‘Low-hanging fruit’: Counting and accounting for children in PEPFAR-funded HIV/AIDS programmes in South Africa

Abstract

The article traces the social life of a policy that aimed to define and circumscribe the ambiguous and contested category of ‘orphaned and vulnerable children’ (or OVC) in South Africa at the height of the ‘emergency response’ to HIV/AIDS. Drawing on several months of institutional ethnographic research conducted over the course of five years with South African organisations receiving funding from the US President's Emergency Plan for AIDS Relief to provide services to ‘OVC’, the project interrogates the influence of governmental forms of counting and accounting on health policy and practice in South Africa. Focusing on the experiences of one organisation, the article describes a process of policy ‘translation’ typified by a series of disconnects between the intentions of a policy and the exigencies of implementation, structured by the ambiguous and flexible nature of the ‘OVC’ category. In this context, the article argues that the uncertainty produced by the implementation of the guidelines was not simply an artefact of a poorly designed policy, but rather signals an underlying epistemological tension in the practice of ‘global health’, in which quantitative metrics designed for monitoring and evaluation are often incapable of approximating the complexities of everyday life.

Keywords:

• HIV/AIDS
• orphanhood
• vulnerability
• PEPFAR
• global health
• measurement

Acknowledgements

Having studied the impacts of HIV in South Africa for more than a decade, the list of individuals who have helped to shape this project is long and diverse. For the material contained within this article, thanks must go to the many staff members at the organisation I dub Orphan Care and other key interlocutors in the OVC field in South Africa, who gave their time and trust to share their experiences with me. The article is based primarily on research conducted for my doctoral dissertation at Johns Hopkins University. Lori Leonard, Jane Guyer and Randy Packard all served as incredibly generous mentors throughout the process, and their insights have shaped my work in powerful ways. In addition, many friends and teachers in the Departments of Anthropology and Health, Behavior, and Society have offered support and feedback at various stages in the process, most notably Thomas Cousins, who offered important feedback on the paper as it developed. Early versions of this paper were presented at the Isaac Schapera Conference and at the African Studies Seminar at Johns Hopkins, where I received generous feedback. Preliminary and follow-up research for this project was supported by the following awards: the US Department of Education Fulbright-Hays Doctoral Dissertation Research Abroad Award (2008), the Social Science Research Council International Dissertation Research Fellowship (2008–2009) and the US National Institutes of Health Ruth L. Kirschstein National Research Service Award (2009–2012, award number 1F31MH084714-01), as well as several internal awards from Johns Hopkins University (including the Bloomberg School of Public Health Doctoral Distinguished Research Award, the Institute for Global Studies Summer Research Fellowship and the Centre for Africana Studies Summer Research Fellowship). The writing of the article was completed with support from a South African National Research Foundation Innovation Postdoctoral Fellowship in the Department of Sociology and Social Anthropology at Stellenbosch University.

Notes

1. ‘Despite charges of simplistic militarism’, Washington Post columnist Mike Gerson wrote in 2008, ‘the Bush Doctrine actually includes three elements: the pre-emption of emerging threats, the encouragement of responsible self-government, and the promotion of development and health as alternatives to despair and bitterness’ (Gerson, 2008). ‘Government cannot solve every problem’, President Bush explained in a 2002 speech, ‘but it can encourage people and communities to help themselves and to help one another. It is compassionate to actively help our fellow citizens in need. It is conservative to insist on responsibility and on results’ (Bush, 2002). The same principles of compassion and conservatism applied, he stated, when the US offered assistance to developing nations.

2. Studies had not been able to clearly show whether orphans in fact suffered higher rates of morbidity and mortality than non-orphaned children living in the same communities. Similarly, studies published before the release of the Guidance that attempted to assess the effects of orphanhood on factors such as relative socio-economic situation or educational outcomes (e.g. Ainsworth & Filmer, 2002; Case, 2004; Foster & Williamson, 2000; Monasch, 2007) had not shown conclusive results. The most conclusive evidence of increased vulnerability of orphaned children could be drawn from psychological studies, in which orphans have been shown to have higher levels of psychosocial distress than non-orphans (Atwine, Cantor-Graae, & Bajunirwe, 2005; Cluver & Gardner, 2007; Cluver, Gardner, & Operario, 2007). Similarly, much work in the social sciences has questioned the assumptions made about the special vulnerability of orphans of AIDS and those made vulnerable because of the illness of their parents and has identified a vast overlap between the difficult experiences of orphans and the large numbers of other poor children in communities affected by HIV (e.g. Bray, 2004; Henderson, 2006; Meintjes & Bray, 2005; Meintjes & Giese, 2006).

3. This is admittedly a reductive description of a complex field of experience and understanding. I explore the dynamics of kinship and care amongst isiZulu-speaking individuals in post-apartheid South Africa in much more depth elsewhere.