9. Memorandum submitted by the Centre
for International Child Health, Institute of Child Health
ORPHANS IN SUB-SAHARAN AFRICA
PREVALENCE OF
ORPHANS
At present there are approximately 11 million
orphans under 15 years in Sub Saharan Africa and approximately
15% of them are under five years (1.65 million) and 35% (3.85
million) are aged between five to nine years (USAID, UNAIDS, UNICEF
2002). In addition, many children are living with HIV infected
parents and not receiving adequate care. In the four worst affected
countries more than 20% of children younger than 15 years are
orphans. In countries where the numbers are large, the welfare,
health and development of these children are critical not only
for the individuals but for long term national development. The
number of orphans is predicted to almost double to 20 million
by 2010.
DISADVANTAGES ASSOCIATED
WITH ORPHANHOOD
The overwhelming majority of orphans are looked
after by extended family members. Traditionally paternal uncles
looked after orphans, however, following the increase in numbers
and the break down of traditional family units, more orphans are
looked after by grandmothers who are often ill equipped to cope.
Families who take in orphans often tend to be more disadvantaged
than other families. They are poorer than other households, tend
to be female headed and have a higher ratio of children to adults.
A minority of orphans live in child headed households and are
at particular risk (USAID, UNAIDS, UNICEF 2002).
It is well established that in addition to losing
their parents, orphans suffer from many stressors that further
increase the risk to normal, healthy development (UNICEF, UNAIDS
2003). To list a few of them: compared with non-orphans, orphans
usually come from poorer homes, experience poorer health care,
are less likely to go to school and are exposed to stigma. They
are more likely to be separated from siblings and have multiple
changes of caretakers. Many have lived with terminally ill parents
for some time with unknown effects on their development. Their
caretakers tend to be older or younger than other caretakers and
are also more likely to be poor and have limited available time
and energy for childcare. It is clear that some of the most vulnerable
young children are orphans and children living with infected parents
ill or infected themselves.
NEED FOR
INFORMATION
In spite of the increasing size of the problem
there is limited information on these children's welfare and extremely
little on their psychosocial functioning (Foster and Williamson
2000). There is also extremely little information on the welfare
of the orphans' caretakers. The Centre for International Child
Health at the Institute of Child Health has recently provided
some unique data, which is reported below (Makame et al).
There is also new information on nutritional
status and demography from Kenya. Orphaned children below five
years may be well nourished but a disturbingly large number of
girl orphans migrate to towns (mostly as cheap labour) (Tomkins
in preparation).
RESEARCH BY
THE INSTITUTE
OF CHILD
HEALTH (ICH) WITH
ORPHANS
The Centre for International Child Health has
immense experience of conducting research with children in Africa.
We have a special interest in the welfare of orphans and have
recently conducted two projects in Tanzania (Makame et al,
2002) and Mozambique (Libombo et al 2004). In both countries
we compared 10 to 14 year old orphans with non-orphans the same
age and sex and living near by.
Tanzania
In Dar-es-Salaam we found that most orphans
lived with aunts and uncles. Compared with non-orphans, they were
significantly less likely to be in school and more likely to go
to bed hungry. Orphans were markedly more depressed and anxious
than non-orphans and 34% reported they had contemplated suicide
in the last year. In addition to being an orphan, sex (females
higher than males), going to bed hungry, not being praised for
good behaviour and not currently attending school made independent
contributions to the children's depression.
Mozambique
We examined the children's environment more
extensively in rural Mozambique where we also studied the orphans'
caregivers. Orphans lived mainly with grandparents or other adult
relatives. Compared with non-orphans the orphans had many more
economic disadvantages, only 63% attended school compared with
95% of non-orphans. They had fewer clothes and personal possessions
and experienced hunger more often. As many as 56% went to bed
hungry two nights or more a week. Furthermore, they also experienced
many psychosocial problems, they were more likely to be bullied,
had less time to play, were also more likely to feel resentful
towards an adult at home and less likely to know an adult they
trusted.
Orphans were markedly more depressed than non-orphans.
In addition to being an orphan, being bullied, going to bed hungry,
resenting an adult at home, and receiving punishment that they
thought unjustified, all contributed to their depression. An important
finding was that some of the stressors such as going to bed hungry
and receiving punishment that they thought unjustified had a much
greater effect on depression in orphans than in non-orphans. This
indicates that orphans are more vulnerable to stressors than non-orphans.
The orphans' caregivers were also markedly more
depressed than other caretakers. They felt isolated and had less
support from friends and relatives than non-orphan caregivers.
Their economic situation added to their depression.
When orphans were asked about their main problems
in addition to grief over the loss of their parents, 66% mentioned
hunger, 21% mentioned rejection by peers and 24% the lack of a
caring adult.
In conclusion, both studies indicate that orphans'
psychosocial development is poor and their long term development
is in jeopardy. Both guardians and orphans feel isolated and need
social support and counselling as well as assistance with basic
needs. At the same time, simple measures such as facilitating
school attendance and relieving hunger should help.
EVALUATION OF
INTERVENTIONS
There are many local and international efforts
to assist orphans, however they are only reaching a small proportion
of them. Most NGOs have little experience in assisting orphans
and there is an urgent need to determine which approaches are
effective. Some international NGOs have begun residential children's
homes and this is not only an extremely expensive form of care
but highly unlikely to benefit the children's development. It
is accepted that efforts should be directed towards strengthening
the extended family, the traditional way of caring for orphans
(UNICEF, USAIDS 2003, Foster et al 1996). Other NGOs have
a policy of only helping children with parents (eg, Plan International)
and this should be changed to meet the current crisis. Existing
evaluations usually describe the process but we have no idea if
they are effective. At best the programme's feasibility and acceptability
by the community is reported (eg, Lusk et al 2003) but
the impact on children's development or caretakers' wellbeing
is not assessed. There is an urgent need not only to expand interventions
but also to carry out careful evaluations to provide information
on the most effective approaches. ICH would be willing to assist
with this.
REFERENCES
Foster, G, Makufa, C, Drew, R, Kambeu, S, Saukombe,
K. Supporting children in need through a community-based orphan
visiting programme. AIDS CARE 8:389-403. 1996.
Foster G, Williamson J. A review of current
literature on the impact of HIV/AIDS on children in sub-Saharan
Africa. AIDS 14, S275-S284, 2000.
Libombo P. MSc Thesis Institute of Child
Health, University College London 2002.
Lusk D, Mararu J, O'Gara C, Dastur S. Speak
for the Child. Academy for Educational Development. Washington,
DC, 2003.
Makame V, Ani C, Grantham-McGregor SM. Psychological
well being of orphans in Dar Es Salaam, Tanzania. Acta Pediat
91: 1-7, 2002.
UNICEF. Africa's Orphaned Generations. UNICEF,
UNAIDS 2003.
USAID, UNAIDS and UNICEF. Children on the
Brink 2002: A joint report on orphan estimates and program
strategies, TVT Associates/The Synergy Project for USAID, UNAIDS
and UNICEF Washington, 2002.
March 2004
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