CHAPTER 6
CONCLUSION
Robyn Pharoah
A Generation at Risk?
HIV/AIDS, Vulnerable Children and Security in Southern Africa
Edited by
ROBRYN PHAROAH
At the beginning of this monograph it was noted that many of the arguments linking AIDS-related orphaning to insecurity and instability are based on a particular vision of what orphanhood generally entails. The picture painted conjures up images of hordes of traumatised, unwanted children being cast to the very fringes of society; suffering wanton neglect and abuse and, ultimately, being left to fend for themselves in a world where life is often ‘short, harsh and cheap’. As noted repeated ly in the preceding papers, this is undeniably the case for some children and, in the absence of comprehensive, context-appropriate responses, may be for many children in the future. The contributions to this monograph also highlight that for most this is not the case and that the situation is more complex than suggested by many of the arguments to date. Several important issues can be noted :
Orphanhood is a complex phenomenon
Empirical data on the state and nature of orphanhood in Southern Africa is relatively limited. Data highlighted in the preceding papers nevertheless suggests that, irrespective of HIV/AIDS, many children are not raised in the ideal, stable family environments that much of the literature seems to take as its starting point. Large numbers of children grow up in single parent households, usually headed by women, and fathers are often absent. The reality of children being sent away from their natal home in order to access care or resources is not new. Fosterage and community-based family care have historically formed important support mechanisms in the region and both adults and children move in and out of households in response to the changing circumstances and needs of families. Even in the absence of parental death, children are often fostered, with the extended family most often providing care.
It also suggests that while orphaning is on the increase, and will have risen exponentially in most countries in the region by 2010, relatively few children would presently seem to be living in situations of extreme vulnerability. As noted by Foster in his paper, it is difficult to obtain accurate estimates of the numbers of children living in extremely vulnerable situations, but the available evidence suggests that less than 2% to 3% of all orphans live in environments where they are completely without support or are exploited. Indeed, although increasing numbers of orphans are beginning to place stress on traditional coping mechanisms such as the extended family, they are still remarkably intact and surprisingly small numbers of children have so far found themselves without the support they have historically provided.
Children are most likely to be orphaned during adolescence and often do not lose both parents. As noted by Richter, the likelihood of becoming an orphan increases with age. Children over the age of ten are most likely to become orphans, yet are generally not targeted by programmes and interventions in support of affected children. The South African data also indicates that a small proportion of children are double orphans and children most often have a surviving parent. As mortality among men is still higher than among women of comparable ages, this tends be their mother. Fewer than half of all maternal orphans in South Africa live with their surviving father and the widespread abdication of paternal responsibility is clearly a major gap in potential resources for affected families and children.
It is often difficult to determine where the effects of HIV/AIDS begin and end
The papers in this monograph all agree that many children in the region are going to be negatively affected by HIV/AIDS. Children may experience a range of impacts including economic need, reduced levels of care, poor health and nutrition, new responsibilities and work and school drop out, as well as psychosocial impacts such as abuse, trauma, stress and a loss of social connectivity. They may also be placed at greater risk of infection.
Such impacts may all be aggravated by both the nature of the virus itself and the environment in which children live. HIV infection tends to cluster within families, making it likely that children will experience repeated illnesses and deaths. As noted by Germann, they may also experience repeated losses as they are lose siblings, friends, fa mili ar surroundings, schooling opportunities and even their childhood as a result of the poverty, stigma and migration that often result from AIDS-related illness and death.
Several papers, however, point to the messiness of these effects. Richter notes that the effects of the epidemic on children are likely to vary considerably by age. Preschool-aged children, for example, are likely to suffer poorer levels of growth and health, while effects among older children are likely to manifest in terms of education, work and psychosocial outcomes. She also argues that while there is a strong, cyclical association between HIV/AIDS and poverty, high levels of ambient poverty often make it difficult to determine the causality of these effects. The conditions in many poor communities mean that few, if any, of these effects are specific to children affected by HIV/AIDS. It is also impossible to isolate and exclude the effects of conditions that pre-date the death of a caregiver.
Killian and Foster also recognise that HIV/AIDS increasingly impacts on almost everyone in severely affected communities, even households without HIV-positive members. As noted by Killian, South African children living in high-prevalence communities are excessively anxious about death and may reflect obsessively about illness and mortality. The prevailing myth that HIV/AIDS can be cured by sleeping with a virgin may in some cases also increase children’s risk of sexual abuse—although there is little concrete evidence available to shed light on this issue. As argued by Foster, children may also be affected when families provide money to support sick relatives, mothers leave home to provide care for AIDS-affected relatives, or their standard of living deteriorates as relatives move in following the death of their parents.
‘Affected ’ children are not habitually treated differently to ‘unaffected ’ children
In line with the above point, the authors also argue that the experience of orphans and children affected by HIV/AIDS is often not qualitatively different from that of other poor children. This is not to say that no children find themselves in situations that dramatically set them apart from their peers. Cases of abuse, mistreatment or exploitation of fostered and orphaned children have been reported. Many children have also been left to fend for themselves; to cope with adult problems without the benefit of adult support. The argument is simply that children are generally not treated differently by others on the basis of their orphaned or fostered status.
Foster argues, for example, that although studies have demonstrated that orphans are disadvantaged compared to non-orphans in other families, few have demonstrated significant differences in the ways relatives treat their own biological children compared to fostered children. He argues that although such cases undoubted ly occur, it seems for the most part that relatives go to considerable lengths to keep orphans in school, including borrowing money through informal networks and selling their own assets. Richter notes a study by Case and her colleagues which found that fostered orphans are less likely to attend school than co-resident children in the same household, but agrees with Foster that there is little available evidence to suggest that caregivers habitually treat orphans in their care differently from other children.
Not all children are equally vulnerable
Three of the four papers also suggest that while some children are left in precarious circumstances as a result of parental illness and death, many children remain linked into support networks of various kinds. For example, Foster argues that while many child-headed households receive little support from relatives who are already struggling to feed, clothe and educate their own children, not all child-headed households are equally vulnerable. He gives the example of Swaziland, where large numbers of child-headed households have formed as a coping mechanism in the context of the epidemic. He argues that the high prevalence of child-headed households in Swaziland is a consequence of traditional extended family living arrangements, which enable child-headed households to live in supported situations.
He also notes that, despite appearances, many street children also benefit from adult support. He draws the distinction between children on the street and of the street. Where children live on the street, they help to provide for their own survival and that of others by working on the street, but generally return home at night. Despite potentially deteriorating family relationships, fa mili al ties are still in place, and the children continue to view life from the perspective of their families. Children of the street constitute a smaller number of children who live, work and sleep on the street, alone and without support.
Negative experiences do not necessarily result in negative psychosocial outcomes
The risk and resilience literature highlighted by Richter and Killian indicates that while HIV/AIDS stands to exacerbate the multitude of risks faced by children in poor communities, children are often remarkably successful in overcoming such difficulties. A key point made by both authors is that although the epidemic is likely to increase poverty and social fragmentation—and thus the risk environment in which children operate—such effects will not automatically translate into widespread psychosocial maladjustment. Indeed, studies suggest that only about one-third of children exposed to severe adversity will suffer negative psychosocial outcomes. This is obviously not an insignificant proportion but highlights that while there is a very real need for appropriate interventions to support vulnerable children, there is not a neat, linear relationship between adversity and a negative outcome.
They note that the impact of risk factors is mediated by a range of factors, including personality and temperament, learned coping style, age of exposure, the availability of caring adults and social supports in their environment and, critically, opportunities for recovery afforded by achievements, new relationships, changing circumstances and the like. The implications of negative experiences are thus as much a result of the circumstances surrounding the experience, and the way it is interpreted, as the nature of the experiences per se; and long-term maladjustment is dependent on the availability of conditions for recovery as much as, or more than, the form or severity of precipitating stresses.
The likelihood of maladjustment is increased when adverse conditions are cumulative or endure over time, or when children are given few opportunities for support and hope, but relationships with caring others and access to supportive networks and social institutions can present opportunities for recovery.
They argue that children tend to seek out these positive experiences—even in conditions of great difficulty. Experience gained from working with street children, displaced children and children in conflict and disaster situations suggests that even on the street, in conflict, under abusive and dehumanising conditions, children seek out bonding experiences with adults and engage their support. It also suggests that even low levels of support in childhood enable quite dramatic compensatory responses in children. Richter argues that these formative influences may therefore be absent only in children deprived of any adult supervision or support, subjected to cruel and dehumanising treatment, or reared in institutions over a long period of time. She argues that a very small proportion of children affected by HIV/AIDS will find themselves subject to such conditions.
Richter also notes that where children do suffer negative effects as a result of their exposure to difficulties, these are unlikely to habitually manifest themselves in ways that would affect the security of communities and states. She argues that three groups of determinants—poverty; separation, loss and bereavement; and cruel and impersonal care—may be associated with poor psychosocial adjustment. Children exposed to such determinants are likely to exhibit physical or internalised conditions, such as poor growth and health, decreased motivation, increased passivity, impoverished frames of reference, lower cognitive performance, anxiety, rumination, depression, social isolation, guilt and low self-esteem. Only children exposed to cruel and impersonal or abusive care are likely to experience more externalising conditions such as a reduced capacity for affection and compassion, acting out and more aggressive coping styles.
Effective responses are being put in place
Given these dynamics, several of the papers also draw attention to the fact that effective responses to the challenges posed by the epidemic are being developed. Foster notes that over the past two decades, communities throughout Africa have begun to add additional layers to their community safety nets by providing material, educational, emotional and psychosocial support to children affected by HIV/AIDS.
These community-based support initiatives have been established largely in the absence of significant external facilitation or financial support and are often initiated by churches, mosques, other religious groups, women’s groups and CBOs. Such initiatives support vulnerable children by enabling families to continue to provide care for orphans.
Germann also notes examples of a number of local, national and regional level initiatives which have successfully helped to mitigate the psychosocial impacts of the epidemic on children and families. Such initiatives are still relatively few in number and have been limited in their reach and impact, but illustrate that valuable, cost-effective responses can be, and have been, put in place.
Implications for current thinking
In conclusion, few would dispute that the HIV/AIDS epidemic and the growing numbers of orphans that will be its legacy poses a notable humanitarian and developmental challenge. Millions of children will lose caregivers and will suffer the economic, physical and psychosocial implications of both the prolonged illness of these caregivers and their deaths. What is open to question is whether the impacts of the epidemic will play out in such a way that children themselves pose a significant threat to stability and security in the Southern African region. Although by no means an exhaustive review of the available evidence, the papers in this monograph highlight issues that suggest that we may want to be more cautious in drawing the linkages between large-scale orphaning and crime and instability.
Certainly, potential linkages exist between HIV/AIDS, insecurity and instability. The epidemic is likely to increase social fragmentation and, most importantly, poverty. Poverty in turn not only increases the risk of children becoming infected with the virus, but also exposes them to high levels of psychosocial risk. It is thus likely that a certain number of children affected by HIV/AIDS will suffer negative psychosocial outcomes; that some will be exploited and abused, will be victimised and may themselves perpetrate crime and violence. This is obviously undesirable and every effort should be made to address the underlying vulnerabilities that expose children to such conditions. Yet, not all children are equally vulnerable and there exist a number of factors that will determine whether children at risk suffer such outcomes. As noted by Bray, context is important and although there is need for a great deal more research in this area, the context suggests that such outcomes may more often be the exception than the rule. Moreover, in a context where ambient levels of poverty are already high, few if any of these outcomes will be confined to children affected by HIV/AIDS (even if such a category can be defined).
families and local communities have to date demonstrated remarkable resilience and creativity in addressing the myriad needs of affected children and surprisingly few have been left in situations of extreme vulnerability. Given the extent of the HIV/AIDS epidemic, however, it is likely that traditional coping mechanisms will become increasingly stressed. It is important that mechanisms be put in place to support vulnerable children, families and communities. The contributions to this monograph suggest that community institutions, governments and international agencies can, and have, put in place effective programmes. The lessons presented by such initiatives need to be heeded and decisive action taken by stakeholders at all levels to mobilise the human and financial resources necessary to implement such responses successfully.
