“Keep me away from wisdom which does not cry, philosophy which does not laugh and greatness which does not bow before children”

Kahlil Gibran

AIDS orphans & Vulnerable Children

An evidence-led response

Dr Michael Elmore-Meegan FRSHTMHIV/AIDS UnitICROSS Kenya

IFCW WORLD FORUM 2003 Cape Town

• Scale and complexity of AOVC

• Vulnerability

• Responses

• Knowing what works

• Resources

“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.

“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

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

• 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

• 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

“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

• 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

• Mortality, morbidity trends reversing

• Crude death rates and life expectancy changing by 2 decades in parts of Africa

• 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)

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

We have limited resources

• Where are we going to put our money?

• How will we choose a project?

• How will we measure success?

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

• Dynamics of who is vulnerable

• Starts in the household

• Children’s adult-network

• Children's child-network

• Family network

• Community network

• External support structures above all internal stability

• 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

Chronic vulnerability• Classically defined as exposure to risk• Exposure to stress• Lack of ability to cope with exposure symptoms

e.g.

Anxiety TearsNightmares WithdrawalTerror FearDepression Ob Compulsive DPanic

Important programme distinction between symptoms and causes of vulnerability

Responding to SYMPTOMSrelief, destitute, impoverished families

livelihood failure

We need to shift focus to CAUSES

Programmes targeting causes E.g.

Family planning (demographic curves)Environment (deforestation)Climatic (floods in Asia)

Policy-based Good governanceRightsLand tenure

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

Sound cultural baselines root projects in peoples values not in donors log frames

Stigma fear,denial,silence,religious objection,alienation,rejection

Not gender neutralWomen and girls more biologically and

culturally vulnerable

The pandemic has multiple “accelerating” effects on other risk factors

(primary indices, disease patterns, economy, mortality, trends, social structures)

Responses

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

decreasing

“A plan… we need a plan?”

Homer Simson (at the controls of the nuclear plant during melt down)

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

Interventions that work

• Holistic approaches including MCH, PHC

• Strengthening local coping systems

• Community-driven safety networks

• Helping formal and informal support groups

• Protection of children’s assets

• Local psychosocial safety networks

• Targeting families

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

Successful programmes have

Education, social services and community support with Gov/NGO

Community working together.

Multi-lateral institutions

Bilateral institutions

Government policies

International organsiation programmes

Community-based organisations

Faith-based organisations

Informal community responses

• The problem greatly exceeds existing efforts

• Little evidence of impact

• Community responses often more practical in the lives of children than larger programmes

• 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

Evidence

“Walk the path that is lit, hold hands or you will walk into the ditch”

Maasai proverb

Types of evidence

• Experience

• Results

• Observation

• Proof

Knowing what works (measuring and assessing program input)

• Quantitative• Epidemiological• Health statistics• Demographics• Performance analysis• Cost effectiveness

• Qualitative• Psychosocial• Sociological• Anthropological/cultural• Socio-economic

• 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

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

• 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

• 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

FBOs Dr Geoff Foster’s 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

• Medical care

• Income generation and vocational training

• Day care centres

• Other education

• Community schools and child development centres

• Promotion of foster care

Other responses

Residential children’s homesStreet children centres

Community-led FBO responses wereWell organisedLimited impact

• 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.orgwww.unicef.org

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.

“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

• 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.

• Manuals and guides to provide psychological symptoms to children

• Instruments to assess the psychological well-being of childrenat www.repssi.org

But …

these require research and interpretation skills

Real lessons are being learnt and shared

• www.aidsalliance.org• www.ich.com• www.unicef.org• www.wcrp.org• www.aidsmap.com

• www.cdc.com

• www.unicef.org/aids

• www.aegis.com

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

“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

“It starts and ends in loving”

The Dalai Lama

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

The Dalai Lama