Orphans and Vulnerable Children in the Urban Slums of Africa

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Orphans and Vulnerable Children in the Urban
Slums of Africa

• John Bryant Nancy Bryant, Racheal
  Nduku
• Christian Connection for International Health
• May, 2008

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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
  studentsProf Jack!

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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.

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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.

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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.

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Nancy Art for Orphans in Nyalgunga, Kenya
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Jack on a Boda Boda in Kisumu
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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.

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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.

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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 was Old
  Mlolongo, slum village of 3000 people, part of a
  larger settlement of 25,000, named Mavoko.

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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.

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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.

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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.

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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

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Project Areas to Initiate in Communities

• Growth Monitoring
• Immunizations
• Hand Washing
• Insecticide Treated Bed Nets
• Nutrition
• Nutritional Supplements
• Micronutrients
• Caregiver-Child Attachments

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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!!

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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 UgandaThe Growth of Love in Young
  Children. Mary D. Ainsworth, Johns Hopkins Press,
  1967.

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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 childs entire
  life.

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Loving Mother and Her Baby
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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.

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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.

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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, WHOs 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.

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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.

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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.

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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.

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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 Africas
  children from these unintended but damaging
  harms?

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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.

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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 on
  child survival!
• Shonkoff emphasized that it is of critical
  importance that child development be included in
  priority concerns.

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Health and Social Survey of Children lt5

• The APHRC helped us to develop a household survey
  focused on children lt5.
• 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 lt5,
  they interviewed the caregiver.
• In all, 1732 child-related interviews.
• Here are the maps we developed for the survey.

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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

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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

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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.

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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.

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Caregiver-Child Interactions

• Racheal has taken special interest in supporting
  caregiver-child interactions.
• She arranges local workshops in each of the
  communities, bringing together caregiver-child
  interactions that range from secure to insecure
  attachments.
• The caregivers are learning the differences in
  the nature of their interactions, and often make
  efforts to evolve toward more loving and secure
  interactions.
• Racheal is tracking those changes carefully, and
  recording changes as they occur.

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Involving Other Communities

• We met with Health Committees of Sophia and
  Bondeni, the other communities of Mavoko
  Municipality.
• They expressed their interest in proceeding with
  the project, and offered their full support.
• We have a Coordinating Committee of the three
  communities, with Racheal as Coordinator, and
  they are working well together.

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Looking Ahead

• Our plan is to return to Nairobi, KENSUP, Old
  Mlolongo and Africa, to extend this work we
  started there which is going so well.
• We see the possibility of developing local
  leadership to support and guide the work that has
  been started, to be continued and extended.
• UN Habitat is ready and willing to push this
  process to other parts of Kenya and Africa.
• Here, then, is an example of response to an MDG
  having positive outcomes extended broadly across
  Africa.

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Looking Ahead

• We are currently interacting with NGOs that have
  successful community based health care programs
  in Africa.
• AMREF African Medical Research and Education
  Foundation.
• AKHSK Aga Khan Health Services of Kenya.
• Both are interested in absorbing our approaches
  to caregiver-child interactions into their
  Primary Health Care programs.
• We are also in conversations with the MVP, Sauri,
  Kenya about joint actions.

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Looking Ahead

• Racheal and other community colleagues are
  pleased with the possibilities of sharing their
  experiences with other communities, in Kenya and
  beyond.
• And we can see the benefits of extending this
  work in other sites through interested colleagues.

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Looking Ahead

• FINALLY we suggest again that this matter of
  the caregiver-child interactions be seen as
• A new paradigm for Primary Health Care
• A new paradigm of Social Determinants of Health
• And, thereby, a new dimension of
• Global Health.

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