A Generation at Risk is the first edited volume to assemble an internationally known and respected group of field workers and academics to discuss the staggering impact of the AIDS pandemic on the lives of children. With an estimated 5 million newly infected people a year, including 700 000 under the age of 15, and a prediction that by 2010, an estimated 20 million children (5.7% of all children in sub-Saharan Africa) will have lost one or both parents to AIDS, it is surprising that more has not been written about this topic. In the opening chapter of the volume the editors explain this neglect to be attributable to an initial (and understandable) focus on biomedical responses to the pandemic (basic epidemiology and prevention and care efforts). However, as also suggested in a foreword from Archbishop Emeritus Desmond Tutu, it is now recognized that AIDS has cascading and disastrous effects on the lives of children. The editors present a useful framework in the introduction outlining these effects, beginning with children as care providers for ill parents before the parental death; ensuing psychosocial distress (including stigma and discrimination), economic problems and diminished access to health and educational services after the death; and ending with possible removal of the child into unfamiliar care, or in some cases living without adult care.
Chapters 1–6 each focus on one or a mixture of three different levels of response to manage the cascading effects of HIV/AIDS on children: the level of community and family response; the level of ‘influence’ including non-governmental organizations and faith institutions; and the level of ‘enabling’ institutions, for example the responses of governments and international organizations. Chapters tend to follow similar structures: first the challenges associated with the relevant level of response are analysed followed by a set of recommendations and strategies to improve such responses. Chapters 1–3 focus on family- and community-based care, including a discussion of institutional forms of care, fostering and adoption (chapter 1), the economic impact of HIV/AIDS on households (chapter 2), and the response from the educational system (chapter 3). Of particular interest to readers of Psychological Medicine is a section in chapter 3 dealing with the educational system's response to addressing psychological needs of children affected by AIDS. Chapter 4 continues this theme and despite the dearth of empirical studies on this topic, the authors provide a comprehensive discussion of the psychosocial impact of the pandemic on children. Risk factors include the effects of chronic illness in the child itself, the illness of the parent, parental depression, parental death, cumulative loss, single parenthood, parentification, deficits in parenting, and the effect of stigma and discrimination. A range of resilience and protective factors form the basis for a discussion of strategies for responding to children's psychosocial needs.
Chapter 5 discusses issues pertaining to the human rights of the child in the context of HIV/AIDS and emphasizes the special role of government in fulfilling these rights. The authors demonstrate how age and gender may affect the human rights of children – age, because certain age cut-offs in the definition of children preclude children older than 15 from receiving health services; and gender, because girls endure higher rates of discrimination if infected with HIV/AIDS. Interestingly, the issue of discrimination becomes apparent again in chapter 6 where the role of faith-based organizations is discussed. Value-based views of religious organizations have in some cases diminished a positive response to lessen the impact of AIDS on children. In chapters 7 and 8 a discussion of the impact of AIDS on children in the Asia-Pacific region and the USA demonstrates how children in these more developed countries suffer similar consequences to those in Africa. The volume completes with an overview of current interventions (chapter 9) and a map for future interventions, including an agenda for future research (chapter 10).
One of the central points underlying all chapters is that the loss of parents is only the most obvious impact of the pandemic on children and that other vulnerabilities must be recognized and addressed as well. Therefore a great deal of coordination between the different levels of response is needed in order to address the needs of these very vulnerable children. As summarized in the final chapter by one of the editors: ‘What is needed is a planned and coordinated set of policy, social-mobilization, and programmatic interventions by public sector and civil society actors. Achieving this goal requires a strategic response from leaders that only recently has been seen in a few countries’. In addition, the volume highlights a great need for empirical research to inform and guide such coordination. A Generation at Risk is the only available integrated introduction to this area of research and practice and is an inspiring must-read for paediatricians, psychiatrists, psychologists, social workers and anyone interested in understanding, studying or preventing the global effect of HIV/AIDS on children.
