Within the July 2012 Health Affairs issue, “Assessing The President’s Emergency Plan For AIDS Relief” is an excellent article in which Bryant and colleagues present their attempt to evaluate the impact that the President’s Emergency Program for AIDS Relief (PEPFAR) has had on orphans and vulnerable children in the PEPFAR targeted countries. The Boston University researchers evaluated five PEPFAR funded OVC projects that were chosen by the US Interagency Technical Working Group for OVC and the Office of HIV/AIDS at USAID, in consultation with the researchers. The researchers found that, despite PEPFAR having spent approximately $1.6 billion to provide four million children care and support, they “could not demonstrate empirically the impact of most of the PEPFAR initiatives” examined. The researchers struggled to find quantifiable impact as a result of a lack of baseline data and because the programs were “spread so thin across a vulnerable population” that there was little chance of the programs making a significant difference in an individual child or family’s life. The authors recommend having better measurement and rigorous evaluation and also either dramatically expanding the program funds or better target funds so that they have a chance at improving lives.

Reading the Results section of the article is frankly depressing. The authors list the various outcomes that effective interventions should have improved stating that there was no observable difference between those receiving the PEPFAR funded service and others in the community. The researchers examined outcomes for programs that provided support for education, health care, food and nutrition, psychosocial needs, legal protection, shelter and care, and economic strengthening. The researchers did find in at least one program that substantial provision of school fees (~$400 per child per year) did improve school enrollment rates but that other programs did not and similarly there were mixed psychosocial support outcomes.

A major conclusion of the authors is the need to start funding and conducting rigorous research and evaluations around interventions. The authors note that while the programming has moved from the emergency implementation stage to a more structurally integrated programs, the evaluation methods have not similarly evolved. “In other words, most programs are still being implemented in a way that precludes empirical measurement of inputs and outputs against a well defined baseline.” The authors could similarly not find an evidence-base for OVC programming.

Let’s take this work as a further call to action!

This blog post was written by Dr. Kate Whetten, the Director of the Center for Health Policy & Inequalities Research, as well as Professor of Public Policy, Global Health, Nursing and Community and Family Medicine at Duke University. Professor Whetten is a member of the OVC Wellbeing advisory board.

 Please respond to this article in our discussion forum.

Featured article:

PEPFAR’s support for orphans and vulnerable children: some beneficial effects, but too little data, and progress spread too thin

By Malcolm Bryant, Jennifer Beard, Lora Sabin, Mohamad I. Brooks, Nancy Scott, Bruce A. Larson,

Godfrey Biemba, Candace Miller, and Jonathon Simon

One June 26^th members of the OVC researchers, policy makers, advocates, and journalists gathered in Washington DC for U.S. Global AIDS Effort to Help Orphans and Vulnerable Children, a briefing hosted by the Kaiser Family Foundation.  This event included a range of panelists from non-profit and US government organizations who discussed the role of both the U.S. government and faith-based groups in supporting African orphans and vulnerable children.

John Donnelly, a panelist at this briefing and global health journalist with GlobalPost, noted that faith based group are one of the largest source of remittances and donations to OVC worldwide. Donnelly explores the role of faith-based groups in the African OVC crisis in his forthcoming book: A Twist of Faith:  An American Christian’s Quest to Help Orphans in Africa.

Panelists at this event included:

• Nicole Behnam, Senior Technical Advisor for Orphans and Vulnerable Children, Office of the U.S. Global AIDS Coordinator

• John Donnelly, Global Health Journalist, GlobalPost

• Charles Lyons, President and CEO, Elizabeth Glaser Pediatric AIDS Foundation

• Pauline Muchina, Senior Partnership Adviser, UNAIDS

• David Nixon, Jr., President, The NOAH Project

• Jen Kates (Moderator), Vice President and Director, Global Health & HIV Policy, Kaiser Family Foundation

To learn more about this event, please visit: globalhealth.kff.org/Multimedia/2012/June/26/gh062612video.aspxgg

The health of a caregiver is the most important predictor of orphan health, according to a new study conducted by the Positive Outcomes for Orphans (POFO) Research Team. The study, conducted by an international research team, spans five culturally-and economically-diverse less-wealthy nations in Africa and Asia. More important than an orphan’s geographic location, living conditions, or past trauma, the study finds that an unhealthy caregiver likely means an unhealthy child.

The findings prompt researchers to call for international orphan policies to place greater attention on assessing and treating children and their caregiver’s health together, rather than focusing on children’s health in isolation.

Published in PLoS One today, the Duke University sponsored study of over 1300 randomly selected orphans and abandoned children from six diverse settings found that one in five was in fair or poor health and one in four had experienced symptoms of illness in the previous two weeks.  Forty-five percent of the caregivers reported their own health to be fair or poor, and one in four caregivers reported symptoms like fever, cough and/or diarrhea in the last two weeks. Strong and consistent associations were found between poorer child health and poorer health among their caregivers. Children whose caregivers were more involved in their lives and well-being were less likely to be sick or unhealthy.

“This study produces strong evidence to inform policy and resource allocation relevant to the health of this large vulnerable child population worldwide,” said Nathan Thielman, lead author and associate professor of medicine and global health at the Duke Global Health Institute. “Specifically, policies that promote orphan well-being should include health assessments and interventions that target the caregiver-child dyad. ”

Researchers say a lack of economic resources may be a contributor to poor child health. Orphans are often cared for in households headed by females or the elderly; these households may have less money and are less likely to cover medical expenses associated with caregiver illness, further limiting their ability to provide adequate nutrition and access to health care for the child.

Researchers argue the study provides strong support for establishing more family-based clinics in resource-poor settings that offer services and treatment to both children and their caregivers. They also suggest adding comprehensive caregiver health assessments to existing tools used to measure the well-being of orphans.

The multi-site study included community-dwelling orphans ages 6-12 and their caregivers from six culturally- and economically-diverse sites across five countries: Cambodia, Ethiopia, India, Kenya and Tanzania. All of the children in the study have survived the death of one parent or were abandoned by both parents. Of 153 million children orphaned worldwide, 145 million reside in less -wealthy nations where high rates of HIV/AIDS and other diseases like malaria and tuberculosis claim thousands of lives every day.

This research was supported by a wide range of international partner organizations, including: ACE Africa, Bungoma, Kenya; Homeland Meahto Phum Ko’Mah in

Battambang, Cambodia; KIWAKKUKI and TAWREF, Moshi, Tanzania; SaveLives Ethiopia and Save the Vulnerables Organization, Addis Ababa, Ethiopia; and Sahara Centre for Rehabilitation and Residential Care in Delhi, Hyderabad and Nagaland, India.

This work was supported by the National Institute of Child Health and Development (NICHD), grant No. 5R01HD046345-04. The Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health also supported this study.

Eleven experts from across Africa met in Addis Ababa, Ethiopia at the end of March as a part of the 19^th Ordinary Session of the African Committee of Experts on the Rights and Welfare of Children (ACERWC). The meeting focused on harmful traditional practices (HTP). Particular attention was paid to female genital mutilation (FGM), a practice that the ACERWC committee Chairperson cited as not only a health risk, but also a human rights violation. The committee also discussed a variety of topics connected to Day of the African Child 2012, which will take place on June 16 with the theme  “The Rights of Children with Disability: the Duty to Protect, to Respect, to Promote and to Fulfill.”

Orphan reunification, or the process by which orphaned and abandoned children are returned to their extended family for care, has long been a policy intervention favored by researchers opposed to the institutionalization of children. Though the reunification process often takes longer than adoption, many researchers and policy-makers favor the process because they believe it leads to better outcomes.

But a recent narrative of one family’s repeated attempts to adopt an Ethiopian infant in need, and the regional government’s attempts to force reunification on the unwilling—and incapable—father, sheds light on another side of orphan reunification programs. The article, published last month in the Huffington Post, follows the life of an Ethiopian infant whose birth resulted in the death of her mother, a father without the means to support the child on his own, an American family wishing to adopt the child and a regional government that favored reunification over relinquishment. Though the story is not over for anyone involved, it highlights a rarely-seen side of reunification programs.

Many research projects support the claim that reunification supports the overall well-being of the child. For instance, one study conducted in Eritrea, Ethiopia discovered a wide-scale reunification project in the area was “significantly more cost-effective, psychosocially acceptable and sustainable than the alternative strategy of keeping the children in orphanages.”

Other studies have highlighted the flaws of reunification programs. For instance, some orphans are more likely to be successfully reunified than others; infants and adolescents are less likely to successful complete the process than children of other ages, and African-American children are less likely to be reunified than are children of other racial and ethnic backgrounds. Moreover, the study discovered that many reunifications eventually fail—in 1990, almost 30 percent of children who were reunified reentered foster care within 10 years. Yet, according to this study, the reunification system can be salvaged—as long as states and countries institute a series of reforms, including increased monitoring and evaluation.

But the account described in the Huffington Post raises questions regarding the feasibility of working with state and country officials to improve global reunification programs. In this tragic case, regional government officials appeared to have forced the father to care for his biological daughter in exchange for meager financial support, despite his hesitations about safely raising his infant. Later, after trying to convince his deceased wife’s mother to care of the child, the regional Women Children and Youth Affairs Bureau allegedly forced the man to take back his daughter–or risk going to jail. As the article explains:

[box] “…With an obviously failing-to-thrive child, the father expressed a desire to return his daughter to an orphanage. However, he would only do so if he could be sure he would not be sent to jail; he would rather keep her and watch her die than be sent to jail. He felt he was given no other option but to raise his daughter, and could not understand how he had been given the right to relinquish her in the first place.

It appears that this father and daughter are victims of an ill-planned reunification program. No permanent or viable solution was given to the father that would empower him to raise her. In the end, he didn’t keep his daughter because he wanted to or was capable of doing so; he had been threatened.

….It is now mid-April 2012, and the father has given up. Because he has been so bullied by local government, he is no longer able to trust the helpers who assured him that his country’s constitution provides fathers in his situation with basic rights. Though Ethiopian family law clearly states that it is legal for him to relinquish his daughter, the father still does not believe this.”[/box]

The purpose of this post is not to look down on all reunification programs and favor reunification of children housed in orphanages; instead, it is meant to highlight the complexities of the situations many orphans, their families, and families wishing to adopt must confront. Moreover, it shows the potential dangers associated with adopting a one-sided policy program regarding orphans and adoption services. Reunification may be a good option for some orphaned and abandoned children, but, as this case shows, it is not necessarily appropriate for all. Thus, countries are placing themselves in potentially dangerous situations when adopting a clear-cut “yes-or-no” stance to certain programs.

 Please respond to this article in our discussion forum.

Although standard theory suggests that genes are not supposed to change as they are passed down generations, recent studies have found that mistreatment as a child can physically affect one’s genetic material. The recent findings could have important implications on orphan and vulnerable children research, especially projects that pertain to the long-term effects of childhood trauma.

A recent Wall Street Journal article discusses the research results of two recent studies that link exposure to traumatic events—such as bullying, beating and domestic violence—and genetic “scarring.” As a part of one study, researchers examined the effect of psychosocial stress on the physical makeup of telomeres, or regions of genetic sequences on the end of chromosomes. Telomeres are partially meant for protection—they safeguard the chromosome from deterioration and from fusing with other chromosomes. These sequences deteriorate over time—a natural process, but one that is more rapid among people who recall psychosocial stress during childhood, researchers found.

Specifically, Stacy Drury, a professor of psychiatry and neurology at Tulane University, and coworkers discovered that the telomeres of children who resided in Bucharest orphanages were shorter than those who lived in foster families. Another cohort of the research team, from Duke University, used blood samples from study participants—which had been collected throughout their lives—to discover that telomeres shrink more rapidly, on average, in participants who experienced violence. The findings are not completely clear, however—the telomeres grew longer among some individuals.

Another study that the Wall Street Journal article highlights discovered that stress during childhood—either through maltreatment or through the loss of a parent—”results in greater ‘methylation’ of some spots near a gene tied to stress response in adulthood.” This finding is explained in further detail below:

[box] “Methylation, the addition of a methyl group of atoms to one DNA ‘letter,’ tends to reduce the activity of nearby genes. The implication of the Butler study is that adults who recall maltreatment as children may have reduced activity of a key gene in the system that responds to the stress hormone cortisol. This may be linked to increased anxiety or depression.

These are early days in the study of epigenetics. Scientists are like people finding coins under lampposts but not knowing how many coins remain in the dark. Although the ‘methylome’—a complete map of where methylation happens in the genome—is being talked of, others caution that we still have almost no idea of both the causes and effects of most such changes, let alone other epigenetic effects like histone modification.”[/box]

Though the implications of these recent studies is not entirely clear, it is important to note that some of these findings contrast with certain studies published on this site. For instance, the discovery that living in a Bucharest orphanage resulted in shorter telomeres than residing in a foster home conflicts with the finding of Positive Outcomes for Orphans, a longitudinal study conducted across the world that discovered that health, emotional and cognitive functioning, and physical growth were no worse for institution-residing than community-residing orphaned and abandoned children. In other words, the study discovered that living environment—institutional care versus community care—explained very little of the variability in child outcomes.

This study and others demonstrate that early life experiences can have long-term effects—regardless of whether such experiences result in physical DNA damage, or merely influence the emotional and physical wellbeing of an orphan. It will be important to see how studies like these impact policy outcomes, especially regarding the closure orphanages.

 Please respond to this article in our discussion forum.