Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 240 - 259)



Mr Rowe

  240. Can I ask particularly Save the Children for their view of the use of infant formula as a substitute for breast milk for HIV positive mums?
  (Dr Webb) This is a minefield. The recent research is telling us that mixed infant feeding with breast feeding is more of a risk than exclusive breast feeding. That is interesting. The debate is shifting backwards and forwards. We tend to come back to the basic principle of the best interests of the child. The problem is that that is so context specific that in some contexts infant feeding might be the best solution; in other contexts where water is not clean and equipment is not sterile exclusive breast feeding is the best way. Overall, we would still advocate exclusive breast feeding until four to six months. Where you have adequate counselling services and antenatal services, you may get the aspects of informed choice for the mothers, particularly in places like South Africa now, but for the vast majority of mothers in Africa, for example, infant formula feeding is not the answer. We have to be very vigilant about this regarding the actions of certain infant formula companies.

Ms Kingham

  241. This is a question about systems of care provided for children who are orphaned through AIDS. To what extent are children cared for in institutions or through extended families or through alternative community support? Are AIDS orphans experiencing discrimination in provision of care when compared with other orphans?
  (Dr Webb) We did some work in Zambia a few years ago on this kind of breakdown of caring structures. 90/95 per cent of orphans will be absorbed by extended family members. They may move and they may migrate. We know there is a lot of migration related to that. Institutional care in the sub-Saharan Africa context is virtually non-existent. We would not ever encourage that anyway. The caring is being done by mainly the grandparents and it varies according to where you are. We would encourage the mechanisms which communities themselves identify for supporting these children. The households are very resilient but they do require external resources in looking after these children, child care training, additional funds, income generation. These are the critical things. The difficulty is in identifying these children and where they are and whether we want to make a distinction between an orphan and a non-orphan anyway. A label is not very helpful in many contexts. We prefer to talk about the increase in the number of vulnerable children. If you go into a community looking for the orphans, you will suddenly find there are three times as many as there were beforehand because you are implying that there is some kind of assistance coming their way. The big mistake that was made in sub-Saharan Africa is that enumerators went in, counted orphans, disappeared and there was no follow up support. The labelling of children and the categorisation of children according to presupposed vulnerabilities can be very counterproductive. We would encourage looking at the family support structure, rather than the categories of children by orphan status.
  (Ms Simms) I would support that. The term "orphan" as we know it does not apply in Africa because in most African cultures children belong to the extended family and not to their parents. If the parents die, they are automatically absorbed within the extended family. Laws often support that. The problem is not that there are orphans; it is when the family cannot afford to meet their basic needs. I did research in Lesotho looking at all the children in all the homes there. There were 309 children in homes at that time and only 6 per cent were orphans. The orphans were not there because they were orphans; they were there because of poverty and that was the case with nearly all the children in the homes. What is happening is that there are carers for these children—at least there were at that time and on the whole there are now—but they must have support in terms of supporting those children which could be income generating, for material aid and psychological support as well, possibly, but basically it is the income that they need.
  (Mr Gorman) Looking at the issue in terms of vulnerability is a helpful way of looking at it. One measure of vulnerability that we have noted in a number of African countries is that older, female-headed households are almost invariably extremely vulnerable. One way in which they are vulnerable is that older women left often without a husband, with orphaned grandchildren in the household, are required not only to care for those household members but also to go out and try to find work. We were talking before this morning about the kinds of things that women do. One of the easiest things is to work in the sex field. Even for older women, age is not a barrier in that respect. We are looking at not just HIV/AIDS; we are looking at the issue of household poverty and we need to look across the generations of household poverty and at what factors are pushing people from just keeping their heads above water into crisis situations or into chronic poverty, which older people themselves repeatedly will say, "We are handing down poverty from one generation to another." They are very well aware of their own situation.
  (Ms Simms) Although most children are cared for in the extended family, I do think the problem of institutions is an increasing one. This has been put to me, for example, by the Director of the Social Welfare Department in Lesotho. She is particularly concerned that this problem of institutions is increasing because that is the easiest thing to do when you have children in need, to collect them into a children's home. It is very expensive and very damaging in every way. She was saying that what we need is aid support to support our families so that the children are not coming into institutions. They are also getting sexual abuse in institutions now, which is increasingly a new problem which has raised its head. What they are asking for is resources for families. If children really cannot be in their families, let us have foster care systems, not institutions. It may be a small problem but it is increasing fast and it is very damaging and expensive.


  242. It coincides with the experience in this country, does it not?
  (Ms Simms) Yes.
  (Dr Webb) We have to make a distinction between institutions and transit homes. We do know that transit homes are very useful. That is where there are children who are literally abandoned and they will be looked after for a short term before being pushed out into foster communities. In the name of philanthropism, we are seeing foreign donors coming in, finding a village, collecting money from school children. The money gets given to the orphans in a village somewhere and an orphanage is built. The reason why this is happening is it is misguided philanthropism in the first place. It is well meant, but it is the absence of a policy framework which allows these things to happen, which can be counterproductive. As soon as one chief gets one, everybody wants one.

Mr Rowe

  243. Does Save the Children pay for foster care?
  (Dr Webb) No.

  244. The donors do not pay for foster care?
  (Dr Webb) We would not pay for foster care in the direct sense. We would not pay foster parents, if that is what you mean. We would support NGOs who are looking at ways of placing children within foster families. We have a programme in Kampala, for example, which is working with HIV widows in preparing for their deaths to get the children to participate in where they are going to live after their death.

  245. In this country, foster parents are paid. If it works in this country, listening to what Ms Simms says about families needing money, why do we not have a system whereby the donors pay for foster care?
  (Ms Simms) The first thing must be support financially for the extended family, rather than paying for foster care. If there really is not an extended family member, and that is very rare in Africa—

  246. In this country, extended families are often able to be paid as foster parents.
  (Ms Simms) This is what I mean: pay the extended family first and if there really is not an extended family member, then pay locally-based foster parents as your next step.

Ms Kingham

  247. You said that most children are cared for by extended families. We have had evidence from Professor Alan Whiteside which gave a different angle on that situation. He said, "There is a myth that the African extended family absorbs the orphans that are left . . . The idea that the household can cope is not the case. One of the whole emphases, particularly in southern African countries with rapid urbanisation, has been towards a more nuclear family. In a setting where you are living in a township house, it is not designed for an extended family, so we have some serious, serious problems there." Can I have your comments on that?
  (Dr Webb) I know Alan. He is speaking from a South African perspective anyway which is a different situation. Going over the Limpopo, you do find that extended families are coping to a very limited extent. You are not finding hordes of children wandering around aimlessly. You are seeing increasing numbers of street children, yes, but we have done surveys of those street children. Only between a third and a half are orphans and that is not massively more than the background child population. Poverty is the cause of that kind of thing. If we are looking at institutionalisation as an answer to that problem, I would not go down that route at all. We have to find ways of supporting communities and taking care of these children to prevent children becoming street children and abandoned in the first place. What we have tended to focus on in the past is addressing the end result of family breakdown. What has been lacking is the work in the communities to identify these children and strengthen the capacity to cope and keep the children in the communities. We are doing this work in Cambodia right now, even where the epidemic is still in its early stages. We are keeping the children in their communities during the dry season, for example, so they are not pushed out into a more vulnerable situation. This debate about whether extended families are breaking down or not has been going on for a long time. It is used as a flag to wave at meetings. The image of children running around city centres, of being abandoned, is a dangerous image. We have to focus on what is positive and what is doable.
  (Mr Gorman) I agree with much of that and I think I would somewhat take issue with what Alan Whiteside said because even in South Africa, even in urban situations in the townships, you do find very well developed family and community networks. One of the glues that holds that together is the fact that the South African Government pays an almost universal old age pension which is often the most considerable part of the household's income. That has both a positive and a negative effect for older people but it has been shown to be a very effective anti-poverty strategy because those older people use that money very strategically. They pay school fees with it; they start up micro enterprises for younger relatives and so on. They tide people over in terms of financial crisis. We can overdo the nuclearisation of the family argument. Migration has stretched families in lots of different ways. Geographically, they are moving apart. One of the problems that Francesca alluded to earlier on is the fact that migration into, say, a township in South Africa implies that the rural community, the rural family, the older person and the grandchildren that they may well be supporting are not receiving financial transfers to the extent that used to happen. Poverty is affecting all generations. The issue of family support is a very complex one. We need to keep on returning to two issues. One is the vulnerability issue. Who are the most vulnerable families? The other is the means by which we can respond to that vulnerability through putting in external support, rather than continuing with the debate on whether the family is disintegrating.

Mr Rowe

  248. I would be interested to know, if you are keeping children in their families in Cambodia, for example, what mechanism are you using? Are you giving them money? If you are not giving them money, what mechanism are you using, because this is a key issue.
  (Dr Webb) They go to the city during the dry season because there are employment opportunities in the city. What we have to do is not say, "Here is some money"; what we need to say is, "Here are some skills. Here are some opportunities for you to make money", which is a totally different thing. We are working with organisations to look at vocational training. We use market gardening quite a lot, bringing in skills from outside to get some basic skills in marketing. It does not take an awful lot to get the children to understand that life in the city is not so great anyway. Working with the community does give them the opportunities to stay there. That might be recreational activities but the most important thing is income generation activities. When we are talking about money, I do not think we are walking around with cheque books. We are talking about giving people the means to make a living or help the household economy where they actually are. The migration to make money is a very big problem and households will change their composition to maintain a dependency ratio. What we are finding is there is a big backwards and forwards migration between affected households of children and young adults to make sure the household can maintain itself. Once it does not maintain itself, it vanishes.
  (Ms Simms) I would support that. It is income-generating projects first. However, there may be a few who do actually need money because you are now getting elderly people looking after children and sometimes they have land and they just are not able to farm it. Also with some families, you may get an interim period where they need material aid before income-generating aid. When we are talking about extended families, Colin Murray has researched this in detail in southern Africa and does point to the fact that extended family networks are not breaking down. It is the transfer of money in between them that is decreasing and as a result there are an increasing number of families who therefore cannot support the basic needs of their children.


  249. It is the impoverishment that AIDS brings about which is really the crucial question?
  (Ms Simms) Yes.

Mr Worthington

  250. Can I ask questions relating to the status of children who are connected with HIV/AIDS, not that they necessarily themselves have the virus, but what legal difficulties do they experience? What stigma do they experience? What are the best strategies for overcoming this?
  (Dr Webb) The legal domain has not really touched on this area yet, as far as I am aware. It is still a very subtle, community, stigmatised thing. I was with some children in Kampala recently who do not know their status because they are in families affected by AIDS who openly come out. They have found that their biggest problem is with their peers and the school environment. The amount of psychological torment these children receive is quite horrendous in terms of their ability to mix with peers, accepting their own family status. Their self-esteem is completely ruined in many cases. A lot of younger children will only find out that they are orphans, for example, by being told by their peers or overhearing it in conversation. It is far more a case of the subtle psychology of discovering you are an orphan in the first place and getting to grips with being part of an affected family. This has massive implications for voluntary counselling and testing. The biggest problem with that is that young people, on the whole, do not want to know their status because they fear discrimination and rejection, like we all do when we are adolescents. In an HIV prevalent environment, that is the biggest fear for young people.

  251. Can you expand that a little bit? Say the child has lost one or both parents from AIDS. What is the peer group's explanation of what that means to the child who has had that loss? What is the form of that stigma? What is the explanation as to why he or she has been picked out?
  (Dr Webb) AIDS is a very stigmatised disease. We should not think the stigma is disappearing because of this. Children can be horrible to each other anyway, let alone given an excuse. It comes in different forms. More serious and more prone to our ability to intervene is the fact that children are being chased from school, for example, by teachers or there is a certain lack of sensitivity within the—

  252. Because it is contagious?
  (Dr Webb) No. We are talking about children who are of unknown status, more than likely negative, whose parents are ill or dying or dead. The first point of reference is that that child is an AIDS orphan and the problem is then that the foster parents, for example, are reluctant to pay school fees because they think the child is going to die, because they assume that the child is HIV positive. Any illness the child displays is assumed to be AIDS. This point about 30 per cent transmission: we might be able to talk about it here, but in the communities in many places if the parent dies the child is by connection infected. The stigma is often linked to assumed infection but also the fact that they are from a contaminated, polluted family environment.

  253. In the past, the disease you would compare it with would be something like leprosy?
  (Dr Webb) Yes. Every country has gone through the stages of classic denial and then acceptance. South east Asia is going through this right now.
  (Mr Gorman) You asked about the nature of stigma. It is important not to forget the care givers as well. This is something that affects whole families, not just children with AIDS and people with AIDS. We heard earlier on about the fear of stigmatisation and misreporting of death and so on. That certainly has been our experience both in Africa and Asia, that whole families fear stigmatisation. They internalise the shame. We were talking about religious support earlier on. I think I would support what our UNICEF colleagues were saying, that religion can be part of the problem because there is a tendency in some religious organisations and churches to stigmatise and blame and to impute HIV/AIDS to godlessness or to lack of faith. There is a whole range of pressures acting on whole families. We have come across this in running small counselling programmes with older people. The first thing they feel is shame. The second thing they admit to is ignorance. The third thing is they say, "I do not want to know any more about this disease." This is with older people who are care givers to people with AIDS. They simply want to screen it out. An enormous amount of that comes from outside stigmatisation and pressure that they feel from their communities. Communities are very supportive, in our experience, with families with illness until they discover that the illness is HIV/AIDS.
  (Ms Simms) What is so damaging is that the children suffer not only all the distress that other children whose parents and sibling die suffer, but also the stigma. Generally there are excellent informal African support systems for bereaved people. They are not being accessed by AIDS orphans and AIDS affected families because of the stigma.[10]

Ann Clwyd

  254. We have touched on quite a bit of this anyway. One of you said that South Africa pays an almost universal old age pension. Is the answer for the elderly to ensure that in every country that is the case? Are there other things that we should be exploring that you have not talked about already?
  (Mr Gorman) There is a raging debate as to how sustainable the South African pension system will be. It is a uniquely generous system in sub-Saharan Africa. There is room though for experimentation with different forms of payment, cash payment, maybe in kind payment through vouchers, for example. That is being experimented with in other circumstances in Africa, for payment for medical treatment, but there is also much that can be done with public financing, even at a very low level. The Indian Government, for example, pays a very small monthly pension to what they call destitutes and it reaches a very small proportion of the older population below the poverty line. It could reach more and it could be better targeted. It could also be paid in a different way. It is paid monthly at the moment. It could be paid annually at a critical time such as the end of the hungry season, for example. It could have a major impact, as we have seen the South African pension have on household economies at critical moments during the year. Overall, state pension systems unfortunately, in my view, are not going to be likely answers in developing countries but targeted payments in cash or kind could well have a role to play.

Ms Kingham

  255. The World Bank have been looking at these poverty reduction strategy papers and trying to encourage social safety nets within countries as part of their country plan. Are they looking at providing any kind of social service payments in relation to trying to give support networks in HIV/AIDS issues?
  (Mr Gorman) Not as far as I know but I have not dealt directly with the Bank. As part of an overall safety net strategy, it is certainly very vital and there are people in the Bank who may be interested not just in HIV/AIDS but looking at critical issues like health status and supporting that through a safety net system. I think that is to be encouraged and the Bank is really moving on it.

Ann Clwyd

  256. How would you sum up the impact of HIV/AIDS on the elderly in particular?
  (Mr Gorman) Older people are affected in a number of ways but the critical effect is that older people's start in life is that they are amongst the poorest in communities in sub-Saharan Africa and Asia. If additional burdens come into older person headed households, particularly female ones, we are seeing some of the things we were talking about earlier on: greater care giving responsibilities, reduced, ability to earn a living, to work on the land, to earn a basic income, which pushes people below that chronic poverty line into the crisis situation that many families affected by AIDS are facing. The other side of that is the impact it has on those older carers who have huge motivations to provide for younger relatives. They make enormous sacrifices to pay school fees, for example, but it is almost like the rainbow disappears. As they sell off an asset to pay the school fees, they find the fees have gone up. Then they have lost the asset, the piece of land, an animal, whatever it is that they have sold off, without the gain even of having their grandchildren complete a year of primary school. Nevertheless, there is a remarkably high incidence, in Uganda for example, of particularly older women managing to pay for grandchildren to get through the school year, but it means they do not eat or it means they go without light. It means that they are making strategic decisions about sacrifices for themselves.

  257. Do you think donors are sufficiently considering the elderly in their HIV/AIDS programmes and anti-poverty programmes?
  (Mr Gorman) No. At all levels, older people seem to disappear from over the horizon. There is a mention in the DFID memorandum of grandparent care but it is not followed up. It has to be seen very much in the household context. Older care givers and older people affected with AIDS are part of the equation and they need to be seen as part of that intergenerational household, not asking for special treatment but they are targeted appropriately as part of the household.

  258. Are there any examples of good practice which ought to be replicated elsewhere?
  (Mr Gorman) A very small number. For example, in Botswana, there have been some very successful experiments, pilot projects, looking at peer training, older people working with each other. They do not find it appropriate to work with younger people in training programmes but they do with their own peer groups. That has been shown to have an important knock-on effect in giving appropriate and accurate information to the younger generation. There is work going on in that field.

Mr Khabra

  259. Your organisation recommends that donors should support the direct and indirect school costs of orphans. What impact is HIV/AIDS having on the education of children? Are governments, donors and NGOs thinking innovatively on how to provide education when children are being withdrawn from school or schools are closing because there are too few teachers?
  (Dr Webb) The impact of AIDS on the education sector is probably the most critical sector that we have to address. That and the health sector are the two very difficult sectors to work in. What we are seeing is a contraction of education sectors. We are seeing very high mortality rates of teachers. In the most heavily affected countries, you are looking at 20-30 plus per cent of teachers HIV positive. Also, you are seeing a reduced demand for education from families who cannot afford to send their children to schools or that child labour is needed for other things as the children become producers in the household economy before their time. The other problem with that is, if we are trying to increase the capacity of the education sector to be an education tool for HIV/AIDS work, teachers themselves are in no position to be educators. We are seeing a decline in the health of teachers, the number of teachers and also the ability of them to be effective educators around HIV/AIDS issues as well as their normal curricular activities. We did some work with teachers in Zambia before. We found that we had to overcome their own attitudes towards the disease, their own insecurities about their own infection if they are seeing their colleagues dying off at an enormous rate. The experiences of Uganda are very interesting here because of the universal primary education. What we found there is that the quality of education is seriously under threat. The Government, in response to the impact of AIDS and the fact that children were being denied access to education, said that primary education should be provided for everybody, the first four children in each household and every orphan. The problem with that is that children become orphans when they are not orphans; households start making decisions about who gets access to education and we are hearing reports of class rooms of 200 children plus. In that context, where the quality of education is going down, the opportunity costs for the family of sending a child to school are going up. The sectoral response is very difficult when you have such high infection rates within the sector of staff itself. What is the answer? You train more teachers. You have improved teacher training curricula. Also, you look beyond the formal education structure. You have to look at community school development, vocational training for those children who are not going to be in the education system and make sure that the children are in some kind of training or education or at least busy. We must move away from this idea that every child must be educated because the sector simply cannot cope with this. We need innovative models of how to address the immediate needs of communities using the children and adolescents as a resource in a non-formal education environment because at the moment it really is under a lot of stress.

10   Note by witness: So one of the major things that must be tackled is community education concerning the needs and suffering of AIDS affected families and systematic work with communities to dissipate stigma and to elicit community support for these children and families. Back

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