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Decosas, J.; Kane, F. "Migration and AIDS." Lancet, 9/23/95, Vol. 346 Issue 8978, p826


Half Page Summary of the Article

The main focus of this article is the growing AIDS epidemic in Southern Africa. The article explains that the spread of AIDS is due to several factors including: prostitutes, the men who solicit them, and the seldom use of condoms and other contraceptives. The article claims that the pattern of mixing (the number of people your partner has had intercourse with) and not the actual number of partners you've had, increases your chances of being infected with the deadly virus.

This article was chosen because We knew AIDS is a serious problem in Africa, yet were unclear as to why, it's cause, as well as the steps being taken to bring it under control. It is important to educate one's self about problems in the global community since, in the long run, it affects you as much as what is happening in your own community.

The central issue in this article is the spread of AIDS through prostitution and the efforts being made to solve this problem.

The secondary issues are the African Economy; which is in dire need of help, and unemployment, which is one of the main causes of prostitution (a catalyst in the spread of HIV), the problem of AIDS being spread through human migration, inadequate health care, and homelessness.

The issues in this article are immediately relevant to: This article focuses on Southern Africa , but affects the entire African Continent since this epidemic is quickly spreading to Eastern, Western, and parts of Northern Africa and may even migrate with immigrants to Europe and Asia.


5 Critical Thinking Discussion Questions

  1. Discuss some ways to prevent the spread of HIV/AIDS in Africa.
  2. Do you think the prostitutes who carry HIV or the men who spread it are most at fault? Explain you answer.
  3. Do you think prostitution should be legal or illegal? Explain your answer.
  4. How do you think Africa could improve employment for their citizens?
  5. What effect, if any, does mass deportation and closing borders have on the HIV problem in Africa?


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MIGRATION AND AIDS: Mapping the spread of HIV

Decosas, J.; Kane, F. "Migration and AIDS." Lancet, 9/23/95, Vol. 346 Issue 8978, p826

There has been keen interest in mapping the routes of HIV infection since the pandemic was first discovered. We have seen years of acrimonious debate about where the virus came from, and about who was responsible for its spread. Mercifully, the public health community has all but abandoned this useless discussion. Once we knew that HIV did not behave like the plague or like cholera, that it could not be contained through quarantine and isolation, public health officials started to lose interest in the fanciful maps with the swooping arrows. But the discussion has not disappeared. Governments, the news media, and the public in general are still keenly interested to find out who is carrying HIV where. Immigration officials still perk up when AIDS is mentioned, ready to slap on another travel restriction or another regulation for mandatory HIV testing.

HIV, like any other infection spread from person to person, will follow the movement of people. But the low infectivity of the virus, its transmission dynamics which have very specific contextual determinants, and the long latency and chronic course of HIV disease, preclude effective control of the epidemic through a cordon sanitaire. We have not seen any significant epidemic triggered by the arrival of immigrants from another country. However, we need just one press report of a single infected migrant who lacks judgment and good sense and knowingly infects his or her local partner, to restart the witch hunt for the foreigner carrying disease from abroad. The "patient zero" myth--that fanciful story of a Canadian airline steward said to have spread HIV throughout North America--has never been completely buried.

Talking in one breath about AIDS and human migration is dangerous. Many of us have preferred to remain silent on this issue out of fear of having our analyses denatured into arguments for mass testing and deportation. But silence has ceased to be an option. Population migration has become a central theme in the discussion of AIDS, and we have an obligation to engage in this discussion in order to prevent it from producing grist for the mills of xenophobia. This is the idea behind presenting a symposium entitled Migration and AIDS at the First European Conference on Tropical Medicine to be held in Hamburg, Germany from October 22 to 26, 1995 (panel). It is an attempt to redefine the discourse on AIDS and population movement, and to contribute to a better understanding of the factors which render mobile populations vulnerable to HIV.

Migration in Uganda

Data from Uganda to be presented show a strong correlation between HIV infection and migration status. Among the 5553 adults included in the study, age-standardised and sex-standardised HIV seroprevalence rates ranged from 5.5% among those who never moved, to 12.4% among those who moved to a different village, to 16.3% among those who joined the cohort from another area during the study period. A similar association between mobility and HIV status has previously been reported in Senegal? The findings suggest the hypothesis that in a situation of HIV endemicity, mobility is an independent risk factor for acquiring HIV regardless of destination or origin.

This hypothesis alters the conceptual approach to AIDS and human migration. Until now, the preoccupation has been with trying to explain the geographic spread of HIV by retracing the routes of population movement.[3] We postulate that it is not the origin, or the destination of migration, but the social disruption which characterizes certain types of migration, which determines vulnerability to HIV. The fact that population movements distribute HIV is secondary to the fact that certain types of migration cause HIV epidemics. Once we have performed this conceptual shift, we are in a position to explore and hopefully address the factors that render migrants so vulnerable to HIV infection.

Male migration in West Africa

The other contributions to the symposium in Hamburg explore this issue in the context of West Africa, where a newly launched project of the World Bank has focused much attention on the issue of human migration and AIDS. Populations in West Africa are highly mobile. Fishermen follow the southern coast from Cameroon to Liberia in pursuit of the seasonal migration of fish stocks, traders ply the coastal routes from Senegal to Nigeria, and farmers of the Sahel migrate to the plantations in the coastal countries to survive the dry season. Migration predates the establishment of today's nation states. National borders may influence the routes of migration, but not the extent of the population movements. Entire villages in northern Burkina Faso speak Twi, the language of the Ghanaian gold fields in the south. During the 1970s, a whole generation of Ghanaian nurses, teachers, and physicians launched their professional career in Nigeria.[4] Today, the main destination of migrants is Cote d'Ivoire. Among its population of about 12 million, one quarter is are migrants from neighbouring countries. In the capital, Abidjan, this proportion is as high as 40%.[5] Cote d'Ivoire also has the highest HIV prevalence rates in West Africa, a finding consistent with our hypothesis. The country has the largest concentration of mobile populations. It is therefore the place to observe the factors that make migrants vulnerable to HIV, and to develop approaches to decreasing this vulnerability.

Seasonal migration in West Africa is a predominantly male institution. A large agricultural enterprise in Cote d'Ivoire may have a camp of as many as 2000 young male migrant workers. At home, these men are subject to the very strict social control of their village. Social behaviour is highly codified, and privacy is an alien concept. In the camps, this tight external control is temporarily replaced by the culture of maleness. Being male, young, at least temporarily single, and receiving your pay on the same day, are the common attributes that bind this group together. Competitions in physical prowess replace the controlled social interactions in the village. On the weekend after pay-day, a convoy of 30 to 40 female prostitutes may arrive at the plantation, often brought from town by the employer, and service a mean of 25 workers each over a period of two nights.[6] This incredible burst of sharing of genital microflora is a powerful motor for the spread of HIV infection. Over a six-month period in his village in the Sahel, a young man may have three or four female sexual partners, sequentially or even concurrently. Over the same time span, while working on a farm in Cote d'Ivoire, he probably has the same number of different partners. However, he is sharing each one of these latter partners with ten to fifteen other men in the same night. It is this pattern of mixing, and not the actual number of partners, which is responsible for the extensive spread of HIV among migrant workers. Mathematical models of the effect of mixing patterns in the generation of epidemics of sexually transmitted disease confirm this observation.[7]

Female migration in West Africa

Female migration in West Africa is a smaller and much less known phenomenon. The migrating Ghanaian "fishmothers" who provide a range of on-shore services to the Ghanaian canoe fishermen on their trek along the coast,[8] and the travelling Yoruba traders in printed cloth from Nigeria[9] are institutions with a long history. But independent and autonomous migration of West African women in significant numbers only began in the mid 1970s (to be reported by JKA). This was the time, when many single Ghanaian women started to move to Nigeria and to Cote d'Ivoire for largely the same reason as their male countrymen, to find well-paid jobs.

At least two thirds of all Ghanaian migrants in Abidjan are female, and a large proportion of them are prostitutes. More than half of all professional prostitutes in Abidjan are Ghanaian. JKA studied the profile, the motivation, and the migration behaviour of these women. That so many of them end up working as prostitutes may be explained solely by the fact that this is the most mobile occupation, and one of the easiest to enter, especially if you do not speak the national language. Why such an inordinately large proportion of Ghanaian prostitutes come from a small rural area is a sensitive issue for which there are only hypothetical explanations. One compelling theory is that this area saw a huge influx of migrant labourers during the 1950s at the time of the construction of the Volta river dam. Prostitution was then established in the area. With the withdrawal of the dam workers, local women started to migrate to continue their business.[10] Today, more than 80% of those who are still working as prostitutes in Abidjan are infected with HIV. What was once a lucrative business and a rational strategy for economic survival has now become a strategy for death.

FK has studied the health needs of a representative sample of prostitutes in Abidjan, including about 6000 Ghanaian migrants working from rented rooms in slum areas, charging a rate of less than US$1 per client. Almost all of them report that they would like to leave the profession, but few see a way out. Although a few prostitutes in the survey report monthly savings up to US$200, over one third are unable to save any money at all, and the mean savings per person are less than US$20 per month.

The five most frequent health problems reported in the survey were malaria, pelvic pain, menstrual irregularity, vaginal discharge, and genital sores. While in Abidjan, most women treat their health problems with drugs bought on the street or obtained from friends. In contrast, once they return to their home country, most state that they visit public health services. Medication to treat reproductive health problems is generally bought from street vendors on the basis of the colour and the shape of the preparation. In a previous medication survey, FK analysed 143 pills and capsules for pelvic symptoms bought on the street. The products contained 13 main active ingredients and 19 unidentified substances. The most common ingredient (46 of the 143 pills) was paracetamol, followed by tetracycline, chloramphenicol, and ampicillin.

Ghanaian migrant women working in prostitution in Cote d'Ivoire receive health care which is inadequate and probably more harmful than beneficial. They know how to gain access to the formal health care system in their home country, but at their destination seek care in a wildly informal and unregulated free market. We have thus closed the loop to describe an explosive social situation which, in our estimation, is responsible for the high HIV-infection rates in Cote d'Ivoire. The situation is characterised by the presence of a large migrant labour force of young men living in all-male communities and receiving sexual services from a group of migrant female prostitutes. Each member of either group has one main motivation; to scrape together some money in order to leave his or her present situation and return home. While the male workers may or may not receive some form of health care through their employment, the migrant women have no access to adequate services, and may even be the economic substrate for the expansion of yet a third dysfunctional institution, that of medical quackery.

Migration to cities

In the last presentation of the symposium, KDRS will present another aspect of migration in West Africa, the movement of rural women to the large cities. In Lome, the capital of Togo, Forces d'Action Pour le Mieux etre de Mere et Enfant (FAMME)--a private voluntary organisation--provides services to these migrants. Most of them are adolescents or young adults from very poor families. They do not have the right to own land and, once married, face a life of servitude working their husbands' fields. They are fully responsible for raising their children. The husband usually provides staple foods such as corn or cassava, but never any money for clothing, school fees, or medical care. Some seek to escape this bleak future by moving to the city in search of paid employment. Many arrive with one or two small children in their arms. Illiterate, unable to speak French, and without any marketable skills, they find themselves at the bottom of the social ladder. They work as market carriers, cleaners, or coconut sellers. They sleep in open lots without water or sanitation. They have no access to medical care because they do not know where to go. Violence and rape are common, and the younger women often end up augmenting their meagre earnings by engaging in part-time prostitution. Among these women, the charges per male customer are in the range of US30 cents.

FAMME provides services to more than 1000 of these women in four districts of Lome. The organisation operates a small medical clinic, stocked with essential drugs and staffed by volunteer physicians and midwives during the evening hours. Two social workers visit the camps and organise education sessions on health, family planning, and AIDS prevention. Women who are found to be ill are directed to the appropriate services. A small low-interest loan scheme has been started, and training programmes to improve the prospects for employment are being considered.

Population movement world wide

West Africa is not an exception. As the world's population grows, differential pressure on ecosystems will invariably lead to larger and larger population movements. Population policy, environmental protection, and economic development may provide the long-term answer to many problems brought about by migration. But in the short-term, a policy of providing accessible and acceptable basic health and social services to migrants at their destination has a chance of creating the sense of security and the sense of community that is necessary for health. As long as migrants are excluded from community life and victimised as the carriers of HIV, they will continue by default to organise themselves into anti-communities driven only by the need for daily individual survival. Rapid spread of HIV is one of the consequences of this type of dysfunctional social organisation. It is a consequence which affects the host country as much as the country of origin, because many migrants return home to die. Closing borders and mass deportation may be a feasible option for a few island states, but in West Africa it is neither feasible nor desirable for the economic development of the region. However, if we understand the migration routes, the profile of the migrants, their motivation, and their needs, we can decrease their vulnerability to HIV and other disease. A goal from which everybody would profit.

Copyright of Lancet is the property of Lancet and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Source: Lancet, 9/23/95, Vol. 346 Issue 8978, p826, 3p, 1 chart.

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THULANI MTHETHWA. Swaziland's city girls ignore king's five-year sex ban. AP Worldstream, 09/30/01


MBABANE, Swaziland, Sep 30, 2001 (AP WorldStream via COMTEX) -- Frustrated by the high rate of HIV infection in his country, Swaziland's king ordered all his young female subjects to don a symbolic chastity belt, a tasseled scarf signaling a 5-year ban on sexual relations. Yet nearly three weeks later two scarfless teen-age schoolgirls waited for a bus on the streets of the capital, Mbabane, and openly questioned their ruler's edict.

"Five years is too much," said Siphiwe Nkosi, a 14-year-old wearing a maroon school uniform. "If they had said two years, we could have observed the tradition."

Nearly two decades after this tiny mountain kingdom was last subjected to a sex ban, young women in traditional rural areas - where powerful local chiefs enforce the king's will - appear to have accepted the order. But it is nearly

mpossible to find a scarf among the thousands of newly urbanized girls in Mbabane and Swaziland's manufacturing hub of Manzini.

Nkosi's mother went to the trouble of buying her one of the multicolored tasseled scarves. But it sits unused in her home in a suburb just outside Mbabane.

"I can't even go to school wearing it because my friends would laugh at me," she said. Lungile Dlamini, 16, who attends a different school, agreed.

"If they wanted us to embrace this tradition, it should not have been imposed on us," she said.

Describing teen-age girls as "flowers that should be protected," King Mswati III announced on Sept. 9 the reinstatement of the traditional chastity rite of umchwasho.

Many Swazis, already confused and annoyed by Mswati's order, were infuriated when soon after announcing the umchwasho the 33-year-old king announced his engagement to a 17-year-old girl, who would be his ninth wife.

Under the tradition, in place for the next five years, all unmarried girls under the age of 18 must wear the multicolored, woven scarves signaling they are not to be touched by men.

Banning young women from having sex is a long-standing Swaziland tradition that is enforced intermittently. It is up to the king to decide when to issue a chastity order. If a boy violates umchwasho, the girl and others in the village are to march to his house and throw their scarves at it. The boy's family will then be forced to pay his chief a fine of one cow or 1,300 rand (dlrs 145). No one has been fined yet.

Unmarried women over the age of 18 are to wear red and black scarves, which allow limited sexual contact, but not intercourse.

Mswati said the umchwasho was necessary to combat the frightening HIV-infection rate in the country. More than 25 percent of adults in Swaziland are infected with HIV, according to UNAIDS. The disease has already killed tens of thousands of Swazis. The last umchwasho, decreed by Mswati's father, King Sobhuza II, was largely adhered to when it was enforced in the early 1980s. But Swaziland was a vastly different country then. The cities were smaller and far more heavily influenced by the conservative values of the rural areas. Girls wore long skirts and even though some of the more urban girls were embarrassed by the chastity scarf, they still wore it, hidden beneath their clothing. Now, Mbabane boast buildings 12 stories high and nearly a quarter of the 1 million Swazis live in the cities, where teen-age girls show off their constricting designer jeans, skintight tank tops and platform shoes.

"The tradition now has lost meaning," broadcast journalist Comfort Mabuza said. Queen Mother Ntombi Thwala defended the sex ban, saying the tradition would help promote moral values in unmarried women. But teachers and women throughout the cities decried it as misguided and bizarre. Philile Mamba, a 23-year-old student at the University of Swaziland, wondered how effective umchwasho could be in stopping the spread of HIV in a country where young girls were still forced to marry sexually experienced men far older than them.

"By eradicating this practice, we would have taken a giant step toward combating HIV, instead of just having wool hanging down from the girl's head to her shoulders," she said. "Why can't we channel all the resources into educating young girls to uphold their self-esteem ... (so) they are able to say no to sexual advances." "I think we are missing the point here," she said.


Associated Press Writer

Copyright 2001 Associated Press, All rights reserved


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RAVI NESSMAN . . Catholic bishops in South Africa condemn condoms for preventing AIDS except in limited situations. AP Worldstream, 07/30/01


PRETORIA, South Africa, Jul 30, 2001 (AP WorldStream via COMTEX) -- Roman Catholic bishops in southern Africa strongly condemned Monday HIV prevention programs that recommend condom use, but said married couples with the virus could use condoms in very limited circumstances.

The Southern African Catholic Bishops' Conference said the widespread promotion of condom use was "an immoral and misguided weapon in our battle against HIV/AIDS," according to a document released at the end of the bishops' annual meeting.


Prevention programs should replace condom distribution programs with efforts to promote abstention, Napier said.

"This is God's way. Choose life. Don't choose the way of sin or destruction," he said.

However, married couples could use condoms if one or both them was infected and they abstained from sex while the woman was ovulating, Napier said. This way, the condom would not prevent the creation of life.

"This is one possibility during which the condom could be used in a morally responsible situation," Napier said.

The Vatican had no immediate comment. The bishops' limited proposal for condom use would have little impact without Vatican approval.

In his 1968 encyclical "Humanae Vitae," "Of Human Life," Pope Paul VI reaffirmed the church's ban on contraception, asserting an inseparable link between the unifying and reproductive dimensions of sexual intercourse.

That position has been attacked in recent years by some governments and AIDS activists who say the church's blanket ban on condom use has hindered efforts to contain the AIDS pandemic.

The southern African bishops' debate was sparked by a proposal for the conference to sanction the condom use as part of a wider program to stop the spread of HIV in Africa, where more than 25 million people are infected with the virus that causes AIDS.

However, the conference, which includes bishops from South Africa, Botswana and Swaziland, rejected that measure.

Bishop Kevin Dowling, who strongly backed the proposal, left the conference early. He did not return a phone call from The Associated Press Monday.

Most HIV prevention programs preach abstinence and monogamy, but they promote condoms - proven effective for helping stop HIV transmission - for those unwilling to abstain from sex.

The bishops argued condoms promoted promiscuity and actually hurt prevention efforts.

"Using condoms is not really saving people's lives," Bishop Michael Coleman said. He condemned the South African government for distributing the contraceptives.

"They are promoting a hedonistic society," he said. "Young people see these messages, they get condoms dropped on them from helicopters and all kinds of things, and this is not telling them to have any respect for themselves and their sexuality and their future partners. It is just a free love society."

The bishops also questioned whether condoms truly helped prevent HIV transmission.

The Treatment Action Campaign, an advocacy group working to get treatment for people infected with HIV, strongly condemned the bishops' comments as "highly irresponsible" and said condoms remained an important cornerstone of HIV prevention.

"The Catholic Church is confusing its religious morals with science," said Mark Heywood, secretary of the group.



Associated Press Writer

Copyright 2001 Associated Press, All rights reserved

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Kelso, B.J. .ORPHANS OF THE STORM, Africa Report, Jan/Feb94, Vol. 39 Issue 1, p50, 5p, 3bw

Financially wracked governments of southern Africa, uncagle to cope with the drain of resources caused by the effects of AIDS, especially the orphanin of children, are leaving the burden of care where it has traditionally belonged--to the extended families. Rather han spend money on building orphanages, governments are cooperating with social workers and NGOs to strengthen communities in caring for AIDS orphans and to combat prejudice against those with the disease.

Miriam Mutiti's life changed dramatically overnight. The single mother of three suddenly found herself responsible for three more children and barely eking out a subsistence. She and tens of thousands of others like her can blame their woes on one thing: AIDS.

The disease killed her brother after claiming his wife the previous year. With few other options, 36-year-old Mutiti took in his children, aged 9, 11, and 14. Survival for the family of seven became a tough task. Mutiti's only source of income is from her crochet work, which she sells near her home in eastern Zimbabwe.

"It is very, very difficult," Mutiti said. "Food and school fees are the biggest problems. The children are a burden, but I'm the only one left in my family. I sell my things, but people won't give me all the cash. They give me riffle, riffle."

Across the developing world, the children left behind and their surrogate parents are emerging as the newest casualties of the AIDS pandemic.

In Africa alone, by the year 2000 there may be as many as 2 million children without one or both parents as a result of the disease. In southern Africa, the number of children orphaned by AIDS has already soared.

In Zimbabwe, there are 67,770 of these children, 26,000 from 1993 alone. With more than 800,000 of the nation's 10.4 million people now infected with the virus, the number of orphans is expected to rise to 620,000 by the turn of the century. Other countries face the same tidal wave of parentless children.

In Malawi, where 20 percent of the urban and 8 percent of the rural population are HIV-positive, there are at least 24,000 children orphaned by the disease and there could be up to 361,000 within seven years. In Zambia, at least 80,000 children have lost one or both parents and officials expect that another 30,000 new orphans will join them in each coming year of this decade.

One reason these numbers will skyrocket is that few HIV-infected women take precautions against further pregnancies. In part, this is because the mother may have seen one child, already born infected, sicken and die, and so she chooses to have another to survive her. Such a gamble is

risky: Nearly one of every three of these newborns will be infected. The majority, however, are uninfected and eventually survive their parents as orphans.

To date, most governments in southern Africa have not felt the financial drain of caring for foundling children. With cash shortages and little additional room in orphanages, they've had little ability to even consider it. The burden of care has been left with the extended family--where it traditionally belongs in this region, and in most cases, will have to stay.

In Zimbabwe, the 32 public and private orphanages are struggling to meet their daily needs. Most of the state institutions are for older, troubled children and state help to private homes is far from enough. For example, it costs the Harare Children's Home a monthly average of $130 to care for each of its 90 children, while the government gives only $16 per child.

That's all the state can afford to contribute and, as the number of orphans increases. the amount could become even less. Getting the available money from the bureaucracy isn't easy, either. Staff at Makumbi Children's Home in the Chinamora area say they are receiving funding for only 50 of the 85 children.

The private institutions also have the ability to reject children, a move expected to become more common as the number of orphans rapidly multiplies. An influx could jeopardize creating the very family atmosphere needed by orphans in such programs, according to Father Konrad Landsberg of Makumbi Children's Home.

Landsberg has worked hard to simulate family life by ensuring that each housing unit has only 11 children and one or two foster mothers. Teenagers serve as older sisters. Men from a nearby parish often visit as surrogate uncles. To date, Makumbi Home has only two sets of children known to be orphaned by AIDS.

"I'm scared this huge number of children orphaned by AIDS will come and we will have to make compromises," Landsberg said. "I'm aware of this thing coming toward us, but how to cope--I don't know. There is need for heavy thinking in this country but I'm afraid no one is ready for that. It'll be a big disaster."

A disaster, however, is exactly what many social workers, non-governmental organizations (NGOs), and state officials insist will not happen if

they work together today to avert it tomorrow. They're all mobilizing, but not to boost state financial assistance dramatically or to build new orphanages. Their aim is to help caregivers and strengthen communities to play that role.

Such a goal is a tall one. Elderly women so regularly assume the role of caregivers--tending their dying son or daughter, possibly his or her spouse, and then the children left behind--that AIDS is now known as "The Grandmother's Disease" in many southern African countries. If a grandmother doesn't inherit the orphans, then an aunt almost always will.

The numbers of relatives caring for newly orphaned children can be seen in Zimbabwe's Manicaland Province, where Mutiti and her three new children are not alone in their situation. The province of 1.5 million people has 47,000 children who have lost one or both parents; institutions care for only 170. But as Mutiti found, some NGOs are doing more than just talking about the need to help.

The Mutare-based Family AIDS Caring Trust recently began assisting Mutiti and 29 other families with basic necessities, such as food, clothes, and school fees. One beneficiary, a 57-year-old grandmother, is taking care of her deceased daughter's five children. The youngest, a 5-year-old boy, is infected with the AIDS virus and is already ill.

The program, funded by Plan International and Save the Children U.S.A., includes educating communities about the disease and how to care for both the infected and affected, such as the deceased's children. It also gives grants to local churches for their orphan programs, according to pediatrician Geoff Foster, who serves as the trust's voluntary director.

Foster, who has worked as a government doctor for more than seven years, said the most important thrust of the program is to revitalize the traditional coping system of communities. He said the system is intact, but ruptured by modern society, leaving families no longer as cohesive as they once were.

"If this situation were happening in the United States or United Kingdom, children would be lying all over the streets and dying because the extended family system is destroyed there," Foster said. "Here, it's still coping. We don't need to design Western-style means of dealing with orphans. We need to sit quietly and let the community find its way--not by default, but with resources."

In Malawi, national policy guidelines put forth by the National Task Force on Orphans are designed to help families caring for orphans as well.

The guidelines call for more emphasis on assisting and empowering these extended families by helping them with agricultural supplies to produce enough food and with skills training to earn incomes and meet their cash needs.

The formation of the task force, which includes Unicef and the Ministry of Women and Children Affairs, followed a national consultation on the plight of children orphaned by AIDS. The ministry has since launched a countrywide survey to determine the number of orphans and Unicef began a project to identify their needs. Both moves could bring assistance to these families.

In Zambia, NGOs are taking the lead on the orphan issue. They must. As one health official said: "Our budgetary capacity just couldn't cope." At least 250,000 of Zambia's 8.1 million citizens are infected. Patients with AIDS-related illnesses occupy up to 70 percent of hospital beds.

Children in Distress (CINDI) is one organization doing what Zambia's government cannot The program helps set up committees of neighbors, friends, and teachers of orphans to serve as foster parents along with the children's relatives. These additional "parents" assist families with their day-to-day needs.

"CINDI is only a catalyst to increase awareness of orphans and also to increase care for them," said Dr. Shilalukey Ngoma, a pediatrician at Lusaka's University Training Hospital who founded the program with help from the Family Health Trust. "Communities themselves are central to the care of these orphans."

Maybe so. But the sheer number of orphans is not the only challenge that must be met by CINDI and others working throughout the region to help children in need. In most communities, AIDS is still the best kept secret of many households because it brings with it a heavy stigma, which the public often transfers to the surviving offspring regardless of their health status.

Efforts are under way region-wide to convince communities that those whose lives have been affected by AIDS should not be social outcasts.

Dozens of programs educate the public through their peers, from prostitutes to schoolchildren. The infected are also beginning to speak out. In Botswana, where 90,000 of the 1.3 million people carry the virus, three HIV-positive people went public in October in a national campaign against discrimination.

Attitudes are changing, but slowly and not in all communities. A Zimbabwean newspaper profiled one HIV-positive woman, who then found her property full of villagers. They didn't come to offer support. They came to see an AIDS victim, and their persistence included peeping through her windows at all hours. In another area of Zimbabwe, a social worker told of how people lean close and whisper, "Show me someone with AIDS."

But perhaps the greatest challenge in helping orphans and their caretakers is to convince authorities to act--fast. As governments and donors undertake studies or plot strategies, some young female orphans are turning to prostitution to help their families survive. This leads to tragic irony, possibly exposing the girl to the same disease that robbed her of her parents.

Abandoned children are becoming more common. Some relatives give up; others never even tried. The newest phenomenon emerging in southern Africa is child-headed households, in which the eldest orphan becomes the parent because no relative can or will. In addition, hospitals have become dumping grounds for the young and their lengthy stays indicate just how overstretched orphanages really are.

In Zimbabwe, some health experts estimate that there are up to nine abandoned children living in each of the major hospitals at any time. They were often admitted with their mothers who later died and no relatives subsequently stepped forward to take the children home. In some cases, the foster caregivers admit ill orphans to the hospital and never return to reclaim them.

In Parirenyatwa Hospital in Zimbabwe's capital city, there are eight orphans living in the children's ward. Among them is 3-year-old Angelica, whose mother died there a year ago. It's been seven months since 4-year-old Tafadzwa's mother died in the hospital, but a relative has yet to come for him. "For them it's like being in prison." the matron told one local newspaper.

It's prison virtually ignored by the government and all the programs to help families caring for or-phans. In Zimbabwe and elsewhere in the region, these "forgotten children" could soon become more common as extended families become over-extended and institutions continue to be left out of the official strategies.

Then, maybe these children, too, will benefit from efforts to make the lives of orphans that much brighter. There is one aspect, however, that most people haven't considered: Ensuring care for them could take years of assistance.

Nkiki Ngcongco, a Zimbabwe-based public health nurse with the World Health Organization's Global Program on AIDS, recognizes that social disruption caused by AIDS is fast eroding the strong family life inherent in many African societies. Most alarming, she said, is that the repercussions aren't temporary.

"Even if we have good progress today and are somehow guaranteed an AIDS-free youth in 10 years' time, these women and children will still be deprived, still suffering because of their situations," Ngcongco said. "We are going to feel the impact of AIDS well beyond the existence of itin our countries."


B.J. Kelso is a freelance journalist based in Harare, Zimbabwe.

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