Examination of Witnesses (Questions 1-19)
4 MAY 2004
MR DOUGLAS
WEBB, MRS
JOY MUGISHA,
MR PETER
MCDERMOTT
AND DR
STUART KEAN
Q1 Chairman: This is my first time in
the chair of a Select Committee, so you will forgive me if I am
a little bit nervous. My first pleasant duty is to welcome our
witnesses: Doug Webb, who is the HIV/AIDS Adviser for Save the
Children; Joy Mugisha, who is the UK Coordinator, Uganda Women's
Effort to Save Orphans; Peter McDermott from UNICEF; and last
but not least Dr Stuart Kean, HIV/AIDS Policy Adviser for World
Vision. Can I welcome you all to our hearings today on AIDS orphans.
I am very pleased that the Select Committee has decided to look
at what is a very important and of course, as we are all aware,
growing issue. The impact of HIV/AIDS on children, especially
in many of the sub-Saharan African countries, is very well documented,
and of course it represents a growing and serious challenge to
families and communities, and indeed societies and countries in
those regions. There are currently over 14 million children under
the age of 15 who have lost one or both parents to HIV/AIDS, and
the predictions are that those figures will have risen to 25 million
by 2010. Not surprisingly, many NGOs and governments are calling
for action. My first question is: how would you define an AIDS
orphan, and how are they identified? It is clearly a growing phenomenon,
but countries are having enormous difficulty dealing with actually
identifying what the numbers are. I wonder if anyone could answer
the question of whether orphaned children in Africa have been
orphaned because of HIV/AIDS or are there a larger percentage
who die from other causes? Who are the primary carers for these
children? Indeed, do they have carers? And what problems do they
face?
Mr Webb: I will take the first
question. The difficulties we have are 14 million children orphaned
by AIDS under the age of 15 at the moment, and we are going to
be looking at a total of about 25 million by 2010. The definition
is going to expand to include children aged under 18, which is
important to bear in mind regarding the human rights commitments
that have been made. 44 million orphans under the age of 18 by
2010 who are both AIDS and non-AIDS orphans, and what we do not
want to do is discriminate against these children by using the
phrase "AIDS orphans" in the first place; we would much
rather talk about Orphans and Vulnerable Children, or orphans
and children made vulnerable by AIDS. In terms of the definitions,
there are national definitions which we are working with, demographic
and health surveys to help with national level monitoring, which
does need international support on collecting such information
and using such information. The most important criteria for identifying
these children must come from the communities actually involved
in the pandemic itself, and we have all been working with organisations
on the ground to help them identify vulnerabilities of families
who are affected, not always by AIDS, and we have to stress that
AIDS is a factor amongst others—poverty and nutrition. So
while we have the label of "AIDS orphans" we would much
rather not discriminate in that way. The question about carers,
it varies, but it is mainly grandparents: mainly grandparents,
aunties, uncles, a whole plethora of carers across the extended
family, where the systems are being stressed. The final point
about AIDS as a cause of death: about half of children in about
15 years' time will be orphaned by AIDS in Africa, but again we
must stress that we do not want to target those children specifically,
and we must talk about all children who are vulnerable.
Q2 Chairman: Would you say that children
orphaned because of AIDS or HIV are stigmatised in general terms,
or is that more of a problem in certain countries than it is in
others?
Mr Webb: I will quickly say something
and then maybe Joy could say something. If you use the phrase
"AIDS orphan" the immediate thing that comes to people's
mind is an orphan who has AIDS, so we just do not use it. Most
children will not know their status, so very often the definition
of AIDS in children is actually a difficult starting point.
Mrs Mugisha: In most of the communities
orphans are not stigmatised; they treat them as children. In most
African communities words like "orphans" did not exist.
If your mother or father died your next-of-kin, your relatives,
looked after you. In most African communities the word "orphan"
is not referred to, even previously, but it has come to everybody's
attention now because of the numbers. The communities will protect
these children, and they will not want to stigmatise them. That
is why they take the responsibility of caring for them, so that
they are protected. The only problem is that most of these families
are poor and are spread out, so when you take on another ten children
you are already poor, and the whole business becomes very, very
difficult. There is willingness to care for these orphans in the
communities, but it is the financial implications, ensuring that
the children go to school, they have the medical care, they grow
up like other children, they are protected, some of the communities
are finding it very difficult.
Q3 Mr Robathan: Can I come to something
Mr Webb said? I think I am right in saying you said that in 15
years' time half of all children will be orphaned by AIDS?
Mr Webb: No.
Q4 Mr Robathan: Did you mean half of
all orphans, or as a result of AIDS? OK. Sorry, that is just to
clarify. Then what I would like to ask beyond that is, apart from
the possibility and the fact that many of these children will
be HIV positive themselves, apart from that what is the difference
in terms of care and treatment that a child orphaned by AIDS requires
to the other half of children that are not orphaned by AIDS?
Mr Webb: There are three main
things. One is they are likely to be double orphans, so the care
and protection of them is going to be different from a child who
is orphaned from other causes; the whole familial structure is
going to be very, very different. The other major aspect will
be that the child is likely to move; if both parents are dead,
they are going to be moving to another household. There are all
the social implications about remigration, relocation. The third
element is that the psychological profile of these children is
likely to be more affected. Watching your parents die is a traumatic
event for any child, and we know that the children will likely
show depressive disorders throughout their childhood and into
adolescence and adulthood. So there is a psychological profile
which needs stressing, which really requires a response of psychosocial
support, what we call the basic engagement of children, making
sure they are included in community responses, and that their
health needs are met, as a priority, but also their social needs—bonding
and communication with other children and adults.
Mr McDermott: First of all, Madam
Chair, let me congratulate you on the assumption of your chair.
On the numbers, I think there are a couple of points I would like
to make, if I may. One is that although the numbers are huge so
far—11 out of the 14 million in sub-Saharan Africa—the
issue is the magnitude of the problem; worse is yet to come. We
have an opportunity to be out in front of the curve at the moment.
If you look at Uganda currently, where the rates of infection
have dropped quite precipitously down to 5 or 6% over the last
decade, it is only now that we are seeing the plateauing out of
orphanhood in that country, so we have the decade-long lag of
response. The second issue is that the vast majority of countries
which are the most impacted currently in the sub-Saharan belt
are the very, very countries that have the least capacity to deal
with the problem. They have poor health infrastructure, they have
the rudimentary education structure, they have human capacity
deficits and they have limited financial resources. So the very
countries that have the biggest burden have the least ability
to respond, and yet the worst is to come: the numbers are going
to be much, much bigger in a decade and two decades to come. We
are used as responders to dealing with short sharp shocks; we
are not very good at planning generational programmes, and that
is one of the dilemmas that we have.
Q5 Chairman: We hear a lot now about
child-headed families with regard to AIDS orphans, but in fact
none of you have mentioned that; you are rather talking about
the fact that within the many extended families that you find
in Africa, which is part of African culture, that where a child
has lost both parents they are more likely to go and live with
a relative or somebody else in the village. So do child-headed
families exist, and are they in the minority or majority?
Mrs Mugisha: They exist. They
are in a minority, but they exist. In some areas you find that
the uncle has died and the cousin has died, and many in the homestead
have died, and 13-year-old girls and boys are left with the responsibility
of looking after their siblings; and perhaps there is nobody who
can take on them all, or maybe they want to stay together, live
together and be supported. The community still has the responsibility,
even if they stay in their homestead, to look after them, to ensure
they go to school, and so on. So some of them are better off staying
together but being supported.
Mr McDermott: The recent UNICEF
publication Africa's Orphaned Generation estimates that
about 1% of orphans currently are child-headed households. That
is not a large number, but in fact there has been a sharp increase
in some countries over the last few years, so it is a concern.
Perhaps the other point I would like to make is that the situation
of children affected by AIDS and orphans is not a singularly sub-Saharan
Africa problem. Clearly that is where the pandemic has been at
the greatest for the last decade or two decades, and it is an
area, as I said earlier, where they have the least capacity to
cope, but if you look at the areas of greatest threat some are
in your back door: Estonia, Ukraine, Russia, and then of course
India and China. So we have a globalisation of the problem, and
I think that we must not under-estimate that the situation of
children affected by HIV/AIDS, including orphanhood, will increase
and become a global phenomenon. Of course the different responses
will therefore vary, because in Africa the reason we have not
had a catastrophe of greater proportions to date is because of
the extended family, but that is under threat. That may not be
a safety net that we have the advantage of in other parts of the
world.
Q6 Chairman: Dr Kean, do you have anything
to add to that?
Dr Kean: No. I think this is something
that is clearly a critical question and it is one that a number
of agencies are trying to make sure that there are specific interventions
that are looking at supporting children and child-headed households;
but I will leave that for now.
Q7 Chairman: So really what you are saying
is that where there are countries where the extended family network
has ceased to exist, and where there are not social security safety
networks—let us take the former Eastern Bloc countries—there
could be a very major problem with who cares for AIDS orphans?
Mr Webb: Yes. 90% of these children
still live with family members. You are finding far more households
falling apart or being completely recompositioned than you do
child-headed households. As Joy says, when you have a child-headed
household very often it is in connection with other supporters;
but we are finding that when these households cease to exist,
so you do not see them at all, children will be migrating, and
we have just done some work in Swaziland showing that in a community
we found twice as many girl orphans as we did boy orphans, the
reason being because the boys orphans had migrated out of the
village and were living probably on the streets in the informal
sector. So the support networks must be to the whole community
rather than just to individual families.
Q8 Hugh Bayley: I would like to move
on to the issue of prevention and treatment. Do any of you have
an estimate of the relative cost of buying one extra AIDS-symptom-free
year of life from prevention on the one hand, as opposed to treatment
on the other? Who has done work on the health economics of to
how to respond to the pandemic?
Mr Webb: Everybody is looking
at me. It is far more cost-effective to prevent infection; there
is no doubt about it. It is difficult to prevent infection. If
you look at the costing across the spectrum from primary prevention
of infection through to supporting the mother, if the mother is
infected, infecting the child, through to supporting a patient
over a long period of time, treatment, to supporting the whole
family ad infinitum with treatment and care, then you are
probably talking about a 10- to 15-fold differential. There are
different figures coming from each specific context. To keep a
patient on anti-retroviral therapy for a year you are talking
about between $300 and $600, once you have added the drugs for
management. So in terms of cost-effectiveness, prevention still
must be absolutely critical, but now we have availabilities of
treatment it is bringing those into the picture without shifting
resources away from prevention.
Q9 Hugh Bayley: The last part of your
question is the critical one. Is the WHO's "3 by 5"
target likely to be met, and given the levels of funding we have
at the moment would it be a good thing if it was met, or would
it simply leach out resources which could be more cost-effectively
used to save lives through a mixture of prevention and treatment?
Mr Webb: Very quickly, the target
probably will not be met, but that is not the point. The point
is expanded access to care and treatment, and resources for that
must be additional, so we are not talking about moving money from
one place to another. If donors actually are seen to be moving
money out of prevention into treatment they will be hammered.
The other thing is that good treatment and good care for anti-retroviral
therapy and for other opportunistic infections is good prevention;
we would not dissociate those two things. So keeping people alive,
knowing their status, supporting them and their families, is actually
very effective prevention work as well.
Dr Kean: I just want to say I
think we have been talking about the whole epidemic spreading
to other parts of the world, but this is why prevention must be
the focus in Eastern Europe and Asia, because we can actually
prevent this from becoming a crisis. I think the example of Brazil
is very interesting here, where because treatment has gone side
by side with prevention, we have actually had fewer deaths and
obviously then fewer orphans as a result. So I think in terms
of the balance between prevention and treatment, it must be a
comprehensive package, and we have to, where we can, probably
the same as other countries, give greater emphasis to prevention
than treatment at this stage.
Mr McDermott: I would like to
come in on two points. One is that WHO/UNAIDS have published in
The Lancet some historic data on the relative costs of
both prevention and treatment, but that has changed quite dramatically
in the last year with the reduction in the anti-retrovirals, and
certainly we can make those estimates available to you. One aspect,
if we could just bring this back to the orphan situation, if I
may, the best thing we can do for a child is to keep the parent
alive, and as much as we need this balance between prevention
and treatment—and it will change according to the level
of prevalence in the country whether you invest more in prevention
or in treatment—if we can keep the mother or the parents
of a child alive longer, that is the best thing that we can do
for a child, which is one reason why we are perhaps so aggressively
advocating to make sure that mothers in particular are at the
front end of the queue on any treatment that is being made available,
so that we can have the burden of orphanhood being looked after
by the mother herself, once she is rehabilitated.
Dr Kean: Can I come in again?
On the case of treatment I think we should not get fixated on
the whole anti-retroviral treatment, but also the importance of
being able to look after children and deal with opportunistic
infections, so that we have a broader range of health treatments.
I am pleased to see in DFID's evidence to the Committee that they
are looking at a number of possibilities, abolition of charges—but
in particular the health charges have not been included, and those
are going to be prohibitive for family members trying to get healthcare
for children orphaned by HIV/AIDS. So it is an important element
that should be included in the HIV/AIDS strategy.
Q10 Hugh Bayley: I would agree with you
that if you are going to set priorities one of the priorities
must be to keep at least one parent, the mother, alive while a
child is growing up. Even if three million are receiving treatment
in a year's time there will still be 17, 18, 19 million who are
not. So you will need a series, not just one priority but a series
of very clear criteria about who you treat. For instance, you
might decide that the treating of opportunistic infections is
a better thing to do, because you gain more years of life for
parents with children by doing that than through anti-retroviral
therapy. So, to what extent have people drawn up a list of criteria
so there are clear and transparent rules about who gets treatment,
and who should be doing that? Should it be the community, should
it be the government in the African country, should it be the
WHO setting guidelines? Because if it does not happen, we know
what will happen: men in the towns will get the drugs.
Mr Webb: I think just quickly
on that, the Indians have set a very good example by actually
stating as policy that women and children will be first on that
treatment list; so I think in terms of a national government taking
that stance, that is the first one I am aware of. We certainly
do want to avoid a triage situation where you have some kind of
selection mechanism. We want to try and avoid that as much as
we can.
Q11 Hugh Bayley: You cannot avoid it.
If you are treating 3 million out of 20 million you have to make
choices. Surely you need to be making the right choices, not saying
"We're not going to make choices and it's going to be a free-for-all".
Mr Webb: The point is how to access
the individuals. Ninety per cent of individuals do not know their
status. Not everybody with HIV needs anti-retroviral therapy.
Once you start bringing all these factors into play the numbers
are not as great as they initially would seem. How do you get
people to go voluntary counselling and testing, which is the main
entry point? How do you get more women to enrol in child transmission
interventions at antenatal clinics? How do you get more people
to disclose the status to their family members? We know how to
access these people, and it is scaling up those responses, and
if that is done appropriately then we can actually reach those
targets. It is those existing mechanisms on the ground which will
help us avoid any kind of triage situation.
Q12 Hugh Bayley: Let me ask one thing
of Joy, and this really is my last point. If these difficult decisions
do have to be made, how in Africa and Uganda could you create
a situation where the public has a say over priorities, and that
people generally accept the rules that are laid down? It is very
difficult to accept when it is life or death for you personally,
but somebody has to set the rules.
Mrs Mugisha: I think the government
can take the lead, and heads of communities can also help—the
religious leaders, heads of communities, NGOs, people who are
already working with orphans or AIDS-related organisations can
also help. It is not that there are no centres where people can
go; these centres can be created; but if they go, do they get
help? The centres must be equipped to help people affected by
HIV/AIDS. We must be careful not to give desperate people false
hope.
Q13 Mr Colman: Assuming the therapy has
been used and the child has been born free of HIV/AIDS, could
you comment as a panel in terms of the two other threats that
there are, if you like, to the potential orphan. I agree with
my colleagues that the priority should be for the mother to get
the ARVs, but the potential in terms of the mother's breast milk
reinfecting the child and the availability of baby milk powder
for use, and secondly, to ensure that any subsequent vaccination
of the child is done with a single-use injectable rather than
has been done in the past, where there has been a high level of
HIV infection of children through, if you like, the good works
of people who have not insisted on single use. The figures vary,
but I think UNICEF agree that potentially 5% of children have
subsequently been infected by HIV/AIDS—but there are higher
numbers put about by some American NGOs, up to 35%. So two questions
in terms of protecting children born without HIV/AIDS: one, provision
of baby milk powder to ensure that the baby does not get infected
by the mother; and secondly, protection to ensure that any vaccinations
are not going to cause infection with HIV/AIDS.
Mr McDermott: Thank you very much.
We have had this conversation before.
Q14 Mr Colman: We have indeed.
Mr McDermott: And I thank you
for raising it, because I think both points are very, very valid,
and you have made us, UNICEF, and many other agencies, go back
time and again to look at this. There is some very exciting news
coming out, probably at the Bangkok conference, regarding some
of the latest studies from Zimbabwe on this, and I did send the
honourable member some information earlier. We originally reduced
transmission from mother to child with Nevirapine quite dramatically
following the Uganda study. It is quite clear now that if you
combine Nevirapine with an AZT you can reduce the infection rate
even further; but clearly there will still be a number of children
who are born positive, or those who are born negative have the
potential to be reinfected or infected through breastfeeding;
it is a real concern. The issue really then becomes balance of
risk, and the balance of risk of providing formula and 20 or 30
years of evidence as to the risk factors of applying formula in
a non-hygienic, clean manner, wrong dose, etc, and the child getting
ill, but there has also been a risk factor that we have now measured
as to what happens if a child gets formula, what happens if a
child only breastfeeds, and what happens if a child gets a mixture—this
leakage issue—of formula and breastfeeding. We have done
the modelling, and it is quite clear that the worst option for
the child is having formula and breastfeeding and having the mixed
feeding. It raises the infection potential rates quite significantly.
So clearly we are moving. It is also clear on modelling that,
depending on the level of clean water and infrastructure and the
mother's knowledge, you can actually reduce breastfeeding infection
rates through exclusive breastfeeding quite dramatically. The
evidence that is coming out from this 12,000-mother cohort that
will be, I think, presented in Bangkok or soon after, shows that
counselling of mothers on safe breastfeeding actually provides
huge gains, and we can now, importantly, prove that. However,
clearly in some circumstances the mother has the choice, if counselled,
and certain countries are availing themselves of infant feeding.
I think that the issue then comes down to country-specific balance
of risk according to existing evidence, and that is where we are.
On your second point—and I think this is something to your
credit, and others'—I think we have historically under-estimated
the contamination through safe injection practices. South Africa
and other countries I think have shown that now, that we have
had significantly higher infection rates than we should have done,
and the WHO has done a lot of work in the last year trying to
revise standards of safe needle practice. UNICEF and others have
policies, as you know, of disposable syringes being the norm;
but countries have the opportunity to buy from whatever source
they wish; they do not have to buy through international procurement.
The other issue is to make sure that health workers, especially
in the periphery, but also in the private sector, realise the
significant infection potential for re-using needles.
Dr Kean: Just on this issue of
children and ARVs, the importance of research to be done should
be recognised and funded, probably publicly funded, on paediatric
formulations, certain children's formulations, so that they are
able to take the ARVs.
Q15 Chairman: On the point of how do
we try and prevent further deterioration, the issue of the balance
between treatment and prevention, you are well aware, I am sure,
like we all are, there are very separate funding streams for HIV/AIDS
and for reproductive health. I wondered whether perhaps you could
comment on why there has been so little linkage between those
two funding streams, because it would seem to me that even in
some of the most poor countries there is a basic network to deliver
some semblance of reproductive health, family planning, where
there may be no network at all to deliver for HIV/AIDS prevention,
and yet the funding streams are separate and there seems to be
a completely separate delivery system, although they move in parallel,
which seems to me a very bad use of resources. I wondered if you
could comment on that?
Mr Webb: Just one comment. I will
not talk about funding streams, but the importance is of the national
ownership of a strategy which is comprehensive, and a good national
strategic framework for a good HIV/AIDS response incorporates
all the elements of sexual reproductive health within it. So we
are trying to move away from this division, and I know there has
been debate in the House before on this. But if we are trying
to make sure that on the ground there is an integration, it is
working with national governments to ensure that all the elements
of a reproductive health nature have been included, how do we
actually get HIV funding to push part of the primary healthcare
system? The fund developed over the last 30 years—there
is an opportunity there but it needs to be planned effectively
at country level, and donors need support.
Mrs Mugisha: When AIDS started,
there were no drugs, so most of the work was in prevention, so
it was other methods that each country used for prevention. By
the time the drugs were introduced individual organisations did
not have the capacity to administer the drugs, only relevant Ministries
or NGOs were able to provide the drugs for controlling HIV/AIDS
effectively. Now some of the governments, at least in Uganda,
are trying to have a strategic plan where the two will work together.
Mr McDermott: I think also UNAIDS
is doing quite a lot of work around this. There was the meeting
in advance last Sunday of the IMF/World Bank meeting in Washington,
where the international donor community and member states got
together and really they are trying to come up with a global consensus
which I think for the most part is there, around three things—they
are called the three ones: that there would be one plan in a country—not
a reproductive health plan and an AIDS plan and a health plan,
but there would be one plan that everybody supports. Secondly,
there would be one coordinating mechanism, so that we are not
having different donors coming in with their own pots of money
having their own mechanisms for coordination. It sounds eminent
common-sense, but sometimes it is not so easy to apply. The third
one is to have one monitoring evaluation system, so not everybody
is running around the country trying to do reports for themselves.
To the UK Government's and DFID's credit they have often been
the champion of such common-sense approaches. Not everybody has
always listened, but I am pleased to say that under UN leadership—UNAIDS'
leadership—there seems to be a growing consensus. I think
for certain big players on the HIV/AIDS field it is slightly more
difficult than others, but at least there is a commitment in principle
to this.
Dr Kean: Can I just add to that?
The key strategic framework that Peter mentions is now an internationally
agreed framework for how to respond to the whole crisis of children
orphaned and made vulnerable by HIV/AIDS, and what we are looking
for now is to try and make sure that the whole international community
does get behind this. This now represents taking forward the UNGASS
commitments from 2001 and articles 65, 66, 67 and 68 which relate
to this, and these are commitments that all governments have signed
up to. This now represents the best practice and opportunities
for rolling out a totally integrated common practice for that.
So what we are now looking for is obviously for the UK Government
to not just sign up to it, but make specific policy commitments
and measurable targets and resources to implement that.
Q16 Chairman: It is music to my ears.
I am curious as to who you are referring to when you talk about
big players, because the country that looms most in my mind when
we are talking about these issues is the United States, who are
of course the biggest donor in terms of HIV/AIDS, but seem to
be stopping delivery of condoms and other commodities to NGOs
and others who are working in the field of reproductive health
because they do not like their—not support for abortion,
but are working in areas where if abortion is legal in the country,
they continue to work and practise. I think there is a real issue
there of the big donors giving with one hand and taking away with
the other. So I am very interested in who you do mean by the big
players, and if you do mean the United States, can you tell me
how you are going to convince them that the policies that DFID
are encouraging are the right and sensible ones?
Mr McDermott: I
may be in a unique position to answer that question. I think,
first of all, there are a number of big players out there. We
now have the global fund for AIDS, malaria and TB which is generating
huge resources, and it has set up a country consultation mechanism.
We have the World Bank—the Chancellor of the Exchequer himself
is the chair of the Programme Committee—also putting a billion
dollars, and perhaps more now, for grants for HIV/AIDS, setting
up these mechanisms at country level. We do indeed have the US
Government, but we also have the EU initiative on AIDS at country
level. So there are a number of competing entities, it is not
a single entity, but the issue is to get the cohesion between
those various parties to make sure that if there is a national
plan, they are coming in behind the national plan and not trying
to do something that is duplicative or even diverting. I think
that is one point. On the US, I think clearly the US Government
is in a position to answer for itself, and it obviously does not
need a ventriloquist; but I think what some people forget is that
to date, along with DFID, it is probably the highest procurer
and distributor of condoms in the world. So I think we need to
balance perhaps some of the more recent ideological shifts along
with their traditional practice. I think it would be very interesting
to see what the outcome of the US Government/USAID/DFID consultations
of two weeks ago were, where they sat around a table for two days
and looked at health, reproductive health and child survival in
HIV/AIDS to see where there was a common agreement and where there
might be a work in progress.
Q17 Chairman: Last comment, and then
I think we should move on.
Mr Webb: Just quickly, we are
being shamed to a certain extent by the American Government at
the moment, and I think that is important. We can criticise the
American policy on specific areas within a huge intervention,
but until we actually start putting commensurate resources on
the table we are actually in no position to start criticising
their policy. So with the DFID response, it is there, but it needs
to be jacked up enormously; but the most important thing is the
entry point of the EU and the G8 discussions next year. Frankly,
we are kind of tired of hearing about the criticisms of American
policy when we are not actually on the same playing surface regarding
the resources that are being put forward. So while we can criticise
all day, it is not the starting point, and as Peter has said,
there are dialogues, there is a task force that has been set up.
What I would like to see, there is a Bill in Congress going through
on AIDS-affected children which could raise another $3 billion
per year. We are seeing Congress and the Senate moving forward
very quickly as well as USAID and we are not seeing a parliamentary
response to DFID on the same scale. I think that is important.
Mr McDermott: Of the $15 billion
that is on the table under the new presidential initiative for
emergency relief, the US Government has earmarked 10% of that
fund for Orphans and Vulnerable Children currently, notwithstanding
the additional Bill that is before the House. No other country
in the world has earmarked a dedicated amount even to that level,
or to any other level, and when we had this global partners' meeting
on "What are we going to do about orphans?" last year,
it was somewhat embarrassing that only one country in the world
has actually dedicated funds for Orphans and Vulnerable Children,
including infected children, which we feel is really an untenable
position to be in as an international community.
Q18 Mr Robathan: Work actually needs
to be done—this is what I want to ask Joy—focusing
on the lives of this growing number of very unfortunate children,
90% of whom we understand live in extended families, some of whom
live in child-headed households. Either in terms of aid or in
terms of government action, what more can be done, what should
be done, to help the families looking after these orphans? To
use the jargon, how can the capacity of the families be strengthened?—because
it must be quite a shock, with the scale of the number of children
involved, and it is indeed already undermining a lot of these
families. So what more can we do? Whilst on the same question,
what more can we do to assist child-headed households?
Mrs Mugisha: Most of these communities
who take on these children are very poor. They live in rural areas,
and they need economic support. Also in other areas some of the
children are actually taken on by grandparents; the people who
care for them are very elderly, they are in their seventies So
what each of the agencies do, they economically support those
families so they can look after the children they have taken on.
For example, in the case of Uganda, most rural communities are
farmers, so you can help them to improve their farming, provide
them with an extension worker, tools, inputs, whatever is required
to improve the economic status of the individual families. They
will tell you, and you can see for yourself, how each family can
be improved. It is not that difficult a thing to do. Most of these
agencies have extension workers in these communities. Children
are identified and placed in foster families, so it is not difficult
actually to identify the way these families can be helped economically.
There should be free primary education; that is already happening
in Uganda, but maybe it is not happening in every country. If
they drop out of school they can be helped with vocational training,
so that they do not have to drift to town centres and become street
children. The good news is that the families are willing, and
the amount of money that you need to invest to help these families
is not a lot. They want to expand on what they are already doing,
and the children will be provided with school fees, clothing etc.
For child-headed families it is the same thing: they will need
to go to school, they will need clothing, etc. The economic factor
is very, very important in AIDS, because in Africa where some
of the families are poor and they have to be supported, AIDS goes
hand in hand with economic factors, nutrition. I do not know if
I have answered your question.
Q19 Mr Robathan: You have, extremely
well.
Dr Kean: There are a couple of
things I would mention there: the importance of care-givers within
the community to actually come alongside and support the people
looking after the orphans. You actually can get coalitions of
community helpers coming together and being able to provide support,
and monitoring the status of the orphans, providing things like
social support, providing the opportunity to develop wills and
succession planning. The important thing is really for these intermediary
groups within the community, the community-based organisations,
to be resourced. The problem that the World Bank has already identified
is that these community-based organisations are not actually getting
access to resources. Many of them are faith-based organisations,
and they lack in particular the organisational capacity to be
able to tap the level of funds that are available that require
particular reporting systems. So we have had requests from many
of these community-based organisations to simplify the procedures
for proposal writing and for reporting, to enable the community-based
organisations to work more effectively. There is a tremendous
amount of support that is being provided, which in turn now needs
to be resourced externally.
|
