samuel to try and stand up. He struggles. “Get up, use your legs,” says Dorea. “You are lazy. Be strong!”

Samuel has made huge progress under the program. (Hannah Yi)

Samuel ignores the women’s requests. He wants to play. They shift gears. “Where is the ball?” da Silva asks. He grabs it and plays. “He’s very smart!” she says. She and Dorea are trying to get Samuel to use one hand, which cannot open, to play with the ball and then the truck. They work together for 15 minutes to find a way to get him to use his weak hand, but he just wants to play with his dominant hand.

Dorea adores her son and plays with him patiently. But it has been hard, she says. When da Silva started to visit, Samuel could not sit up, he was quite shy and often cried. Da Silva has helped the family access the services and care that Samuel needs: a physiotherapist, an occupational therapist, an acupuncturist, and a doctor to check his hearing. These are services the government will provide, but finding them and organizing the appointments is time consuming and can be overwhelming.

Dorea says Samuel has changed since Keith has been coming. “His interaction with people, he’s totally different. He was so shy.” In fact, she says the whole family has benefitted. Her older daughter also knows how to play with Samuel and loves to help. She appreciates the support. Raising a child with a disability is hard work. “The visitor is a like a friend who comes every week not just for fun but also to share my concerns,” she says. Her biggest complaint about the program? “It’s too short.”

Will it survive?

There is a maxim in investing that you have to survive short-run volatility to get to the long run—you can’t make money if you don’t have any. Criança Feliz faces the same problem. Child development takes time. It is not a jobs program or a construction project, which voters can see. The benefits can take years to show up, and politicians have never been known for their long-term thinking.

Alberto Beltrame, the current minister of social development, is a believer. Start early and you shape character, transforming the child into a better young adult and, eventually, creating an improved workforce, he says. You reduce violence and crime. He agrees that Bolsa Familia alone is not enough. It does not promote autonomy, or break the cycle of poverty. What is needed is a two-pronged approach: In the short term, promote training, microcredit, and entrepreneurialism to create jobs. For the medium and long term, Criança Feliz.

“We have a huge array of benefits that we are going to gain with this one program, and the cost is very, very low compared to others,” he says.

In every home we visited, mothers said they loved the support, be it information, toys, or more often, company to share their challenges and triumphs. Priscila Soares da Silva has three children, including six-month-old Allyce, and another on the way. With Allyce, she says, she has changed her approach to parenting, setting time aside to play every day now. “You raise children your way,” she explains cooing over Allyce. “When you see there are other visions, you see the way you did it was not so right.” She is also refreshingly honest about something all parents know: We do it better when someone is watching. “There are things we know, but we are lazy. When she comes, we are better.”

When I quietly ask her teenage daughter, who is lingering in the corner, what she thinks of the visits, she answers immediately: “She’s so much more patient,” she says of her mother. Her own takeaway: Parenting is hard, and she does not want to do it anytime soon. Priscila smiles at this, agreeing she started too soon, and noting the benefits of the program have extended beyond Allyce and the baby she will soon have. “The program got the family closer.”

Evans, from the World Bank, is watching the program closely. “I see Criança Feliz as a big, bold, gamble about which I am optimistic,” he says. “But I think the measurement and the evaluation is crucial to see if it is a model that other countries want to echo.”

If it survives the near term political turbulence, Beltrame says it can go way beyond the poor to benefit everyone. “We are trying to make the Brazilian people realize, independent from their level of income, that stimulating children from pregnancy through the first 1,000 days of life is important,” he says. Better young people equal healthier and better adults, who are more emotionally connected and can be better citizens.

With Crianza Feliz, Beltrame says, we have the “possibility of having a new destiny and future for each one of these children.”



Source: QZ

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