Transcript AIDS orphans & vulnerable children An evidence

“Keep me away from wisdom which does not
cry, philosophy which does not laugh and
greatness which does not bow before children”
Kahlil Gibran
IFCW WORLD FORUM 2003
Cape Town
AIDS orphans & Vulnerable Children
An evidence-led response
Dr Michael Elmore-Meegan FRSHTM
HIV/AIDS Unit
ICROSS Kenya
• 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 multicountry 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
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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
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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
Nightmares
Terror
Depression
Panic
Tears
Withdrawal
Fear
Ob Compulsive D
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
Programmes targeting causes
E.g.
Family planning (demographic curves)
Environment (deforestation)
Climatic (floods in Asia)
Policy-based
Good governance
Rights
Land 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 neutral
Women 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
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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
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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 homes
Street children centres
Community-led FBO responses were
Well organised
Limited 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.org
www.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 wellbeing of children
at www.repssi.org
But …
these require research and interpretation skills
Real lessons are being learnt and shared
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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