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The Lost Children of AIDS

Today Sizanani has headquarters in a shipping container behind a church in Meadowlands. It employs twenty-eight staff who work as counselors, cooks, drivers, and drama and sports coaches. After school hours and on weekends, the yard outside the shipping container is alive with children’s shouts and games until the church gates close at dusk. The children receive three meals a day and snacks, as well as clothes, toothpaste, and other necessities. When the principal of a local state-run school tried to expel some Sizanani children because they could not afford tuition, Elizabeth badgered him into letting them attend for free. In South Africa, even state-run schools charge fees, but by law, principals must admit all children, even if they are too poor to pay. In practice, many schools refuse to waive the fees and many poor children—especially orphans—drop out, unless an adult is willing to advocate for their rights. When Elizabeth finds a child being beaten or otherwise abused, she calls the police. When the abuse doesn’t stop, she moves the children into her own tiny house.

So far she has rescued seven children from particularly abusive homes, including a teenage girl whose uncle used to drag her from her bed night after night and send her out in the dark to buy beer for him at a local pub. Even now, the uncle sometimes comes around to Elizabeth’s place and calls for his niece in a drunken rage. Another fifteen-year-old orphan decided she could stand her aunt’s beatings no longer, and fled to Johannesburg where, she said later, she planned to kill herself. Elizabeth frantically looked for her everywhere. The aunt seemed unconcerned. Elizabeth contacted local government social workers, who got in touch with their colleagues in Johannesburg. They discovered the girl three days later wandering the streets of the city, and brought her back to Meadowlands. She now lives with Elizabeth too.

Elizabeth pays for the care of all these children out of her own Sizanani salary of $400 per month. The government offers a foster-care grant to guardians like her, but the application process is so bureaucratic and laborious that only some 2 percent of eligible children benefit from it.7

In her small office inside the shipping container, Elizabeth spends most of her time writing letters and making phone calls, trying to raise money. She worries about whether there will be enough food for the children, whether they all have toothpaste and shoes, and whether they are all going to school. The South African government provides Sizanani $60,000 a year, an amount that Elizabeth reckons permits the group to help about half the orphans in Meadowlands who need it. Moreover, the payments from the government sometimes arrive months late. She receives occasional donations of food and clothing, but it is never enough. So, shortly after Oprah’s party, Elizabeth asked Hope’s directors whether they would be willing to help support Sizanani.

Elizabeth reasoned that Hope’s existing programs, though valuable, could not reach most of the children who needed help. Hope runs group counseling services in health clinics for AIDS patients and their children, but the counseling sessions take place only once a week, and are not open to children whose parents have already died of AIDS or are in a state of denial and refuse to be tested for HIV or to enroll in antiretroviral drug programs. Hope also places social workers in a small number of schools around the country who train teachers to run group therapy sessions for troubled children and to conduct a fifteen-step “bereavement curriculum.” But Elizabeth knew that traumatized children need more than occasional support groups and short-term counseling services; they need stable, daily human contact—a group of people to rely on and trust, to make them feel less abandoned—something a weekly support group can’t provide.

Hope officials in South Africa declined to support Sizanani, saying that Hope did not support “feeding programs”—an odd claim in view of all the help Sizanani gives aside from meals.8 Eventually, Elizabeth quit her job at Hope to run Sizanani full time. She received occasional donations of food or other items from Hope, but otherwise did not hear from them. Then in 2004 officials from Hope contacted her again. They wished to offer Sizanani a “Memorandum of Understanding,” or MOU. According to this document, Hope would promise to help Sizanani by “reviewing its current HIV/AIDS-related needs and responses”; by “developing/strengthening a local working group on HIV/ AIDS”; by “developing HIV/OVC strategies”; by “developing community competency”; and by performing other, similarly vague activities. Meanwhile, Sizanani would continue to pay its own staff, purchase all supplies of food and other commodities for the children, and provide “space and resources” for its own programs. In addition, Sizanani would be required to fill out three sets of forms each month listing the number of children helped, the “kids clubs” set up, and other data, and send these forms to Hope. Hope would provide no money.

Elizabeth declined the offer. “I’d been running this program for three years,” she said. “Why do I need advice from them?” The offer did seem odd. Hope’s South African budget is several million dollars a year; Sizanani’s is $60,000. Sizanani has offices in a shipping container; Hope has offices in one of the most exclusive neighborhoods in South Africa.

What was Hope up to? Hope officials did not return my phone calls, but it is possible to imagine their concerns. In 2004, Hope Worldwide received an $8 million grant from PEPFAR to “support the care” of 165,000 orphans. Hope officials probably knew this was an overly ambitious target. However, like other organizations that receive PEPFAR funding, Hope is now under enormous pressure to produce statistics on the numbers of children it has helped in some way. This may explain the mysterious Memorandum of Understanding, which was presented to Sizanani in late 2004, around the time Hope received its PEPFAR grant. Had Sizanani signed the MOU, Hope would have been able to claim right away that it was “supporting care” for all three hundred of the children registered with the organization, even though it was doing virtually nothing for them.

Every month, PEPFAR officials report to Congress how many people have been helped by its programs overseas. This is important to the Bush administration because PEPFAR has political as well as humanitarian goals. President Bush announced the $15 billion PEPFAR program on national television one week before the declaration of war against Iraq, and it was meant to send a clear signal that his foreign policy was compassionate as well as tough. Bush pledged that by the end of 2008, PEPFAR-funded programs will have supported antiretroviral drug treatment for two million people living with HIV/AIDS; will have prevented seven million new HIV infections; and will have supported care for ten million people infected with and affected by the disease, including orphans and vulnerable children.

US government–funded programs routinely set such targets because they make it easier to evaluate the success or failure of particular projects; and in attempting to meet the targets, PEPFAR has put thousands of people on antiretroviral drug treatment.9 However, measuring the care of children affected by AIDS is much more difficult than measuring the number of patients being treated, because there is no pill that can be given to an abused or neglected child. Thus “supporting care” can mean many things, including “mentoring” organizations like Sizanani that do not need it.

The emphasis on “meeting targets” rather than on actually helping people may well be having a detrimental effect on US-funded AIDS programs. A number of Hope’s counselors have quit in recent years, because, as one former Hope counselor told Jonathan Cohen and me, the pressure from PEPFAR to produce numbers made their work all but impossible. She had worked for Hope for years, and had been devoted to it, but then something changed when organization officials started angling for PEPFAR’s millions.

You cannot give quality counseling anymore because PEPFAR has counseling quotas. If you have to do one thousand people by the end of the month, you end up not doing good counseling. It compromises people’s dignity. And the stress on people from the paperwork! All the time we were thinking, ‘I have to fill this form because PEPFAR is coming!’ They’re not asking ‘Are we really meeting the needs of these people?’”

In order to receive ongoing funding from PEPFAR, organizations like Hope must meet their targets—however empty. Their predicament reminded me of Nikolai Gogol’s novel Dead Souls, in which the main character, a minor nobleman named Chichikov, travels through the countryside, trying to purchase the names of dead serfs from local landowners, reasoning that landowners would be only too happy to hand over the names of serfs who had died between one census and another, because then they wouldn’t have to pay taxes on them. Chichikov planned to mortgage the dead serfs to an unsuspecting bank, which—thinking the serfs were alive—would give Chichikov a loan with which he could build a real fortune of his own. Hope’s strategy of leveraging the names of children for future gain seemed to me similar.10


What is Hope doing with the $8 million PEPFAR grant if it is not giving it to organizations like Sizanani? From Hope’s Web site, I learned that shortly after Hope received its grant it established the ANCHOR program—which stands for African Network for Children Orphaned and at Risk. According to its Web site, ANCHOR will do the following things: “promote effective OVC policies”; “provide training and support for scaling up HIV/AIDS treatment, care and prevention”; “coordinate and facilitate capacity building in communities using tested community support and mobilization strategies and technical assistance”; and carry out “monitoring and evaluation to assess program impact.”11

I was curious to know what these goals meant in practice. Activities such as “technical assistance” and “capacity building”—which means helping organizations to improve management—can help fledgling community-based groups manage their funding and work more efficiently. But the same terms can also serve as jargon behind which public health contractors can hide when donors make impossible demands on them for political purposes. Such activities can also allow these organizations to appear to be helping far more people than they actually are.

The ANCHOR program is run by a consortium of organizations, including Hope and the Rotarian Fellowship for Fighting AIDS (RFFA), a subsidiary of Rotary International—a private membership organization that raises money for humanitarian relief projects around the world. When Hope officials did not reply to my requests for an interview I contacted Marion Bunch, the Atlanta-based director of RFFA—and one of the authors of the grant proposal that funded ANCHOR—about Rotary’s role in the program. She said that Rotary was encouraging South African Rotary Club members to raise funds and solicit donations locally and abroad. “Sometimes someone will donate one thousand blankets,” she said. “We’ll give those directly to people in the communities. We also fund-raise from local businesses in South Africa, like a supermarket will give us a food donation, something like that.”

  1. 7

    See Case and Ardington, “The Impact of Parental Death on School Enrollment and Achievement.”

  2. 8

    Or so said Elizabeth. Hope officials did not return phone calls or reply to e-mails.

  3. 9

    Although perhaps not as many as the US claims. See Craig Timberg, “Botswana’s Gains Against AIDS Put US Claims to Test,” Washington Post Foreign Service, July 1, 2005.

  4. 10

    My thanks to Allison Prete for drawing my attention to this.

  5. 11

    Mark Ottenweller, “ANCHOR Program in Africa,” Hope Worldwide newsletter 2004, issue 2.

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