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HORIZONS
Testimony Before the House International Relations Committee

17 April 2002

Laelia Zoe Gilborn, MPH
Staff Program Associate
Horizons Program
International Programs Division
Population Council

Chairman Hyde and members of the Committee, thank you for the opportunity to testify on orphans and vulnerable children (OVC) in Africa. The Population Council is an international, nonprofit, nongovernmental organization that seeks to improve the well-being and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical, social science, and public health research and helps build research capacities in developing countries. Horizons is a USAID-funded cooperative agreement mandated to conduct interventions research in order to refine HIV/AIDS programming in developing countries. Ms. Peterson of USAID spoke on the magnitude of the problem. I am going discuss what is being done on the ground for orphans and vulnerable children, whom I will be referring to as OVC.

A wide body of literature tells us that children affected by AIDS are vulnerable in almost all aspects of their lives. AIDS-affected children often have lower school enrollment rates and nutritional status in comparison to their peers. They have less access to basic health care. They suffer from poverty and emotional distress and are vulnerable to various forms of exploitation.

What does research tell us about the best response to orphans and vulnerable children in the developing world? The most important thing that can be done—and this is often overlooked—is to prolong the lives of their parents. In addition, we have found several complementary approaches that have been effective in making a difference for children. One is to support families, communities and local organizations in their ongoing care for OVC. The second is to strengthen professional and governmental capacity to respond to this crisis. The third is to provide interim or permanent shelter for children in especially difficult circumstances.

Families and communities will always provide the vast majority of day-to-day care for vulnerable children. Most OVC are taken in by aunts, uncles, and grandparents—a response built on a strong and long-standing tradition of extended family networks and informal fostering. As we sit here today, five million grandmothers and grandfathers in Africa are raising orphaned grandchildren who have lost their parents to AIDS. Nothing that outsiders can do could approach the scale, effectiveness, sustainability, and cultural relevance of the local response. Yet, as the epidemic escalates, families and communities are increasingly strained in their efforts to care for orphans.

Local efforts can be strengthened through capacity-building and support for NGOs, faith-based and other community organizations, and through a wide range of development efforts that ensure access to food, safe water, health care, school, psychosocial support and legal assistance. Community activities that can be supported by outsiders include: visiting programs, mobilizing resources for school fees, engaging local leaders in advocating for OVC, and offering economic opportunities for families fostering orphans.

It is also important to include as part of the solution the ministries, the political officials, and the professionals—teachers, psychologists, social workers, lawyers—who have the skills and the responsibility to protect OVC in their own countries—now and in the future. There hardly exists a sector that is not deeply affected by HIV/AIDS and at the same time does not bear some of the burden for prevention and care for the infected and affected.

When the Ministry of Education in Uganda introduced universal primary education, the enrollment gap between orphans and non-orphans disappeared. But there are other things that remain to be addressed in the education sector, such as the high rate of mortality among teachers and the need to train teachers to better respond to the emotional and other needs of orphans and vulnerable children. Countries like Malawi have begun to develop national policies on Orphans and Vulnerable Children. Just last week, USAID and other groups supported this kind of political commitment by sponsoring the West and Central Africa Regional Workshop on Orphans and Vulnerable Children. This enabled delegates from throughout the region to engage in technical exchange and to draft country action plans.

So what are the nuts and bolts of successful community interventions for AIDS-affected children? What specifically has research shown should be done for OVC? First, as I mentioned earlier, we can prolong relationships between children and their caregivers by addressing the critical health needs of both parents and guardians. For example, programs that prevent mother-to-child transmission of HIV during pregnancy and delivery, can then stay with that mother-child dyad, offering ongoing care and support for both. And orphan support programs can provide health services for guardians, many of whom are elderly and some of whom are HIV positive. Half of the people living with AIDS in Africa succumb to tuberculosis. By providing TB prophylaxis and treatment, millions of children would have a few more years with their caregivers.

Second, children and their families can be reached before their parents die. The research leaves no doubt: the setbacks incurred by AIDS-orphaned children in terms of health, nutrition, emotional well-being, and access to education all start while the parents are still alive, ill, struggling to feed their families and relying heavily on their children to take on adult responsibilities. Nearly all HIV-positive parents express serious concerns about their children. They worry about their children's education, access to love, food, and shelter, and their vulnerability to exploitation. The National Association of Women Living with AIDS (NACWOLA) and PLAN International in Uganda pioneered an approach now known as succession planning or future-planning in which parents were offered the opportunity to earn income, arrange guardians, prepare wills protecting their children, and make Memory Books—akin to our family albums—so that their children would always know where they came from and who they could go to for help.

Let's take an example. Typically a child's father might fall sick first, reducing the family income. Then perhaps her mother becomes ill. Soon this girl may be pulled out of school for lack of fees or because her help is needed at home. She may be caring for younger siblings, cooking for the family, looking to earn some money on the side, and nursing her own parents who—as you know—succumb slowly and painfully to AIDS. One after the other her parents die. Most likely she has lost someone else too: a sister, an uncle, a teacher. And finally she moves into the house of her grandmother, with whom she may or may not be comfortable, possibly losing touch with siblings shunted off to different households. She may even become the head of a household. Is this the time to intervene? No, children must be reached earlier to avert and mitigate the many impacts of AIDS.

Basic emotional support is essential. It goes without saying that seeing your parents fall ill and pass away is very traumatizing. Community volunteers, teachers, HIV-positive parents and guardians can be trained in adult-child communication. Our research in Uganda demonstrated, for example, that the vast majority of older children want their parents to be honest with them about their HIV-infection. They want to do what they can to help, they want to know the truth, and they don't want to learn about their parents' infection through gossip. Memory books provide a wonderful medium for fostering communication in families. Another program in Tanzania trains orphaned adolescents to support their peers and serve as mentors to younger orphans. This is an excellent example of how children can be part of the solution.

Expanding access to education is also extremely important. Again, many OVC drop out of school. Eliminating school fees and other school-related costs helps bring these children back to school. Not only does school provide obvious educational and social benefits, but it is enormously important in integrating OVC with other children and giving them a chance to play and take a break from troubles at home.

More can be done to protect the property rights of women and children. I work in two rural districts in Uganda where one in four widows loses her inheritance—including the land on which she grows food and the roof over her head—when her husband dies. This is devastating for a household that has just lost its primary breadwinner. Lawyers, paralegals, and even community volunteers are training parents to write wills. Local officials have been involved in disputes over property. This program has already helped orphans hold on to their family property and land, and in some cases to support themselves with small gardens.

Before I conclude, I would like to add a word of caution about programs that go out of their way to target and identify AIDS-affected children exclusively. It is surprisingly difficult to determine which children are affected by AIDS when so few people know or reveal their HIV status. Community programs can spend valuable resources on elaborate systems of identifying AIDS-affected children, only to further label them and to leave behind other vulnerable children. With programs that elevate the well being of all vulnerable children, these pitfalls can be avoided, and the entire community is helped.

Today I have shared with you some outstanding program approaches that fill all of us with hope for the future of these children. But in the year 2000, the Uganda AIDS Commission surveyed sources of outside assistance for orphans and vulnerable children and found that only 5% of OVC receive support from programs. Our work is cut out for us, but we have a valuable foundation of lessons learned on which to build. Thank you.