Orphans and Vulnerable Children in the Urban Slums of Africa

1. Orphans and Vulnerable Children in the Urban Slums of Africa John Bryant; Nancy Bryant, Racheal Nduku Christian Connection for International Health May, 2008

2. Kenya • Recent years -- teaching and research in a Kenyan university. • Tropical Institute for Community Health and Development (TICH). • Now upgraded: Great Lakes University of Kisumu (GLUK). • Teaching there for 10 years, on a visiting basis – Ethics, Equity, Human Rights, PHC, SDOH, MDGs. • Inspiring to teach and learn with the African students…Prof Jack!

3. UN Habitat, Nairobi • UN Habitat made a commitment to the MDG of improving the lives of at least 100 million slum dwellers. • Senior Staff of UN Habitat were concerned that young children would be left out. • J. and N. Bryant were asked if they could help in the development of health care and social support for Orphans and Vulnerable Children (OVC) in the Urban Slums of Africa.

4. UN Habitat, Nairobi • We said “Yes”, and were excited by the challenge. • Then we asked: “What will the budget be? • UN Habitat answered: “Zero, budget”! • Rather than saying – “no budget, no work!” -- virtually all of the urban slums of Africa are faced with tightly limited resources – thus, this became a core challenge of the project. • It meant we had to seek our own resources.

5. Fulbright Grant • 2005, we received a Fulbright Grant, U.S.State Dept. • 2006, received Rockefeller Grant, through the African Population and Health Research Center (APHRC), and joined them in a collaborative project focused on the OVC in the Urban Slums of Africa.

6. Nancy – Art for Orphans in Nyalgunga, Kenya

7. Jack on a Boda Boda in Kisumu

14. The Urban Slums of Africa • About 1 billion people in the world live in slums. In Africa, about 70% of the urban populations live in the slums. • The slum areas have high concentrations of poverty and social and economic deprivation • In the urban slums of Nairobi, 87% of households live in one room homes with no running water, no sanitation and no electricity.

15. OVC and the Slums • Millions of children have lost one or both parents, many of them to HIV/AIDS. • Thus, we see the immensity of the HIV/AIDS burden. • The children are left with the remaining parent, aunt, grandma, or with no one. • Some are in a caring community and looked after by foster households. • But not all are happy in households that use them mainly for housekeeping, gardening, but no schooling.

22. Slum Up-grading in Kenya • UN Habitat and the Government of Kenya have agreed to work on upgrading of the slums of Kenya, beginning with Nairobi. • KENSUP – Kenya Slum Upgrading Program • It was decided that the work of Jack and Nancy on OVC of urban slums should begin in Nairobi in collaboration with KENSUP. • The community selected for that purpose wasOld Mlolongo, slum village of 3000 people, part of a larger settlement of 25,000, named Mavoko.

23. Working with a slum community of Nairobi – Old Mlolongo. • The plan was to develop health care programs for OVC in Old Mlolongo, initially as a pilot project to then be expanded to the entire settlement of Mavoko. • However, one of the realities of Old Mlolongo was that there was no active health care system with which we might integrate our care of the OVC. So it is with much of the slums of Africa! • Further reality – almost no budget.

24. Old Mlolongo • Our reality was that our task would not be to implement a well known health care system. • It would be to help the people of Old Mlolongo to realize the things they could do to improve the health of their children. • This approach would be shaped so as to be applicable to other urban slums of the greater Africa! • Modest costs would strengthen the likelihood of its uses elsewhere.

25. Old Mlolongo • Old Mlolongo has a Health Committee, a group of women and a man who have been involved in some community surveys with UN Habitat and providing home-based care in the community for PLWA. • The Health Committee is lively, socially committed, interested in working with us, and understanding of the local social, cultural and economic issues.

27. Old Mlolongo • The Health Committee helped us to organize a workshop to consider the activities the community would be willing to undertake. • They arranged for 30+ caregivers, many of them with children, to meet with us. • There was a lively and socially open discussion, with agreement on the following project areas:

28. Project Areas to Initiate in Communities • Growth Monitoring • Immunizations • Hand Washing • Insecticide Treated Bed Nets • Nutrition – • Nutritional Supplements • Micronutrients • Caregiver-Child Attachments

29. Caregiver-Child Attachments • This may be the most important work in which we have ever been involved. • There has been an explosion of research on early childhood development in recent years, with some startling new findings. • When this little child is born, neurologically it is wired and ready to learn. Does it make much difference what it learns? • Indeed it does!!

30. Caregiver-Child Attachments References • From Neurons to Neighborhoods – The Science of Early Childhood Development. NAS, NRC, IOM, National Academy Press, 2000. • The importance of caregiver-child interactions for the survival and healthy development of young children. A Review. Department of Child and Adolescent Health, WHO, Geneva, 2004. • Infancy in Uganda—The Growth of Love in Young Children. Mary D. Ainsworth, Johns Hopkins Press, 1967.

31. Caregiver-Child Attachments • It is very important that the child has a relationship with the mother (or caregiver) that is nurturing, loving, protective, supportive, stimulating, encouraging – every day for considerable time. • With that close attachment, the child builds a foundation that includes a sense of self-worth, physical, social, cultural, cognitive development that prepares it to cope with this complex world into which it is born. • That can be beneficial for the child’s entire life.

32. Loving Mother and Her Baby

33. Caregiver-Child Attachments • But, let us say the child is neglected or abused, and lacks that secure attachment; let us say that it is an insecure attachment • This can be disruptive and truly harmful, with lifelong consequences. • Studies of these issues in Africa have shown that maternal-child interactions in stable African settings can be as supportive and loving as in the U.S., or even moreso.

34. Caregiver-Child Attachments • We are, of course, concerned about the many children in the slums who would not have parents or caregivers. • Importantly, there would be limited under-standing that children who are simply neglected, even if not mistreated, could be harmed by the lack of a nurturing caregiver attachment. Indeed, harmed for life.

35. Caregiver-Child Attachments • We see it as fair to say that such caregiver-child attachments represent a new paradigm of Social Determinants of Health. • Sir Michael Marmot, Director, WHO’s Commission on SDOH, agrees with this perspective. • Further, as the health and well-being of the child are strongly influenced by such interactions, it is reasonable to say that such caregiver-child interactions also represent a new paradigm for Primary Health Care.

36. Caregiver-Child Attachments • So, we shared these ideas with our Health Committee and they were truly excited by the knowledge, and deeply interested in taking steps to protect the children in Old Mlolongo – and beyond. • So they began teaching the community about this, and gaining widespread support from them.

37. Caregiver-Child Attachments • They have actually been scoring households in terms of whether the caregiver-child attachment appears to be secure or insecure. • We understand that for them to identify the nature of the attachment would be quite challenging, but they have worked diligently at it, and we think their efforts and cultural insights are important. • Now let us tell you of some of their findings that surprised and impressed us.

38. Caregiver-Child Attachments • They found that households where a child was malnourished was also a household in which the caregiver-child attachment was often insecure! How dramatic! • Actually, the literature in this field is quite supportive of these findings. • It is telling us that correcting childhood malnutrition may require more than feeding. Somehow, nurturing, loving care has to come alongside the feeding.

39. Caregiver-Child Attachments • We see the core challenges of developing Africa-wide approaches to enhancing awareness of these factors, along with practical approaches to strengthening caregiver-child interactions. • The importance of these observations for the OVC of Africa more generally is immense. • Numberless children are suffering from unrecognized harms to their social, emotional, cognitive well-being. • What will it take to protect millions of Africa’s children from these unintended but damaging harms?

40. Center On the Developing Child • An important resource relating to our work on caregiver-child interactions is the newly established Center on the Developing Child, Harvard University. • Director of the Center is Professor Jack Shonkoff, senior editor of the book -- From Neurons to Neighborhoods, National Academy of Science, 2000. • Professor Shonkoff invited J. Bryant to visit Harvard and share insights on challenges of addressing the needs of the developing child in the African urban slum context.

41. Center for the Developing Child • Shonkoff emphasized emerging understandings of the needs and difficulties faced by the developing child. • In the broad fields of public health and the health care of children, particularly in developing countries, the emphasis so often is onchild survival! • Shonkoff emphasized that it is of critical importance that child development be included in priority concerns.

42. Health and Social Survey of Children <5 • The APHRC helped us to develop a household survey focused on children <5. • Our Health Committee and other helpful persons visited all households in Mlolongo, Sophia and Bondeni, 4500 households. • In every household where there was a child <5, they interviewed the caregiver. • In all, 1732 child-related interviews. • Here are the maps we developed for the survey.

44. Health and Social Support in the Future • Our work in process is to have local women trained as Community Health Workers (CHWs) who visit every household. • They oversee implementation of the health care processes, such as growth monitoring and immunizations, and also encourage caregiver-child interactions. • The information they collect in that process will serve as the basis for a Health and Social Support Information System

45. Health and Social Support in the Future • The Governmental Health Center and Dispensaries have agreed to back up this community-based system with immunizations, treatments, and, when necessary, referral to District Hospital. • So, the various components of a health care and social support approach come into place

46. Community Leadership! • One of the delights of this work has been the lively and effective involvement of the communities. • We have been careful to be involved in a sharing of thinking, planning and actions, and listening more than telling! • Racheal Nduku began as Secretary for the Health Committee of Old Mlolongo. Excellent organizational skills and writing of minutes of our meetings. • We advanced Racheal to be the Community Coordinator of the Project.

47. Community Leadership! • Racheal amazed us with her capacities for organizing activities, recording processes, and involving community members in these processes. • She also produced a Report of events that we consider as the best description of the processes and data base of this project. • Here are some photos of Racheal and this work that she pursues.