The Village and the Children

The slightly lumpy profile of Millicent Nomsa Mnqayi’s booklet is the only indication of its specialcontents: photographs—specifically portraits—of clean, healthy, brightly dressed children, eighteen in all. A group shot shows thirteen of them together, seated in order along a white wall, their expressions alert, engaged, and as individual as their mothers and fathers could hope for. Their parents, however, are unlikely to see them. The youngsters in the photographs are now Mnqayi’s children—her “babies”—and they are eighteen of the millions of children in Africa who have been orphaned by an epidemic many of them are not yet old enough to know by name.

Mnqayi and the infants she cares for in her infant care center in KwaZulu–Natal provide one glimpse of a catastrophe that is widely described as the orphan crisis of the AIDS epidemic. The story of the magnitude of this crisis is found in large, tragic numbers. The story of its solution, however, is being found in community.

Statistics are Numbing
In 1997, the U.S. Agency for International Development (USAID) released a 56-page report, Children on the Brink: Strategies to Support Children Isolated by HIV/AIDS, that rocked the international development community. Virtually overnight, the statistics laid out in the report increased twofold the estimated number of orphans the epidemic was expected to produce in twenty-three nations: Brazil, Haiti, Thailand, Guyana, and nineteen sub–Saharan African countries. By extension, it also ratcheted up the orphan toll projected for nations such as India, Cambodia, and Vietnam, where increases in HIV incidence were just beginning to be significant.
“In Children on the Brink,” says Susan Hunter, coauthor of the report, “I took U.S. Census Bureau estimates of maternal orphans and expanded them to include the number of children in these countries who would likely lose their fathers—the paternal orphans.” Hunter is a medical anthropologist who, for more than a decade, has researched the crisis and managed field projects for such groups as Save the Children (UK), USAID, and UNICEF.

The inclusion of paternal orphans doubled the orphan tally, yielding numbers that reflected the harsh reality—and special nature—of this epidemic. Because HIV is sexually transmitted, the virus can easily be passed between spouses. Patterns of HIV infection and AIDS manifestation, in fact, bear this out. The effects of the epidemic often peak among males before they do among females, and the lag time between these peaks is indicative of infection moving from males to females. In developing countries especially, the loss of male members of a household is the first step in a family’s decline in welfare and security. When infection manifests itself in the mother, the family’s resources are further jeopardized. Loss of both parents usually completes the family’s slide to poverty and destitution.

For the twenty-three countries it examined, USAID’s Children on the Brink determined that the number of orphans (paternal, maternal, and both parents) could reach 40 million by the end of 2010. It also estimated that, by the end of 2000, in the nineteen African nations in that group, the orphan crisis would personally affect one in every five children under the age of fifteen, and, in some of these nations, one in every three such children. Says Hunter, “This isn’t an abstract issue for children in Africa.”

UNAIDS uses a more focused field for its estimates, including only children who will have lost their mother or both their parents to AIDS. It recently released estimates setting the worldwide number of orphans at 13 million. Of this estimate, 95 percent, or slightly more than 12 million orphans, are projected for the nations in sub–Saharan Africa.

Hunter continues, “When you look at 13 million [UNAIDS’ global estimates, 2000] and the 35 million orphans we project for the year 2000, you get a very different idea of the type of societal response needed—and you get very different individual responses. People either love or hate these numbers. Folks in Africa working on projects to help orphans love them because they reflect the reality in which they work every day. Policymakers tend to hate them because they reflect the yawning gap in service delivery they face every day as responsible public officials.”

Information that can help people in the United States comprehend the magnitude of the estimates from UNAIDS and USAID can be found in projections from the U.S. Census Bureau. According to their figures, 13 million men, women, and children will live in all six New England states by mid-year 2000. The figure of 35 million would add the populations of Oregon and New York to the list.

To those working to meet the needs of these millions, it is increasingly critical that governments and other decision-making groups translate the numbers into action. “What is absent is political will,” says Suzi Peel, executive director for the François-Xavier Bagnoud U.S. Foundation, a nongovernmental organization (NGO) dedicated to international humanitarian action, especially to issues concerning children orphaned by the AIDS epidemic and other global catastrophes. “Currently, there are thousands of examples of people coping, managing the crisis on a local level. Often it is just a question of scaling up.”

Assisting the Needs of Neighbors
One group that is very aware of the wealth of activity going on, and the difficulty of properly focusing government action on that activity, is the AIDS Foundation of South Africa. Through its fledgling orphans program, the foundation has been working to draw together structures and institutions operating within defined geographic regions to assist orphans within those regions. By doing so, the foundation hopes to build regional collaboration and to extend services without adding additional red tape.

“In African society,” says Debbie Mathew, NGO grants manager for the foundation, “people always have organized themselves. Centralizing efforts or creating new structures to deal with community activities will work for a short time. But it is not sustainable, and it is very costly. We know the response must come from the community, using existing community structures, and building on the community’s existing good will.”

Although her project is not one currently funded by the foundation, Mnqayi’s work with abandoned infants well illustrates Mathew’s point. Located in Melville Village, a semirural community near Stanger on the north coast of KwaZulu–Natal, the Othandweni (“Place of Love”) Children’s Home was founded a few years ago by Mnqayi and a handful of other women belonging to the Melville Community Development Group (MCDG). Although these women had already significantly contributed to their community, each was a teacher or nurse before retirement, they saw a need for a safe place for the area’s growing number of abandoned babies and they responded.

In Addis-Ababa, Ethiopia, a three-year-old girl orphaned by AIDS plays with a baby at the Mother Theresa home for HIV-infected mothers and children.

photo by L.Grubb/World Health Organization

“We have a rising unemployment rate, increasing poverty, increasing rates of divorce, and HIV infection,” says Mnqayi, project coordinator for the home for infants. “Many parents cannot give their children the medical care they need. Also, many cannot cope with the stigma that having HIV brings to the family. So they choose to abandon their babies at the Stanger Hospital. We take them in and give them tender loving care in a homelike environment.”

In 1995, the women of the MCDG established the Vulamehlu (“Love in Action”) Health Resource Center, an organization that has grown to include the Othandweni home; a home for older children; the Enduduzweni (“Place of Comfort”) Information and Drop-in Center, a walk-in center for information on sexually transmitted diseases, HIV, and tuberculosis; the Siphesihle (“An Ideal Gift”) Center, a rehab center for street boys; and an assortment of projects for the village’s needy: sewing classes, community gardens, adult education, and home-based care for those infected with HIV.

“Community stakeholders,” as Mnqayi, her fellow activists, hospital personnel, police, social workers, and others who hold together the human threads of a community are known, are crucial participants in what are increasingly considered to be the most viable, culturally relevant, sustainable efforts for helping orphaned children: community-based organizations. Throughout Africa, communities are organizing grassroots programs that seek to stabilize and strengthen the system of extended family, a system that has for centuries kept generations of orphans and other vulnerable members of communities safe, thriving, and within their midst.

“Despite the strain, the extended family in most countries in Africa is alive and well,” says Lloyd Feinberg, manager of USAID’s Displaced Children and Orphans Fund. “However, many poor families are being stressed to the breaking point. Our work in Malawi, Zambia, and other nations focuses on strengthening the responses of communities and families to the crisis and on helping them to respond to it in positive ways.”

In Zimbabwe, Prisca Nemapare, a researcher who heads up an Earthwatch project assessing the health, nutrition, and resources of AIDS orphans in that nation, became involved recently in one such local initiative.

“The leaders of the village came to us and asked us to help them work with the orphans in their community,” says Nemapare. “We helped them start some small business efforts—bricklaying, sewing, gardening—that involve the older orphans, those between the ages of twelve and eighteen. By building skills in these children, the village heads hope the orphans will increase their abilities to do things for themselves while remaining a part of the village.”
Keeping the orphans within the extended family of the village is the heart and soul of these and other community-based programs in Africa. In fact, discussions of orphanages and adoption, either in-country or international, are generally met with resistance. Orphanages are seen as destructive to the children and the culture, while fears of abuse and mistreatment of orphaned children plague discussions of adoption.

“Orphanages,” says Mathew, “are expensive to maintain and are socially and culturally alienating for the children.” John Williamson, senior technical advisor for USAID’s Displaced Children and Orphans Fund and coauthor of Children on the Brink, expresses a similar view. Having recently returned from a trip to Ethiopia where he assessed services for orphans and other vulnerable children, he reported, “Organizations that began providing institutional care for children orphaned by the drought of 1984–85 have seen them become dependent on having everything provided to them. They feel they do not have a place in society. Some have even lost the language they spoke when they were young.”

On the issue of adoption, a hot-button one for many people, Williamson takes a moderate approach, believing that formal adoption may have a role in the crisis but that that role will be inadequate to the need. For Nemapare, however, the possibility is unlikely no matter what the scale, “In Africa, there is huge cultural resistance to adoption.”

A Blueprint for Action
Despite near unanimity on the need to foster community-based responses to the orphan crisis, all efforts could be stopped by the question of how to act on it. Fortunately, as Peel notes, the knowledge for building on these efforts exists. “The studies of effective interventions have been done. We know what works and what doesn’t.”

Those studies have shown that community-based organizations must actively involve community stakeholders, must be cost-effective, must be sustainable, and must be collaborative—that is, they must be partnerships that allow the strengths of the partners to blossom but avoid imposing structure from the top down. In Children on the Brink, this approach is called, “building an enabling environment.”

For Mnqayi and her babies, however, what is required to ensure an enabling environment for their lives is far less involved. “If we could afford to hire a registered sister [nurse],” says Mnqayi, “we would qualify for the stipends the government gives those who care for foster children. And if we could afford to replace our cots and add some new ones, we could better care for our babies—and for one or two more.”

—Ann Menting is associate editor of the Harvard AIDS Review.