Select Committee on International Development Third Report

Section 2 — The Impact of HIV/AIDS

HIV/AIDS and the elderly

86. One impact of HIV/AIDS which has been badly ignored has been the impact on the elderly. HelpAge International submitted a memorandum stating that "older people are now primary carers and supporters of younger family members, both those dying of the disease and orphans of the middle cohort who are currently dying in ever increasing numbers. Older people who are already poor face the loss of economic support from their adult children, little social security and income support ... and unexpected social, psychological and economic burdens due to the caring role they assume. Older people are also contracting the virus in increasing numbers although research is limited on the cases of HIV/AIDS in the over 50s".[104]

87. Traditionally many older people rely on their children for support. Thus "when the middle cohort dies older people are vulnerable to crisis".[105] In addition to that loss of care and support, there is the additional burden of labour and financial outlay in caring for sick children and orphaned grandchildren. These costs can result in financial ruin. Caring for the sick is also reported to have resulted in "decreased access to food for consumption and for sale, and decreased access to markets. All the research available makes the clear link between the reduction of time available for agriculture and income generation because of the time spent in caring for the sick".[106] Studies in Tanzania suggest that a key reason why orphaned children are not attending school is the inability of grandparents to afford the school fees.[107] There are also significant costs of time and money associated with burials.

88. HelpAge International also emphasise the psychological and social cost for the elderly of HIV/AIDS. They make the point that "the stigma and further social isolation that caring for people with AIDS causes is a significant and unacknowledged burden on top of the economic cost to the caregiver".[108] The grief of bereavement, of knowing that one is unable to provide for one's grandchildren, the fear of infection in caring for those with HIV/AIDS, the worries and uncertainties of the old person's own circumstances — all these take an immense psychological toll. HelpAge International state, "There are indications that the multiple stresses and fears caused by the epidemic may be compromising the caring relationships between households. The implications may go beyond questions of care, to issues of social stability and governability. The findings from Uganda point to the compromising of the caring relations between and within families and households caused by the stresses associated with the disease".[109]

89. In oral evidence Mark Gorman from HelpAge International emphasised 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 ... One of the easiest things is to work in the sex field. Even for older women, age is not a barrier in this respect".[110] The elderly were already amongst the very poor in sub-Saharan Africa and now HIV/AIDS was pushing people "below that chronic poverty line into the crisis situation that many families affected by HIV/AIDS are facing".[111] Older people were making great sacrifices to enable grandchildren to go to school — selling off assets such as land and livestock, or going without food or light.[112]

90. A number of recommendations come out of the analysis of the impact of HIV/AIDS on older people. As in many other policy areas, the needs of the elderly with regard to HIV/AIDS have been ignored for far too long. We recommend:

  • that more research be conducted into the incidence of HIV/AIDS amongst the over 50s
  • that there be greater provision of HIV/AIDS information and education for older people
  • that there be greater provision of counselling both for older people who are HIV-positive and for those caring for the ill or those bereaved
  • that income-generation opportunities and other forms of economic and social support be provided for older people affected by HIV/AIDS and those elderly involved in caring for dependents
  • that all HIV/AIDS strategies include explicit policies and action plans to meet the needs of the elderly

We recommend that DFID promote such an approach in its own HIV/AIDS strategy and internationally.

HIV/AIDS, children, education and household survival

91. Prospects for development are inextricably linked to the prospects for children in developing countries — their health, their education, their sense of social involvement. In recent years, as we have seen above when discussing the international development targets, there has been a renewed emphasis on children, for example their universal right to education or to live a life free from conflict. HIV/AIDS is undoubtedly a scourge blighting the future of millions of children, denying them security, education, health, and indeed life itself. In discussing the effects of HIV/AIDS on children one is inevitably drawn into discussing the impact on the household unit — children are by their nature dependents. It is impossible to understand their circumstances without examining the household of which they form a vulnerable part.

92. The statistics on HIV/AIDS and children make terrible reading. By the end of 1999 600,000 children (defined as those under 15) were infected with HIV/AIDS. The cumulative deaths to HIV/AIDS amongst children had reached 3.6 million. In addition to the impact of HIV/AIDS through infection, illness and mortality, there is the growing crisis of orphaning. By the end of 1999 there were estimated to be 13 million orphans as a result of HIV/AIDS, 95 per cent of them in sub-Saharan Africa (an orphan being defined as someone under the age of 15 who had lost their mother or both parents).

93. Witnesses emphasised discrimination and stigma faced by young people, not only those infected with HIV/AIDS but also those from households with HIV-positive adults, or those orphaned by HIV/AIDS. Douglas Webb from Save The Children said that "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".[113] Children were not only stigmatised by their classmates and peers but even by teachers who on occasion have chased from school "children who are of unknown status, more than likely negative, whose parents are ill or dying or dead".[114] Any illness suffered by such a child was assumed to be AIDS-related. With such stigma comes a burden of shame and denial amongst children. A survey amongst AIDS orphans in Rusinga Island, Uganda, discovered that, whilst almost all knew about HIV/AIDS none of the 72 orphans questioned in the study said that their parents had died of AIDS.[115] The 'handing down' of such attitudes does not bode well for countries which need above all else an honest and open public discussion of the issues surrounding HIV/AIDS.

94. The stigmatisation and exclusion of children in some way connected with HIV-positive people is one immediate and obvious way in which HIV/AIDS is having an impact on the education sector. Such exclusion has an effect on any attempt to reach the agreed target of universal primary education by 2015. The withdrawal of children need not only be as a result of such overt discrimination. In many instances it will be because children are called on either to work or to take on part of the burden of care as income-generating adults become ill. Moreover, as incomes are affected by the costs associated with HIV/AIDS and as wage-earners themselves become sick, children are withdrawn simply because school fees or associated costs can no longer be afforded. Douglas Webb said, "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".[116]

95. At the same time that demand is being constrained by the epidemic there is an equally disastrous impact on the supply of education. Alan Whiteside thought that education was "the most important sector that has been affected, simply because it holds in charge the next generation".[117] Similarly Douglas Webb said, "The impact of HIV/AIDS on the education sector is probably the most critical sector that we have to address".[118] He pointed to the effect of HIV/AIDS on teachers, "What we are seeing is a contraction of education sectors. We are seeing very high mortality rates of teachers. In the most heavily affected of countries, you are looking at 20-30 per cent plus of teachers HIV-positive ... 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".[119] Experience in Zambia suggested that it was necessary to deal with teachers' own insecurities about the disease and low morale as a result of their own infection and the deaths of those around them.[120]

96. Alan Whiteside mentioned another possible impact of HIV/AIDS on the education sector. Teachers may not only be lost to the epidemic itself. It was also likely that as mortality across the workforce increased other sectors, which can pay better than schools, may well poach teachers to go into the private sector or other parts of the state sector. Thus there will be a further contraction of the education sector.[121] Douglas Webb spoke of the effect on the quality of education provided, with classes in Uganda on occasion of over 200 persons, "The sectoral response is very difficult when you have such a high infection rates within the sector of staff itself".[122]

97. DFID has recently published its strategy paper 'The challenge of universal primary education' in which we were pleased to see an attempt to tackle the impact of HIV/AIDS on the education sector. The paper stresses the need to address teacher supply and morale as well as the costs of HIV/AIDS to the educations system.[123] It concludes, "Responding to this challenge will require new, decentralised planning models that allow schools and local administrations sufficient flexibility to react quickly to changing circumstances. At school level, a whole school approach to management and development, which encourages community support to teaching and allows for new staff to be quickly absorbed and trained on the job, is likely to be vital".[124] The paper also concludes that education must be inclusive, "responding flexibly to the needs and circumstances of all excluded children".[125] The means encouraging non-formal and complementary education provision and addressing the needs of working children.[126]

98. When DFID officials gave evidence to the Committee at the beginning of the inquiry in June last year, they told us that they were starting to look at the impact of HIV/AIDS on the education sector - "it is a late stage, but we are now trying to get more involved".[127] They were assisting in the preparation of guidance for South African policy makers,[128] and looking at "human resource development and human resource protection for ministries of education".[129] They had not then given much thought to informal and home education as one way to mitigate the impact of HIV/AIDS.[130] The strategy paper 'The challenge of universal primary education' is an encouraging example of how DFID can design its development approach to take account of the impact of HIV/AIDS. Even within the last few months, there has clearly been progress and further thought in the Department on this issue.

99. We consider that all donors must agree on an education strategy which both aims to achieve the international development target of universal primary education by 2015 and which also takes account of the new realities caused by HIV/AIDS. Priorities in such a strategy must include:

  • the provision of education for those unable to attend formal schooling, in particular for those having to work to provide for households;
  • the protection of children stigmatised by association with HIV/AIDS; and
  • measures to maintain the supply of teachers, perhaps involving the community, volunteers and the private sector, as well as those formally trained and employed.

100. There is particular concern at the impact of HIV/AIDS on household structures. The figures from the June 2000 UNAIDS Report on the global HIV/AIDS epidemic make appalling reading. To date 3.8 million children have died of HIV/AIDS since the onset of the epidemic, nearly 500,000 of them in 1999 alone. Another 1.3 million children are currently living with HIV and most will die before they reach their teens. The vast majority of these children were born to HIV-infected mothers.[131] UNAIDS estimates that 620,000 children were newly infected with HIV in 1999.[132] There is thus an immediate developmental impact in terms of rates of child mortality, with all the consequences of grief and trauma for the surviving families. Before these effectively inevitable early deaths the family or household will need to endure the burden and additional trauma of dealing with the AIDS-related illnesses.

101. The impact of HIV/AIDS should not, however, be seen solely in the context of the illness and deaths of children, shocking though the statistics are. As working adults, parents and carers die in the prime of life, there are immediate and inevitable impacts on children. Of these the most discussed is the increase in the number of orphans, particularly in sub-Saharan Africa. UNAIDS reports that before HIV/AIDS 2 per cent of all in developing countries were orphans. By 1997 the proportion of children with one or both parents dead had increased to 7 per cent in many cases and in some countries had reached 11 per cent.[133] This translates into a figure of 13.2 million orphans, 95 per cent in sub-Saharan Africa, created by AIDS since the beginning of the epidemic.[134] It is worth noting that this is a cumulative total and that many of that number are no longer under 15 and others are no longer alive. The result is of course an increase in the number of households headed by a single parent (often women) and of households headed by children. Such households are particularly vulnerable. Their earning capacity is severely limited. They will often be the poorest of the poor. Such economic weakness is then compounded by a vulnerability to exploitation and abuse. Widows and orphans are often the subject of sexual exploitation, are denied property and other legal rights, stand to be dispossessed or defrauded of what is theirs.

102. Douglas Webb from Save The Children said that his organisation preferred to speak of "vulnerable children" rather than orphans. He said that "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".[135]

103. There were some differences in evidence as to the effect of HIV/AIDS on family structures and the household. Alan Whiteside said, "There is a myth that the African extended family absorbs the orphans that are left. I think the problem is that the very few studies that have been done of the impact on households have missed one glaringly obvious fact, and that is the worst affected households have disappeared. You cannot measure what is not there. Households which have collapsed, and where the children are living under bushes (and there are those households) are not being measured".[136] He made the point that in South Africa there had been a move to a more nuclear family with the onset of rapid urbanisation. Thus the extended family structures to cope with vulnerable children were no longer in place. He strongly opposed the placing of such children in residential care. Instead he advocated the transfer of cash to support households and communities in distress, alongside other social security benefits.[137]

104. A slightly different perspective was provided by other witnesses. Douglas Webb emphasised that Professor Whiteside was speaking from a South African perspective, "Going off 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 massively more than the background child population. Poverty is the cause of that kind of thing".[138] Mark Gorman of HelpAge International considered that "even in South Africa, even in urban situations in the townships, you do find very well developed family and community networks".[139] Such coping strategies in South Africa were assisted by the fact that South Africa paid an almost universal old age pension.

105. Mark Gorman claimed that "the family and the household has remained immensely strong. It has not existed for hundreds of thousands of years in African and Asian communities without being very strong. We should be careful not to write it off too early, but what it needs above all is support from outside. Family structures, older people, young people, cannot do without that external support and that is where, for example, education programmes can be immensely helpful and supportive if they are sensitive and appropriate".[140] Francesca Simms agreed, "Research suggests the extended family is not breaking down. What is happening is that there is less transmission of money between the extended family, so you are getting an increasing number of families without the means to support the basic needs of their children, but the carers are still there and the relationships are still there. There is a lack of money to provide for that care and that is what is needed. Unless we provide that, we are going to see the destruction of an extended family system which has gone on for generations in Africa and has very successfully provided for the needs of all, children, old people and disabled in a very cost effective way".[141]

106. The differences amongst witnesses are then ones of degree rather than basic message. There will of course be variations amongst countries as to the nature and strength of the extended family. Witnesses differ as to how severely the extended family system has been affected by HIV/AIDS — has it already broken down or is it still functioning? There is a consensus that the "traditional coping mechanism, which was the extended family, is being stretched beyond capacity now", to use the words of Carol Bellamy.[142] In other words, HIV/AIDS threatens to unravel what has been for generations a remarkably robust and effective social security system, the extended family, leaving the old uncared for, children vulnerable to abuse, uneducated and deeply traumatised.

107. Alan Whiteside recommended the transfer of funds, managed by town councils, NGOs or churches, to those with caring responsibilities for the poorest families and orphans.[143] He admitted that this went contrary to accepted development practice and there would have to be a willingness to see some percentage of the funds diverted but added, "I do not think we have a choice. I think we either have to be imaginative and look at some of these options". Such interventions would "be immeasurably cheaper than putting that person in an institution".[144] He emphasised that such payments would have to be for all children in distress, not only those orphaned as a result of HIV/AIDS.

108. Douglas Webb said that studies a few years ago in Zambia suggested that 90 to 95 per cent of orphans were absorbed by extended family members.[145] What was needed was extra resources to assist in the care of the children, child care training, income generation opportunities. Francesca Simms said that "there are carers for these children ... but they must have support ... which could be income generating, for material aid, and psychological support as well".[146] All witnesses spoke strongly against putting such vulnerable children in institutions, it being both damaging and expensive. Douglas Webb gave the example of Save The Children's work in Cambodia where they noted a high incidence of migration to and from cities amongst children and young people from affected households. He explained, "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 ...".[147]

109. What is clearly needed is "the work in the communities to identify these children and strengthen the capacity to cope and keep the children in the communities".[148] Francesca Simms argued for the mobilisation and scaling up of those community projects which had been seen to work, workers mobilising community structures, through village chiefs, so that every child in need has a named volunteer and care plan.[149] Douglas Webb, however, warned that there was real problem of replication, "this problem of taking things forward is far more difficult because the central authorities are not taking that lead role in taking these small scale projects, saying, 'They work. Let us take them to another place'. ... The lack of central capacity in government to do that is probably the critical barrier".[150]

110. The needs of orphaned and vulnerable children must be a priority in the international response to the epidemic. We have already mentioned the importance of education, training and the protection of their legal and human rights. It is also clear that households must be supported as they take in and care for such children. Much good work is being done in individual projects and programmes. But this is not enough. Support to households caring for vulnerable children needs to be extended and replicated on a national scale in high-prevalence countries. This is a significant challenge, particularly for public sectors already weakened by poverty. It requires determined coordination amongst national governments, donors and civil society. Consideration should be given as to whether cash payments or other forms of support are most appropriate. We recommend DFID in its response to this Report provide further details of how it plans to support the identification and care of vulnerable children in the community.

104   Evidence, p.113 Back

105   Evidence, p.115 Back

106   Evidence, p.116 Back

107   Evidence, p.116 Back

108   Evidence, p.117 Back

109   Evidence, p.117 Back

110   Q.241 Back

111   Q.256 Back

112   Q.256 Back

113   Q.250 Back

114   Q.252 Back

115   UNAIDS June 2000 Report p.40 Back

116   Q.259 Back

117   Q.124 Back

118   Q.259 Back

119   Q.259 Back

120   Q.396 Back

121   Q.124 Back

122   Q.259 Back

123   'The challenge of universal primary education' para.4.45 Back

124   'The challenge of universal primary education' para 4.45 Back

125  'The challenge of universal primary education' para 4.13 Back

126  'The challenge of universal primary education' para 4.13-14 Back

127   Q. 78 Back

128   Q. 77 Back

129   Q. 78 Back

130   Q. 78 Back

131   UNAIDS June 2000 Report p.81 Back

132   UNAIDS June 2000 Report p.6 Back

133   UNAIDS June 2000 Report p.28  Back

134   UNAIDS June 2000 Report p.6 Back

135   Q.241 Back

136   Q.127 Back

137   QQ.127-131  Back

138   Q.247 Back

139   Q.247 Back

140   Q.239 Back

141   Q.239 Back

142   Q.234 Back

143   Evidence p. 75 Back

144   Q.131 Back

145   Q.241 Back

146   Q.241 Back

147   Q.248 Back

148   Q.247 Back

149   Q.398 Back

150   Q.399 Back

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