According to the UNAIDS data (2006), Southern Africa is the world region most affected by HIV/AIDS, and that is where most of the children living with HIV live. Other high infection regions are in the Caribbean, Latin America, and South/Southeast Asia. South Africa, where I have direct experience, has the 6th highest prevalence in the world; almost 20% of its citizens are estimated to be infected, and new infections are increasing with no sign of reaching a natural limit. However, the disease is not equally distributed among South African society: Black Africans have the highest prevalence (18.4%) compared to other racial groups (whites-6%; coloured-7%; indians-2%).
Indeed, while anyone can get the virus under the right conditions, HIV/AIDS is not an egalitarian disease; even in affluent countries the groups most at risk for contracting the virus have shifted to the poor, and particularly the female poor. Like the history of Tuberculosis, which today can only be found in impoverished and abandoned communities in the poorest regions of the world (or the poorest sections of western cities), HIV/AIDS is globally selective of its victims; it is most virulent among the poor in the poorest nations and there is evidence that the highest rates of infection now occur in women (Farmer, 2001; Walker, 2007).
The HIV/AIDS pandemic has perpetuated its most devastating effects upon the poor in developing countries across the world, particularly in sub-Saharan Africa, including South Africa. In 2003, one fifth of South Africa’s adults were HIV positive and 16,000 were dying every day (Hunter, 2003). The highest death rates occur among employable adults, decimating the income-generating members of communities, leading to lower tax income to support community infrastructures, such as education and the now over utilized health services. This cycle of AIDS and poverty has meant that South Africa has dropped dramatically over the course of the last five year on the scale of economic development, creating greater numbers of poor and people vulnerable to the virus and without adequate services.
While the afflicted in the early years were predominantly heterosexual men who, due to Apartheid’s system of separate homelands for Black South African employable men, who were forced to become migrants in order to earn a living for white mines and factories in large cities. Far from their wives, these men caught and spread the virus through their exchanges with sex-workers, who also had migrated to cities for money to survive. By 2003, the HIV/AIDS epidemiology statistics made a gender switch: women came to make up two-thirds of Africans infected with HIV (Hunter, 2003). South African women also came to have a higher prevalence than men; 18% compared to 13%, and that gender infection gap is thought to be widening. Women, like children, are more vulnerable than adult men because they have no power or rights in their communities. However, global statistics remind us that, even in our own country, it is poverty that makes misogyny so toxic. [UN on Women}
The high occurrence of HIV in southern African women has meant that, due to vertical infection, rates of HIV in children have also risen. About 90% of infected children get virus from their mothers during pregnancy, birth, and/or breast milk. Without antiretroviral treatment (HAART): (a) 1 in 3 infected newborns will die before age one, (b) over ½ die before reaching their 2nd birthday, and (c) most are dead before 5 years. In Zimbabwe and Botswana child mortality rates have doubled since 1990. Tragically, only 15% of the 780,000 children living with HIV in these regions were receiving treatment at the end of 2006; every hour, 40 children die due to AIDS.
As the greatest number of infections and deaths are adults ages 20-35, the physical, emotional and cognitive impacts of HIV/AIDS on infants and children has reached a tragic scale; more and more poor households are headed by grandmothers and children who have, respectively, lost their children and parents to AIDS-related diseases. In addition to suffering the stresses of multiple losses, upheaval of their family systems, inadequate care from ill-prepared or frail caregivers, and removal from their homes, infants have been infected with the virus by their HIV+ mothers. Before ART, infection was an early death sentence for a child; with treatment, these children still face the stresses above, and many will grow up in institutional settings.
Linda Richter and colleagues of South Africa’s Human Sciences Research Center (HSCR) report that “it has been argued, particularly where children are concerned, HIV/AIDS needs to be treated as a broad developmental concern rather than as a narrow health or even public health issue” (Richter, Manegold & Pather, 2004, p. 4).
As a result of the AIDS Pandemic, a new international crisis category has emerged: “Orphans and Vulnerable Children” (OVC). These are (Richter, Manegold & Pather, 2004, p. 3):
- Children infected with the virus
- Children living in regions with high infection rates affected by the stress, the decrease in services and the damage to social institutions
- Who lose a parent or parent substitute
- Who live in a household in which one or more people are ill, dying or deceased
- Who live in households which receive orphans
- Whose caregivers are too ill to continue to look after them
- Living with very old and frail caregivers
- Older than 15 years of age
HIV/AIDS has torn apart South African family structures more effectively than Apartheid’s homeland and migrant worker systems. Here is a partial list of the impact of the virus on South African families (Richter, Manegold & Pather, 2004, p. 5):
- "The emergence of child- or adolescent-headed households
- An increase in elderly caregivers, and children caring for old people;
- Increases in household dependency ratios;
- Separation of siblings
- Family breakdown
- Child abandonment
AIDS has also impacted communities by producing declines in skilled and professional services, strains on health care and educational service delivery, and extreme stress on small communities who must absorb the children of the dead and dying into their care (Richter, Manegold & Pather, 2004, p. 6). HIV/AIDS is ravaging sub-Saharan societies, especially by diminishing health, welfare & education systems due to the extreme volume of needs due to the epidemic, loss of people to staff these institutions due to AIDS-related illness & death, and reduced tax-base because of the illness & death of employable persons (Richter, Manegold & Pather, 2004, p. 5).
The next set of influences on the impact of AIDS in South Africa will leave us in no doubt of its complex web of psychological, social, physical forces and needs. This set consists of the influences of gender, age, and household location (Richter, Manegold and Pather, 2004, p. 7-8):
- Education for boys valued more highly (they are considered to be potentially more economically productive), so girls are often the ones to leave school or work to care for the sick or younger children;
- Female-headed households are poorer than those headed by men;
- Female-headed households tend to allocate more of the family’s resources to children’s healthcare and education than male heads;
- Infants and toddlers are most vulnerable to effects of AIDS and health risks;
- Preschoolers are vulnerable to malnourishment, abuse and neglect, poor stimulation, and lack of opportunities for schooling;
- Adolescents are vulnerable to school drop-out, sexual exploitation, and overwork;
- All children are vulnerable to the emotional consequences of multiple losses, including parents, and to being separated from their homes and communities.
Location of household
- Rural households are typically poorer and have fewer employed adults than urban households;
- Children are expected to contribute substantially to subsistence activities
- Social networks in informal urban areas are less developed and less supportive;
- Caregivers often leave their children alone because of their “livelihood activities.”
Like on the global stage, South African HIV positive children’s mental health and cognitive developmental needs have historically been neglected in the child development research and in most intervention programs. South Africa is not the only developing country lacking national psychoeducational data. Most child development research and programming has been done with U.S. and European samples, and psychologists in western nations have not concerned themselves with internationalizing their theories and studies, particularly in those parts of the globe with the greatest needs for help and understanding. In the international and national responses to the HIV/AIDS pandemic in southern Africa, “psychological” has, until recently, been considered a less important or less acute problem than HIV/AIDS affected children’s nutrition and shelter, as if, Linda Richter (2003) suggests, their “need for food and shelter is greater than their need to feel loved by others and to respect themselves” (p. 245). The 2007 HIV and AIDS and STI Strategic Plan for South Africa, 2007-2011, makes no mention of insuring that children’s conditions actively contribute to rather than undermine their emotional and social development, and by extension their academic achievement and potential to contribute to South African society. This oversight confirms the relative neglect of orphans’ and vulnerable children’s mental health and achievement by funders and policy makers, at least in South Africa. National policies that support multifaceted treatments in the services of children’s development are crucial components of meeting the first and second UN Millennium Development Goals: (a) eradication of extreme poverty and hunger, and (b) insuring that all children complete primary schooling.
As the preceding suggests, we know a fair amount about the risks and stressful conditions that occur under conditions of chronic poverty and HIV/AIDS; however, there are as yet only a few studies on the psychological effects of HIV/AIDS and poverty on South Africa’s (and other severely affected nations’) children, including their cognitive functions, academic achievement, and mental health (Cluver, 2007; Richter, 2003; Walker, 2007). For example, studies on the mental health of AIDS orphans are not only few in number but incapable being interpreted across studies; the variabilities of procedures, measures and samples used makes it impossible to come to firm conclusions. There are suggestive trends, however, such as the higher levels of psychological problems in AIDS African orphaned children, such as internalizing problems (hence depression and anxiety), symptoms of post-traumatic stress, behavioral problems, and delinquency (Cluver & Gardner, 2007; Cluver, Gardner & Operario, 2007). However, more research on the mechanics of increased mental health problems in these children is needed in order to better understand the factors in their lives “which are acting as stressors or buffers in mental health outcomes” in order to inform options for therapeutic intervention” (Cluver & Gardner, 2007, p.9).
A 2003 round-table on mental health consequences of the pandemic, compiled by the Human Sciences Research Council includes a list of people projected to be likely to experience mental health problems due to AIDS by 2015: those who are uncertain about their HIV status, people living with the infection, families and caregivers of people with HIV/AIDS, children and adolescents orphaned by AIDS, people caring for AIDS orphans, and those who fit into more than one of the previous categories (Social Aspects of HIV/AIDS and Health Research Programme, 2003, p. 40).
International and national studies are unanimous on calling for internationally accepted measures and indicators for child development for planning, monitoring, and assessment (Cluver & Gardner, 2007; Engle, et al., 2007; Irwin, Siddiqi, & Hertzman, 2007; Social Aspects of HIV/AID and Health Research Programme, 2003). “Very few of the programs that try to intervene for children, families and communities have been monitors systematically and none have been rigorously evaluated (experimentally). This has meant an over-reliance on local knowledge to the detriment of building a knowledge base on “the real impacts of AIDS” and “what the responses should be in any given context” (Richter, Manegold & Pather, 2004, p. 7).
Need for Interventions
We must also ask ourselves, where are the western psychologists when there is so much global poverty? A South African psychologist asks why it is that in psychology, have we such a “lack of knowledge in terms of interventions to prevent and ameliorate the effects of poverty on infants and small children. In our professional child development journals and conferences, why is there no strong and growing theme that expresses concern for the compromised conditions which the majority of infants and small children in the world live” (Richter, 2003, 245)?
There are urgent needs for the design and implementation of culturally sensitive and evidence based intervention programs to improve the conditions of infants’ and young children’s psychological development in impoverished communities across the globe. More than ever, psychologists need to prioritize humility and collaboration as practices by cooperating with local networks of community health services (professional and paraprofessional), community members and leaders, nongovernment organizations, and politicians in order to be effective in the developing world. Psychologists living in developing countries are hard at work trying to meet these needs, but there are not enough of them to tackle these problems on their own. Where should we Western psychologists turn, if we want to make a difference?
Thankfully, there are a number of opportunities for western psychologists to explore of sufficient diversity that we can choose the type and degree of investment we want to make from international and global psychological associations and publications. Another way we can help is to expand the engagement of psychologists and trainees in the field of international/global psychology by developing undergraduate and graduate curricula and practice opportunities.