AIDS orphans

1
Keep me away from wisdom which does not cry,
philosophy which does not laugh and greatness
which does not bow before children
Kahlil
Gibran
2
AIDS orphans Vulnerable ChildrenAn
evidence-led response
IFCW WORLD FORUM 2003 Cape Town

• Dr Michael Elmore-Meegan FRSHTM
• HIV/AIDS Unit
• ICROSS Kenya

3

• Scale and complexity of AOVC
• Vulnerability
• Responses
• Knowing what works
• Resources

4

• You do not know what is coming over the
• mountain, darkness is about to fall on our world
  if you do not act we will be lost
• Leonidas King of Sparta to the Greek states
  before leading 300 spartans to hold back the
  Persian invasion at Thermopylae 480 B.C.

5

• Know before you act everything possible from
  all intelligence or your plans shall fail if you
  are unprepared you will be defeated
• Julius Caesar 51 BC

6

• Scale and complexity of the problem
• This is a rapidly emerging dynamic (often
  responded to by assumption not knowledge)
• Needs to be understood in context of the broader
  situation. Early child development, nutrition
  safety, well-being, disease, emotional suffering
  and poverty

7

• Statistics do not capture tears
• The numbers miss pre-orphaned children whose
  their parents die difficult deaths
• The data of ten misses the changes in safety,
  security, diet, happiness and social failure

8

• Statistics and data are essential
• There is limited evidence of patterns, social
  dynamics or psychosocial damage to children
• In 3 meta-analyses , only 214 studies and 7
  multi-country studies covering 4.2 million
• 22 psychosocial studies underway and 7
  multi-country studies being planned

9

• By 2010 an estimated 106 million children under
  15 years are projected to have lost one or both
  parents with 25 million of this group due to
  HIV/AIDS
• Children on the brink 2001
• UNAIDS UNICEF

10

• There are other orphans, other children who are
  vulnerable
• HIV/AIDS strikes in may ways
• Some countries are more vulnerable than others
• 12 of all children in sub-Sahara are orphans,
  6.5 in Asia, 5 in Latin America

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• Mortality, morbidity trends reversing
• Crude death rates and life expectancy changing by
  2 decades in parts of Africa

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• In Sub-Sahara, by 2010 it is estimated 42million
  orphans, 20 million from HIV/AIDS
• In 2001, 12 sub-Saharan countries made up 70 of
  orphan population (esp Nigeria, Ethiopia Congo)
• The mean average age on the continent of Africa
  is 17 (tables on www.unaids.org)

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In AOVC

• Limited hard evidence yet
• Lots of material, much of poor
• Lot of theories and assumptions
• Short time scales
• Danger of up-scaling ideas that have not been
  proven to work
• But
• We know some things are working
• We know what we do not know

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We have limited resources

• Where are we going to put our money?
• How will we choose a project?
• How will we measure success?

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Vulnerability

• History will judge us by how we cared for our
  children, how we protected the weak and the
  powerless. Civilisation is determined by our
  love
• Albert Einstein

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• Dynamics of who is vulnerable
• Starts in the household
• Childrens adult-network
• Children's child-network
• Family network
• Community network
• External support structures above all internal
  stability

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• Our team has been looking at stress, emotional
  well-being, trauma and coping
• Achenbach child behaviour scale
• Modified triple validated scale
• State of well-being scale
• Other important studies and assessment tools on
  www.repssi.org

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Chronic vulnerability

• Classically defined as exposure to risk
• Exposure to stress
• Lack of ability to cope with exposure symptoms
  e.g.
• Anxiety Tears
• Nightmares Withdrawal
• Terror Fear
• Depression Ob Compulsive D
• Panic

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• Important programme distinction between symptoms
  and causes of vulnerability
• Responding to SYMPTOMS
• relief, destitute, impoverished families
• livelihood failure
• We need to shift focus to CAUSES

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Programmes targeting causes

• E.g.
• Family planning (demographic curves)
• Environment (deforestation)
• Climatic (floods in Asia)
• Policy-based
• Good governance
• Rights
• Land tenure

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AOVC causes of vulnerability

• Include
• Household security
• Rights education
• Community protection of children
• The multiple dynamic of HIV and AIDS ripple
  damage to social fabric
• Kills most productive members of society

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• Sound cultural baselines root projects in peoples
  values not in donors log frames
• Stigma fear,denial,silence,religious
  objection,alienation,rejection

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Not gender neutral

• Women and girls more biologically and culturally
  vulnerable

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• The pandemic has multiple accelerating effects
  on other risk factors
• (primary indices, disease patterns, economy,
  mortality, trends, social structures)

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Responses

• As HIV impact intensifies the local, national and
  regional capacity to respond is decreasing

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• A plan we need a plan?
• Homer Simson
• (at the controls of the nuclear plant during melt
  down)

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What is working

• Organised Collaborations
• Networks based on equality of partners
• Government linked strategies
• Joint interventions are working better
• Long-term integrated strategies
• Multi-disciplinary responses

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Interventions that work

• Holistic approaches including MCH, PHC
• Strengthening local coping systems
• Community-driven safety networks
• Helping formal and informal support groups

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• Protection of childrens assets
• Local psychosocial safety networks
• Targeting families

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• This is no longer a crisis for charities or
  donors alone
• It is a regional emergency requiring dramatic
  legislation, interventions and new types of
  alliances

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• Successful programmes have
• Education, social services and community support
  with Gov/NGO Community working together.

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• Multi-lateral institutions
• Bilateral institutions
• Government policies
• International organsiation programmes
• Community-based organisations
• Faith-based organisations
• Informal community responses

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• The problem greatly exceeds existing efforts
• Little evidence of impact
• Community responses often more practical in the
  lives of children than larger programmes

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• Less than 10 of all orphaned children are being
  reached by support initiatives
• If AOVC are able to go to school they are
  performing as well as other children

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Evidence

• Walk the path that is lit, hold hands or you
  will walk into the ditch
• Maasai proverb

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Types of evidence

• Experience
• Results
• Observation
• Proof

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Knowing what works (measuring and assessing
program input)

• Quantitative
• Epidemiological
• Health statistics
• Demographics
• Performance analysis
• Cost effectiveness
• Qualitative
• Psychosocial
• Sociological
• Anthropological/cultural
• Socio-economic

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• Organisations across the world are still trying
  programmes that never worked and were never
  cost-effective
• Need to share
• Best practices
• Lessons learnt
• Design skills
• Evaluation methods
• How to use evidence
• Build through culture

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• Need to understand the difference between
  counting things and real information
• We need to plan from well-designed
  scientifically structured investigation and use
  information well
• But
• We must be cost effective and cost efficient

40

• In many programmes baselines, design, methodology
  or knowing the real starting point are not
  evident
• Interventions often fail to understand local
  context, cultural assumptions, non-negotiable
  values and community wisdom
• Success does not depend on money but on the
  acceptance of the strategy by the community

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• In reviewing 28 articles on AOVC in 2002
• 19 had fundamental statistical errors
• 24 had incomplete literature review
• 16 had insufficient sample single
• 17 had design errors
• 11 had no new contribution
• 8 did not understand controlling variables
• 12 had no situational analysis context
• 3 were recommended for publication

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FBOs Dr Geoff Fosters findings

• (686 FBOs in 6 countries Uganda 193, Kenya 171,
  Mozambique 105, Namibia 91, Malawi 68 and
  Swaziland 57)
• Material support
• School assistance
• HIV prevention
• Visiting children/home support
• Counseling and psychological support

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• Medical care
• Income generation and vocational training
• Day care centres
• Other education
• Community schools and child development centres
• Promotion of foster care

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Other responses

• Residential childrens homes
• Street children centres
• Community-led FBO responses were
• Well organised
• Limited impact

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• Need for partnership
• Need for flexible support from donors
• Need to redefine donor policies
• Need to recognise role of small CBOs and FBOs and
  work with them
• www.wcrp.org
• www.unicef.org

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Resources

• The best things in life are free except me
• Mae West
• There are growing resources available free on
  the internet with more advice, support and help.
  AOVC web-based resources have tripled in 2003 to
  46 sites.

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• The three richest people in the World own more
  than the poorest 32 countries
• The 6 richest people in the world own more than
  the 600,000,000 poorest
• The 250 richest people in the world own more
  than the 2.5 billion poorest
• World Bank

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• Resources are insufficient
• Global fund multi-lateral programmes are
  expensive and bureaucratic
• Donors are often not good listeners
• Need for donors to learn from NGOs and from
  partner-countries, values, culture and beliefs.

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• Manuals and guides to provide psychological
  symptoms to children
• Instruments to assess the psychological
  well-being of children
• at www.repssi.org
• But
• these require research and interpretation skills

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• Real lessons are being learnt and shared
• www.aidsalliance.org
• www.ich.com
• www.unicef.org
• www.wcrp.org
• www.aidsmap.com

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• www.cdc.com
• www.unicef.org/aids
• www.aegis.com

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• Guiding principles for programming for AOVC are
  available on www.unicef.org

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• In the end they shall forget their children and
  in their thousands shall they be lost for they
  failed to see the light and the tears in their
  eyes, they saw them not
  
• Nostradamus

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• It starts and ends in loving
• 
  
• The Dalai Lama

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If our tears do not lead us to act then we
have lost the reason of our humanity which is
compassion
The Dalai Lama