Supporting Early Childhood Development in the Slums of Africa – Emerging Concepts

Supporting Early Supporting Early Childhood Development Childhood Development in the Slums of Africa – in the Slums of Africa –

Emerging ConceptsEmerging Concepts

John H. BryantJohn H. Bryant

CORE-GROUP, BaltimoreCORE-GROUP, Baltimore

April 27, 2010April 27, 2010

IntroductionIntroduction

We have been working on the problems of Orphans We have been working on the problems of Orphans and Vulnerable Children (OVC) in the Urban Slums of and Vulnerable Children (OVC) in the Urban Slums of Africa for the past 6 years, using Nairobi, Kenya as Africa for the past 6 years, using Nairobi, Kenya as our test site.our test site.

We began with fundamentals of primary health care We began with fundamentals of primary health care (PHC), reaching every household, that had a child-(PHC), reaching every household, that had a child-under-5.under-5.

We had a fine relationship with the communities – sensitive, mutually respectful, learning together about what is necessary to keep the child healthy.We had a fine relationship with the communities – sensitive, mutually respectful, learning together about what is necessary to keep the child healthy.

Evolving patterns of child careEvolving patterns of child care

Now, we wish to invite you to Now, we wish to invite you to join us in a join us in a journeyjourney we have been taking in the context of we have been taking in the context of care of the OVC in the urban slums of Kenya. care of the OVC in the urban slums of Kenya.

While focused on the slum communities – While focused on the slum communities – and proceeding with implementation of and proceeding with implementation of PHC…..PHC…..further advances in the science of further advances in the science of early childhood development (ECD) were early childhood development (ECD) were emerging.emerging.

So, let us proceed, step by step, as we came So, let us proceed, step by step, as we came to understand these advances and absorbed to understand these advances and absorbed them into our program. them into our program.

UN Habitat, Nairobi, from 2004UN Habitat, Nairobi, from 2004

UN Habitat made a commitment in 2004 to UN Habitat made a commitment in 2004 to the MDG of the MDG of improving the lives of at least improving the lives of at least 100 million slum dwellers in Africa.100 million slum dwellers in Africa.

Senior Staff of UN Habitat were concerned Senior Staff of UN Habitat were concerned that young children would be left out.that young children would be left out.

J. and N. Bryant were asked if they could J. and N. Bryant were asked if they could help in the development of help in the development of health care and health care and social support for Orphans and Vulnerable social support for Orphans and Vulnerable Children (OVC) in the Urban Slums of Africa.Children (OVC) in the Urban Slums of Africa.

UN Habitat, NairobiUN Habitat, Nairobi

We said “Yes”, and were excited by the We said “Yes”, and were excited by the challenge.challenge.

Then we asked: “What will the budget be?Then we asked: “What will the budget be?

UN Habitat answered: “Zero, budget”!UN Habitat answered: “Zero, budget”!

Rather than saying – “no budget, no work!” Rather than saying – “no budget, no work!” --– this became a core challenge of the --– this became a core challenge of the project.project.

It meant we had to seek our own resources.It meant we had to seek our own resources.

The Urban Slums of AfricaThe Urban Slums of Africa

The realities.The realities.

About 1 billion people in the world live in About 1 billion people in the world live in slums. In Africa, about 70% of the urban slums. In Africa, about 70% of the urban populations live in the slums.populations live in the slums.

In the urban slums of Nairobi, 87% of In the urban slums of Nairobi, 87% of households live in one room homes with no households live in one room homes with no running water, no sanitation and no running water, no sanitation and no electricity.electricity.

Slum Up-grading in KenyaSlum Up-grading in Kenya

UN Habitat and the Government of Kenya have UN Habitat and the Government of Kenya have agreed to work on upgrading of the slums of agreed to work on upgrading of the slums of Kenya, beginning with Nairobi.Kenya, beginning with Nairobi.

KENSUP – Kenya Slum Upgrading ProgramKENSUP – Kenya Slum Upgrading Program It was decided that the work of Jack and Nancy It was decided that the work of Jack and Nancy

on OVC of urban slums should begin in Nairobi on OVC of urban slums should begin in Nairobi in collaboration with KENSUP.in collaboration with KENSUP.

The communities selected for that purpose The communities selected for that purpose were Mlolongowere Mlolongo, Sophia and Bondeni, , Sophia and Bondeni, 10,000 10,000 people, part of a larger settlement named people, part of a larger settlement named Mavoko. Mavoko.

Working with slum communities Working with slum communities of Nairobi.of Nairobi.

The plan was to develop The plan was to develop health care health care programs for OVCprograms for OVC in those communities, in those communities, initially as a pilot project to then be initially as a pilot project to then be expanded more widely.expanded more widely.

However, one of the realities was that the However, one of the realities was that the existing governmental health system was existing governmental health system was largely facility-based and with limited largely facility-based and with limited community access to needed servicescommunity access to needed services. . So it is with much of the slums of Africa!So it is with much of the slums of Africa!

Further reality – almost no budget. Further reality – almost no budget.

Mlolongo, Sophia, BondeniMlolongo, Sophia, Bondeni

Our reality was that our task Our reality was that our task would not be towould not be to implement a well known health care system.implement a well known health care system.

It would be to help the people of Mlolongo, It would be to help the people of Mlolongo, Sophia and Bondeni to realize the things they Sophia and Bondeni to realize the things they could do to improve the health of their could do to improve the health of their children. children.

This approach would be shaped so as to be This approach would be shaped so as to be applicable to other urban slums of the applicable to other urban slums of the greater Africa, at modest costs!greater Africa, at modest costs!

Mlolongo, Sophia, BondeniMlolongo, Sophia, Bondeni

Mlolongo, Sophia and Bondeni have a Mlolongo, Sophia and Bondeni have a Health Health CommitteeCommittee, a group who have been involved , a group who have been involved in some community surveys with UN Habitat in some community surveys with UN Habitat and providing home-based care in the and providing home-based care in the community for PLWA.community for PLWA.

The Health Committee is lively, socially The Health Committee is lively, socially committed, interested in working with us, committed, interested in working with us, and understanding of the local social, and understanding of the local social, cultural and economic issues.cultural and economic issues.

Mlolongo, Sophia, Mlolongo, Sophia, BondeniBondeni

The Health Committee helped us The Health Committee helped us to organize to organize a workshopa workshop to consider the activities the to consider the activities the community would be willing to undertake.community would be willing to undertake.

There was a lively and socially open There was a lively and socially open discussion.discussion.

The WorkshopThe Workshop

The workshop was lively and interactive.The workshop was lively and interactive. With our own broad experience in Primary With our own broad experience in Primary

Health Care, we were able to introduce them Health Care, we were able to introduce them to aspects of PHC that to aspects of PHC that they could pursue in they could pursue in their own householdstheir own households, while depending on , while depending on back-up from the Government Health Centers back-up from the Government Health Centers and Hospitals. and Hospitals.

Project Areas to Initiate in Project Areas to Initiate in CommunitiesCommunities

Growth MonitoringGrowth Monitoring ImmunizationsImmunizations Hand WashingHand Washing Insecticide Treated Bed NetsInsecticide Treated Bed Nets Nutrition – Nutrition –

Nutritional SupplementsNutritional Supplements Micronutrients Micronutrients

Home-based Care For People Living with Home-based Care For People Living with HIV/AIDSHIV/AIDS

Caregiver-Child AttachmentsCaregiver-Child Attachments

Evolving patterns of child careEvolving patterns of child care

Soon after the start of our project, I was Soon after the start of our project, I was asked by the AJPH to review an article asked by the AJPH to review an article focused on early childhood development.focused on early childhood development.

The article involved concepts that were new The article involved concepts that were new to me, based on recent advances in the to me, based on recent advances in the science of early child development (ECD).science of early child development (ECD).

The main reference: The main reference: From Neurons to From Neurons to Neighborhoods – the Science of Early Neighborhoods – the Science of Early Childhood Development, NAS, IOM, 2000.Childhood Development, NAS, IOM, 2000.

Neurons to NeighborhoodsNeurons to Neighborhoods An explosion of research in the neuro-biological, An explosion of research in the neuro-biological,

behavioral, and social sciences has led to major behavioral, and social sciences has led to major advances in understanding the conditions that advances in understanding the conditions that influence influence whether children get off to a promising whether children get off to a promising or worrisome start in life.or worrisome start in life.

These scientific gains have generated a much These scientific gains have generated a much deeper appreciation of:deeper appreciation of:

(1) early life experiences, as well as the (1) early life experiences, as well as the inseparable and highly interactive influences of inseparable and highly interactive influences of genetics and environment, on the development genetics and environment, on the development of the brain and the unfolding of human of the brain and the unfolding of human behavior; behavior;

Neurons to NeighborhoodsNeurons to Neighborhoods

(2) the central role of early relationships as a (2) the central role of early relationships as a source of either support and adaptation or source of either support and adaptation or risk and dysfunction; risk and dysfunction;

(3) the capacity to increase the odds of (3) the capacity to increase the odds of favorable developmental outcomes through favorable developmental outcomes through planned interventions.planned interventions.


It is very important that the child has a It is very important that the child has a relationship with the mother (or caregiver) that relationship with the mother (or caregiver) that is nurturing, loving, protective, supportive, is nurturing, loving, protective, supportive, stimulating, encouraging – every day, week, stimulating, encouraging – every day, week, month, for considerable time.month, for considerable time.

With that With that secure attachmentsecure attachment, the child builds a , the child builds a foundation that includes a sense of self-worth, foundation that includes a sense of self-worth, physical, social, cultural, cognitive physical, social, cultural, cognitive development that prepares it to cope with this development that prepares it to cope with this complex world into which it is born.complex world into which it is born.

That can be beneficial for the child’s entire life.That can be beneficial for the child’s entire life.

Loving Mother and Her BabyLoving Mother and Her Baby


But, let us say the child is neglected or But, let us say the child is neglected or abused, and lacks that abused, and lacks that secure attachmentsecure attachment; let ; let us say that it is an us say that it is an insecure attachmentinsecure attachment

This can be disruptive and truly harmful, with This can be disruptive and truly harmful, with lifelong consequences.lifelong consequences.

It can actually cause damage of the little It can actually cause damage of the little one’s brain which is undergoing early one’s brain which is undergoing early maturation.maturation.


We are, of course, concerned about the many We are, of course, concerned about the many children in the slums who would not have children in the slums who would not have parents or caregivers. parents or caregivers.

Importantly, there would be limited under-Importantly, there would be limited under-standing that children standing that children who are simply who are simply neglected, even if not mistreatedneglected, even if not mistreated, , could be could be harmedharmed by the lack of a nurturing caregiver by the lack of a nurturing caregiver attachment. attachment. Indeed, harmed for life!Indeed, harmed for life!


So, we shared these ideas and problems with So, we shared these ideas and problems with our Health Committee and they were truly our Health Committee and they were truly excited by the knowledge, and deeply excited by the knowledge, and deeply interested in taking steps to protect the interested in taking steps to protect the children in Mlolongo, Sophia, Bondeni and children in Mlolongo, Sophia, Bondeni and beyond.beyond.

So they began teaching the community about So they began teaching the community about this, and gaining widespread support from this, and gaining widespread support from them.them.

Community Health Workers Community Health Workers (CHWs)(CHWs)

An important aspect of our Project has been An important aspect of our Project has been the selection and training of CHWs.the selection and training of CHWs.

These are women and men from the local These are women and men from the local communities who agree to visit every communities who agree to visit every household on a regular basis, maintaining household on a regular basis, maintaining records on elements of PHC and caregiver-records on elements of PHC and caregiver-child interactions, and maintaining an child interactions, and maintaining an information system that records and information system that records and monitors the care of the children-under-5.monitors the care of the children-under-5.

There are currently 2400 households with at There are currently 2400 households with at least one child-under-5.least one child-under-5.

Caregiver-Child AttachmentsCaregiver-Child Attachments We are developing We are developing a diagnostic toola diagnostic tool to be used by to be used by

the CHWs in estimating whether the attachment is the CHWs in estimating whether the attachment is secure and loving, or insecure and neglectful.secure and loving, or insecure and neglectful.

They have actually been They have actually been scoring householdsscoring households in in terms of whether the caregiver-child attachment terms of whether the caregiver-child attachment appears to be appears to be secure or insecure.secure or insecure.

The CHWs take action accordingly, supporting The CHWs take action accordingly, supporting the secure attachments, and encouraging the secure attachments, and encouraging correction away from insecure attachments.correction away from insecure attachments.

Now let us tell you of some of their findings that Now let us tell you of some of their findings that surprised and impressed us.surprised and impressed us.


They found that households where a child They found that households where a child was was malnourishedmalnourished was also a household in was also a household in which the caregiver-child attachment was which the caregiver-child attachment was often often insecureinsecure! !

Actually, the literature in this field is quite Actually, the literature in this field is quite supportive of these findings.supportive of these findings.

It is telling us that correcting childhood It is telling us that correcting childhood malnutrition may require more than feeding. malnutrition may require more than feeding. Somehow, Somehow, nurturing, loving care has to come nurturing, loving care has to come alongside the feeding.alongside the feeding.

Health and Child Development Health and Child Development Information Management SystemInformation Management System

HCDIMS.HCDIMS. CHWs visit every household, collect CHWs visit every household, collect

information relating to the well-being of the information relating to the well-being of the children.children.

This is done monthly or bi-monthly, This is done monthly or bi-monthly, depending on the households.depending on the households.

They have a small data book in which they They have a small data book in which they enter the data from every household.enter the data from every household.

The Project Secretary, Betty, is also a data The Project Secretary, Betty, is also a data clerk, and she enters into the computer the clerk, and she enters into the computer the data from the CHW’s data books. data from the CHW’s data books.

Health and Child Development Health and Child Development Information Management SystemInformation Management System

Computer-based OVC DATAComputer-based OVC DATA Each step of PHC – for each householdEach step of PHC – for each household

Weight for Age…ChangingWeight for Age…Changing Nutritional SupplementationNutritional Supplementation Malaria and BednetsMalaria and Bednets HandwashingHandwashing Oral Rehydration SolutionOral Rehydration Solution Home-based care of PLWAHome-based care of PLWA Caregiver-Child AttachmentsCaregiver-Child Attachments

Health and Child Development Health and Child Development Information Management SystemInformation Management System The nature of caregiver-child attachmentsThe nature of caregiver-child attachments Initial assessment of attachmentInitial assessment of attachment

11stst visit visit 22ndnd visit visit 33rdrd visit visit

Changes in attachment?Changes in attachment? Comments: doing well; she is now loving; Comments: doing well; she is now loving;

no change – doesn’t understand; etc. no change – doesn’t understand; etc. PHC Status and Caregiver-Child Attachment PHC Status and Caregiver-Child Attachment

for every child recorded, with changes added for every child recorded, with changes added as they occur.as they occur.

HCDIMS – updated quarterly.HCDIMS – updated quarterly.

Community Leadership!Community Leadership!

One of the delights of this work has been the One of the delights of this work has been the lively and effective involvement of the lively and effective involvement of the communities.communities.

We have been careful to be involved in a We have been careful to be involved in a sharing of thinking, planning and actions, sharing of thinking, planning and actions, and and listening more than tellinglistening more than telling!!

Racheal Nduku began as Secretary for the Racheal Nduku began as Secretary for the Health Committee. Excellent organizational Health Committee. Excellent organizational skills and writing of minutes of our meetings.skills and writing of minutes of our meetings.

Community Leadership!Community Leadership!

Racheal amazed us with her capacities for Racheal amazed us with her capacities for organizing activities, recording processes, organizing activities, recording processes, and involving community members in these and involving community members in these processes. processes.

We advanced Racheal to be the Community We advanced Racheal to be the Community Coordinator of the Project.Coordinator of the Project.

Here are some photos of Racheal and this Here are some photos of Racheal and this work that she pursues.work that she pursues.

Caregiver-Child InteractionsCaregiver-Child Interactions

Racheal has taken special interest in Racheal has taken special interest in supporting caregiver-child interactions.supporting caregiver-child interactions.

She arranges local workshops in each of the She arranges local workshops in each of the communities, bringing together caregiver-communities, bringing together caregiver-child interactions that range from secure to child interactions that range from secure to insecure attachments.insecure attachments.

Racheal is tracking those changes carefully, Racheal is tracking those changes carefully, and recording changes as they occur.and recording changes as they occur.

Caregiver-Child Caregiver-Child AttachmentsAttachments

Child’s relationship Child’s relationship with primary caregiver with primary caregiver begins even before begins even before birthbirth

Plays critical role in Plays critical role in developmentdevelopment

Affects emotional, Affects emotional, cognitive, social, cognitive, social, physical development physical development with lifelong impactwith lifelong impact

Secure AttachmentsSecure Attachments

Relationships that are Relationships that are nurturing, loving, and nurturing, loving, and stimulating result in stimulating result in positive patternspositive patterns

These children do These children do better at school, at better at school, at work, in relationships, work, in relationships, and as parentsand as parents

We call this “secure We call this “secure attachment”attachment”

The Project – in CommunitiesThe Project – in Communities

Project Office in MlolongoProject Office in Mlolongo Racheal, and her secretaryRacheal, and her secretary Computer, printerComputer, printer Room for meeting with CHWs and Room for meeting with CHWs and

community peoplecommunity people Shelves -- household information systemShelves -- household information system Walls with photographs, maps, and Walls with photographs, maps, and

statements of visions, goals, hopesstatements of visions, goals, hopes

Center On the Developing ChildCenter On the Developing Child

An important resource relating to our work An important resource relating to our work on caregiver-child interactions is the newly on caregiver-child interactions is the newly established established Center on the Developing Child, Center on the Developing Child, Harvard UniversityHarvard University..

Director of the Center is Professor Jack Director of the Center is Professor Jack Shonkoff, senior editor of the book -- Shonkoff, senior editor of the book -- From Neurons to Neighborhoods, National From Neurons to Neighborhoods, National Academy of Science, 2000.Academy of Science, 2000.

Professor Shonkoff invited J. Bryant to visit Professor Shonkoff invited J. Bryant to visit Harvard and share insights on challenges of Harvard and share insights on challenges of addressing the needs of the developing child addressing the needs of the developing child in the African urban slum context.in the African urban slum context.

Center for the Developing ChildCenter for the Developing Child

Shonkoff emphasized emerging Shonkoff emphasized emerging understandings of the needs and difficulties understandings of the needs and difficulties faced by faced by the developing childthe developing child..

In the broad fields of public health and the In the broad fields of public health and the health care of children, particularly in health care of children, particularly in developing countries, the emphasis so often developing countries, the emphasis so often is onis on child survivalchild survival!!

Shonkoff emphasized that child survival is Shonkoff emphasized that child survival is not enough -- it is of critical importance that not enough -- it is of critical importance that child developmentchild development be included in priority be included in priority concerns.concerns.

Daystar University and ECDDaystar University and ECD

Daystar University is located in downtown Daystar University is located in downtown Nairobi, with another campus in a rural area. Nairobi, with another campus in a rural area.

A fine institution with strong faculty and A fine institution with strong faculty and cultural commitments to the needs of the cultural commitments to the needs of the people of Kenya.people of Kenya.

One of the Departments of Daystar is that of One of the Departments of Daystar is that of Child Development.Child Development.

That Department has become very interested That Department has become very interested in our work, and has invited Racheal’s in our work, and has invited Racheal’s involvement in the academic programs.involvement in the academic programs.

Daystar University and ECDDaystar University and ECD She has been invited to give lectures to the She has been invited to give lectures to the

students, and they have welcomed Racheal’s students, and they have welcomed Racheal’s inviting the masters level students to visit our inviting the masters level students to visit our community slums sites as field work, which has community slums sites as field work, which has delighted all of them. delighted all of them.

I have been invited as a visiting professor to provide I have been invited as a visiting professor to provide support for presenting the science base of ECD.support for presenting the science base of ECD.

The relationship between Daystar and our project The relationship between Daystar and our project has become very positive, and it pleases us that the has become very positive, and it pleases us that the university is revising the Department to become university is revising the Department to become the the Child Development InstituteChild Development Institute..

Racheal is now enrolled as a student in the Child Racheal is now enrolled as a student in the Child Development degree program. Development degree program.

New Dimensions in Our Journey!New Dimensions in Our Journey!

In the course of interacting with other In the course of interacting with other scholars in related fields, an interesting and scholars in related fields, an interesting and important dimension of ECD came to our important dimension of ECD came to our attention.attention.

Lancet: child development in developing Lancet: child development in developing countries series – three articles, 2007.countries series – three articles, 2007.

OVERVIEW -- OVERVIEW -- 200 million children under 5 200 million children under 5 years years fail to reach their potential in cognitive fail to reach their potential in cognitive and socioemotional developmentand socioemotional development because of because of poverty, poor health and nutrition poverty, poor health and nutrition and lack of and lack of early stimulation.early stimulation.

New Dimensions!New Dimensions!

These disadvantaged children are likely to do These disadvantaged children are likely to do poorly in school, and subsequently to have poorly in school, and subsequently to have low incomes, high fertility, and provide poor low incomes, high fertility, and provide poor care for their children, care for their children, thus contributing to thus contributing to intergenerational transmission of povertyintergenerational transmission of poverty..

Four causes: malnutrition, iron and iodine Four causes: malnutrition, iron and iodine deficiency, and inadequate stimulation.deficiency, and inadequate stimulation.

Governments and civil societies need to Governments and civil societies need to consider consider expanding high quality, cost-expanding high quality, cost-effective, ECD programseffective, ECD programs..

Core ValuesCore Values

At the heart of our project has been the At the heart of our project has been the secure loving, supportive interactions of secure loving, supportive interactions of caregivers and children in family settings.caregivers and children in family settings.

The product of those secure, loving The product of those secure, loving interactions is a stable, maturing process interactions is a stable, maturing process whereby the children evolve as productive, whereby the children evolve as productive, creative members of families and society.creative members of families and society.

We now see the relevance of our work to the We now see the relevance of our work to the 200 million children under-5 across the world 200 million children under-5 across the world who are missing the loving stimulation that who are missing the loving stimulation that our children receive. our children receive.

Our Journey ContinuesOur Journey Continues

And so our journey continues, as we are alert And so our journey continues, as we are alert to further advances in the science of ECD, to further advances in the science of ECD, and sensitive to how such advances can and sensitive to how such advances can enhance the strengths of our project and enhance the strengths of our project and how these might benefit children in the how these might benefit children in the larger Africa. larger Africa.

Health & Medicine

Supporting Early Childhood Development in the Slums of Africa – Emerging Concepts