Orphans and Vulnerable Children

Instead of going to the wards on Friday as per my usual, I got to spend the day doing home visits with the Field Director of AMPATH’s Orphans and Vulnerable Children (OVC) Program. The OVC arm of AMPATH aims to identify and assist children in the AMPATH catchment area who are either orphaned or vulnerable to lack of support due to HIV/AIDS. There are many situations that qualify children for assistance from OVC. In general, these include things such as loss of one or both parents to HIV/AIDS, being HIV positive without one or both parents alive and healthy enough to care for them, or extreme poverty. The goal is to intervene as early as possible to improve children’s outcomes in all areas of their lives: health, education, emotional, financial, and independence.

I left early this morning with Emma, the Field Director. We drove out to Mosoriot – the site in Western Kenya of AMPATH’s first satellite clinic as well as the rural clinic to which I travelled with Dr. M during my first visit to Kenya. We stopped briefly at the clinic, picked up two of the Mosoriot social workers, and drove out into the community. Per Emma, these weekly field visits are completely unannounced. The social worker(s) identify families and patients at clinic who need closer follow up and/or a home assessment, put them on the weekly docket, and essentially just point Emma in the correct direction every Friday.

The first home we arrived at was a small, one room mud hut with a single bed, the size of the room approximately the size of my kitchen at home. In this room lived Beatrice and Sylvia, 8 and 6 years old respectively. Their mother died from complications of HIV/AIDS (maternal orphans) several years ago, and their father, as well as their two younger siblings, are currently admitted at Mosoriot Hospital with severe AIDS-related infections. Since that time, the girls have been living and caring for themselves alone. We spoke with a neighbor who has been helping to care for the girls, but she has two children of her own, so admitted to us that it is “difficult.” Especially difficult is ensuring that Beatrice is consistently taking her medicines, which, after a quick pill count, we discovered has not been happening regularly.

After taking some basic information from the neighbor, the social worker conducted a quick home assessment, making note of the strengths (structurally sound, intact roof, stove, tap outside) and weaknesses (dirty mattress/bedding, piles of laundry, broken window) of the dwelling. She also conducted a quick assessment of the girls themselves, asking them some basic questions. In addition to lack of care and supervision, the second major issue that arose was that the girls are not currently in school. We spent about an hour in house, discussing strategies for assisting the girls amongst the neighbor, social workers, and field director. In the end, the neighbor agreed to continue to assist the girls as long as the father was hospitalized. This is a great short-term solution; however, there was further discussion between the OVC team regarding the father’s medical prognosis, as he apparently has had significant issues in the past with treatment compliance. Ergo, there needs to be a plan of care in place for all four children if and when the father dies. Unfortunately, there is no extended family to care for them; the father’s father has died, his mother is re-married “somewhere in Nakuru,” and he has no siblings. The mother’s parents are still living, and when she became sick she went back to live with them. She took her youngest baby with her (there are actually five siblings total), and died in their home. Now that she is gone, and the mother and father were never married, the mother’s parents want nothing more to do with the children’s father or the remaining four siblings (though they do still have the baby). This is what we in the US would refer to as a “hot mess.” In the end, it was decided to refer the case to the DCO (District Children’s Officer – essentially like our DCS or CPS at home) both for the truancy issue as well as the potential for the children to become true orphans without identifiable caregivers.

As the Kalenjin conversation went on over my head (the OVC social workers and community health workers are all members of the actual community, so they speak the local language), I found myself looking at and contemplating the children. Beatrice, the biggest, the eldest, also HIV positive, but appearing relatively healthy. I could see already the weight of responsibility she carried, as she never made eye contact with anyone, stared mostly at her feet, never smiled, and answered only in short hapana (“no”) or ndyio (“yes”) answers. She was far too somber for such a young age, and the magnitude of the sorrows and burdens she has experienced were poorly reflected by her small size. Sylvia, the 6 year old, HIV negative sister, peering out occasionally from behind the protective stance of her older sibling. She wore a bright pink dress that looked like flower girl attire, clearly too big for her with dirt ringing the bottom and the lace edging torn and hanging in several places. She would occasionally peek out from behind Beatrice, make quick eye contact with me, smile, giggle, and quickly duck back to where I couldn’t see her. If anyone can be lucky in this family, I suppose she would be the one – the only sibling to be HIV negative, clearly not yet schooled in the realities of her life, and sheltered by a fiercely protective older sister. The neighbor’s two little boys were also in the house, the older one looking to be around 4 or 5, the little one looking like he just recently learned to walk. All four standing close together, staring at me, backlit by a halo of early morning sunlight beaming through the open door, they made one of the most beautiful pictures of Africa I have yet seen. Sitting there, looking at them, dirty, little, and vulnerable, I was overcome by an enormous wave of sadness about their situation and the enormity of the problem. How are these four children any less worthy of the same privileges and opportunities afforded the hundreds of children I have cared for in the US? The simple answer is that they are not. Simply, they were born in Africa, which has been an unfortunately disadvantaged continent since white man first made his mark here. Here stood just two of thousands of sick, vulnerable, and orphaned children in the AMPATH catchment area alone, and we were struggling to find viable solutions for them. It was a somber first visit.

The second visit was a much more positive one. We made our way to the house of Gloria and her mother, a four-acre farmstead with several buildings; including a grain storage house (per Emma, the size of the storage house directly reflects the wealth of crops, and this one was mid-sized), chicken coop, cow pen, as well as a large garden. Gloria is a 40 year old HIV positive woman with a 17-month old son. She has some type of heart condition, and was told from a young age that pregnancy could make her sick and that she should not have children. Therefore, when she discovered that she was pregnant, she was afraid and “ashamed” (in her own words) to seek medical attention. Unfortunately, this meant that she received no pre-natal care, including no treatment for HIV, which greatly increases the risk of transmission to the baby. Luckily, her baby has thus far tested negative for HIV, with the definitive lab test coming up soon at 18 months of age. She is currently taking her ARVs (anti-retrovirals) regularly, has no health complaints, and told us she was feeling positive about life. Her baby also is currently taking no medicines, is growing well, and has received all of his immunizations. It seemed almost too good to be true. In fact, it wasn’t, and if the baby tests negative at his 18 month visit, the plan was to un-enroll him from the OVC program. This is a good thing.

The third visit was to a farmstead much further away, down 60 minutes of winding, dirt roads. We made it out there after stopping several times to ask for directions (including at a school, where the appearance of two muzungus clearly interrupted the outside class that was taking place). We found a house close by, and a neighbor walked us down to the farm. We met the patriarch, a white-haired gentleman in overalls probably in his 60s. He greeted us enthusiastically (having no idea who we were or why we were there) and proceeded to give us a tour of his substantial farm. Like a proud father, he joyfully pointed out his various plants and trees (passion fruit, avocado, banana, guava), crops (corn, beans), and livestock (goats and cattle). He showed us how he had cultivated the rockier ground that is poor for crops into a tree farm, periodically cutting down the trees and selling the wood, always making sure to re-plant and have a constant supply. Overall, he had a very impressive homestead, totaling about 13 acres (all of which, thankfully, he did not make us tour). After finally figuring out that we were not there to give him anything, he graciously introduced us to his daughter, who we were actually there to see.

Rebecca, one of the farmer’s nine children, lives and works on the homestead with her parents and several siblings. Sadly, tragically, she was raped eight years ago and not only became pregnant but also contracted HIV. Now she, as well as her 3rd and youngest child (a daughter) are AMPATH patients. I was awed at how calm and collected she was while telling us her story, which she began by saying: “I am Rebecca, and I am positive.” Despite the leaps and bounds made in HIV/AIDS care in the past ten years, there is still a social stigma associated with HIV infection, even in Western Kenya. This was further evidenced when Rebecca spoke of her own mother, saying that she would not allow Rebecca and her daughter to share utensils with other members of the household, or allow Rebecca’s daughter to play with her HIV-negative cousins. Despite the many obvious hurdles Rebecca had faced in the past decade, she was clearly determined to live her life as well as possible. She had created a business for herself, buying fruit from her father and then selling it for profit at the local university. Through her business, she has been able to put her three children through school thus far, as well as start saving for school fees for secondary school (high school) for the two older boys. I was completely amazed at her strength in the face of adversity, including open animosity from her own mother.

While we were visiting the last farm, it began to rain, and by the time we finished it was an outright deluge. Even though we had three more homes to visit, it was decided to delay these visits, as the muddy roads become impassible even after a short rainfall. As it was, Emma had significant difficulty navigating the car through the various potholes, mud puddles, and nearly washed out roads we needed to drive to get back to Mosoriot. It was a white-knuckle drive for all of us. The best I can compare it to is driving on an ice covered road in the US, without any traction but with the addition of large rivers of water flowing across and deep ravines on either side. But, we made it back to the paved roads, back to Mosoriot clinic to deposit our social workers, then back into Eldoret by mid-afternoon.

Today was truly another great day in Kenya. I think the faces of the four children at the first home will stay with me for a long time, hopefully continuing to remind me of why I am here.

To learn more about AMPATH’s OVC program, click here.