In Brazil's Ceara State, a Reversal of Fortune

By expanding the role of local governments and ending patronage, two governors have turned an impoverished Brazilian state into a model. And their health-care reforms have won international acclaim.

MOST residents of Maracanau - a rural municipality in the northern Brazilian state of Cear are illiterate and earn less than $80 a month, the official minimum wage. Favelas, or shantytowns, mottle reddish plains parched by a seven-year drought. Most of the sewage flows into open drains. Many people have no clean supply of drinking water.

There is little sign of activity, except in the garbage dumps, where those willing to brave the sun, dust, and stench scrounge with the vultures amid the smoldering refuse for saleable scraps.

But despite the impoverished appearance, this state was heralded as "an example to the world" for its successful health-care reforms by the United Nations International Childrens' Fund (UNICEF). The report has focused Brazil's attention on Ceara as a model of how political leadership can bring needed change. Political leadership

Cears current and previous governors, Ciro Gomes and Tasso Jereissati, have carried out sweeping reforms that have improved the quality of life here.

When Mr. Jereissati, a wealthy businessman, took office in 1987, the state was nearly bankrupt. Its institutions were used primarily as a means of handing out jobs for patronage, and the state's money was kept from the most needy.

But the new governor replaced the patronage system with merit exams and began dismissing nonperforming employees. Teachers were induced to improve their credentials with higher salaries. Those who refused to improve were fired. Unlike most of Brazil, nearly every child attends public school. The state's budget was put in order, and it paid its bills on time.

While Brazil's economic growth rate dropped to zero in 1992, Cears economic growth rate increased by more than 3 percent. It is still the country's third poorest state, but it exports four times more products per person than the rest of Brazil.

Jereissati gave up day to day control of state services to local governments. And under Mr. Gomes, who took office in 1991 and at 35 is Brazil's youngest governor, the program was accelerated.

"We are saying: `Give control to the local people and forget the ribbon cuttings,' " Gomes says. "I can't answer the concerns of 9 million people. They're better off knocking on the doors of their mayors. Many local politicians are corrupt, but we can't protect people from democracy. If they elect bad mayors, they need to know that they will pay for it with bad health care."

Gomes's approval rating is 67 percent and he is considered the most popular governor in Brazil, according to recent public opinion surveys.

Both are being touted as serious contenders for Brazil's presidency, but Gomes seems to be keeping his eye on problems at home.

"The old model has been broken," Gomes says. "We may be one of the poorest states, but we are also the strongest. No one has done anything like the [state's much-lauded] health agent program.

"If we can do so much with so little, imagine what we will do in the future, or what Brazil as a whole could do," he says. `Barefoot doctors'

The health agent program, launched in 1987, is one of Brazil's rare success stories.

Local young people, mostly women, were recruited and taught practical sanitation and health-care skills.

The state now has more than 4,000 of these "barefoot doctors" serving 80 percent of the rural population. Every month, each one walks an average of 60 miles and visits every person on their route at least once. Each agent receives 60 days of training and is paid $80 a month, the government's minimum wage but far more than most people in the area earn.

In Ceara, state officials say, 6.7 percent of the children born do not live to see their first birthday. Five years ago, the figure was 32 percent higher.

"Most of the infant deaths are from diarrhea, as they are throughout the third world," says Frederico Augusto de Lima e Silva, a doctor and head of the local health program. "The terrible thing is that it is easy to prevent and almost as easy to cure. But while public health is simple, it is difficult for many to comprehend." Educating local agents

Getting this message to the local population proved difficult. The state decided to transform local citizens into health workers and teach them to make house calls.

"When there's a lack of medical help we always have education," says health agent Fatima Gonsalves. "It's hard work, but I think it's helping. Most people didn't understand how to make their lives better."

While there is still a long way to go, the results have been impressive.

The infant mortality rate, once one of the highest in the country, is now near the national average. State officials hope to cut it in half by 1995. Much of the success, according to health agents in the field, has come from such basics as teaching pregnant women how to eat better on their meager salaries.

In recognition of this work, UNICEF awarded Ceara its Peace and Liberty Award. To date, the state is the only unit smaller than a country to have won the prize.

"Ceara has a special advantage," UNICEF's 1992 report on the state of the world's children says. "Almost two-thirds of the population lives below the poverty line, but its leaders are politically and personally committed to improving the lives of the people. In countries where this commitment exists, there are ways to revolutionize the third world."

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