SECTION VI: DISCUSSION AND CONCLUSIONS Chapter 12: Discussion of Results
2.3. General issues impacting on the well being of children
2.3.1. HIV/AIDS and poverty
There is no doubt that HIV/AIDS is a poverty-related illness (Hunter & Williamson, 2002; UNICEF, 2001; Gow et al., 2002; Foster & Williamson, 2000). HrV/AIDS is most likely to spread rampantly in poverty-stricken communities, both in third world countries as well as in first world contexts, such as in the United States of America (Geballe & Gruendal, 1998; Giese et al., 2003; Taylor et al.,
1999). The high risk situations for rapid spread of HrV have repeatedly been found to be impoverished, disempowered communities, who have undergone rapid urbanisation, with the new- found anonymity of town and city life, combined with the social upheaval and disruption associated with political violence, war and counter-insurgencies (Hunter & Williamson, 2002; Marks, 2001;
Zwi & Cabral, 1991). South Africa and other sub-Saharan countries rank high on this risk scale (Barbarin, 1999; Dorrington, 1999; Gow et al., 2002; Johnson & Dorrington, 2001; Marks, 2001).
The socio-economic impact of HIV/AIDS will vary across families, communities, provinces and countries, but statistics indicate the following impact areas:
• Income decline: The GDP will show a slow but steady decline (UNICEF, 2000), negatively impacting on all aspects of life. The greatest impact will be felt at the micro and meso systemic levels - families, communities and micro businesses will substantially suffer (Foster
& Williamson, 2000). Households are likely to experience an income decrease of 45 to 52%
(Hunter & Williamson, 2000), while expenses related to health care are quadrupled (UNICEF, 2000)7. Many people suffering with AIDS-related infections spend their limited resources seeking cures for their sickness, thereby leaving family finances severely depleted in even relatively wealthy sectors of the population (Ntozi & Mukiza-Gapere, 1995). The
7UNICEF (2000) estimated a decrease in real income terms of 52 - 67%. This figure also
curtailment of much needed income is most likely to occur as families endeavour to carry the financial burden of illness, hospitalisation, treatment regimens and then, the care of orphans and extended family members (Foster & Williamson, 2000; Marcus, 2002). Frequently the family's resources will be depleted, leaving no contribution towards future care, or inheritance, for the children (McKerrow, 1995; UNICEF, 1999; Wild, 2001).
Costs of illness, death and funeral: When a breadwinner is ill, the family income shrinks and at the same time the costs related to traditional and clinical treatment soar (Fox et al..
2002). Funeral costs are a drain on resources, as expensive funerals are expected by the communities. In rural and even most peri-urban areas, individuals are buried in the land surrounding the household. Children often see their families' graves on a daily basis.
Fewer economically active adults: The number of economically-active individuals will decrease and there will be a corresponding increase in dependent sick adults, children and young people who will need to leave school early and enter the labour force (USAID & the Synergy Project of TVT Associates, 2001; UNAIDS, 2001; UNICEF, 1999). This will exacerbate the already unacceptable South Africa statistics of 35% of rural African children between the ages of 6 and 17 years, do not attend school (Johnson & Dorrington, 2001) and it is particularly girl children who are likely to be discriminated against in this regard (Global Movement for Children, 2003).
Child labour, both within and outside of the home, will become more widespread despite an increasing awareness of children's rights (Cook, 1998; COPE, 2002; Cluver, 2003;
Mailman, 2002; Muchiru, 1998). In twenty sub-Saharan African countries, children aged 5 -14 years who had been orphaned were less likely to be in school and more likely to be working in excess of a 40-hour week (Hunter & Williamson, 2002). For example, in a Kenyan sample, 52% of orphaned children were not in school, while only 2% of non- orphaned children were out of school (ibid.). Many children will drift to the streets.
Globally an estimated 250 million children (aged 5-14 years) from developing countries are working, of whom 60 million are exploited in the worst forms of child labour (Global Movement for Children, 2003). Some 120 million children work in excess of 9 hours per day and 80% of these are not paid for their labour. A further one million children every year enter the multi-billion dollar commercial sex trade, where they are coerced, bonded by debt, sold or simply kidnapped (ibid.). These horrific trends are likely to escalate due to the dire poverty in which many children live. Child labour is not only the result of poverty. It simultaneously perpetuates poverty and repeats the cycles of disadvantage in the long run.
Business, commercial and agricultural impact: All aspects of income generation are adversely affected (Cook, 1998; UNICEF, 1999). Labour costs skyrocket as economically- active adults fall sick; rates of absenteeism increase; productivity declines; costs for recruitment and retraining are incurred; and there is increased demand for the provision of insurance and health resources. The cumulative impact of these factors may cripple many
businesses, industries and agricultural enterprises (Hunter & Williamson, 2000). Some local government departments now only permit employees to hold collective weekly memorial services for recently deceased colleagues, during lunch breaks, as the mourning rituals and memorial services were negatively impacting on the number of productive working hours (Personal communication, 2001).
Subsistence farming has traditionally fed families and communities. The decrease in agricultural activity has led to (i) correspondingly compromised nutritional status and widespread malnutrition (Care International Zambia and Family Health Trust and Family Health International; 2001); (ii) loss of inter-generational transmission of skills and knowledge; and (iii) inability to follow prescribed cultural mourning rituals that require the slaying of an animal since, at times, there are no animals available to be slaughtered. Food consumption in sub-Saharan Africa has been estimated to have dropped by 41 % over the last decade (Hunter & Williamson, 2002). Malnutrition and stunted growth rates have increased (Giese, 2002) and many children are no longer being trained in healthy eating or food preparation by their primary caregivers.
• Costs of social and health services will be stretched beyond capacity, creating a financial drain, saturation of available resources and demotivated staff who feel over-whelmed and over-burdened (Gow et al., 2002). In addition because of the disheartening nature of their jobs, it has been noted that there has been a drift away from social and welfare careers, leaving a high probability that these services will become even more understaffed (Hunter
& Williamson, 2000; UNICEF, 1999). Most sick people will need to be given home-based care placing extra financial and psychological stress on the families. National budgets are adversely affected as health costs soar, leaving substantially less for education, welfare, development of infrastructure and other government services.
Basic human rights necessitate that all people have their most basic needs for food, shelter, clean water, clothing and health care met. The fact that there is no food security for the majority of Africa's residents augurs poorly for the future. Tenuous access to food on a daily basis leads to malnutrition, illness-proneness, risk of mental retardation, inability to concentrate at school due to hunger pangs, as well as a host of social problems. Compromised health care precipitates additional health problems: people are not immunised; they become more illness-prone; they have no access to contraceptive, bacterial and viral infection control measures; and they lack understanding of preventive and treatment programmes. The deficient infrastructure means that increasingly people will not have access to clean water, sanitation, adequate housing, or ventilation. The unavailability of public transport facilities force people to walk long distances to school and health facilities, so that they are tired on arrival or give up en route. Over-crowding leads to increased irritability, loss of privacy, increased stress and daily hassles.
The HTV/AIDS pandemic has reversed much of the development work that has been conducted in sub-Saharan African countries to offset colonial adversities (Gregson, Gamett & Anderson, 1994;
UNAIDS, 2001). These nations are becoming poorer (World Bank, 1997). The sheer magnitude of the pandemic dictates that all social service agencies need to combine and co-ordinate intervention strategies for the sake of future generations. It is time for the government, NGO, CBO, FBO sectors, as well as civil society to unite and work synergistically.
The socio-economic factors are not presented to paint a picture of gloom and doom but to inform the type of intervention strategies that are needed. The multi-directional and circular impact of these factors clearly indicate that any meaningful intervention has to be aimed at large scale, cost effective, readily replicable intervention strategies at national, community, family and child levels. African people have historically and still do, live in relatively small but cohesive communities (Ayieko, 2003; Giese et al., 2003). These strong interdependent microsystems can be powerful. However, in the face of the current pandemic, they need support to counteract the negative impact of HIV/AIDS on children (Foster, 2001). There is the potential to strengthen communities, capacity build and network to create co-operation between service organisations and communities (Phiri et al., 2000).
However, it is unlikely that any intervention strategy can have a long-term impact in the absence of concerted poverty alleviation and community development programmes.
23.2. Disrupted education:
One of societies' major gatekeepers is education. People are able to move up or down the socio- economic ladder through educational qualifications. However, schools within poverty-stricken communities are renowned for their high failure rates, demotivated staff, scarcity of educational equipment and lack of resources, uninvolved parents who cannot provide assistance with homework and no resources for extracurricular activities ^Shaffer, 2002)\ The major factors contributing towards educational difficulties are socio-economic in nature.
In addition to the socio-economic variables, educational problems are more evident in vulnerable children thereby dooming their future prospects for adequate adjustment and development (Giese et al., 2003; Hunter & Williamson, 2002; Smart, 2000). In households that are affected by AIDS, children's school attendance and performance tends to decline and they are deprived of the healthy social interaction that is an essential ingredient of psychosocial well-being (Cluver, 2003; UNICEF, 2002). There are several factors associated with the HIV/AIDS pandemic that negatively impact on children's educational opportunities and advancement. These are likely to manifest in terms of scholastic progress and achievement:
• Sensitivity to emotional distress in primary caregiver: Children are usually sensitive to the emotional state of their primary caregivers (Rutter, 1990). When primary caregivers become stressed, distracted or ill, the child is likely to become anxious and concerned. HTV+
individuals seem to have insight into the psychological issues involved in this diagnosis as
many ask for assistance with personal issues and report concomitant psychosocial distress (du Plessis, Bor, Slack, Swash & Colbelt, 1995). Manifestations of this distress in adults can take the form of impairment in daily functioning (Sanford, Offord, Boyle, Peace & Racine,
1992) or the development of significant symptoms, warranting a diagnosis of one or more forms of psychopathology in children. The symptomatology may take the form of (i) internalising disorders such as anxiety, withdrawal, rumination, social isolation, depression, survivor-guilt and low self esteem; (ii) externalising disorders: for example, oppositional, aggressive, hyperactive or antisocial behaviours; (iii) learning and cognitive difficulties including impairments in intellectual or academic functioning, lack of concentration, distractibility; (iv) substance use disorders; or (v) more severe and pervasive forms of social and emotional psychopathology (Corr, 1996; Lutzke, Ayers, Sandler & Barr, 1997; Kazdin, 2000; Tremblay & Israel, 1998). All forms of emotional distress negatively impact on scholastic functioning. For example, a Ugandan study showed that older children reported a 26% decline in school attendance and 28% decrease in average school performance following orphanhood (Gilborn & Nyonyintono, 2000). In Mozambique, 5% of families reported having withdrawn children from school in order for them to help at home (UNICEF, 2002). Improved scholastic performance and intellectual functioning are accepted as valid indicators of effective therapeutic intervention (Kazdin, 2000).
Increased and age-inappropriate responsibilities: As primary caregivers become pre- occupied, distressed, ill, or are grieving, there are likely to be increases in the responsibilities that the child is expected to shoulder (Geballe et al., 1998; UNICEF, 2000; US AID and the Synergy Project of TVT Associates, 2001). Children may be expected to perform (i) domestic chores such as washing, cleaning, fetching water and wood, and doing laundry; (ii) agricultural tasks such as herding livestock, working the agricultural land and ploughing; (iii) caring for younger children, handicapped or elderly people, including taking responsibility for their physical and emotional safety, changing nappies, washing, cleaning and feeding; (iv) caring for the sick by washing, feeding, medicating, dressing wounds, changing bedpans (about one sixth of patients with AIDS are bladder and bowel incontinent and were being nursed at home (PACSA, 2004); and/or (v) income generating activities, for instance begging, hawking, prostitution, farm and domestic labour (Foster & Williamson, 2000; Giese et al., 2003; Gilborn & Nyonyintono, 2000; Smart, 2000).
Responsibility for performing a set of household chores is beneficial in terms of developing a child's self esteem, competence, self-discipline, skills and sense of being part of a collective who share tasks and commitments (Cook, 1998). However when a child is over-burdened by these responsibilities, some of which may be age-inappropriate, it is detrimental to the child and contrary to his or her basic rights (UN AIDS, 2001). The effect of increased tasks and responsibilities is that the child is taken out of the classroom and away from friends and peers. S/he is excluded from developmentally appropriate and necessary activities such as
playing, sports and other socialisation activities. The child's social support circle decreases and the child begins to feel different and alienated (Cohen, Underwood & Gottlieb, 2000).
By force of circumstances, s/he is less likely to develop an internal locus of control - a variable that is recognised to be resilience-promoting8 (Masten, 2001). Usually in the absence of discussion with the child, adult family members make the decision that a child must take on extra responsibilities, or drop out of school, in order to take care of sick relatives or younger children (Foster & Williamson, 2000; Gilborn & Nyonyintono, 2000). Girl children are usually targeted for such responsibilities and this in turn negatively impacts on women's status within society (Cluver, 2003; UNAIDS, 2001).
Economically-based discrimination: Families frequently lack the financial resources for continued school attendance, even in countries that have policies that support free and compulsory education. The additional expenses of uniforms, stationery, snacks and excursion costs, in combination with poverty-related discrimination, operate to exclude poor children.
School fees have been identified as a major barrier to accessing education (Giese et al., 2003). There were numerous accounts of children and their families being turned away, intimidated or discriminated against at school, held back a year, prevented from writing examinations and withholding of school reports on the basis of non payment of school fees (Personal communication, 2002). Furthermore the policies in some countries significantly contribute to stigmatisation through the practice of having some families pay for schooling, while a remission of fees is offered on the basis of needs-based criteria to poor children. The government subsidies for non-fee paying scholars are minimal, thereby discouraging both principals and fee-paying parents from enrolling pupils on a fee-remission basis. Whilst government policies stringently regulate against discrimination on the basis of fee-payment (School's Act of 1996 of SA), in practice the social and emotional repercussions for children who are admitted on fee-remissions is extremely distressing and discriminatory (Giese et al., 2003; Smart, 2000).
Supply and quality of education: The supply and quality of education will be affected by high absenteeism rates and deaths of educators (Babcock-Walters, Booysens, Desmond, Dorrington, Ewing, Giese, Johnson, Gow, McKerrow, Motala, Smart & Streak, 2002;
USAID and the Synergy Project of TVT Associates, 2001), the closing of schools due to decreased enrolments and a reduction in budgets for educational systems due to the increased demand for health services (Shaeffer, 1996). Early childhood education programmes are likely to lack the resources to expand (ibid.). Educators may be reluctant to work in heavily infected areas because they fear infection through contagion (a misconception), or because of the emotional stress created by the deaths of pupils and their family members. The
Locus of control' refers to an individual's belief in their ability to influence what happens to them and to directly affect the external environment. Perhaps a more suitable term would be 'locus of preferred activity,' which refers to an individual's belief that s/he is able to choose her or his own activities, within
financial implications for education budgets will be affected bi-directionally: nationally, less money is likely to be available for education expenses, while simultaneously, more orphans will require fully subsidised education (Giese et al., 2003).
In addition the witnessing of numerous deaths of young people may lead to a change in priorities so that there is less value placed on education. This perception could be coupled with a belief that the available education is of a poor quality and therefore education becomes unworthy of a child and family's investment (Babcock-Walters et al, 2002; USAID and the Synergy Project of TVT Associates, 2001).
There is little doubt that when resources are scarce, it is the orphans who will have to drop out of school (Foster et al., 1997b; Smart, 2000; UNAIDS, 1999). The net result of these factors is that children are likely to forfeit access to the socialisation and gate-keeping functions of schools and become dislocated from their peers. Schools perform numerous functions beyond formal education.
Whilst most educators would argue that schools in developing countries fail in their responsibility of offering 'an education for life' (March & Craven, 1998; Shaffer, 2002), school is still an agent of socialisation influenced by the dominant ideology of the country and is a major mechanism through which children are afforded the opportunity to change their status in society. Disrupted education jeopardises the developmental progress of vulnerable children (Foster et al., 1997a; Ntozi, 1997;
Smart, 2000). In South Africa, the departments of health and education collaborated to introduce a school-based life-skills programme in 2000, however an evaluation of this programme showed that it was conducted erratically and was rather skeletal in operation (Fox et al., 2002; Kelly, Ntlabati, Oyosi, van der Riet & Parker, 2002).