Sub-Saharan Africa is in an orphan-care crisis: 12.3 million children under age 15 have lost one parent (single orphans) or both parents (double orphans) to AIDS . The burden of parental death from AIDS is greatest in southern Africa. In Zimbabwe, 19% of all children were orphans in 2003, four-fifths of them due to AIDS, leaving a population of 11.2 million to support 440,000 double and 820,000 single orphans [1–5]. With one-fourth of Zimbabwean adults infected with HIV [4, 6] and antiretroviral therapies largely unavailable, AIDS will continue to reduce life expectancy – already down to 39 years from 63 years a decade ago – and increase orphan prevalence for years to come [2, 7–11].
Zimbabwe's AIDS epidemic feeds and is fed by an economic meltdown marked by 70% unemployment, triple-digit inflation, a shattered agriculture sector, drastic cuts in social spending, and political uncertainty and paralysis [5–7, 12–15]. In 2002, 49% of Zimbabweans were in need of emergency food aid, ranking worst in southern Africa [7, 16]. The country's poverty rate has doubled since 1995 , and its 50 percent increase in under-5 mortality since 1990 is the largest in the world . Isolated by Western donors critical of its government's human-rights record, Zimbabwe receives a tiny fraction of foreign aid to the region .
The dual disaster of AIDS and economic decline is straining the country's primary, preferred, most cost-effective, and previously well-defined and almost fail-safe system of orphan care – the extended family [2, 5, 7, 19–23]. Within weakening patrilineal structures (including waning wife-inheritance customs), some fathers (of maternal orphans), aunts, and uncles are defaulting on traditional orphan-care responsibilities [5, 24]. In increasing numbers, orphans are being fostered (used here in the sense of being taken in and raised, although Zimbabweans would not usually attach the term "fostering" to what they view as family arrangements) by relatives from the maternal side who are female, widowed, old, and poor, or by siblings – each a risk factor for deepening poverty [8, 10, 14, 16, 19, 25–30].
Almost one-fourth of rural households are fostering orphans [2, 21, 31], including a growing percentage of the poorest households . The numbers of street children and households headed by children, two largely unmonitored bellwethers of the crisis, are believed to be small but rising [2, 5, 14, 19, 22, 24, 32, 33]. Alternatives are scant: The country's 45 registered orphanages house only 4,000 children , and while unrelated families may make mutually beneficial "voluntary fostering" arrangements (e.g. to facilitate a child's education or obtain domestic labor), crisis fostering in response to death or illness remains rare outside the kinship network [2, 26, 30, 34].
While most orphans are still finding homes within their extended families, the costs of unassisted, state-of-emergency orphan care may be unsustainably high for children, caregivers, and society [8, 14, 16, 23, 29, 35]. Starting with their ill parents' impoverishment, cumulative AIDS traumas leave orphans at high risk of malnutrition, emotional problems, illiteracy, economic and sexual exploitation, HIV infection, and future unemployment and poverty [10, 36–41]. Rising school fees intensify the vicious cycle : Primary-school enrollment rates have dropped precipitously, from 95% for boys and 90% for girls in 1999 to 67% and 63%, respectively, in 2003 [17, 42]. Compared to other children, orphans are less likely to be in school, to stay in school during hard times, to be at the proper grade level, and to perform well [8, 11, 16, 26, 27, 36, 39, 41]. Lack of stable, nurturing care exacerbates all of these risk factors, with potentially disastrous aggregate effects on society's public health, economic productivity, and social cohesion [1, 3, 27].
Many caregivers, especially the elderly, are impoverished, ill, tired, and emotionally drained from having cared for and buried relatives and taken in their orphans [22, 43]. As the World Health Organization has noted, orphan care is "provided mostly in circumstances of diminished or non-existent forms of external support, be it familial or state-provided" [22, 35]. Government programs are underfunded and difficult to access [7, 29, 35, 44]; a study in 2000 found only 2% of households were benefiting from such public education, food, and health-care assistance, while family and community capacity was dwindling . Without such support, a caregiver's illness or age-related frailty may thrust the foster child into the role of caregiver or head of household [33, 46]. Moreover, given current population dynamics resulting from AIDS, the next generation of orphans will have far fewer grandparents as potential caregivers [31, 47].
The limits of the extended family's sense of responsibility for orphans are largely unstudied. Evidence suggests that poverty and the prospect of having to pay school fees are barriers to fostering [40, 48] and that mitigating factors, such as the presence of teenage siblings and nearby relatives to provide support, may make child-headed households more acceptable and likely . Little is known about how factors such as finances, degree of relatedness, AIDS stigma, personal preferences, and gender and health of the child interact in orphan-care decisions [8, 22, 23, 34, 40, 43, 49, 50]. We do not know whether extra-familial fostering remains infrequent because of community or personal preferences, a lack of effective mechanisms for prompting and supporting fostering, or simply a financial need to limit obligation. No published study from Zimbabwe has focused on caregivers' views of barriers to orphan care and incentives for overcoming them.
Answers to these questions can stimulate and inform policies and programs to avert what USAID calls "an impending calamity": that millions of children will grow up without the nutrition, education, and social nurturing necessary to sustain a healthy society . This study explores the circumstances, needs, perceptions, and experiences of 371 caregivers in rural eastern Zimbabwe, including 212 who are fostering orphans, then briefly discusses implications for policies to strengthen the capacity of families and communities to care for their own.