International Leaders Confer on Children and AIDS

In Africa, where the growing AIDS epidemic has turned millions of children into orphans, governments and agencies are scrambling to help. Their rescue efforts—and also those of high-profile individuals like Madonna and Angelina Jolie—are leading to what some are calling an “orphan fixation.” Yet these bereft children may not be the hardest hit by the epidemic.

“Orphans have stronger appeal, but nonorphans are also suffering,” said Douglas Webb of UNICEF. Children living in orphanages or with relatives may be better fed, housed, schooled, and medically treated than those living with parents who are ill and destitute. The AIDS epidemic has “trickled up,” weakening the economies of many African countries and making already poor families even poorer.

That AIDS orphans may, in some cases, be better off than these other vulnerable children was one of several conundrums raised at a symposium, “Meeting Children’s Needs in a World with HIV/AIDS,” held on Sept. 24 at HMS and sponsored by the Joint Learning Initiative on Children and HIV/AIDS (JLICA). The discussion was wide-ranging but tended to circle around three questions: How do we best help orphans and other vulnerable children—which programs work? Who should implement those programs—families, communities, agencies, governments? And who should pay—can affected countries afford the expense?

Participants, who came from as far away as South Africa and Malawi, and from an array of organizations—including the World Bank; UNICEF; the World Health Organization (WHO); the U.S. President’s Emergency Plan for AIDS Relief; and the Africa-based Mamas Club, Family AIDS Caring Trust, and The AIDS Support Organization (TASO)—presented opposing positions on the questions. The goal was to find innovative answers and move beyond what TASO cofounder Noerine Kaleeba called “business as usual.”

Part of the problem is that despite their appeal, AIDS orphans and other vulnerable children were, until recently, largely ignored by the international community. In 2004, an alliance of governments and agencies produced a framework for addressing the problem. The following year, UNICEF launched a campaign, Unite for Children, Unite Against AIDS. More than 25 countries in sub-Saharan Africa have been planning national responses to tackle the epidemic and to prevent it from spreading, but unlike attempts to find an AIDS cure or vaccine, these programs have not been rigorously tested. “We know a lot about what works in prevention, we just haven’t had the randomized clinical trials,” said Charles Gilks of WHO. “We don’t have easily measurable and accountable prevention targets.”

To make sense of these efforts and, at the same time, take advantage of the momentum, JLICA was launched in 2006. Its goal is to compile, review, and evaluate existing field efforts for identifying a set of best practices—and to do so in a compressed time frame. The initiative, whose secretariat is hosted by the François-Xavier Bagnoud Center for Health and Human Rights at HSPH, will deliver their evidence-based recommendations by the end of 2008. The symposium was an opportunity for members of the initiative, which is led by Peter Bell, senior researcher at the Hauser Center for Nonprofit Organizations at Harvard University, and Agnes Binagwaho, executive secretary of Rwanda’s National AIDS Control Commission, to present their findings so far (see http://jlica.org for a copy of the symposium papers).

Though much was up for grabs, presenters did agree that programs will succeed only if they work to support efforts already being made by families and communities. “The extended family, the African family, is alive and strong and caring for those who need it,” said Sheila Sisulu, of the World Food Programme. The question is how to strengthen those families and also the communities in which they live, she said.

Many agreed that economic aid is key but as part of a larger “social protection” package that enhances people’s social and legal standing as well as their financial status. Here, debate turned on the issue of whether families should be provided with tools to develop their own livelihood through microcredit programs or given money outright. And if they receive grants, should the cash transfers be tied to some condition, such as attending school, or specifically designated for some purpose, such as buying food.

“People with the least capacity are least able to take advantage of the microcredit approach,” said Michelle Adato of the International Food Policy Research Institute. The poorest families are also least likely to meet the requirements set by conditional cash transfers. Many families find them demeaning, Adato said. Cash-strapped nations may be unable to devote resources to administering and monitoring the conditional transfers.

On the other hand, evidence from Latin America and some African nations like Zambia suggests that unconditional cash transfer programs are achieving the goals of the conditional approach, such as ensuring that children are fed and schooled. Adato recommended that these unconditional transfers be officially put into the hands of female family members since they tend to be directly responsible for the welfare of children.

The discussion turned to community-based efforts and here, too, the message was to preserve autonomy. “Agency-initiated programs that run projects with the expectation that they’ll eventually hand them over to the community almost never work,” said John Williamson, of the U.S. Agency for International Development (USAID). “Community ownership is key—a sense that the problems are theirs, and they hold primary responsibility for addressing them.”

TASO’s Kaleeba described a community-based approach, which consists of helping communities develop kiosks that “surround the child” with a variety of services such as vaccinations, treatments for childhood diseases, school programs, and access to emergency food and shelter. “I want to turn them into a marketplace of services and interventions out of which children and families can choose a menu,” Kaleeba said. Such ground-up programs build upon talents already present in families and communities, and in this sense, go beyond business as usual.

“There is so much capacity within Africa, so many lessons to be learned. Capacity and capacity-building tools don’t always come on planes. They come on bicycles,” she said.

Still, such efforts require broader support. The question remained: Can a developing country support the needs of children affected by AIDS? “The short answer is no,” said Malcolm McPherson, a senior fellow at the Kennedy School of Government, adding that such programs are “inefficient, inequitable, and unaffordable.” Inefficient because they lower a country’s capacity to grow economically and inequitable because they ignore the old, hungry, displaced, and otherwise infirm, he said. As for unaffordable, McPherson calculated that in Zambia, where three million children are affected by AIDS, allocating two dollars a day to every child would cost the government nearly half of its gross domestic product. His alternative: “Promoting economic growth in Africa would be moving beyond business as usual. It would certainly change the childhood experience,” he said.

“We’re both grinches,” said Shanta Devarajan of the World Bank. That did not stop him from taking an opposite perspective from McPherson. Devarajan’s argument rested on two points, first, that economic growth depends on having healthy people and that the epidemic affects future generations.

“There is no one solution here,” Devarajan said, echoing words spoken by Peter Piot, executive director of UNAIDS, during his keynote speech earlier in the day. “But treat someone who is HIV positive, and you’re enabling them to take care of their children,” he said, adding that families not only educate but love their children. “Parents teach things they don’t get in school.”