Africa's emerging AIDS-orphans crisis
Rachel C. Baggaley, MB, BS; Dale Needham, MAcc
CMAJ 1997;156:873-5
[en bref]
Dr. Rachel Baggaley is an honourary research fellow with the London School of Hygiene and Tropical Medicine. She is also a physician and researcher with the Kara Counselling and Training Trust, Zambia. Dale Needham is with the Class of '98, McMaster University Medical School. He spent the spring and summer of 1996 in Zambia.
© 1997 Canadian Medical Association (text and abstract/résumé)
In brief
Although AIDS has had a huge impact around the world, nowhere has its effect been greater than in Africa. In Zambia alone the disease is expected to create 500 000 orphans by the turn of the century. In this article Dr. Rachel Baggaley and Dale Needham examine the huge social problems AIDS is creating in some of the world's poorest countries.
En bref
Même si le sida a eu un impact énorme dans le monde entier, c'est en Afrique que ses répercussions ont été les plus marquées. En Zambie seulement, on s'attend à ce que la maladie crée 500 000 orphelins d'ici au tournant du siècle. Dans cet article, le D[r] Rachel Baggaley et Dale Needham examinent les énormes problèmes sociaux que le sida cause dans certains des pays les plus pauvres du monde.
Katherine is a 24-year-old, unmarried mother who lives in Lusaka, Zambia's capital. Her children are Darlington, 4, and Simon, 2. Lusaka, which has roughly 1 million residents, is a typical African capital city. Katherine lives in a 1-room apartment in Mutendere, a densely populated residential area. She is HIV positive, and knew her status 2 years before the birth of her first son.
Zambia is one of many African countries bearing the brunt of the AIDS pandemic, and Katherine's story is very common. She provides a case study of the impact AIDS has had on children in sub-Saharan Africa.
In Zambia, 70% of people live below the poverty line,[1] and a social-safety net is almost nonexistent. In fact, only 3% of the population has any contact with the social-welfare system (Ministry of Health, Zambia, 1995). With an annual welfare budget of less than $1 per capita, little is available even for those who do receive help. Even supplemental aid from nongovernmental organizations often does not have a significant impact, because very little of it actually reaches the people who need it most.
What does Katherine's HIV status mean for her and her children? It almost certainly means they will join Africa's growing legions of AIDS orphans. In Zambia, the months of sickness that precede an AIDS-related death have meant that the burden of caring for a sick parent often falls on the children, some as young as 6.
They may be forced to drop out of school to provide the necessary care, and this almost guarantees that they face a limited future. In the Third World, education is key in rescuing children from the vicious cycle of poverty.
In Africa, AIDS has meant that childhood is lost for many children, who have prematurely taken on the adult roles of caregiver and guardian. These children are often too young to understand what is happening and they feel angry at their "inadequate" parents for shifting the burden to them.
If they do attend school during a parent's illness, the emotional stress often manifests itself as a lack of attendance and inappropriate behaviour. Teachers with an interest in counselling often say they are overwhelmed with the grief these children express and have neither the emotional or material resources to deal with this.
However, AIDS-related poverty may have the greatest impact. In a country where even working parents are often unable to feed their children appropriately, parental illness results in child malnutrition. This leads to poor academic performance -- another of the many ways the child's future is hurt.
They may not face school-related difficulties for long because if they lack money for food they won't have it for pencils, texts, school uniforms and examination fees either, and all are mandatory requirements for children attending Lusaka's public schools. They may be sent home by teachers and told not to return until they have a clean uniform and money for school fees. This is one of the reasons why more than 700 000 children aged 7 to 13 do not attend school in Zambia, and why less than 30% of children proceed to secondary school.
As the AIDS scenario unfolds and the parent -- often both parents -- dies of AIDS, the child will be left alone, and often must migrate from the city to a rural area to live with a grandparent, aunt or uncle. However, in a country where an average worker has only $25 per month to feed an entire family, there is little spare food available for an added mouth. One result is the stunting of growth, a sign of chronic malnutrition that the Zambian Ministry of Health says plagues more than 60% of rural children in Zambia.
Within guardian families, there may also be resentment toward these AIDS orphans: both overt and subtle physical abuse and neglect is common.[2] They may end up being used as a source of free labour, and young girls may be forced to work as prostitutes.[3]
The saddest news is that little is being done to solve their problems. By the year 2000, UNICEF reports, Zambia is expected to have more than 500 000 AIDS orphans, who will represent close to 5% of the entire population.
With a future so grim, why do women like Katherine still insist on having children? For her, pregnancy was not an act of ignorance. After testing positive for HIV, she actually began work as an AIDS educator.[4] Consequently, she could appreciate the consequences of her decision to become pregnant. Despite knowing these facts, she faced many complicated emotional issues. In many parts of Africa, including Zambia, a person's status and wealth is measured by the number of children he or she produces. The stigma of being a childless woman may be worse than the stigma of being an HIV-positive mother, and being childless is much more obvious to society. Consequently, there is continual societal and family pressure to have children. These conflicting factors weighed heavily on Katherine when she decided to bring two more potential AIDS orphans into the world.
Her work as an AIDS educator did not continue after the birth of her second son because colleagues and members of her HIV support group could no longer tolerate the inconsistency between her actions as a mother and her words as an AIDS educator. She not only lost her job, but a significant source of emotional support. This made life even tougher for her and her sons.
What are the health consequences for children born to HIV- positive mothers? Their risk of infection is reduced by two-thirds when the mother and neonate take zidovudine.[5] However, it is seldom found outside the developed world. As a result, Katherine could outlive her children if they are HIV positive. Her eldest son, Darlington, has been relatively healthy during his first 4 years of life. Her other son, Simon, has experienced many minor health problems since his birth.
Are they HIV positive? Katherine doesn't want to know, because both possible answers are unpleasant. Should they test positive, she knows that they, too, will die. Should they test negative, she would suffer the pain of leaving her sons behind to fend for themselves among Africa's growing legion of AIDS orphans. At the moment, ignorance is bliss as far as Katherine is concerned.
What can be done about the pain suffered by so many children in Africa? Further education to stop the spread of AIDS is key. In educating HIV-positive women, it will be difficult to change a society that values procreation so highly. Education must be widespread and it must focus on children and teenagers, and it must be offered before young people become sexually active. The message must be unambiguous and widely disseminated.
There is a tremendous need for appropriate medical services for people living with AIDS. Within the context of a resource-poor country, this means further support for hospital and home-based care programs and orphan-support programs. The health care system and the community must help relieve the children of their burden of caring for sick parents. Finally, increased social support is needed to assist AIDS orphans -- this is the only way their lives can be improved. Of course, this is easy to say but hard to do in a country as poor as Zambia.
The aid that is being provided by so many organizations must be spent within the target country -- the money must get to the programs and the people. The answers to these problems may not be clear, but the suffering felt by so many children is.
Dale Needham acknowledges the financial assistance provided by the Ontario Ministry of Health AIDS Bureau, Glaxo Wellcome Inc. and Ernst & Young Chartered Accountants, London, Ont.
References
- Zambia Poverty Assessment Report, World Bank Southern Africa Department, Washington, DC, 1994.
- Haworth A, Kalumba K, Kwapa P, Van Praag E, Hamauhwa C. Social consequences of AIDS in 49 Zambian families -- a descriptive study. [paper] VII International Conference on AIDS, Florence, Italy, 1991.
- Feldman D. High-risk behaviour among some female Zambian out-of-school adolescents: a possible future application of the value utilization/norm change model. [paper] Society for Applied Anthropology meeting, Albuquerque, New Mexico, 1995.
- Needham D. Visit to Zambia offers humbling reminder of privileges Canadians enjoy. CMAJ 1996;155:579-80.
- Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O'Sullivan MJ et al. Reduction of maternal-infant transmission of human immunodeficiency virus type I with zidovudine treatment. N Engl J Med 1994; 331:1173-80.
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