The Lost Children of AIDS

In January 2003, President George W. Bush asked Congress for $15 billion to fund international AIDS programs in developing countries under the President's Emergency Plan for AIDS Relief, or PEPFAR. One tenth of the money was to be spent on children whose parents were victims of AIDS. Most of this money would go to Africa, home to some 12 million such children who for nearly two decades had been all but forgotten by their own governments, as well as by foreign donors such as the US.

The new money is part of a welcome trend. Rich governments and private donors now spend some $6 billion a year on international AIDS programs, twenty times more than they did a decade ago. Funding is also increasing for programs to help what are known in aid circles as "orphans and vulnerable children," or OVCs. These are children who lack parental care because their parents have died of AIDS or are too sick to look after them. The OVCs category also includes the relatively small number of such children who are HIV-positive themselves.[1] Roughly $600 million will be spent on aid programs for OVCs in 2005, and this is predicted to triple by 2007.

While this is good news in many respects, it may also be cause for concern. As foreign aid budgets rise, they tend to become more political and sometimes less effective. I worked in Uganda during the early 1990s when the country's HIV infection rate was at its peak, with some two million people infected. In response, foreign donors were pouring money into the country, but it wasn't always clear whether it was going to the right places. European and American consultants came and went from the airport and their brand-new sport utility vehicles churned up the narrow lanes of slums and villages across the country. They hired servants and guards and drivers and translators and set up offices in newly renovated buildings in Kampala's genteel suburbs. Ugandans tended to greet them with outward courtesy and inward skepticism. In private discussions they wondered why the aid workers were spending so much money on offices and vehicles and staff residences that were palatial by local standards, when so many Ugandans were sick and poor and hungry.

The Ugandans were right to wonder. At least 60 percent of US foreign aid funding never leaves the US, but is instead spent on office overhead, travel, procurement of American-made cars, computers, and other equipment, as well as salary and benefit packages so generous that just one of them would be enough to feed, clothe, and educate hundreds of African children for years.[2] Some of the money that arrives in Africa is well spent, but much of it is wasted on ill-conceived projects designed by foreign technocrats with little sense of African realities. In the high-stakes scramble for funding, the best projects-those that truly meet the needs of local people so that they can eventually support themselves-are often overlooked. People used to joke that there were two kinds of AIDS in Uganda: "slim AIDS" and "fat AIDS." Those with "slim AIDS" grow thinner and thinner and thinner until they finally disappear. "Fat AIDS" afflicts development agency bureaucrats, foreign consultants, and medical experts who attend lavish conferences and workshops in exotic places, earn large salaries, and get fatter and fatter.

In June 2005, I accompanied Jonathan Cohen of Human Rights Watch on a mission to South Africa to report on discrimination against AIDS orphans in the education system. Among the many organizations we visited were two programs funded by President Bush's PEPFAR that made me wonder whether history might be repeating itself. Between them, these programs had received roughly $10 million from the US government to help AIDS orphans but, like some of the programs I had seen in Uganda, very little of it seemed to be reaching the people who need it most.[3]

It is far too early to pass judgment on the entire five-year PEPFAR program, slated to run until at least 2008. Most PEPFAR funding is being used to support medical treatment for AIDS patients and HIV prevention programs. Early assessments have been mixed. PEPFAR is supporting some exemplary AIDS treatment programs such as the AIDS Support Organization (TASO) in Uganda and the South African Catholic Bishops Conference, but much of the money for HIV prevention is going to evangelical Christian groups that disparage condoms.[4] In addition, treatment programs are reaching fewer people than was originally hoped. The dire state of African clinics and hospitals is part of the problem, but the greed of US-based contractors is also a factor.

For example, the Maryland-based Institute of Human Virology proposed to spend $600,000 to hire three consultants to "mentor" South African health workers-an amount that could have been spent on antiretroviral drug treatment for some five hundred poor South Africans. In another example, the North Carolina-based Family Health International proposed to hand over $1 million of a $3 million PEPFAR grant to Northrop Grumman, a military contractor, which would conduct "monitoring and evaluation" of Family Health's orphan programs. Under the terms of the original contract, which was fortunately changed, Family Health International and Northrop Grumman would each receive more than twice as much money as all the orphans combined.

The US government makes it nearly impossible to obtain detailed financial information about its foreign aid programs, and federal agencies have thus far failed to give me information about the programs described here; a Freedom of Information Act request has been pending for two months. USAID officials need to tell us more about where taxpayers' dollars go after they leave their offices, if sending money to Africa is to do more than merely make Americans feel good about themselves.

1.

In December 2002, the American talk-show host Oprah Winfrey rented a sports complex near Soweto, the vast black township on the outskirts of Johannesburg, South Africa, and gave a party for 124 AIDS orphans. There are around one million such children in South Africa. Most live in extreme poverty and many suffer from abuse, discrimination, and neglect. At the party there was food, dancing and singing, and a gift for each child-for some, it was the first they had ever received. "One little girl was so excited that she could not open her present, and instead was kissing the plastic," Oprah told South Africa's Star newspaper after the party.

When we were in South Africa, Jonathan and I met some of the orphans who had attended Oprah's Christmas party. We were introduced to them by Elizabeth Rapuleng, a stout, elderly African woman who lives in Meadowlands, a bleak neighborhood of tiny concrete houses on a flat dusty plain on the edge of Soweto. At the time of Oprah's party, Elizabeth was working for Hope Worldwide, a US-based Christian charity that runs medical relief programs in seventy-five countries. Hope is linked to the International Church of Christ, a fundamentalist evangelical Christian group, and receives funding from the church itself, the US government, and various private donors.

In 2002, Hope was one of the largest US nongovernmental organizations working on AIDS in South Africa, and had been providing counseling, medical care, and HIV prevention advice to patients for some ten years. So when Oprah wanted to give a party for orphans in Soweto, she naturally contacted Mark Ottenweller, the director of Hope's South African office. At the time, Hope had just begun to work with orphans, but Ottenweller knew that his colleague Elizabeth ran an organization in Meadowlands called Sizanani Home Based Caregivers that provided food, counseling, and other services to many such children, and he asked Elizabeth to invite them to the party.

As publicity for Hope, Oprah's party was a great success. Oprah's Angel Network charity produced a film in which Ottenweller introduces Oprah to some of the orphans. Hope's press release about the party is still on its Web site three years later. Around the time of the party, Hope began negotiations with PEPFAR officials and in 2004 it received an $8 million US government contract to provide services to 165,000 AIDS-affected children in South Africa and five other African countries. We can imagine that its chances were not hurt by the publicity from the party and the link with Oprah.

Meanwhile Sizanani-Elizabeth's organization-was struggling for funds. In 2001, Elizabeth, along with her two grown daughters, Florence and Dorothy, had established Sizanani with a small grant from the South African government's Department of Social Development. The administration of President Thabo Mbeki has been rightly criticized for downplaying the impact of AIDS in South Africa. However, for the past four years it has been funding a small number of "Drop-In Centres" like Sizanani that provide services to OVC children. Africa has few formal orphanages. It is the policy of African governments and international agencies to keep as many children as possible out of institutions, and to encourage extended families to take in orphans. However, as Jonathan and I found, and as other studies have shown, many families are too poor to care for extra children and even in relatively well-to-do families, AIDS orphans are sometimes abused and neglected. They are less likely to attend school than the biological children of their guardians, they are more likely to be forced to perform arduous labor, and they are more likely to be physically abused and raped by guardians and others.[5]

In the late 1990s, the South African government began to recognize that its own child welfare officers and social workers-of which there are now only three for all of Soweto, with a population of well over a million- could not meet the needs of the nation's rapidly growing orphan population. Experience from other African countries has shown that small, locally run and managed organizations can provide a crucial safety net for OVCs.[6] So the Department of Social Development began funding a small number of organizations throughout the country -Sizanani among them-to provide AIDS-affected children with food and clothing and other basic needs and to identify cases of abuse or neglect.

Elizabeth had been born and raised in Meadowlands and during the preceding decade she had seen how the AIDS epidemic was wrecking her community. The willingness of African families to take in so many orphans has been seen as an expression of the spirit of "Ubuntu"-the ancient African concept of shared humanity captured in the traditional Zulu saying "A person is a person through other people." However, Elizabeth knew that Ubuntu had its limits. As she witnessed the unfolding horror of the AIDS crisis, she wanted to create a community-based center that would be open all the time where orphans and children with sick parents could receive free food and other necessities, and where they could play safely and find adults who could help them if they were in distress. She wanted, as far as possible, to give these children the care they lacked. When she heard about the new government funding, she jumped at the chance.

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."

"So," I asked, "if Rotary is soliciting donations for food, clothing, and so on, what is the $8 million PEPFAR grant for?"

"That's in the grant proposal," she said, referring to Hope and Rotary's application to PEPFAR. "It has direct costs and indirect costs," and then she suggested I contact USAID if I wanted more information.

But USAID will not discuss the ANCHOR program. A Freedom of Information Act request I submitted to USAID in early August 2005 is still pending.

3.

"We wanted to do something on a huge scale," explained Greg Ash, the white South African plastic surgeon who founded NOAH-or Nurturing Orphans of AIDS for Humanity-another South African orphan program that has received approximately $1.5 million from PEPFAR. "We acted as though the responsibility for every orphan in the country were ours." I had been referred to Ash's organization by a press officer at the US embassy in Pretoria. He said it was a PEPFAR success story-a truly indigenous South African organization that was helping thousands of children.

Ash hadn't thought much about AIDS before he started NOAH. Like many white South Africans, he considered leaving the country after the ANC came to power in 1994. But then he was offered a job at a private hospital in Umhlanga Rocks, an exclusive beach community of swaying palms, oceanfront high-rises, and luxurious shopping malls, and he decided to stay. Having made a commitment to raise his own children in South Africa, he began to think more seriously about the country's future, and that's when he began to worry about AIDS orphans. "Apartheid," he said, "gave us this feeling about ourselves, like we're bad people. Maybe that's why an amazing number of people want to do something for the first time. It's relatively easy to get money for kids. People are just waiting for someone to tell them what to do." In 2001, he approached officials at the US embassy with a scheme that he said would help a million AIDS orphans in South Africa by 2008, and in 2003 NOAH began receiving US government funding.

NOAH is a franchise organization. It funds the construction of "resource centers" in schools-separate buildings that, according to the plan, house a small library and five or ten computers, where orphans can stay after school and receive a free meal, read books, and learn how to use computers. NOAH is currently building twenty-two such centers-at a cost of roughly $1 million-and the plan is to build many more.

I asked Ash why it was necessary to build new buildings and buy computers when so many of the orphans I had met in South Africa seemed to have much simpler needs. "We need to break the cycle of AIDS and poverty," he said.

Many of the schools in South Africa are, frankly, not very good, but in the future South African kids will have to compete for jobs with kids from Korea, from Shanghai.... They need that competitive advantage. And setting up some computers is easy, it doesn't cost anything, and the kids teach themselves how to use them. The resource centers have a staff of six people, and local volunteers are also recruited from the community to work with especially needy children.

One drizzly Wednesday morning in June 2005, I went to visit a NOAH center in a poor black township known as Nkobongo some thirty miles and a world away from Umhlanga Rocks. Nkobongo sprawls over the veldt behind the town of Shaka's Kraal, named for the powerful Zulu king who conquered much of southern Africa in the early nineteenth century. By the early twentieth century, white settlers had forced the Zulus off the best grazing land into tsetse- and malaria-infested valleys and lowlands. Young men were recruited to work in the distant gold and diamond mines of the Transvaal, and the rural economy of small-scale farming and cattle raising that had sustained the Zulus for centuries was gradually destroyed. Today, most Zulus live in desolate rural homelands or impoverished townships like Nkobongo. Staggering levels of unemployment and poverty have further hardened these tough people. In village bars, drunk and rowdy men listen to booming rap music, fight about women, and sometimes kill each other. Even small children greet each other with gangster hand signals. A study conducted in a nearby area found that among adults in their twenties, around a third of all men and half of all women are HIV-positive.

The manager of the local NOAH program was not around when I arrived in Nkobongo, so I waited for him at the Nkobongo community center. The community center is on a hill with a view of the whole region: the neat rows of tiny box-shaped houses spread across barren hillsides, a latrine in each front yard. Right below the community center, I noticed that a large crowd had gathered. About two hundred people, young and old, men and women, were sitting around the periphery of a rain-soaked tarmac lot. "Those people really appreciate the bones," said a woman I had met at the community center. "What bones?" I asked. Just then, a pickup truck arrived and parked in the middle of the lot. Two men got out and began off-loading stripped pork bones -refuse from a local abattoir-which they piled up in a heap on the tarmac. The crowd looked on keenly as the men began to distribute the bones-five or six to each person-until the heap disappeared.

Overseeing this extraordinary event was Charles Southwood, a retired white South African businessman who volunteers to help numerous charities in the area, including NOAH. He'd been distributing bones for a local Catholic charity for years, he said. When he started there would be such a mob when the bones arrived that they knocked Charles over several times, and almost overturned the vehicle once or twice. "I told them they had to sit down and form an orderly queue; otherwise there would be no more bones."

According to the Ministry of Agriculture, roughly one third of all South Africans experience "food insecurity," meaning that they live in fear of hunger. At a high school in Soweto, a teacher described to Jonathan and me how many of the students, especially those who were orphans, complained that they did not get enough food at home. Sometimes they would stare through the windows of the faculty room at the teachers eating lunch. "How do you teach a hungry child?" she asked us.[12]

South Africa is the richest country in sub-Saharan Africa. There are no wars here, no refugee camps; the country has a social welfare system, a free press, and regular peaceful elections. But the agrarian traditions that once sustained people here-the techniques they had developed over centuries of survival on the sandy marginal soils of Africa, and that one nineteenth-century European visitor said showed such a profound understanding of nature that they closely resembled a science-have been all but lost.[13] Meanwhile, the industrial future has yet to arrive, and some three quarters of all adults in places like Nkobongo are unemployed.[14] Although South Africa's powerhouse economy, based on gold, diamonds, commercial farming, and services, is growing rapidly, it produces very small numbers of highly skilled jobs.

Charles Southwood introduced me to some of the people who worked at the Nkobongo NOAH resource center. The new building was still under construction, and the resource center was temporarily housed in a church. There was no library, although there was a kitchen where a daily meal was prepared. I was also shown a room with nine computers. The 150 children registered with NOAH love them, but because demand is so high, each child is allowed only one hour of computer time every two weeks. It seemed unlikely that this would break the cycle of AIDS and poverty that seemed to be churning so rapidly here.

Back in Soweto, Jonathan and I asked Elizabeth what she knew about NOAH. She said that one of their representatives-a tall white South African woman-had visited Sizanani some months before. After a series of meetings the visitor announced that NOAH would begin funding Sizanani, but in order to obtain the funding Sizanani would have to fire its entire paid staff and all of them, including Elizabeth, would have to reapply for their jobs. NOAH would rehire only six of the twenty-eight staff who worked there. "This is my dream!" she said. "I wasn't going to let them kick me out!"

Unlike Sizanani, NOAH relies heavily on unpaid volunteers to provide care for needy children. Ash had hoped that these volunteers-"who are unemployed anyway," he told me-would serve out of a sense of altruism, or "Ubuntu" in African terms. But as Elizabeth and Charles Southwood discovered, this isn't so easy. Few people in this troubled place want to help AIDS-affected families for free. "They come for a few days," Charles said of the volunteers. "Maybe a month. Then they realize there's no salary and then you never see them again. Sometimes you go to visit a sick person and the volunteer will just stand at the door and not go in," he said.

There's an old black man who lives on his own. He's blind and can't walk. Someone stole his wallet and pension book. Some volunteers were supposed to go and feed him, but then I found last week that no one had been there for three days. Sometimes I think the Zulus think I'm mad. When I blow my top, as I did last week about the old man, they fail to understand what I'm angry about. They just don't seem to care. They aren't kind to each other. I don't know why. I guess poverty disempowers people, makes them mean.

"Some families don't want my help," a NOAH outreach worker told me. "Some of them swear at me, chase me away. Sometimes they tell the children to tell me they aren't there. They embarrass me in front of the neighbors, say I am some kind of prostitute."

When Charles finds committed volunteers, he tries to raise money to pay them from local churches or businesses or simply from people he knows. According to Ash this should have been easy, but Charles hasn't had much luck. South African businesses may occasionally contribute food or toys that they can't sell, and they are often keen to donate funds for buildings and computers and other infrastructure projects they can put their names or business logos on, but few will support the salary of a sympathetic human being even if that is what orphans need most of all. "Most of the white people in our country are totally unaware of the situation of poor blacks," Charles said. "The whites around here avoid me; no one wants to know what I am doing."

Before I left South Africa, I tried to visit two other NOAH sites in KwaZulu-Natal. According to the list I had been given by NOAH officials in Johannesburg, there should have been two NOAH community groups in a town called Mtubatuba that I happened to be visiting the following week. But when I arrived, I was told by a NOAH coordinator that they were not yet set up. There was not a single volunteer or community worker I could speak to.

In October 2005, UNICEF will launch a campaign to raise millions of dollars for AIDS-affected children. UNICEF, the US government, the World Bank, and many AIDS experts officially recognize the importance of supporting community-based groups like Sizanani. At present, there are far too few of these groups, and most of their funding comes from local sources, often from the poor themselves.[15] The South African government supports only four such groups in all of Johannesburg, and there are none at all in many regions of the country. When Jonathan and I visited the UNICEF officer in charge of OVC issues in Pretoria, she said she had not had time to visit Sizanani or any of the other community-based organizations supported by the South African government. In her view, NOAH provided a better model for orphan services, although she showed no close acquaintance with its programs.

She repeated a common criticism of community-based organizations-that they were "unsustainable"-meaning they start with good intentions and then collapse after a while. Maybe she had a point, but it seemed hollow to us. Of course these organizations collapse if no one supports them, or if they are uprooted by larger organizations with millions of dollars at their disposal. As Elizabeth said, referring to NOAH's takeover bid.

When the Americans come, we sing, we dance, they take our picture, and they go back and show everyone how they are helping the poor black people. But then all they do is hijack our projects and count our children.

Notes
[1] About one third of children born to HIV-positive women inherit the virus during childbirth or breastfeeding. Most of these children die of AIDS by age five; a very small number are being kept alive for longer periods with antiretroviral drugs.

[2] Curt Tarnoff and Larry Nowels, "Foreign Aid: An Introductory Overview of US Programs and Policy," Congressional Research Service, Library of Congress, updated January 19, 2005.

[3] See Human Rights Watch, "Letting Them Fail: Barriers to Education for Children Affected by AIDS," October 2005.

[4] See Helen Epstein, "God and the Fight Against AIDS," The New York Review, April 28, 2005.

[5] See UNICEF, "Africa's Orphaned Generations," 2003; Human Rights Watch, "Letting Them Fail"; Takashi Yamano and T.S. Jayne, "Working-Age Adult Mortality and Primary School Attendance in Rural Kenya," Economic Development and Cultural Change, Vol. 53, No. 3 (2005), pp. 619-654; Anne Case and Cally Ardington, "The Impact of Parental Death on School Enrollment and Achievement: Longitudinal Evidence from South Africa," unpublished manuscript, February 7, 2005; David Evans and Edward A. Miguel, "Orphans and Schooling in Africa: A Longitudinal Analysis," unpublished manuscript, March 1, 2005; and Martha Ainsworth, Kathleen Beegle, and Godlike Koda, "The Impact of Adult Mortality and Parental Deaths on Primary Schooling in North-Western Tanzania," Journal of Development Studies, Vol. 41, No. 3 (April 2005), pp. 413-415.

[6] See Geoff Foster, "Supporting Community Efforts to Assist Orphans in Africa," The New England Journal of Medicine, Vol. 346, No. 24 (June 13, 2002), pp. 1907-1910.

[7] See Case and Ardington, "The Impact of Parental Death on School Enrollment and Achievement."

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

[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.

[10] My thanks to Allison Prete for drawing my attention to this.

[11] Mark Ottenweller, "ANCHOR Program in Africa," Hope Worldwide newsletter 2004, issue 2.

[12] See http://land.pwv.gov.za/publications /news/speeches/didiza_telefood_concert _2march02.htm.

[13] Colin Bundy, The Rise and Fall of the South African Peasantry (University of California Press, 1979).

[14] See the Department of Agriculture and Environmental Affairs: KwaZulu-Natal Province, http://agriculture.kzn tl.gov.za/dae/index.aspx?ID=4.

[15] See Geoff Foster, Bottlenecks and Drip-feeds: Channeling Resources to Communities Responding to Orphans and Vulnerable Children in Southern Africa (Save the Children, June 2005).